Develop. Med. Child Neurol. 1979, 21, 101-108
Annotations
CHILD ABUSE AND DEVELOPMENTAL DISABILITIES* WE have been abusing children for centuries (see Fig. l ) , but it was not until HENRY KEMPE and his colleagues’ wrote their classic paper on the ‘battered child syndrome’ that the public became aware of the entity of child abuse. By the mid-1960s every State in the USA had a law making it mandatory for all health professionals (physicians, nurses, dentists, etc.) and other personnel (social workers, educators, etc.) to report child abuse whenever it was suspected. In many States there are penalties for professionals who fail to report it; the penalties include a jail sentence and/or a fine of several hundred dollars, and in some cases the professional can be liable for damages because of subsequent injuries to the child after failure to report suspected abuse. The California Supreme Court decision in the Landeros case2now allows litigation for malpractice if a full investigation is not carried out on a patient considered suspect. Most recently, a social worker in Colorado was found guilty of ‘second degree official misconduct’ for knowingly failing to safeguard the life of a seven-year-old girl who died allegedly as the result of abuse at the hands of her step-fathe?. Her supervisor was indicted with her and is awaiting trial. Initially the child abuse laws were formulated in a climate of hysteria, guilt and retribution and were predicated on the accepted model at that time (the psychopathological model), which decreed that any person who could abuse a child must be severely emotionally disturbed and therefore in need of psychiatric treatment. On further investigation this model was found to be not valid. Less than 10 per cent of abusers were severely emotionally disturbed; the vast majority were relatively ordinary people buckling under the stresses and strains of living and rearing children in this complicated and frenetic society of ours. This present concept is known as the social-psychological model. Most
Fig. 1. Road sign near Sparta.
~~
Adapted from the Presidential Address to the American Academy for Cerebral Palsy and Developmental Medicine, Toronto, September 1978.
101
DEVELOPMENTAL MEDICINE AND CHILD NEUROLOGY.
1979, 2 1
States have now changed their laws to be more understanding and compassionate, and every effort is made to keep the family intact. Incidence The actual incidence of abuse is unknown and it is exceedingly difficult to compare the figures of one State with another. Some States include neglect, sexual abuse and emotional abuse in their laws, while others exclude everything other than non-accidental physical injury. 200,000 cases were reported in the United States in 1974, 2000 of the children having been murdered. This reported incidence is considered by most to be a low estimate and at least five times that number-ne million cases per year-is the generally accepted figure. Some investigators believe that it is as high as four to five million cases anually if all forms of abuse are included in the definition. Violence has indeed become a way of life. In a recent survey conducted by sociologistsat the Universities of Delaware, New Hampshire and Rhode Island4,it was reported that ‘American parents kick, punch or bite as many as 1,700,000 children a year, beat up 460,000 to 750,000 more and attack 46,000 with knives or guns’. Child abuse occurs at all socio-economic and educational levels, although it is more often reported in the poor, for obvious reasons. The parents are not the only abusers: step-parents, boyfriends, baby-sitters and foster-parents have been found to abuse children. 60 to 90 per cent of abusers have a history of being abused themselves. Factors Producing Child Abuse There are many factors involved in child abuse. Three of the main ones are (1) stress and strain in the family; (2) unrealistic expectations of the child on the part of the parents; and (3) emotional (and social) isolation of the parents. Usually there is one child in the family who is the scapegoat and receives the brunt of the abuser’s animosity. The siblings are treated much better, often receiving normal or even preferential parenting. However, recent research gives indications that the non-abused siblings of abused children suffer as well. FRIED MAN^ cites a study showing that ‘the non-abused sibling appears to be more damaged in personality and has difficultyin making healthy emotional ties with a foster parent. Half of these siblings had selective significant language learning delay and unsatisfactory mental and emotional development’. Some children are more vulnerable than others, particularly low-birthweight infants and handicapped children. Low-birthweight infants, though only 10 per cent of newborns, comprise approximately 20 to 25 per cent of the physically abused population. Research suggests that a major factor is impairment of maternal-infant bonding. Impaired bonding may occur because of lack of responsiveness by the infant to the mother as a result of immaturity or birth trauma, and/or separation of mother and infant because of the necessity for intensive nursing care6. The critical time for maternal-infant bonding to take place is the first few hours immediately following birth, although of course satisfactory bonding commonly does take place later. The routine procedure now in force in most hospitals in the United States is not conducive to establishing optimum maternal-infant bonding, as normal newborns usually are separated from their mothers for the first six to 12 hours of life while they are observed in a transitional type of nursery. The term ‘handicapped children’ covers a wide range, from the hyperactive to the developmentally disabled. Developmental disabilities comprise a group of handicapping 102
ANNOTATIONS
conditions, including mental retardation, cerebral palsy, epilepsy, autism and severe dyslexia. If we accept that stress is a major cause of child abuse, it is understandable why the handicapped child is so vulnerable. The mere physical care of such a child can be exceedingly taxing, not only physically but also emotionally and financially. If these stresses are compounded by the initial parental reactions of anger, denial and guilt, and the long-term care is without relief, the potential for abuse increases dramatically. Abuse in Relation to Developmental Disabilities Some studies have shown the high incidence of developmental disabilities in abused childrenprior to the abuse. GIL'found that 29 per cent of 6000 confirmed cases of child abuse had some type of developmental disability. In a national survey cited by CHOTINER and LEHR',58 per cent of abused children of members of Parents Anonymous had 'developmental problems' prior to abuse. Nearly 70 per cent of 97 abused children had previous mental or physical deviation in the study by the Denver Department of Welfare9. Of course the abuse itself may cause developmental disabilities, and neurological and GREGG'Ohave reported a impairment is a common after-effect of abuse. ELMER comprehensive follow-up study of 52 children who had sustained multiple bone injuries in the past, diagnosed by x-ray. Of these 52 children, eight had died, five were in institutions and six families refused to co-operate; of the remaining 33 children, 22 were considered to be abused, seven were questionable and four were not abused. Just over 30 per cent of the 22 abused children had signs of central nervous system damage, and 57 per cent had an IQ of 80 or below. 30 per cent had been low-birthweight infants and 33 per cent were below the third percentile for height and weight. The same authors reported in 1969 on a group of 146 children under 13 months of age presumed to have received accidental injuries. 30 of these children were considered to have been abused, and of these 42 per cent were retarded developmentally and 76 per cent had inadequate physical care. Martin", in a three-year follow-up of 42 abused children, found 33 per cent with an IQ below 80, 43 per cent with neurological impairment and 33 per cent below the third percentile for height and weight. JOHNCAFFEY, the pediatric radiologist, wrote the first modern discussion of the battered baby syndrome when he described a condition of subdural hematoma associated with specific radiologicai findings in the long bones12.His research has continued along these lines and he has published two paper^'^"^ on what he eventually called the 'whiplash shaken infant syndrome' and its potential for producing residual effects of permanent brain-damage and mental retardation. He points out that it is an exceedingly common practice for an infant to be lifted by the upper arms and shaken vigorously, often to correct minor misbehavior. The high vulnerability of the infantile head, brain and eyes to trauma frequently causes mental retardation, permanent brain-damage and intra-ocular bleeding. A diagnostic contradiction can be the absence of signs of external trauma to the head in the presence of intracranial hemorrhage and characteristic bone lesions on x-ray (Fig. 2). Many 'battered' babies are really shaken babies. SANDGRUND et al.ISreported more than eight times the number of children from abused and neglected groups with an IQ below 70, compared with only 3 per cent of the non-abused control children (Table I). The abused child therefore is often in double jeopardy: in a significant percentage of 103
DEVELOPMENTAL MEDICINE AND CHILD NEUROLOGY.
1979, 21
TABLE I Child abilee and mental retardation Group
No.
Abused Neglected Non-abused (control)
60 30 30
IQ
Annotations
CHILD ABUSE AND DEVELOPMENTAL DISABILITIES* WE have been abusing children for centuries (see Fig. l ) , but it was not until HENRY KEMPE and his colleagues’ wrote their classic paper on the ‘battered child syndrome’ that the public became aware of the entity of child abuse. By the mid-1960s every State in the USA had a law making it mandatory for all health professionals (physicians, nurses, dentists, etc.) and other personnel (social workers, educators, etc.) to report child abuse whenever it was suspected. In many States there are penalties for professionals who fail to report it; the penalties include a jail sentence and/or a fine of several hundred dollars, and in some cases the professional can be liable for damages because of subsequent injuries to the child after failure to report suspected abuse. The California Supreme Court decision in the Landeros case2now allows litigation for malpractice if a full investigation is not carried out on a patient considered suspect. Most recently, a social worker in Colorado was found guilty of ‘second degree official misconduct’ for knowingly failing to safeguard the life of a seven-year-old girl who died allegedly as the result of abuse at the hands of her step-fathe?. Her supervisor was indicted with her and is awaiting trial. Initially the child abuse laws were formulated in a climate of hysteria, guilt and retribution and were predicated on the accepted model at that time (the psychopathological model), which decreed that any person who could abuse a child must be severely emotionally disturbed and therefore in need of psychiatric treatment. On further investigation this model was found to be not valid. Less than 10 per cent of abusers were severely emotionally disturbed; the vast majority were relatively ordinary people buckling under the stresses and strains of living and rearing children in this complicated and frenetic society of ours. This present concept is known as the social-psychological model. Most
Fig. 1. Road sign near Sparta.
~~
Adapted from the Presidential Address to the American Academy for Cerebral Palsy and Developmental Medicine, Toronto, September 1978.
101
DEVELOPMENTAL MEDICINE AND CHILD NEUROLOGY.
1979, 2 1
States have now changed their laws to be more understanding and compassionate, and every effort is made to keep the family intact. Incidence The actual incidence of abuse is unknown and it is exceedingly difficult to compare the figures of one State with another. Some States include neglect, sexual abuse and emotional abuse in their laws, while others exclude everything other than non-accidental physical injury. 200,000 cases were reported in the United States in 1974, 2000 of the children having been murdered. This reported incidence is considered by most to be a low estimate and at least five times that number-ne million cases per year-is the generally accepted figure. Some investigators believe that it is as high as four to five million cases anually if all forms of abuse are included in the definition. Violence has indeed become a way of life. In a recent survey conducted by sociologistsat the Universities of Delaware, New Hampshire and Rhode Island4,it was reported that ‘American parents kick, punch or bite as many as 1,700,000 children a year, beat up 460,000 to 750,000 more and attack 46,000 with knives or guns’. Child abuse occurs at all socio-economic and educational levels, although it is more often reported in the poor, for obvious reasons. The parents are not the only abusers: step-parents, boyfriends, baby-sitters and foster-parents have been found to abuse children. 60 to 90 per cent of abusers have a history of being abused themselves. Factors Producing Child Abuse There are many factors involved in child abuse. Three of the main ones are (1) stress and strain in the family; (2) unrealistic expectations of the child on the part of the parents; and (3) emotional (and social) isolation of the parents. Usually there is one child in the family who is the scapegoat and receives the brunt of the abuser’s animosity. The siblings are treated much better, often receiving normal or even preferential parenting. However, recent research gives indications that the non-abused siblings of abused children suffer as well. FRIED MAN^ cites a study showing that ‘the non-abused sibling appears to be more damaged in personality and has difficultyin making healthy emotional ties with a foster parent. Half of these siblings had selective significant language learning delay and unsatisfactory mental and emotional development’. Some children are more vulnerable than others, particularly low-birthweight infants and handicapped children. Low-birthweight infants, though only 10 per cent of newborns, comprise approximately 20 to 25 per cent of the physically abused population. Research suggests that a major factor is impairment of maternal-infant bonding. Impaired bonding may occur because of lack of responsiveness by the infant to the mother as a result of immaturity or birth trauma, and/or separation of mother and infant because of the necessity for intensive nursing care6. The critical time for maternal-infant bonding to take place is the first few hours immediately following birth, although of course satisfactory bonding commonly does take place later. The routine procedure now in force in most hospitals in the United States is not conducive to establishing optimum maternal-infant bonding, as normal newborns usually are separated from their mothers for the first six to 12 hours of life while they are observed in a transitional type of nursery. The term ‘handicapped children’ covers a wide range, from the hyperactive to the developmentally disabled. Developmental disabilities comprise a group of handicapping 102
ANNOTATIONS
conditions, including mental retardation, cerebral palsy, epilepsy, autism and severe dyslexia. If we accept that stress is a major cause of child abuse, it is understandable why the handicapped child is so vulnerable. The mere physical care of such a child can be exceedingly taxing, not only physically but also emotionally and financially. If these stresses are compounded by the initial parental reactions of anger, denial and guilt, and the long-term care is without relief, the potential for abuse increases dramatically. Abuse in Relation to Developmental Disabilities Some studies have shown the high incidence of developmental disabilities in abused childrenprior to the abuse. GIL'found that 29 per cent of 6000 confirmed cases of child abuse had some type of developmental disability. In a national survey cited by CHOTINER and LEHR',58 per cent of abused children of members of Parents Anonymous had 'developmental problems' prior to abuse. Nearly 70 per cent of 97 abused children had previous mental or physical deviation in the study by the Denver Department of Welfare9. Of course the abuse itself may cause developmental disabilities, and neurological and GREGG'Ohave reported a impairment is a common after-effect of abuse. ELMER comprehensive follow-up study of 52 children who had sustained multiple bone injuries in the past, diagnosed by x-ray. Of these 52 children, eight had died, five were in institutions and six families refused to co-operate; of the remaining 33 children, 22 were considered to be abused, seven were questionable and four were not abused. Just over 30 per cent of the 22 abused children had signs of central nervous system damage, and 57 per cent had an IQ of 80 or below. 30 per cent had been low-birthweight infants and 33 per cent were below the third percentile for height and weight. The same authors reported in 1969 on a group of 146 children under 13 months of age presumed to have received accidental injuries. 30 of these children were considered to have been abused, and of these 42 per cent were retarded developmentally and 76 per cent had inadequate physical care. Martin", in a three-year follow-up of 42 abused children, found 33 per cent with an IQ below 80, 43 per cent with neurological impairment and 33 per cent below the third percentile for height and weight. JOHNCAFFEY, the pediatric radiologist, wrote the first modern discussion of the battered baby syndrome when he described a condition of subdural hematoma associated with specific radiologicai findings in the long bones12.His research has continued along these lines and he has published two paper^'^"^ on what he eventually called the 'whiplash shaken infant syndrome' and its potential for producing residual effects of permanent brain-damage and mental retardation. He points out that it is an exceedingly common practice for an infant to be lifted by the upper arms and shaken vigorously, often to correct minor misbehavior. The high vulnerability of the infantile head, brain and eyes to trauma frequently causes mental retardation, permanent brain-damage and intra-ocular bleeding. A diagnostic contradiction can be the absence of signs of external trauma to the head in the presence of intracranial hemorrhage and characteristic bone lesions on x-ray (Fig. 2). Many 'battered' babies are really shaken babies. SANDGRUND et al.ISreported more than eight times the number of children from abused and neglected groups with an IQ below 70, compared with only 3 per cent of the non-abused control children (Table I). The abused child therefore is often in double jeopardy: in a significant percentage of 103
DEVELOPMENTAL MEDICINE AND CHILD NEUROLOGY.
1979, 21
TABLE I Child abilee and mental retardation Group
No.
Abused Neglected Non-abused (control)
60 30 30
IQ
