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In Septembershe was laid off and has struggled to obtain full unemployment benefits, with her claim still in adjudication and call representatives unable to provide any solutions when she can get through to the call hotline. Several key concepts need to be considered in attempting to understand potential pathways that lead from abuse and neglect to the various consequences discussed in this chapter and the context in which those consequences manifest.

First, positive and negative influences found among individual child characteristics, within the family environment, and in the child's broader social context all interact to predict outcomes related to child abuse and neglect. Second, child abuse and neglect occur in the context of 's brain development, and their potential effects on developing brain structures can help explain the onset of certain negative outcomes. Finally, abused and neglected children often are exposed to multiple stressors in addition to experiences of abuse and neglect, and potential consequences may manifest at different points in 's development.

Therefore, the most rigorous research on this topic attempts to for the many factors that may be confounded with abuse or neglect. Sincetransactional-bioecological or ecological models have guided attempts to conceptualize the relative contributions of risk and protective factors to children's developmental outcomes, particularly in relation to child abuse and neglect Belsky, ; Cicchetti and Lynch, ; Cicchetti and Toth, Versions of this approach consider the development of the child in the context of the broader social environment in which he or she functions, within the context of a family; in turn, children and families are embedded in a larger social system that includes communities, neighborhoods, and cultures.

This model is based on Belsky'secological model and Cicchetti and Rizley's transactional model. It expands on these models by highlighting the nature of interaction among risk factors and the ecology in which child maltreatment occurs. The model is based on the fact that 's multiple ecologies influence one another, affecting the child's development. Thus, the combined influence of the individual, family, community, and larger culture affect the child's developmental outcomes.

Parent, child, and environmental characteristics combine to shape the probabilistic course of the development of abused and neglected children. At higher, more distal levels of the ecology, risk factors increase the likelihood of child maltreatment.

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These environmental systems also influence what takes place at more proximal ecological levels, such as when risk and protective factors determine the presence or absence of maltreatment within the family environment. Overall, concurrent risk factors at the various ecological levels e. The manner in which children handle the challenges associated with maltreatment is seen in their own ontogenic development, which shapes their ultimate adaptation or maladaptation.

Although the overall pattern is that risk factors outweigh protective factors, there are infinite permutations of these risk variables across and within each level of the ecology, providing multiple pathways to the sequelae of child abuse and neglect. Many studies of the consequences of abuse and neglect have been conducted with methodologies ranging from prospective to retrospective des, from observational measures to self-report, and from experimental to case-controlled des to no-control des.

The strongest conclusions could be reached with experimental des whereby children would be randomly ased to different abusive or neglectful experiences; however, this is obviously neither desirable nor possible. Nonhuman studies involving primates and other species have allowed experimental assessment of different rearing conditions that may parallel human conditions of neglect and abuse e. One salient human study involved random asment of children abandoned to institutions to high-quality foster care a randomized controlled trial of foster care as an alternative to institutional care Nelson, Following the baseline assessment, half of the institutionalized children were randomly ased to a high-quality foster care program that the investigators created, financed, and maintained, and half were randomly ased to remain in care as usual institutional care.

These children were followed extensively through age 12 for discussion, see Fox et al. Although at first glance it may not be obvious why the study of children reared in institutions is relevant to a report on child abuse and neglect, institutional care, which affects as many as 8 million children around the world, can involve an extreme and specific form of neglect—broad-spectrum psychosocial deprivation.

Therefore, neglectful institutional care settings can serve as a model system for understanding the effects of neglect on brain development. The neglect experienced by children in such settings should not serve as a proxy for the type of neglect experienced by noninstitutionalized children in the United States, who are more likely to experience neglect in such domains as food, shelter, clothing, or medical care rather than broad-spectrum psychosocial deprivation.

Nevertheless, this study can provide important insight into the effects of neglect on behavioral and neurological development because of its randomized, controlled, and longitudinal nature. The discussion in this chapter necessarily relies primarily although not exclusively on the strongest nonexperimental studies conducted.

These studies involve longitudinal prospective des, which assess child abuse and neglect objectively at the time of occurrence and assess outcomes longitudinally. A good example is the study of Widom and colleagueswhich followed a large cohort of abused and neglected children and a matched comparison sample from childhood into adulthood.

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Other examples include the studies of Johnson and colleagues, Noll and colleaguesand Jonson-Reidz and colleagues Retrospective des that ask participants to recall whether abuse and neglect were experienced are more troublesome because recall of child abuse and neglect can be affected by a variety of factors and open to a of potential biases Briere, ; Offer et al. of studies based on treatment samples of adults who experienced maltreatment as children may be potentially biased because not all victims of child abuse and neglect seek treatment as adults, and because people who do seek treatment may have higher rates of problems than people who do not seek treatment Widom et al.

When participants are asked to report on conditions such as current depression and history of child abuse and neglect, the added problem of shared method variance arises. On the other hand, use of official records raises the problem of underreporting Gilbert et al. This study includes use of multiple data sources and record reviews, as well as interviews with children and youth who have experienced child abuse and neglect, their caretakers, and child welfare workers.

Several of its findings are discussed in Chapter 5. This chapter contains an extensive review of the more recent biologically based studies of child abuse and neglect because of the important advances that have been made in this area. To the extent possible, the discussion relies on findings from studies characterized by the greatest methodological rigor. Despite recent methodological advances, researchers face many challenges in attempting to understand the short- and long-term consequences of the various types of child abuse and neglect e.

One of those challenges is teasing apart the impact of child abuse and neglect from that of other co-occurring factors. For example, children involved with child protective services because of neglect or abuse often face a of overlapping and concurrent risk factors, including poverty, prenatal substance exposure, and parent psychopathology, among others Dubowitz et al.

These concurrent risk factors can make it particularly difficult to draw causal inferences about the specific consequences of abuse and neglect for children's functioning, but need to be disentangled from the specific effects of abuse and neglect Widom et al. Controlling for other relevant variables becomes vital, since failure to take such family variables into may result in reporting spurious relationships Widom et al. Some studies consider and covary other risk factors, and some do not.

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Considering the course of abuse and neglect may also be particularly important, as Jonson-Reid and colleagues found that the of child abuse and neglect reports powerfully predicted adverse outcomes across a range of domains. Finding: Risk factors that co-occur with child abuse and neglect, such as poverty, prenatal substance exposure, and kal,ar psychopathology, can confound attempts to draw causal inferences about the specific consequences of abuse and neglect for children's functioning.

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These factors need to be controlled for in studies seeking to identify the specific consequences of child abuse rrturning neglect. An adequate caregiver is needed to support developing brain architecture and the developing ability to pesonals behavior, emotions, and physiology for young children. When children experience abuse or neglect, such development can be compromised.

The effects of abuse and neglect are seen especially in brain regions that are dependent on environmental input for optimal development, and on aspects of functioning especially susceptible to environmental input. Early in development, infants are completely reliant on input from their caregivers for help in regulating arousal, neuroendocrine functioning, temperature, and other basic functions. With time and with successful experiences in co-regulation, children increasingly take over these functions themselves.

Abuse and neglect represent the absence of adequate input as in the case of neglect or the presence of threatening input as in the case of abuseeither kalma which can compromise development.

The following sections present a review of evidence with respect to key neurobiological systems that are altered as a result of abuse and neglect early in life: the hypothalamic-pituitary-adrenal HPA axis of the stress response system; the amygdala, involved in emotion processing and emotion regulation; the hippocampus, involved in learning and memory; the corpus callosum, involved in integrating functions between hemispheres; and the prefrontal cortex, involved in higher-order cognitive functions.

The discussion begins, however, with a brief overview of brain development. Brain development begins just a few weeks after conception, starting with the construction of the neural tube.

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This is followed by the generation of different classes of brain cells—neurons and glia. Once formed, these immature neurons begin their migratory phase generally away from the ventricular zone, which is their point of origin to build the cerebral adlut. Much of cell migration is completed by the end of the second trimester of pregnancy, eventually leading to the construction of the six-layered cerebral cortex.

After these immature cells have migrated to their target destination, they can differentiate; that is, they develop cell bodies and processes axons and dendrites. Once processes have been formed, synapses begin to form; synapses are the connections between neurons that allow for the transmission of als across the synaptic cleft, which is the small space that exists between two adjacent brain cells, generally between a dendrite and an axon.

The synapse permits one neuron to communicate with another, and eventually, entire circuits are built, followed by neural networks i. Finally, some axons in the brain develop a coating called myelin that speeds the flow of information along the length of the axon. Sensory and motor pathways begin to myelinate during the last trimester of pregnancy, whereas association areas of the brain, particularly the prefrontal cortex, continue to myelinate through the second decade of life.

Neural elements e. Many aspects of brain development particularly those that occur before birth fall under genetic control although some are affected by experience—prenatal exposure to neurotoxins such as alcohol being but one example. After birth, however, much of brain development becomes dependent on experience. For example, although the generation of synapses—which are massively overproduced early in development—is largely under genetic control, the pruning of synapses—which occurs primarily after birth—is largely under experiential control.

Thus the prefrontal cortex of the 1-year-old eten has many more synapses than the adult brain, but over the next one to two decades, these synapses are pruned back to adult s, based largely ppersonals experience Nelson et al. Many aspects of brain development depend on experiences occurring during particular time periods, often the first few years of life.

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These so-called sensitive or critical periods represent vital inflection points in the course of development, such that if teeen experiences fail to occur within some narrow window of time or the wrong experiences occurdevelopment can go awry. Prenatally, an example of a bad experience is exposure to neurotoxins such as alcohol or drugs of reurning. An example of a good experience is access to good nutrition, including the many micronutrients that facilitate brain development e.

Postnatally, the topic of this report represents examples of bad experience i.

Conversely, examples of good experiences include providing with returnint, sensitive caregiving; a nurturing home in general; and adequate stimulation. In general, most sensory systems develop early in life; thus the ability to see and to discriminate and recognize faces and speech sounds come on line in the first months and years of life, based on appropriate experiences occurring during that time window e. This is not surprising given how vitally important these functions are to subsequent development e.

Critical to the discussion in this chapter, however, is that the functions subserved by some other regions of the brain, most notably the prefrontal cortex—executive control, planning, cognitive flexibility, emotion rteurning a much more protracted course of development for the simple reason that both synaptogenesis and myelination of these cortical regions do not mature until mid- to late adolescence, perhaps even a bit later.

As a result, the sensitive period crom prefrontal cortical functions may be far more prolonged than is erturning case for sensory functions, extending well into the adolescent period. One example of the differential time course of different brain regions, and perhaps their corresponding sensitive periods, is illustrated in Figure The time course of key aspects of brain development.

In both cases, when the expectable environment is violated by either gross alterations in the type of care received or a complete lack of care, subsequent development can be seriously derailed. There is strong evidence across species that the HPA axis is affected by experiences of early childhood abuse and neglect e. Glucocorticoids cortisol in humans, corticosterone in rodents are steroid hormones produced as an end product of the HPA system. The HPA axis serves two orthogonal functions: mounting a stress response and maintaining a diurnal rhythm.

A cascade of events is deed to promote survival behavior by directing energy to processes that are critical to immediate survival e. Glucocorticoids also serve an important role in maintaining adilt patterns of daily activity, such as waking up, sleeping, and energy regulation Gunnar and Cheatham, Diurnal species, including humans, have a diurnal pattern of cortisol production that enhances the likelihood of being awake at the same time in the day. In humans, diurnal cortisol levels peak about 30 minutes after waking up, decrease sharply by mid-morning, and continue to decrease gradually until bedtime Gunnar and Donzella, The higher morning values of cortisol reflect greater metabolism of glucose early in peronals day, providing energy for the day's activities.

The HPA axis is highly sensitive to the effects of early experiences. Diurnal effects ka,mar have been examined as wake-up values and bedtime values because those time points allow assessments of change from nearly the highest reliable waking time point with 30 minutes post wake-up being the kalmqr to the lowest waking time point. Daytime values are affected by a of factors, such as exercise, naps, and travel to work Larson et al.

The most consistent findings involve flatter, more blunted patterns of diurnal regulation among abused or neglected children relative to low-risk children Bernard et al. Similar flattened diurnal rhythms have been found in institutionalized children Geturning et al. Flattened diurnal cortisol patterns may reflect down-regulation of HPA axis activity following earlier hyperactivation Carpenter et al. Cicchetti and colleagues Cicchetti and Rogosch, ab personzls changes across the day among abused and neglected children attending summer camp.

Crom time points included when children first arrived at camp at about 9 AM and before they left camp for the day at about 4 PMlikely tapping diurnal change within a challenging environment. The authors report complex findings regarding cortisol in this setting. Animal models have been used to study experimentally the effects of neglect and abuse on HPA functioning aadult.

Under naturally occurring conditions about 10 percent of rhesus monkeys abuse their infantsa 1-year-old rhesus monkey that was abused primarily in malmar first month of life showed higher cortisol levels under basal and stress conditions than a 1-year-old that had not been abused. These effects were not seen at older ages.

The age translation from rhesus to human is about 1 to 4, so a 1-year-old rhesus is developmentally similar to about a 4-year-old human. In other studies that have manipulated rearing conditions such as isolation rearingdifferences between conditions of abuse or neglect have been inconsistent. Disrupted HPA axis regulation may have negative effects on a of other biological systems. High levels of circulating cortisol resulting from early life stress may cause damage to developing brain regions Teicher et al.

Several brain regions, including limbic regions such as the amygdala and hippocampus and prefrontal regions, may be particularly susceptible to the effects of high levels of circulating cortisol because of the high of glucocorticoid receptors in these areas Brake et al. High levels of circulating cortisol may affect telomere length as well. Telomeres returjing the repeated sequences of DNA that cap the ends of chromosomes. Telomeres shorten each time cells divide, a process generally associated with aging, but also with stress Epel et al.

If telomeres become too short, the cell may become senescent grow old asult may become malfunctional, for personwls, triggering inflammation or tumor development. Children who have been exposed to neglect show shortened telomeres Asok et al. Drury tren colleagues found regurning telomeres among children in institutional care. Similarly, Asok and colleagues found that children living in highly challenging environments showed shorter telomeres than comparison children, but that mothers could buffer children from the environment challenge.

When mothers of neglected children were sensitive to challenging environments, their children's telomeres were as long as those of low-risk children, but when mothers were insensitive, children's telomeres were shorter. Clearly, then, sensitive caregiving kalmaar as a protective factor even under difficult conditions of adversity. There is as yet no compelling empirical evidence among humans that high levels of cortisol result from abuse or neglect and persist long enough to retuning brain development adversely, leaving these returnihg speculative.

Nonetheless, the evidence is compelling that the HPA axis is perturbed in many cases, and perturbations are associated with a range of health and mental health problems McEwen, ; Yehuda et al. Studies e.

Differential zdult of the glucocorticoid receptor gene promoter in the hippocampus was found to be associated with different rearing conditions in rodents, and was reversed by changes in caregiving conditions McGowan et al. Paralleling these findings among rodents are nonexperimental frrom among humans examined in postmortem analyses McGowan et al.

Adult suicide victims pwrsonals had experienced abuse as children differed in glucocorticoid receptor mRNA from adult suicide victims who had teej experienced abuse as children and from controls. These findings are consistent with the experimental rodent findings, and suggest that methylation of receptor sites mediates the association between early care and stress responsiveness.

The amygdala performs a primary role in the formation and storage of memories associated with emotional events. The amygdala undergoes rapid development within the first several years of life and is particularly susceptible to early adversity e. Relative to low-risk children, abused retutning neglected children show behavioral and emotional difficulties that are consistent with effects on the amygdala, such as internalizing problems, heightened anxiety, and emotional reactivity Ellis et al.

Figure illustrates structures in the adutl temporal lobe critically involved in emotion amygdala and learning and memory hippocampus. Most studies have found no evidence that the structure of the amygdala is affected by abuse or neglect De Bellis et al. However, Tottenham and colleagues and Mehta and colleagues found that amygdala volume was enlarged among children following institutionalized care, although this finding was not replicated by Sheridan and colleagues among a similar population.

Importantly, both the Mehta et al. Functional magnetic resonance imaging fMRI studies have shown aklmar early adversity le to a sensitized amygdala. Relative to comparison children, ly institutionalized children showed heightened amygdala activity in response to fearful faces compared with neutral faces Tottenham et al.

Similarly, Maheu and colleagues found that children with a history of abuse or neglect showed greater activation of the left amygdala in response to fearful and angry relative to neutral faces. The hippocampus see Figure plays an important role in learning ;ersonals memory Andersen et al. The hippocampus appears to be particularly susceptible to stress early in life Gould and Tanapat, ; Sapolsky et al.

Damage to the hippocampus due to abuse or neglect can have negative consequences for its roles in regulation of the stress response system and in memory formulation de Quervain et al. Most studies have found no evidence of hippocampal volume deficits among abused children compared with healthy, nonabused control children De Bellis et al. Among frkm, however, decreased hippocampal volume has been linked with the experience of childhood physical and sexual abuse Andersen and Teicher, ; Andersen ffrom al.

Nonetheless, relatively smaller hippocampal volumes in abused adults may be specific to PTSD rather than abuse frrom Kitayama et al. The development of the prefrontal cortex is protracted, extending from birth into the third decade of life Gogtay et al. Prefrontal systems are especially sensitive to experiences of early adversity Hart and Rubia, ; McLaughlin et al.

Evidence is mixed with regard to structural changes in the prefrontal cortex following abuse and neglect, with some studies showing smaller volumes of the right orbitofrontal cortex, right ventral-medial prefrontal cortex, and dorsolateral prefrontal cortex Hanson et al. Despite mixed evidence regarding structural changes geen the prefrontal cortex, a of studies suggest that abuse and neglect are associated with functional changes in the prefrontal cortex and related brain regions.

In particular, children with trauma experiences show patterns of neural activation during tasks requiring executive function that are similar to patterns observed in children with attention-deficit hyperactivity disorder ADHD e.

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Consistent with these findings among abused and neglected children, ly institutionalized children and adolescents have been found to demonstrate disruptions in the prefrontal network that is associated with inhibitory control. For example, Mueller and colleagues found that children with a history of neglect or institutional care showed greater activation kalmr several regions of the prefrontal cortex e.

Similar findings have been reported by McDermott and colleagues and Loman and colleagues among currently and ly institutionalized children. The corpus callosum facilitates communication between the two hemispheres of the brain Giedd et al. The white matter fibers composing the corpus callosum are myelinated throughout childhood and adulthood Giedd et al. Myelinated regions such as the corpus callosum are susceptible to the impacts of early exposure to high levels of cortisol, which suppress the glial cell division critical for myelination.

Teicher and colleagues compared corpus callosum volume in adults with different abuse and neglect experiences. The total corpus callosum area of the abused children was smaller than that of both healthy control children and children with psychiatric disorders and no abuse or neglect. Other findings suggest that gender may moderate these effects, with the effects being more pronounced among males than females De Bellis and Returnjng, ; De Bellis et al.

Sheridan and colleagues performed structural MRIs on children enrolled in the Bucharest Early Intervention Project, described ly in this chapter. In a follow-up of 8- to year-olds, Sheridan and colleagues found smaller total white and gray matter volume and smaller posterior corpus callosum volume among personal who had been institutionalized relative to those who had never been institutionalized.

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By middle childhood, however, there were no ificant differences in total white matter volume or posterior corpus callosum volume between the never-institutionalized community children and the foster care children. These early differences in corpus callosum may be associated with less efficient cognitive functioning among children who experience early adversity.

The influence of profound neglect early in life has been examined using electroencephalography EEG and event-related potentials ERPs. EEG measurements of the brain's electrical activity can serve as a coarse metric for brain development. Most work on EEG in the context of neglect has been performed on children with a history of institutional care. The most extensive study of brain electrical activity among children with a history of institutional care was conducted with the children rreturning in the prospective, longitudinal Bucharest Early Intervention Project.

At baseline mean age 20 monthsprior to random asment to continued institutional care or foster care, institutionalized children showed higher levels of theta power low-frequency brain activity and lower levels of alpha and beta power high-frequency activity compared with children who were not institutionalized Marshall et al. The pattern of activity observed in institutionalized children suggests a maturational delay or deficit in cortical development associated with an extreme form of neglect Marshall et al.

Adulr follow-up, as a group, children ased to foster care did not differ from the care-as-usual group Marshall et al. However, the subset of children placed in foster care before 2 years of age showed EEG activity that more closely personalz that of the never-institutionalized group than the personasl group. This last finding was replicated when the children were 8 years old Vanderwert et al. Specifically, ly institutionalized children placed in foster care before about 2 years of age had patterns of brain activity that resembled those of never-institutionalized children, whereas children placed in foster care after 2 years of age had patterns of brain activity that resembled those of children randomly ased to institutional returnong.

ERPs measure changes in the brain's electrical activity in response to an internal or external stimulus or event. The components of the ERP i. The P i. Whereas nonabused children show similar P activity across emotional expressions, abused children show larger Ps to angry target faces Pollak et al. Finding: Across human and nonhuman primate studies, perturbations to the HPA system often are seen to be associated with child abuse and neglect. The findings are complex, moderated by a of factors and seen at some ages and not others.

Further, the perturbations sometimes are reflected in atypically high production of cortisol across either basal or reactive contexts and sometimes in atypically low production. Recent work in epigenetics suggests that this may well be an area of future inquiry into the mechanisms whereby abuse or neglect alters gene expression and, in turn, behavior. Finding: Abused and neglected children show behavioral and tene difficulties that are consistent with effects on the amygdala, such as internalizing problems, heightened anxiety and emotional reactivity, and deficits in emotional refurning.

Most studies have found no evidence that the structure of the amygdala is affected by abuse or neglect; however, fMRI studies have shown that early adversity le to a sensitized amygdala. Finding: Despite mixed evidence regarding structural changes in the prefrontal cortex, a of studies suggest that abuse and neglect are associated with functional changes in the prefrontal cortex and associated brain regions, often affecting inhibitory control. Finding: Examination of patterns of brain electrical activity in institutionalized children suggests that extreme forms of neglect are associated with a maturational delay or deficit in cortical development.

There is a long history of research exploring the effects of child abuse and neglect on cognitive development. Studies have examined executive functioning and attention, as well as academic achievement. As discussed earlier, some studies have found that child abuse and neglect have effects on the prefrontal cortex, a brain structure centrally involved in executive functioning. Executive functioning refers to higher-order cognitive processes that aid in the monitoring and control of emotions and behavior Lewis-Morrarty et al.

Executive functioning abilities develop rapidly between the ages of 3 and 6 years, but continue to develop retjrning at least the second decade of life. Children who experience abuse and neglect appear to be especially at risk for deficits in executive functioning, which have implications for behavioral regulation. Extreme neglect, as seen in institutional care, has been related to executive functioning in a of studies conducted by the Bucharest Early Intervention Project team McDermott et al.

For example, McDermott and colleagues found that children who were randomly ased to foster care showed better performance on an executive functioning task i. The assessments of executive functioning were conducted when children were 8 years old. Similar findings among comparably aged internationally adopted children with histories of institutionalization have been reported e. These findings petsonals that extreme forms of neglect may interfere with the development of executive functioning.

Problems in regulating attention represent one of the most striking deficits seen among children who have experienced severe early deprivation in institutional settings Gunnar et al. Gunnar and colleagues found that problems with inattention or overactivity were more pronounced among children who had experienced early institutional care than among those who had been adopted internationally without early institutional care.

Kreppner and colleagues found that many children who had been adopted following institutional care showed problems with inattention or overactivity, but that such problems were usually seen in combination with reactive attachment disorder, quasi-autistic behaviors, or severe cognitive impairment. Using NSCAW data, Heneghan and colleagues examined mental health returningg in teens older than age 12 who were the subject of welfare agency investigation.

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