Child abuse, which is defined as any act or series of acts of commission or omission by a parent, other caregivers, or a stranger that results in harm, the potential for harm, or the threat of harm to a child (Daphna-Tekoah et al., 2019), is a worldwide phenomenon (Wildeman et al., 2014; Stoltenborgh et al., 2015). In addition, violence against children is hugely prevalent, with more than half of all children worldwide annually exposed to violence in all its forms (Lev-Wiesel et al, 2018). A nationwide study on American youth’s exposure to violence covering conventional crime, child maltreatment, peer and sibling offenses, sexual assault, witnessing, and indirect exposure to violence, and internet offenses revealed that 60% reported at least one form of direct exposure to violence in the past year (Finkelhor et al., 2005). A recent epidemiological survey in Israel that focused on the level of youth’s exposure to the different forms of abuse revealed that 52% reported experiences of abuse at least once during their lifetime (Lev-Wiesel et al., 2019). These victims often suffer multiple and varied forms of abuse (Clemmons et al., 2003; Arata et al., 2005; Finkelhor et al., 2007), within and outside the family, by adults or peers (Oriol et al., 2017). Studies report a higher prevalence of bullying in boys than in girls (Hong and Espelage, 2012). Girls were found to be exposed to a higher incidence of emotional abuse by peers (Seals and Young, 2003). These findings demonstrate that every second child is exposed to any injury.

Yet, despite the high prevalence of child abuse, whether inflicted by a family member, a stranger, or a peer, less than 10% of the children ever disclose the abuse, and about 70% of children are reluctant to disclose it to professionals (Lev-Wiesel and First, 2018). Thus, the prevalence of abuse and its enduring harm and the gap between the prevalence of child maltreatment and disclosure underscores the need to document how children and youth perceive abuse and which abusive behaviors are required to be disclosed to adults according to children and adolescents. Although studies have examined perceptions of child maltreatment among pediatricians (Al-Moosa et al., 2003), social workers (Ashton, 2010), law enforcement officers, educators, and mental health and healthcare professionals (Eisikovits et al., 2015), as well as among teachers (Gamache Martin et al., 2010), much less work has been done on children’s and teens’ perceptions (Lev-Wiesel et al., 2020).

Recently, Lev-Wiesel et al. (2020) compared children’s and parents’ perceptions of child maltreatment and abuse. The findings showed that both parents and children considered sexual, emotional, and physical maltreatment, as well as neglect, as more damaging than child labor. However, children perceived emotional abuse to be significantly more severe than did their parents, and the parents, unlike their children, rated sexual abuse as the most damaging. Built on these preliminary efforts, the current study aimed to shed light on the ways children and adolescents from the general population perceive child abuse, as manifested in their drawings and narratives. Unfolding children’s perception of the abuse may assist therapists, parents, and educators in understanding the ways children experience this disturbing reality. Moreover, if clinicians, parents, and educators want to encourage children to disclose the abuse, they need to comprehend when children perceive violent situations as either abusive or non-abusive.

The current study examined how children and adolescents from the general population perceive child abuse as reflected in drawings and narratives. In general, the findings indicated that the children did not perceive a distinction between abuse and violence and referred to them interchangeably, referring equally to intrafamilial and extrafamilial scenes of child abuse and violence. The most frequent form of abuse depicted by the participants was emotional abuse. This is consistent with previous findings indicating a higher prevalence of emotional abuse reported by children and adolescents than other forms of abuse (Lev-Wiesel et al., 2019). Because emotional abuse often accompanies other forms of abuse, whether intrafamilial or extrafamilial, children and adolescents may be more familiar with it. It is consistent with previous findings showing that many children experience and engage in hostility, teasing, bullying, yelling, criticism, rejection, and ostracism, whether as indirect victims or observers, as victims, or as perpetrators (Nansel et al., 2001; Modecki et al., 2014; Stark, 2015).

Although violent engagement between peers or siblings is common (Nansel et al., 2001; Tucker et al., 2013; Modecki et al., 2014; Wolke et al., 2015), the participants here did not appear to consider these interactions as acceptable but rather as abusive/violent acts, in which there were clear roles of victim and perpetrator. These imbalanced situations can exacerbate feelings of embarrassment, humiliation, sadness, loneliness, and helplessness, which were reflected here in the children’s powerlessness drawings and narratives, as well as in their restricted and chaotic narratives, which may imply children’s difficulties in reflecting and resolving the abuse (Main and Hesse, 1990; Scharf and Shulman, 2006). This raises the more general question of the impact of exposure to violence—whether domestic, in the community, or in the media—on children and how it shapes their views of the world and themselves, their ideas about the meaning and purpose of life, their expectations for future happiness, and their moral development (Cummings et al., 2009).

Most of the drawings communicated the abusive/violent experience realistically through the use of symbols of aggression, injuries, and words, particularly the drawings that depicted physical abuse or multiple forms of abuse. This finding lends weight to previous studies indicating that drawings encourage disclosure of disturbing content that can elevate distress by bypassing dissociative mechanisms (Amir and Lev-Wiesel, 2007). The fact that none of the participants avoided or refrained from completing the assignment, but some employed various graphical techniques such as receding themselves from the situation by seldom drawing themselves within the abusive scene, avoiding taking a specific role in the event, or distancing the aggressor from the victim, may indicate an attempt to protect themselves from the troubling subject and its associated negative feelings by dissociative mechanisms. Furthermore, despite the high prevalence of sexual assault among children (Oriol et al., 2017; Lev-Wiesel et al, 2018), children and adolescents rarely drew this type of assault.

Obviously, some of the children and adolescents could have served as the aggressors, perpetrators of bullying, or bystanders (Nansel et al., 2001); however, using these techniques, as well as adding positive objects such as flowers or hearts, non-related objects, or words, may also reflect the participants’ ambivalence toward contemplating on the subject or disclosing their personal abusive experience (Malloy et al., 2011; Lev-Wiesel et al, 2018). The use of excessive cuteness or sweetness in drawings as a dissociative mechanism previously was found in various studies that aimed to identify attachment representations in children (e.g., Pianta and Longmaid, 1999; Goldner and Scharf, 2012). Specifically, children characterized by disorganized attachment representation tended to add hearts, flowers, and butterflies to their drawings, and these objects tended to take over much of the page.

The dissociation literature considers dissociation as both a symptom of distress and a defense mechanism that can lead to distress (Nijenhuis et al., 2010; Lahav and Elklit, 2016). The classical approach regards dissociation as a pathological response to trauma in which the victim splits daily reality into the part in which he or she functions appropriately and the abuse experience (Nijenhuis et al., 2010). The two parts of the self, the one that acknowledges the harm and the one that detached itself from it, are thought to be separated on a different level of consciousness (Nijenhuis et al., 2010). However, it is essential to note that using dissociative mechanisms in the narratives and drawings should be regarded as a normative adjustment mechanism since it protects individuals who have undergone painful experiences from emotional flooding (Spiegel et al., 2011; Stein et al., 2013).

Children can be exposed to indirect victimization across multiple socio-ecological contexts, including in the neighborhood, school, and home. Jakob (2018) suggested that even children who do not directly observe domestic or community violence are often aware of violent events or hear repeated accounts of a specific incident and tend to form mental imagery of the violence (Bacchini and Esposito, 2020). In our study, three-quarters of our sample generated narratives of exposure to indirect violence. Data from surveys conducted in the United States showed that more than 58% of the children and adolescents had witnessed or experienced indirect violence, including exposure to war or ethnic conflict, rape, flashing, domestic violence, kidnapping, witnessing a murder, and dating violence (Finkelhor et al., 2007, 2010). Even though the scenes of children who narrated indirect violence narratives tended to involve violence occurring mostly outside the family and their drawings tended to depict less helplessness than those of children who produced narratives of direct exposure to violence, studies have documented harmful effects of indirect exposure to violence, including PTSD symptoms, depression, externalizing problems, and delinquency (Fleckman et al., 2016; Shukla and Wiesner, 2016; Gollub et al., 2019). Thus, the choice to draw indirect violence scenes can attest not only to the high prevalence of the phenomenon in children and adolescents but also to the way children emotionally protect themselves from the consequences of indirect violence and the mental pain involved.

Our study also revealed differences in the children’s drawings and narratives across genders, family structures, and socioeconomic statuses. While boys tended to draw smaller victims and use preschematic drawings, girls produced more vital drawings but negative narratives. These tendencies replicated prior studies that indicated girls’ disposition to depict more expressive metaphorical drawings using a broader range of colors and boys’ tendency to depict more simple and plain drawings (Deaver, 2009; Picard and Boulhais, 2011; Goldner and Levi, 2014). The smaller victim figures in boys’ drawings and the negative narratives of girls can be understood based on boys’ higher rate of physical aggression and girls’ higher rate of emotional aggression, perceived risk of victimization (Carbone-Lopez et al., 2010), and emotional distress (Dao et al., 2006).

In addition, children from families with two parents who were not divorced, and families with higher socioeconomic status tended to use less dissociative mechanisms in their drawings. They drew more abuse scenes (mostly between siblings), and their drawings accorded their narratives. These findings may indicate these children’s higher level of accessibility to the abusive experience and broader internal and external resources to approach the task without bypassing it. Note, however, that other reasons can explain children’s emotional detachment from the drawings, such as their desire to engage with the concept more cognitively and personal predispositions (e.g., personality traits or attachment tendency). Future studies might examine these reasons.

The findings of this study may shed light on the ways children and adolescents perceive child abuse, their concerns, and the ways they try to cope or avoid coping with the distress. Abuse (or a combination of abuse and/or violence, as they perceived it), either within or outside the family, left most of the children feeling lonely and defenseless. Struggling with feelings of humiliation, guilt, and shame, they tried to communicate the abuse/violence, depicting realistic violent scenes, injury, aggressive symbols, and words in an attempt to gain an understanding for the painful experience. Clearly, for some children, art-making accompanied by producing narratives enables a concretization of the abusive experience (Buk, 2009; Loumeau, 2011) as well as its externalization into tangible symbols and narratives, which might support the containment and processing of the event (Avrahami, 2006; Malchiodi, 2012). However, for some children, this task may be perceived as anxiety-provoking and overwhelming, which evokes a more defensive response than would maintaining greater emotional distance (Kaiser, 1996). Since clinicians consider that art-based interventions and drawing techniques facilitate disclosure and foster sharing (Bekhit et al., 2005; Leon et al., 2007), they should be aware of the complexity of asking their clients to produce this type of drawing and the mechanisms children/teens use to cope with evoked distressful feelings.

This study has several limitations that should be taken into consideration. First, the research design was observational and correlative; therefore, it does not allow for causal inference. Second, the study was composed of a small convenience sample of Israeli children and teens who depicted the ways they perceived abuse. Future studies aiming to replicate the findings should apply a representative larger sample. Finally, our findings concentrated on drawings and narrative analyses. Future studies should include additional measures such as self-report questionnaires on children’s adjustment or in-depth interviews to validate the findings and gain a deeper understanding of children’s perceptions of abuse and violence. In addition, personal variables such as the history of trauma and child abuse, emotional regulation, and attachment orientations could also moderate the analysis or shed light on the participants’ perceptions as reflected in their drawings and narratives.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving human participants were reviewed and approved by the Committee to Evaluate Human Subject Research of the Faculty of Health Sciences and Social Welfare of the University of Haifa. Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin. Written informed consent was obtained from the minor(s)’ legal guardian/next of kin for the publication of any potentially identifiable images or data included in this article.

LG and RL-W analyzed the drawings and data. All authors were involved in writing the article.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.