Child Maltreatment in DSM‐5 and ICD‐11

• Author: Heather M. Foran,Richard E. Heyman,Amy M. Smith Slep
• Date: 01 March 2015
• Published date: 01 March 2015
• DOI: http://doi.org/10.1111/famp.12131

Child Maltreatment in DSM-5 and ICD-11

AMY M. SMITH SLEP*

RICHARD E. HEYMAN

*

HEATHER M. FORAN

†

Child maltreatment is widespread and has a tremendous impact on child victims an d

their families. Over the past decade, definitions of child maltreatment have been developed

that are operationalized, face valid, and can be reliably applied in clinical settings. These

definitions have informed the revised Diagnostic and Statistical Manual (American

Psychiatric Association, 2013) and are being considered for the International Classifica-

tion of Disease–11 (World Health Organization). Now that these definitions are available

in major diagnostic systems, primary healthcare providers and clinicians who see children

and families are poised to help screen for, identify, prevent, and treat child maltreatment.

This article reviews the definitions of maltreatment in these diagnostic systems, along with

assessment and screening tools, and empirically supported prevention and intervention

approaches.

Keywords: Child Maltreatment; Child Abuse; Diagnosis; Assessment; Intervention

Fam Proc 54:17–32, 2015

Child maltreatment occurs around the globe, with far-reaching implications for chil-

dren and their families’ physical and psychological well-being. For many people, the

thought of abusing one’s child is so horrific that they tend to think of maltreatment as rare

and only occurring in families very unlike their own. This distancing may contri bute to a

general reluctance to consider that abuse and neglect might be occurring. Even profession-

als tend not to routinely assess for maltreatment, but many are confident they would

“know it when they see it.” That rates of suspected maltreatment reported through man-

dated reporters and highly trained sentinels are so much lower than rates obtained

through anonymous surveys of parents (Sedlak et al., 2010; Slep, Heyman, & Snarr, 2011;

Straus, Hamby, Finkelhor, Moore, & Runyan, 1998) would suggest this is not the case.

There is a pressing need for professionals working with children to become more sensi-

tized to the possibility of abuse and neglect, familiarize themselves with thresholds defin-

ing maltreatment, screen for maltreatment, and know what services to refer families to

when maltreatment or high risk for maltreatment is identified.

In this paper, we will briefly review the epidemiology of child maltreatment and its

impact, present a summary of the definition of child maltreatment in the current revision

of the Diagnostic and Statistical Manual (DSM-5, American Psychiatric Association, 2013)

and the definitions that might be closer to optimal given existing evidence. We will also

describe the screening process for child maltreatment in primary care settings, and review

some empirically supported interventions to which families with maltreatment could be

*Family Translational Research Group, New York University, New York, NY.

†

Psychology, Technical University of Braunschweig, Braunschweig, Germany.

Correspondence concerning this article should be addressed to Amy M. Smith Slep, New York Univer-

sity, 345 E 24th St VA-2S, New York, NY 10010. E-mail: amy.slep@nyu.edu.

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Family Process, Vol. 54, No. 1, 2015 ©2015 Family Process Institute

doi: 10.1111/famp.12131

referred and that family therapists could deliver. The implications of these issues for a

more coordinated international approach to the definition, screening, and treatment of

maltreatment will be considered.

International prevalence estimates of maltreatment (which vary due to operationaliza-

tion differences) suggest the phenomena are far from rare. A review of child physical

abuse (CPA) estimates in high-income countries found 1-year prevalence rates of 4–16%

(Gilbert et al., 2009). In many countries, such as Romania, India, and the Republic of

Korea, rates of CPA occur at alarmingly high rates with one-third to one-half of all chil-

dren experiencing physical abuse (World Health Organization, 2002). A review of 21 stud-

ies, primarily from English-speaking and Northern European countries, found a range of

prevalence rates of 7–36% for female victims of child sexual abuse (CSA) and 3–29% for

male victims of CSA (Finkelhor, 1994). Childhood prevalence of neglect is estimated at

6–12% in U.S. and U.K. samples (Gilbert et al., 2009). There is a high rate of co-occurrence

among the maltreatment types (Gilbert et al., 2009; Higgins & McC abe, 2001). It is esti-

mated that about 35–64% of victims of child maltreatment experience more than one type

of maltreatment (Donga et al., 2004; Edwards, Holden, Felitti, & Anda, 2003; Manly, Kim,

Rogosch, & Cicchetti, 2001). However, the relative rates of maltreatment types vary by

country. In Canada and the United States, neglect is most common (Trocm

e, Tourigny,

MacLaurin, & Fallon, 2003), whereas in Australia, emotional abuse is the most prevalent

(Hatty & Hatty, 2001). Cultural differences in child rearing beliefs and practices and in

universal social services, combined with different definitions of maltreatment, likely influ-

ence variability in prevalence rates.

Child maltreatment is consistently found to be a significant predictor of mental health

disorders during childhood, and this risk continues into adulthood. Victimized children

are more likely to have conduct disorders, attention hyperactivity disorders, depression,

academic problems, and delinquency during childhood and adolescence (Maschi, Morgen,

Hatcher, Rosato, & Violette, 2009; Teisl & Cicchetti, 2008). In adulthood, maltreatment is

associated with substance abuse, depression, PTSD, antisocial personality disorder, and

suicidal behaviors (Banyard, Williams, & Siegel, 2001; Draper et al., 2008; Fergusson,

Boden, & Horwood, 2008; Malinosky-Rummell & Hansen, 1993; Putnam, 2003; Silverman,

Reinherz, & Giaconia, 1996). Child maltreatment victims are at elevated risk for attach-

ment disorders, which can, in turn, contribute to later problems (Felitti & Anda, 2010).

Victimization during childhood places individuals at risk for revictimization as well as

mental health problems during adulthood (Banyard et al., 2001). In addition, there is

strong longitudinal evidence that severe neglect of young children can lead to a wide range

of developmental problems including emotional regulation problems, cognitive difficulties,

and altered neurological development (Beckett et al., 2006; Manly et al., 2001). This is

consistent with the larger literature on the neurobiological correlates of childhood adver-

sity more generally (e.g., Tyrka, Burgers, Philip, Price, & Carpenter, 2013).

In addition, there are a variety of physical health problems that have been associated

with child maltreatment in large-scale surveillance studies and longitudinal studies fol-

lowing children into adulthood. Child victimization is associated with high rates of type II

diabetes, obesity, and cardiovascular disease (Fuller-Thomson, Brennenstuhl, & Frank,

2010; Lissau & Sorensen, 1994; Thomas, Hypponen, & Power, 2008) and is a significant

cause of child homicide and unintentional death throughout the world (World Health

Organization, 2002).

DEFINING CHILD MALTREATMENT

Given the number of families impacted by maltreatment and its far-reaching health

consequences, why is screening not universal in healthcare settings? Several cha llenges

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