Child Maltreatment

Child Physical Abuse With and With...
Child Physical Abuse With and Without Other
Forms of Maltreatment: Dysfunctionality
Versus Dysnormality

Marie-Claude Larr...

studies that tell us anything about co-occurrence of         ...
Larrivée et al. / PHYSICAL ABUSE AND CO-OCCURRENCE           305

OBJECTIVE                                            ...
306     Larrivée et al. / PHYSICAL ABUSE AND CO-OCCURRENCE

TABLE 1:     Proportional Co-occurrence of Child Physical A...
Larrivée et al. / PHYSICAL ABUSE AND CO-OCCURRENCE                     307

TABLE 3:    Name and Description of 32 Sele...

RESULTS                                                      ...
Larrivée et al. / PHYSICAL ABUSE AND CO-OCCURRENCE           309

TABLE 4:    Statistical Associations between 21 Varia...
310        Larrivée et al. / PHYSICAL ABUSE AND CO-OCCURRENCE

TABLE 5:      Results of Direct Logistic Regression Anal...
Larrivée et al. / PHYSICAL ABUSE AND CO-OCCURRENCE          311

incidents of physical abuse take place in a context of...
312     Larrivée et al. / PHYSICAL ABUSE AND CO-OCCURRENCE

know is that the different forms were assessed as part     ...
Larrivée et al. / PHYSICAL ABUSE AND CO-OCCURRENCE                        313

Mash, E. J., & Wolfe, D. A. (1991). Meth...
Upcoming SlideShare
Loading in …5



Published on


Published in: Education
1 Like
  • Be the first to comment

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide


  1. 1. Child Maltreatment Child Physical Abuse With and Without Other Forms of Maltreatment: Dysfunctionality Versus Dysnormality Marie-Claude Larrivée, Marc Tourigny and Camil Bouchard Child Maltreat 2007; 12; 303 DOI: 10.1177/1077559507305832 The online version of this article can be found at: Published by: On behalf of: American Professional Society on the Abuse of Children Additional services and information for Child Maltreatment can be found at: Email Alerts: Subscriptions: Reprints: Permissions: Citations Downloaded from by radu anca on November 28, 2009
  2. 2. Child Physical Abuse With and Without Other Forms of Maltreatment: Dysfunctionality Versus Dysnormality Marie-Claude Larrivée Member, GRAVE-ARDEC Marc Tourigny Université de Sherbrooke Camil Bouchard Université du Québec à Montreal The fact that most etiological studies of physical abuse have T he etiology of child maltreatment is complex: it is not taken into account co-occurrence of different forms of related to a range of characteristics that demand a maltreatment calls into question the validity of our knowl- broad understanding of the problem (Brown, Cohen, edge on the subject. The aim of this study, therefore, is to Johnson, & Salzinger, 1998; Herrenkohl, Herrenkohl, compare the etiological patterns of cases of physical abuse & Egolf, 1983; Mayer, 1997). The contemporary liter- reported to Quebec child protective services (CPS) according ature describes personal, family, and social character- to whether the abuse occurs alone or co-occurs with other istics that are supposedly good predictors of physical forms of maltreatment. The data are taken from the Quebec abuse (Black, Heyman, & Smith Slep, 2001; Brown Incidence Study (QIS), which examined 4,929 reports et al., 1998; Dufour, Massicotte, & Mayer, 2005). For investigated by Quebec CPS in the fall of 1998. The cases example, children who have behavioral problems or included 514 children who were physically abused: 269 of difficult relationships with their parents are said to be them were not subjected to any other type of maltreatment at greater risk; parents who are young, have unrealis- and 245 were also victims of one or two other forms of mal- tic expectations of their children’s development, or treatment. The survey form provided information on more resort to corporal punishment are thought to be more than 30 characteristics of the children reported, their likely to physically abuse their children; and children families, and their parental figures. Bivariate and direct living in neighborhoods with a high proportion of logistic regression analyses revealed that the profile of physi- low-income or single-parent families may be at greater cal abuse cases varies depending on whether the physical risk of physical abuse. abuse occurs alone (what we are calling dysnormality) or in As interesting as this list of etiological characteris- combination with one or two other forms of maltreatment tics associated with physical abuse may be, an increas- (dysfunctionality). Those results will help deepen our etio- ing number of researchers are uncomfortable with it. logical knowledge of physical abuse and may serve to inspire Daro (1988) points out that sociofamilial etiologies different types of intervention for the two groups of children. or typologies that distinguish families by forms of maltreatment have failed to take into account cases in which there is more than one form of maltreat- Keywords: child physical abuse; co-occurrence; etiology ment. In fact, in the vast literature on the subject, CHILD MALTREATMENT, Vol. 12, No. 4, November 2007 303-313 Authors’ Note: The authors would like to thank the Quebec DOI: 10.1177/1077559507305832 Director of Youth Protection caseworkers for their invaluable help © 2007 Sage Publications with this project. 303 Downloaded from by radu anca on November 28, 2009
  3. 3. 304 Larrivée et al. / PHYSICAL ABUSE AND CO-OCCURRENCE studies that tell us anything about co-occurrence of of cases of physical abuse that occur along with other maltreatment or mult-type maltreatment are rare (Higgins forms of maltreatment, then the interaction compo- & McCabe, 2001; National Research Council, 1993; nents between group differences and risk factors are Ney, Fung, & Wickett, 1994; Rossman, Hughes, & in the error term. That, at least, is the hypothesis that Hanson, 1998). Some researchers believe that we have formulated on the basis of data obtained co-occurrence is fairly frequent among maltreated from the only three CPS studies we are aware of that children (Barnett, Manly, & Cicchetti, 1991; Briere & document the correlates of physical abuse by clearly Runtz, 1990; Higgins & McCabe, 2001; Kinard, 1994, distinguishing cases in which it occurs with and with- 1998; Mash & Wolfe, 1991; Silverman, Reinherz, & out other forms of maltreatment (Bath & Haapala, Giaconia, 1996; Trickett & McBride-Chang, 1995). 1993; DiLauro, 2001; Hartley, 2002). For example, in studies of children enrolled at a sum- These data paint two different etiological pic- mer camp, children using health-care services, or tures, depending on whether the physically abused children taken into the child protective services children are victims of other forms of maltreatment (CPS) system, estimated rates of multitype maltreat- or not. Physically abused children who are also neg- ment range from 34% to 95% (Manly, Kim, Rogosch, lected (PA+Neg) (Bath & Haapala, 1993; DiLauro, & Cicchetti, 2001; McGee, Wolfe, Yuen, Wilson, & 2001) or exposed to spousal violence (PA+SV) Carnochan, 1995; Ney et al., 1994; Van Hasselt, (Hartley, 2002) seem to have more negative sociode- Ammerman, Glancy, & Bukstein, 1992). mographic characteristics (single-parent, low-income If co-occurrence of different forms of maltreat- family) and live in a more difficult family climate ment is that frequent, it seems likely that some pro- (higher parental stress, more episodes of spousal portion of the studies of physical abuse would be violence) than those who are only physically abused. based on samples of children who were solely victims of Similarly, such children and their parental figures physical abuse (PA) as well as children who were victims of seem to have more physical and mental health prob- physical abuse plus other forms of maltreatment (PA+). lems. These results corroborate those reported by That, at least, is the hypothesis we have formulated on Daro (1988) and Higgins and McCabe (2000) (who the basis of a review of studies of physical abuse distinguished between forms of abuse that occurred reported to North American CPS agencies that have alone and cases of co-occurrence but without speci- clearly distinguished cases of physical abuse alone fying the different forms of maltreatment): multi- from cases of multitype maltreatment (Larrivée, 2005). type maltreatment seems to be associated with According to the eight studies reviewed, co-occurrence families that have more problems. is found in an average of 57% of cases of physical The data obtained by Bath and Haapala (1993), abuse (minimum 24% and maximum 85%). DiLauro (2001), and Hartley (2002) suggest that the Any attempt to determine the extent of co-occurrence exhaustive list of characteristics associated with cases in cases of physical abuse runs up against the of physical abuse, as seen in the contemporary liter- methodological problem of a mixed sample (Jonson- ature, should be split into two lists, one for cases of Reid, Drake, Chung, & Way, 2003; Mash & Wolfe, physical abuse that occurs with other forms of 1991), which arises when a child experiences more maltreatment (PA+) and another for cases without than one form of maltreatment but only one form is co-occurrence (PA). The small number of studies on identified (Jonson-Reid et al., 2003). This is the case, which this observation is based, and especially the for instance, in some studies based on administrative small samples from which this differential picture data generated by CPS. The architecture of comput- emerges (60 to 292 children) and the use of only erized information systems often reduces the classifi- bivariate analysis, means that caution should be used cation of maltreatment to one main form, although in interpreting the differences noted between the there may well be several forms of abuse involved two groups of physically abused children. Our scien- (Barnett et al., 1991). tific knowledge of this area is still embryonic. As a The large number of unidentified mixed samples result, it is currently hard to provide CPS agencies casts serious doubt on the validity of our etiological with information adapted to the profile of physically knowledge, which very likely does not reflect the abused children, that is, which takes into account specificity of physical abuse that occurs alone. There whether they are solely physically abused or the vic- may well be evidence of risk factors (or correlates) tims of more than one form of maltreatment. In associated with samples that are either specific or short, Belsky’s (1993) statement that “one focus for mixed, but we cannot tell which are which. From a future research would be to more clearly specify the statistical standpoint, if the etiology of the cases of nature and degree of comorbidity and the conditions physical abuse that occur alone is different from that that give rise to it” (p. 413) still seems to apply. CHILD MALTREATMENT / NOVEMBER 2007 Downloaded from by radu anca on November 28, 2009
  4. 4. Larrivée et al. / PHYSICAL ABUSE AND CO-OCCURRENCE 305 OBJECTIVE form,1 for which they had received 3 hours of train- The main objective of this study is to contribute to ing to introduce them to the study and review the more specific knowledge about cases of physical form and data collection procedures. A training abuse reported to CPS by taking into account co- video was available in each CPS unit. To help them occurrence. We aim to identify the characteristics complete the survey form, caseworkers could also that distinguish the cases of children who are solely refer to a guidebook explaining each question and physically abused (PA) from those of physically consult a regional research assistant. It took an aver- abused children who are also the victims of other age of 20 minutes to complete the form. The mean forms of maltreatment (PA+) (neglect, sexual abuse, completion rate for investigated reports was 86%. abandonment, psychological abuse, or other). Instrument The survey form, designed for the purposes of the METHOD QIS, was largely based on those of similar surveys, such as the Ontario Incidence Study (Trocmé, Sample McPhee, & Tam, 1995), the Canadian Incidence The data are taken from the Quebec Incidence Study (Trocmé, Tourigny, MacLaurin, & Fallon, Study of Reported Child Abuse, Neglect, Abandonment 2003), and the American National Incidence Study and Serious Behavioural Problems (QIS) (Tourigny (Sedlak & Broadhurst, 1996). The Child Well-Being et al., 2002), which prospectively documented Scale (Vézina & Bradet, 1990) was another major 9,790 reports received between October 1 and source of inspiration. December 31, 1998, by 16 of the 19 CPS centers in The form consisted of 52 questions about the Quebec. report, the child, his or her living environment, During the survey period, CPS investigated 4,929 parental figures, abuse, and decisions made after reports. The sample used in the study consists of all investigation. the substantiated cases of physical abuse (N = 514) The form gave uniform clinical definitions of six brought to the attention of CPS during the survey forms of abuse (physical abuse, sexual abuse, neg- period. Of this number, 269 (52%) were solely phys- lect, abandonment, psychological abuse, other) that ically abused, while there was co-occurrence of phys- go beyond the legal definitions in force in Quebec. ical abuse and other forms of maltreatment in 245 Physical abuse was described in terms of six clinical (48%) cases. categories: (a) abusive corporal punishment, the use of In the few cases where there was more than one physical force to correct the child; (b) excessive phys- report concerning the same child during the survey ical deprivation, depriving the child of food or water; period, we chose the earliest report. The unit of (c) excessive physical restrictions, locking the child in; analysis is therefore the child and not the report. (d) irrational, impulsive brutality, assaulting the child This choice is in line with Quebec’s official strategy in a disorganized emotional state unrelated to the for receiving and handling reports. child’s behavior; (e) shaken baby syndrome; and (f) any other type of physical abuse. Procedure To ensure that cases involving multiple forms of When a report is investigated, a caseworker looks maltreatment were tracked, the survey form had into the allegations and determines whether they are room to detail up to three types of maltreatment, substantiated. The caseworker also has a legal and for each of them, the caseworker could make a responsibility to investigate not just the primary com- clinical judgment of whether the allegation was sub- plaint but also whether the child has suffered other stantiated or not. This study examines substantiated forms of maltreatment. The caseworker then ana- cases of physical abuse, that is, cases for which there lyzes the situation in terms of the consequences to was sufficient evidence that the physical abuse had the child and of the parents’ capacities and living actually taken place. conditions, and makes a decision as to whether the Dependent Variable child’s safety or development is compromised (Ministère de la Santé et des Services sociaux, 1998). Among the 514 children whose cases involved at least The Child Well-Being Scale (Vézina & Bradet, 1990), one form of substantiated physical abuse, co-occurrence a validated tool designed for the systematic assess- was defined as the presence of one or two other forms of ment of these aspects, supports the caseworker in his substantiated maltreatment (n = 245) (sexual abuse, investigation. For the QIS, at the very end of each neglect, abandonment, psychological abuse, other) (see investigation, caseworkers (n = 814) filled out a survey Table 1). Table 2 shows the breakdown of categories CHILD MALTREATMENT / NOVEMBER 2007 Downloaded from by radu anca on November 28, 2009
  5. 5. 306 Larrivée et al. / PHYSICAL ABUSE AND CO-OCCURRENCE TABLE 1: Proportional Co-occurrence of Child Physical Abuse variables: CPS intervention, number of problems (PA+) with Other Forms of Maltreatment (n = 245) experienced by reported child, mean number of Form of Maltreatment n % problems experienced by parental figures living with child, cooperation of parental figures during CPS Physical abuse + psychological abuse 79 46.7 investigation, and duration of maltreatment. Physical abuse + neglect 78 46.1 Physical abuse + abandonment 5 3.0 All variables have acceptable metric qualities in Physical abuse + sexual abuse 4 2.4 terms of variance and missing data (less than 10%). Physical abuse + other form of maltreatment 3 1.8 The 32 selected variables were grouped into four Co-occurrence = 1 169 100.0 broad categories: (a) characteristics of the reported Physical abuse + neglect + psychological abuse 61 80.3 child, (b) characteristics of the family, (c) character- Physical abuse + abandonment + psychological abuse 8 10.5 istics of the parental figures living with the child, and Physical abuse + sexual abuse + psychological abuse 4 5.3 (d) characteristics of the physical abuse (see Table 3). Physical abuse + neglect + sexual abuse 2 2.6 Physical abuse + neglect + abandonment 1 1.3 Co-occurrence = 2 76 100.0 Analytical Strategies Chi-square tests and t tests were first performed to compare the children who were solely physically TABLE 2: Categories of Physical Abuse with (PA+) or without (PA) Co-Occurrence abused with those who were also victims of other forms of maltreatment, based on the 32 variables. PA PA+ Total The comparisons revealed 23 significant differences (n = 269) (n = 245) (N = 514) (p < .10) between the two groups of children. We Categories of physical abuse n % n % n % then performed a direct logistic regression analysis to control for colinearity between the 23 variables. Abusive corporal punishment 185 69.0 147 60.0 332 65.0 An examination of multiple correlations revealed Excessive physical deprivation 1 0.4 8 3.0 9 2.0 Excessive physical restrictions 5 2.0 7 3.0 12 2.0 that the tolerance for two variables was problematic Irrational, impulsive brutality 72 27.0 80 33.0 152 30.0 (less than 0.20). As a result, those two variables (num- Shaken baby syndrome 5 2.0 3 1.0 8 1.0 ber of problems experienced by the reported child and mean Other type of physical abuse 1 0.4 0 0.0 1 0.2 number of problems experienced by parental figures living with the child) were eliminated to avoid a problem of multicolinearity. We therefore used 21 variables in of physical abuse according to whether there was a the regression analysis to assess the unique contribu- co-occurrence of another form of maltreatment. tion of each variable to the explanation of the pres- ence or not of co-occurrence in cases of physical Independent Variables abuse. The asterisks in Table 3 identify the 21 vari- We selected 32 variables to determine the differ- ables examined. ential etiological patterns of cases of physical abuse Direct logistic regression analysis was performed occurring alone or with other forms of maltreat- solely on cases not missing any data on any of the 21 ment. These variables were chosen for the frequency variables selected. This condition brought the number with which they appeared in the literature as risk fac- of children down from 514 to 426, an attrition rate of tors associated with physical abuse and other forms 17% of the original sample. A check was done to deter- of maltreatment (Black, Heyman, & Smith Slep, mine whether the cases of children excluded from the 2001, 2001a; Schumacher, Smith Slep, & Heyman, regression analysis (n = 88) were significantly differ- 2001). Furthermore, given the small number of stud- ent from those included (n = 426), on the basis of all ies surveyed (Bath & Haapala, 1993; DiLauro, 2001; 32 selected variables. The series of chi-square tests and Hartley, 2002), we were careful to select variables t tests (with Bonferroni correction: p = .05/32 = .002) that made it easier to draw comparisons with those indicates that only 2 of the 32 variables significantly used in these three studies as well as with other large- distinguished the two groups of children. Fewer of the scale incidence studies (Sedlak & Broadhurst, 1996; excluded children (26%) than the included children Trocmé, McPhee, & Tam, 1995; Trocmé et al., 2003). (54%) had been abused by their fathers [χ2 (1, N = However, considering what is known about the cooc- 514) = 21.3, p < .002], whereas more of the currence of cases of physical abuse, some variables excluded children (19%) than the included children that do not appear in the survey of the literature (7%) were abused by a relative or person outside the were also selected. This was true of the following family [χ2 (1, N = 514) = 12.3, p < .002]. CHILD MALTREATMENT / NOVEMBER 2007 Downloaded from by radu anca on November 28, 2009
  6. 6. Larrivée et al. / PHYSICAL ABUSE AND CO-OCCURRENCE 307 TABLE 3: Name and Description of 32 Selected Variables Name Description Categories or Interval Characteristics of reported child Gendera male / female Age 0-17 years Previous report Child has been subject of investigated report in year before current dichotomy report CPS intervention Child has been subject of CPS intervention in 5 years before current dichotomy report Developmental disabilitiesa Developmental delay or impaired hearing, vision or speech dichotomy Learning difficultiesa Learning disorder or attention deficit and disruptive behavior dichotomy Mental health problemsa Psychiatric disorder or depression and/or anxiety dichotomy Behavioral problemsa Violence toward others, running away, irregular school attendance, etc. dichotomy Number of problems 4 problems above plus any others (e.g., substance abuse-related birth 0 to 5 defects or chronic health condition) Characteristics of family Number of childrena Number of children in household (including reported child) 0 to 10 Family structure Two-parent family (e.g., original or adoptive family, blended family) two parents / single parent or single-parent family (one parental figure) Characteristics of parental figures living with child At least one parental figure is Mother’s partner or father’s partner is living with child dichotomy step-parent At least one parental figure is in Person receives welfare benefits or employment insurance or dichotomy a difficult financial situationa has no income At least one parental figure is Born outside Canada dichotomy immigranta At least one parental figure During investigation, person actively resists any contact with agencies dichotomy does not cooperate fullya or is only slightly involved in planning care and services At least one parental figure is Person is or has been physically, sexually or verbally abused dichotomy victim of spousal abusea At least one parental figure has Person abuses or has abused alcohol or illegal drugs dichotomy alcohol or drug problema At least one parental figure has Person appears to have or to have had mental health problems dichotomy mental health problemsa At least one parental figure is Person is going through difficult separation or divorce dichotomy going through difficult separation or divorcea At least one parental figure has Inadequate social or family support (social isolation or lack of social dichotomy social problemsa support in crisis) At least one parental figure has Person is or has been in delicate health (chronic disease, frequent dichotomy physical health problem hospitalizations, etc.) At least one parental figure has Person has or has had frequent or ongoing financial crises dichotomy financial problems a At least one parental figure is Person engages in criminal activity (rape, prostitution, drug dealing, etc.) dichotomy involved in criminal activitya Mean number of problems 8 problems above plus cognitive impairment and any other type of 0 to 10 problem (irregular lifestyle, gambling problems, etc.) Characteristics of physical abuse Context of physical abusea Physical abuse is abusive corporal punishment or any other category of disciplinary other physical abuse (excessive physical deprivation or restrictions; irra- tional, impulsive brutality; shaken baby syndrome; other type of physical abuse) Single incidenta Physical abuse is chronic (going on for at least six months) or is one- dichotomy time incident Number of other children Number of other children in same household reported at same time 0 to 6 reported or during investigation Alleged perpetrator: mother Biological or adoptive mother dichotomy Alleged perpetrator: father Biological or adoptive father dichotomy Alleged perpetrtor: stepparent a Mother's or father's partner dichotomy Alleged perpetrator: other Relative or nonfamily dichotomy Number of alleged perpetratorsa Number of alleged perpetrators from list above 1 to 4 a. The 21 variables examined in the regression analysis. NOTE: Dichotomy (yes/no). CPS = child protective services. CHILD MALTREATMENT / NOVEMBER 2007 Downloaded from by radu anca on November 28, 2009
  7. 7. 308 Larrivée et al. / PHYSICAL ABUSE AND CO-OCCURRENCE RESULTS The large proportion of cases of co-occurrent Table 4 shows the results of chi-square tests and physical abuse strongly supports the hypothesis con- t tests comparing physically abused children with cerning mixed samples that might not have been (PA+) and without (PA) co-occurrence. Like the identified in most etiological studies on physical adults taking care of them, the PA+ children seemed abuse. Mixed samples cast serious doubt on the to have more social and health problems and their validity and specificity of etiological knowledge of families were more likely to be financially insecure. physical abuse that occurs alone. In fact, our find- These children also suffered worse physical abuse— ings, most of which corroborate those of the three the situation was more likely to be chronic—and studies reviewed (Bath & Haapala, 1993; DiLauro, there were more siblings who could potentially have 2001; Hartley, 2002), indicate that children who are been maltreated in the same way. solely physically abused (PA) are different from the Table 5 shows the results of the direct logistic others (PA+). Based on the results of bivariate analy- regression analysis of the 21 variables selected. ses, we suggest that the profile of cases of physical Overall, the logistic regression model [χ2 (21, N = abuse alone (PA) is evidence of what we refer to as a 426) = 109.2, p < .01] significantly distinguishes dysnormal environment, whereas the profile of cases the children who were solely physically abused (PA) of physical abuse co-occurring with one or two other from those who suffered physical abuse plus one or forms of maltreatment (PA+) is evidence of a dys- two other forms of maltreatment (PA+). The model functional environment. correctly categorizes 69% of the 210 PA children and Among children solely physically abused (PA), the 69% of the 216 PA+ children. The results of the abuse seemed more often to occur in a context of regression show no problem with convergence and abusive corporal punishment. The children of this the standard errors for parameters are not exceed- group, most of them boys, displayed more behavioral ingly large. Therefore, no multicolinearity is evident. problems. Although we do not claim to have estab- Of the 21 characteristics selected, 8 favor belong- lished a causal relationship, it is possible that in some ing to the (PA+) group of children. Boys were thus half cases, physical abuse may be precipitated by the as likely as girls to be both physically abused and the child’s disruptive behavior (Herrenkohl et al., 1983; victim of one or two other forms of maltreatment. Trickett & Kuczynski, 1986). The child’s more erratic Children with behavioral difficulties were also half as behavior might overload the parents, who might likely as those without to be in the PA+ group. Having adopt an authoritarian parenting style and harsher an immigrant parent (rather than a parent born in disciplinary measures (Urquiza & McNeil, 1996). Canada) reduced a child’s probability of being in the It is also possible that in other cases, abusive cor- PA+ group by more than half. Conversely, if at least poral punishment may be associated with child-rear- one parental figure failed to cooperate with the CPS ing standards and disciplinary strategies not shared (versus parental figure who cooperate with the CPS) by the majority of parents and citizens born and or had economic problems (versus no economic raised in Canada. It has been observed that there are problem) or little social support (versus adequate a greater number of immigrant parents who engage social support), the child was twice as likely to be a vic- in abusive corporal punishment in the PA group tim of PA+. Last, when the physical abuse occurred in (82%) than in the PA+ group (52%) [χ2 (1, n = a disciplinary context (rather than in another context, 120) = 11.84, p < .01]. The cultural component e.g., irrational, impulsive brutality, shaken baby syn- associated with the use of excessive physical force to drome, etc.), the probability of co-occurrence was discipline or correct children has been documented reduced by a third. When the physical abuse was a sin- in some studies (Clément & Côté, 2004; Tourigny & gle incident (rather than a chronic situation), the Bouchard, 1990). probability was reduced by half. In the group of children who were solely physi- cally abused, the physical abuse was more frequently a one-time occurrence rather than recurrent. The DISCUSSION larger proportion of single incidents may be associ- Co-occurrence is a very real problem in the lives ated with the presence in this group of a greater of physically abused children reported to Quebec number of abusers who were related to the child or CPS agencies: close to half of them suffered other third parties in positions of authority. In these cases, forms of maltreatment. The estimate of frequency the physical abuse would not be likely to recur, as the determined in our study (48%) is therefore close to parents would take steps to protect their child from the mean estimate (57%) calculated on the basis of these people. In other cases, abuse that occurs only the eight American studies reviewed (Larrivée, 2005). once may be more likely related to a temporary loss CHILD MALTREATMENT / NOVEMBER 2007 Downloaded from by radu anca on November 28, 2009
  8. 8. Larrivée et al. / PHYSICAL ABUSE AND CO-OCCURRENCE 309 TABLE 4: Statistical Associations between 21 Variables and Presence (PA+) or Absence (PA) of Co-Occurrence in Cases of Physical Abuse (N = 514) PA (n = 269) PA+ (n = 245) Characteristics of Reported Child n % N % χ2 p Previous report (yes) 48 18 48 20 0.4 0.533 CPS intervention (yes) 30 11 37 16 1.8 0.175 Gender (male) 154 58 118 49 3.7 0.055* Developmental disabilities (yes) 17 7 32 13 6.4 0.012* Learning difficulties (yes) 54 21 78 33 8.5 0.003* Mental health problems (yes) 18 7 41 17 12.2 0.000* Behavioral problems (yes) 57 21 36 15 3.7 0.056* M SD M SD t p Age (years) 9 4.6 8 4.5 1.4 0.159 Number of problems 0.6 0.9 0.9 1.0 -3.0 0.002* Characteristics of family Number of children 2.2 1.1 2.5 1.2 –3.1 0.002* n % n % χ2 p Family structure (single parent) 78 29 64 26 0.6 0.436 Characteristics of parental figures living with child At least one parental figure . . . is a stepparent (yes) 75 28 80 33 1.2 0.272 is in a difficult financial situation (yes) 131 53 165 69 12.9 0.000* is an immigrant (yes) 78 30 42 17 11.5 0.001* Does not cooperate fully (yes) 79 30 126 52 24.7 0.000* is a victim of spousal abuse (yes) 75 28 110 45 15.7 0.000* has an alcohol or drug problem (yes) 51 19 91 37 20.8 0.000* has mental health problems (yes) 48 18 78 32 13.3 0.000* is going through a difficult separation or divorce (yes) 69 26 82 34 3.6 0.058* has social problems (yes) 31 12 87 36 41.2 0.000* has a physical health problem (yes) 30 11 25 10 0.1 0.707 has financial problems (yes) 60 23 129 53 50.1 0.000* is involved in criminal activity (yes) 20 8 38 16 8.2 0.004* Mean number of problems 1.1 1.2 2.1 1.4 -7.7 0.000* Characteristics of physical abuse Number of other children reported 0.8 1.1 1.2 1.2 –3.7 0.000* Number of alleged perpetrators 1.2 0.5 1.3 0.5 –1.4 0.160 n % n % χ2 p Alleged perpetrators: Mother (yes) 118 45 120 49 1.0 0.314 Father (yes) 131 49 120 49 0.0 0.918 Stepparent (yes) 40 15 52 21 3.2 0.072* Other perpetrator (yes) 31 12 15 6 4.8 0.028* Context of physical abuse (disciplinary) 185 69 147 60 4.3 0.038* Single incident (yes) 76 32 37 16 15.6 0.000* *p < .10. NOTE: Missing data percentage ranges from 0% to 10%. of control on the part of the abuser (very often a par- between corporal punishment and physical abuse ent). Such parents may see corporal punishment as (Gershoff, 2002). A Quebec-wide telephone survey a necessary means of correcting their child’s behavior, indicates that the prevalence of serious physical vio- and their discipline crossed the line into abuse. A lence is six times higher in families in which the meta-analysis has highlighted the close relationship mothers questioned also reported minor physical CHILD MALTREATMENT / NOVEMBER 2007 Downloaded from by radu anca on November 28, 2009
  9. 9. 310 Larrivée et al. / PHYSICAL ABUSE AND CO-OCCURRENCE TABLE 5: Results of Direct Logistic Regression Analysis of 21 Variables Predicting Cases of Children Suffering Physical Abuse Plus One or Two Other Forms of Maltreatment (PA+) Variable β SD Wald Odds Ratio Characteristics of reported child Gender (male) –0.74 0.24 9.61** 0.47 Developmental disabilities (yes) 0.32 0.41 0.60 1.37 Learning difficulties (yes) 0.54 0.29 3.54 1.72 Mental health problems (yes) 0.48 0.39 1.52 1.61 Behavioral problems (yes) –0.63 0.31 4.02* 0.53 Characteristics of family Number of children 0.08 0.16 0.25 1.08 Characteristics of parental figures living with child At least one parental figure . . . is in a difficult financial situation (yes) 0.27 0.25 1.16 1.31 is an immigrant (yes) –0.73 0.30 5.76* 0.48 does not cooperate fully (yes) 0.66 0.25 7.07** 1.93 is a victim of spousal abuse (yes) 0.01 0.26 0.00 0.99 has an alcohol or drug problems (yes) 0.24 0.29 0.70 1.28 has mental health problems (yes) 0.03 0.28 0.01 0.97 is going through a difficult separation or divorce (yes) 0.03 0.27 0.01 0.97 has social problems (yes) 0.74 0.31 5.70* 2.09 has financial problems (yes) 0.73 0.26 7.99** 2.08 is involved in criminal activity (yes) 0.13 0.42 0.09 1.14 Characteristics of physical abuse Number of other children reported 0.11 0.16 0.49 1.12 Alleged perpetrators: Stepparent (yes) 0.17 0.30 0.32 1.18 Other perpetrator (yes) –0.03 0.48 0.00 0.97 Context of physical abuse (disciplinary) –0.50 0.24 4.45* 0.60 Single incident (yes) –0.68 0.28 6.00* 0.51 (Constant) –1.75 0.55 10.07** *p < .05. **p < .01. violence than in families in which the mother did group, physical abuse may be the expression of not report minor incidents (12% vs. 2%) (Clément, instrumental assault (Mammen, Kolko, & Pilkonis, Bouchard, Jetté, & Laferrière, 2000). Last, the larger 2002). We would then be dealing with situations of proportion of one-time incidents of physical abuse what we call dysnormality, in which abuse would be may perhaps indicate that the process of maltreat- more attributable to parents whose child-rearing ment is just beginning in the PA group, whereas it standards or repertoire of disciplinary strategies put may be more advanced in the PA+ group, in which the child at risk and cross the line into what prevail- other forms of maltreatment in addition to physical ing social standards consider to be abuse. abuse are more often accompanied by recurrent Dysfunctionality seems to be more applicable to the physical abuse. surroundings of children who are victims of both physical These various observations suggest that the etiol- abuse and other forms of maltreatment (PA+). In this ogy of physical abuse that occurs alone more often group, the children more often seem to suffer as a goes back to child-rearing practices that diverge result of irrational, impulsive brutality (rather than from the prevailing social standards, even though abusive corporal punishment) (see Table 2). the child’s immediate surroundings may not be According to this clinical category of physical abuse, severely pathological, disorganized, or morbid. Keep parents physically abuse their child more often when in mind that the parents of children who are solely they are emotionally disorganized, under the influ- victims of physical abuse have fewer problems of any ence of alcohol, or extremely frustrated. It is possible kind and are more co-operative with CPS. In fact, that in this group, physical abuse is more frequently one of Tourigny and Bouchard’s (1990) conclusions the expression of impulsive, emotional aggression is that at a given socioeconomic level, Haitian immi- (Mammen et al., 2002). grant families reported chiefly for physical abuse are Furthermore, the high rate of psychological abuse more stable and have fewer problems than French- in this group of children (62%) (see Table 1) and Canadian Quebeckers. This suggests that in the PA the recurrence of physical abuse suggest that the CHILD MALTREATMENT / NOVEMBER 2007 Downloaded from by radu anca on November 28, 2009
  10. 10. Larrivée et al. / PHYSICAL ABUSE AND CO-OCCURRENCE 311 incidents of physical abuse take place in a context of here is obviously not the first attempt to account for persistent parental emotional distress. Many more heterogeneity in cases of physical abuse. Other parental figures in this group also have various prob- researchers have tried to illustrate distinct profiles of lems, such as spousal abuse, substance abuse, crimi- families that are physically abusive (Oldershaw, nality, mental health problems, separation or Walter, & Hall, 1989) or that resort to corporal pun- divorce, or a lack of social support. In this group, the ishment (Wissow, 2001). However, in their studies parental figures are also much more likely to be fac- these authors did not take into account the phe- ing overwhelming financial problems. Poverty or low nomenon of multitype maltreatment. income is a major stress factor, which may make it This study, by proposing a framework for analyz- more difficult for those in this group to fulfill their ing the characteristics associated with physical abuse parenting role, all the more so as they have twice as according to whether this form of maltreatment many problems as the parents of physically abused occurs alone (dysnormality) or along with other children without co-occurrence. Parental stress has forms of maltreatment (dysfunctionality), helps been repeatedly associated with physical abuse enrich our scientific knowledge of the etiology of (Whipple & Webster-Stratton, 1991). As to the physical abuse. Of course, this portrait is not children themselves, more of them have develop- intended to be anything more than a basic concep- mental disabilities, learning difficulties, or mental tual point of reference that provides a very rough health problems. The children’s difficulties require map of the contours of the etiology of physical more attention and care from parents who are abuse. We do not claim that it takes into account the already struggling to cope with their own problems. dynamics of all cases of physical abuse studied. It is Add to that the fact that the parents in this group merely a guide, as Crittenden (1996) says: “No also have more children to take care of. Parental family fully fits any one pattern, and some maltreat- stress in this group may be related to chronic rather ing families fit none of them” (p. 169). In fact, our than temporary conditions. The family environ- findings show that cases in which physical abuse ments also seem to be more dysfunctional, although occurs alone (PA) and in which it co-occurs with the parents are more often unwilling to cooperate other forms of maltreatment (PA+) partially share a with CPS. common etiology: It would be surprising if it were The profile of dysnormality versus dysfunctionality is otherwise. For example, it can be seen that in the AP supported when the same data are subjected to group, 27% of children were the victims of irra- direct logistic regression. This type of very conserva- tional, impulsive brutality, whereas in the AP+ tive analysis does not attribute shared variance (col- group, 60% of children suffered abusive corporal inearity) to any variable, which explains why the punishment. model produced is stripped down from 21 to 8 sig- That said, our study had to deal with a number of nificant differences. limitations. Given that our chosen unit of analysis As far as we know, our study is the first to associate was the child, caution must be exercised in general- cases of physical abuse that occurs alone (PA) with izing findings specifically concerning the character- an aspect of dysnormality. With regard to dysfunction- istics of the family and parental figures, because ality associated with physical abuse co-occurring with brothers or sisters living in the same home as the other forms of maltreatment (PA+), our results cor- reported child might have been reported at the roborate those of the three studies reviewed, which same time. It is possible that the interdependence of found that in such cases, the family and environment these observations about family and parental charac- had serious shortcomings (Bath & Haapala, 1993; teristics may have increased the probability of detect- DiLauro, 2001; Hartley, 2002). Our findings also sup- ing significant correlations among these very port the observations of other researchers who have characteristics. We must also take into account the studied co-occurrence without regard to the form of fact that all the data on the survey form were pro- maltreatment (Daro, 1988; Higgins & McCabe, vided by a single informant, a CPS caseworker. That 2000). Research on maltreatment has already shown said, despite potential interpretation biases, psycho- that maltreating families are obviously dysfunctional metric research indicates that the assessments of CPS in many ways (Harter, 1998). Erickson, Egeland, and caseworkers are generally sound (Alter, 1985; McGee Pianta (1989) have also discussed the difficulty in & Wolfe, 1990). Our study does not allow us to deter- separating maltreatment from family dysfunction. mine whether co-occurrent forms of maltreatment Our findings describe this dysfunctionality more actually occur at the same time as physical abuse, specifically: it appears much more clearly in cases of that is, in the same episode, or whether the forms multitype maltreatment. The profile we are proposing occur sequentially, in separate episodes. What we do CHILD MALTREATMENT / NOVEMBER 2007 Downloaded from by radu anca on November 28, 2009
  11. 11. 312 Larrivée et al. / PHYSICAL ABUSE AND CO-OCCURRENCE know is that the different forms were assessed as part and self-reported child abuse and neglect. Child Abuse and Neglect, 22(11), 1065-1078. of the investigation of a single report. Last, despite Clément, M.-È., Bouchard, C., Jetté, M., & Laferrière, S. (2000). the use of the term etiology in this study, it must be La violence familiale dans la vie des enfants du Québec, 1999. kept in mind that the QIS is a cross-sectional study, [Family violence in the life of the children of Quebec, 1999] Quebec City, Canada: Institut de la statistique du Québec. and that cases of physical abuse are compared Clément, M.-È., & Côté, K. (2004). Description et efficacité d’un among themselves and not with a control group. programme d’éducation parentale offert à une communauté ethnique minoritaire de Montréal. [Description and effectiveness of a parent education program offered to a minority ethnic CONCLUSION community of Montreal.] Intervention, 120(1), 54-63. Crittenden, P. M. (1996). Research on maltreating families: From what we have been able to determine from Implications for intervention. In J. Briere, L. Berliner, J. A. Bulkley, C. Jenny, & T. Reid (Eds.), The APSAC handbook on child mal- our review of the literature, very few studies done treatment (pp. 158-174). Thousand Oaks, CA: Sage. with CPS have been methodologically careful about Daro, D. (1988). Confronting child abuse: Research for effective program distinguishing cases of “pure” physical abuse from design. New York: Free Press. DiLauro, M. D. (2001). Psychosocial factors associated with types co-occurrent cases. Our study, which avoids the trap of of child maltreatment. Dissertation Abstracts International Section mixed samples, makes a significant contribution to A: Humanities and Social Sciences. Graduate School of Social work in progress. Our findings indicate that the etiol- Service, Fordham University. Dufour, S., Massicotte, K., & Mayer, M. (2005). Inventaire des fac- ogy of physical abuse as hitherto known did not really teurs de risque, des facteurs de protection et des facteurs associés aux take into account the specificity of physical abuse when mauvais traitements intrafamiliaux envers les enfants. [Inventory of it occurs alone. Our research also raises questions risk factors, protection factors, and factors associated with child maltreatment.] Montreal, Canada: GRAVE-Ardec. about the best casework strategies to address the needs Erickson, M. F., Egeland, B., & Pianta, R. (1989). The effects of and problems of physically abused children and their maltreatment on the development of young children. In families, depending on the presence or absence of D. Cicchetti & V. Carlson (Eds.), Child maltreatment: Theory and research on the causes and consequences of child abuse and neglect. other forms of maltreatment. For physically abusive New York: Cambridge University Press. families, support and educational information, respect- Gershoff, E. T. (2002). Corporal punishment by parents and fully stated in terms of their own cultural standards, associated child behaviors and experiences: A meta-analytic and theoretical review. Psychological Bulletin, 128(4), 539-579. would seem to be preferable, particularly for immi- Harter, S. (1998). The effects of child abuse on the self-system. In grant parents. For families where children are also sub- B.B.R. Rossman & M. S. Rosenberg (Eds.), Multiple victimiza- jected to other forms of maltreatment, longer-term tion of children: Conceptual, developmental, and treatment issues (pp. 147-169). New York: Haworth Press. protection and more intense casework would probably Hartley, C. C. (2002). The co-occurrence of child maltreatment be necessary, because chronic conditions seem to be and domestic violence: Examining both neglect and child closely associated with family dysfunctionality. physical abuse. Child Maltreatment, 7(4), 349-358. Herrenkohl, R. C., Herrenkohl, E. C., & Egolf, B. P. (1983). Circumstances surrounding the occurrence of child maltreat- NOTES ment. Journal of Consulting and Clinical Psychology, 51, 424-431. Higgins, D. J., & McCabe, M. P. (2000). Multi-type maltreatment 1. A total of 814 caseworkers completed the survey form for and the long-term adjustment of adults. Child Abuse Review, 9, 6-18. the 4,929 investigated reports. Higgins, D. J., & McCabe, M. P. (2001). Multiple forms of child abuse and neglect: Adult retrospective reports. Aggression and REFERENCES Violent Behavior, 6, 547-578. Jonson-Reid, M., Drake, B., Chung, S., & Way, I. (2003). Cross-type Alter, C. F. (1985). Decision-making factors in cases of child neg- recidivism among child maltreatment victims and perpetra- lect. Child Welfare, 64, 99-111. tors. Child Abuse and Neglect, 27, 899-917. Barnett, D., Manly, J. T., & Cicchetti, D. (1991). Continuing Kinard, E. M. (1994). Methodological issues and practical prob- toward an operational definition of psychological maltreat- lems in conducting research on maltreated children. Child ment. Development and Psychopathology, 3, 19-29. Abuse and Neglect, 18(8), 645-656. Bath, H. I., & Haapala, D. A. (1993). Intensive family preservation Kinard, E. M. (1998). Classifying type of child maltreatment: services with abused and neglected children: An examination of Does the source of information make a difference? Journal of group differences. Child Abuse and Neglect, 17, 213-225. Family Violence, 13(1), 105-112. Belsky, J. (1993). Etiology of child maltreatment: A developmen- Larrivée, M.-C. (2005). L’abus physique et sa cooccurrence avec d’autres tal-ecological analysis. Psychological Bulletin, 14(3), 413-434. formes de mauvais traitements. Ampleur du phénomène et contribution Black, D. A., Heyman, R. E., & Smith Slep, A. M. (2001). Risk à une étiologie différentielle. [Child physical abuse and its co- factors for child physical abuse. Aggression and Violent Behavior, occurrence with other forms of child maltreatment. Scope of 6, 121-188. the phenomenon and contribution to a differential etiology.] Black, D. A., Heyman, R. E., & Smith Slep, A. M. (2001a). Risk Unpublished doctoral dissertation, Université du Québec à factors for child sexual abuse. Aggression and Violent Behavior, 6, Montréal, Montreal, Quebec, Canada. 203-229. Mammen, O. K., Kolko, D. J., & Pilkonis, P. A. (2002). Negative Briere, J., & Runtz, M. (1990). Differential adult symptomatology affect and parental aggression in child physical abuse. Child associated with three types of child abuse histories. Child Abuse Abuse and Neglect, 26, 407-424. and Neglect, 14(3), 357-364. Manly, J. T., Kim, J. E., Rogosch, F. A., & Cicchetti, D. (2001). Brown, J., Cohen, P., Johnson, J. G., & Salzinger, S. (1998). A lon- Dimensions of child maltreatment and children’s adjustment: gitudinal analysis of risk factors for child maltreatment: Contributions of developmental timing and subtype. Findings of a 17-year prospective study of officially recorded Development and Psychopathology, 13, 759-782. CHILD MALTREATMENT / NOVEMBER 2007 Downloaded from by radu anca on November 28, 2009
  12. 12. Larrivée et al. / PHYSICAL ABUSE AND CO-OCCURRENCE 313 Mash, E. J., & Wolfe, D. A. (1991). Methodological issues in Trickett, P. K., & Kuczynski, L. (1986). Children’s misbehaviors research on physical child abuse. Criminal Justice and Behavior, and parental discipline strategies in abusive and nonabusive 18(1), 8-29. families. Developmental Psychology, 22, 115-123. Mayer, M. (1997). Les contextes écologiques d’incidence de mauvais Trickett, P. K., & McBride-Chang, C. (1995). The developmental traitements à l’égard des enfants dans la région de Montréal. impact of different forms of child abuse and neglect. [Ecological contexts of child maltreatment incidence in Developmental Review, 15, 311-337. Montreal.] Unpublished doctoral dissertation, Université de Trocmé, N., McPhee, D., & Tam, K. K. (1995). Child abuse and Montréal, Montreal, Quebec, Canada. neglect in Ontario: Incidence and characteristics. Child Welfare, McGee, R. A., & Wolfe, D. A. (1990). Development of a record of mal- 74, 563-586. treatment experiences. Toronto: Institute for the Prevention of Trocmé, N., Tourigny, M., MacLaurin, B., & Fallon, B. (2003). Child Abuse. Major findings from the Canadian incidence study of reported McGee, R. A., Wolfe, D. A., Yuen, S. A., Wilson, S. K., & Carnochan, child abuse and neglect. Child Abuse and Neglect, 27, 1427-1439. J. (1995). The measurement of maltreatment: A comparison of Urquiza, A. J., & McNeil, C. B. (1996). Parent-child interaction approaches. Child Abuse and Neglect, 19(2), 233-249. therapy: An intensive dyadic intervention for physically abu- Ministère de la santé et des services sociaux. (1998). Manuel de sive families. Child Maltreatment, 1(2), 134-144. référence sur la protection de la jeunesse. [Handbook on youth pro- Van Hasselt, V. B., Ammerman, R. T., Glancy, L. J., & Bukstein, tection.] Quebec City, Canada: Gouvernement du Québec. O. G. (1992). Maltreatment in psychiatrically hospitalized National Research Council. (1993). Understanding child abuse and dually diagnosed adolescent substance abusers. Journal of the neglect. Washington, DC: National Academy Press. American Academy of Child Adolescence, 31(5), 868-874. Ney, P. G., Fung, T., & Wickett, A. R. (1994). The worst combi- Vézina, A., & Bradet, R. (1990). Inventaire concernant le bien-être de nations of child abuse and neglect. Child Abuse and Neglect, l’enfant en relation avec l’exercice des responsabilités parentales. 18(9), 705-714. [Child well being scale.] Quebec City, Canada: Université Oldershaw, L., Walters, G. C., & Hall, D. K. (1989). A behavioral Laval, Centre de recherche sur les services communautaires. approach to the classification of different types of physically Whipple, E. E., & Webster-Stratton, C. (1991). The role of abusive mothers. Merrill-Palmer Quarterly, 35(3), 255-279. parental stress in physically abusive families. Child Abuse and Rossman, B.B.R., Hughes, H. M., & Hanson, K. L. (1998). The Neglect, 15, 279-291. victimization of school-age children. In B.B.R. Rossman & Wissow, L. S. (2001). Ethnicity, income and parenting contexts of M. S. Rosenberg (Eds.), Multiple victimization of children: physical punishment in a national sample of families with Conceptual, developmental, and treatment issues (pp. 87-106). New young children. Child Maltreatment, 6(2), 118-129. York: Haworth Press. Silverman, A. B., Reinherz, H. Z., & Giaconia, R. M. (1996). Marie-Claude Larrivée, PhD (University of Quebec in The long-term sequelae of child and adolescent abuse: A Montreal , 2005), is a community psychologist. She is a consult- longitudinal community study. Child Abuse and Neglect, 20, 709-723. ant in prevention with the Inuit communities in Nunavik (north- Sedlak, A., & Broadhurst, D. D. (1996). Third national incidence ern Quebec) to improve the development of children attending study of child abuse and neglect [Executive summary]. childcare centers. She is teaching psychosocial prevention at Laval Washington, DC: Department of Health and Human Services. University and is pursuing research on child maltreatment. Schumacher, J. A., Smith Slep, A. M., & Heyman, R. E. (2001). Risk factors for child neglect. Aggression and Violent Behavior, 6, Dr. Camil Bouchard (McGill University, 1974) has devoted 231-254. most of his academic career in researching the ecology of family life Tourigny, M., & Bouchard, C. (1990). Étude comparative des and of child maltreatment. He has been involved in consulting the mauvais traitements envers les enfants de familles francophones Quebec government on many social policy issues. In this respect, de souche québécoise et de familles d’origine haïtienne: Nature he has inspired the development of a large nonprofit, low-fee child et circonstances. [Comparative study of child maltreatment care network. Since 2003, he occupies a siege as an elected member between Quebecers and Haitian families : Nature and circumstances.] Prisme, 1(2), 56-68. of the National Assembly of Quebec. Tourigny, M., Mayer, M., Wright, J., Lavergne, C., Trocmé, N., Hélie, S., Bouchard, C., Chamberland, C., Cloutier, R., Jacob, M., Marc Tourigny, PhD, is a professor of psychoeducation in the Boucher, J., & Larrivée, M.-C. (2003). Quebec incidence study of Department of Specialized Education at the University of reported child abuse, neglect, abandonment and serious behavioural Sherbrooke (Canada). He has worked extensively on child welfare problems. Montreal, Canada: Centre de liaison sur l’intervention practices and on treatment outcome studies of sexually abused et la prévention psychosociales. children and of adolescent sexual offenders. CHILD MALTREATMENT / NOVEMBER 2007 Downloaded from by radu anca on November 28, 2009