..........) ........
.. ..
Child Abuse: Causes and Prevention Arthur T. Davidson, MD New York, New York
In every organized society there are certain sensitive barometers that, if properly evaluated, will indicate the state of the health and general welfare of the society in question. Perhaps the most sensitive barometer in determining the quality of the health care delivery system of a country is its infant mortality rate. In the same vein, the overall health and general welfare of a society can be rather accurately determined by the manner in which it cares for, protects, or abuses its children. Indeed, the noted psychiatrist, N oshpitz stated that "a society succeeds or fails in direct proportion to the way it enhances or impedes the development of its children."1
Historical Background An indepth historical review of the subject of child abuse in the United States reveals three major events: the first was an article appearing in the August 1946 issue of the American Journal of Roentgenology entitled,
"Multiple Fractures in the Long Bones of Infants Suffering from Chronic Subdural Hematoma" by the distinguished Columbia University Roentgenologist, Dr. John Caffey.2 Here he describes six cases of infants whose principal disease was chronic subdural hematoma and who "exhibited 23 fractures and four contusions of the long bones. In not a single case was there a history of injury to which the skeletal lesions could reasonably be attributed and in no case was there clinical or roentgen evidence of generalized or localized skeletal disease which would predispose to pathological fractures."2 Caffey, however, fell into the same trap as many other physicians who see child abuse cases. This was pointed out by Kempe, the second great contributor to the recognition of the problem of child abuse, who stated that "physicians have great difficulty both in believing that parents could have attacked their children and in undertaking the essential questioning of parents on this subject. Many physicians find it hard to believe that such an attack could have occurred and they attempt to obliterate such suspicions from their minds, even in the face of obvious circumstantial
evidence."3 Caffey, after recognizing that the Read at the Sixth Annual Convention and of the Scientific Assembly of Region National Medical Association, Kiamesha Lake, New York, May 27-30, 1977. Requests for reprints should be addressed to Dr. Arthur T. Davidson, 1378 President Street, New York, NY 11213.
complete fractures in the femurs of three of his cases could not have been caused by "trivial unrecognizable trauma," gently suggested "that the question of intentional ill-treatment" must be raised.2 The second historial milestone
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 69, NO. 11, 1977
focusing mass public attention on the area of physical child abuse was the coining of the emotional term, "the battered child." This shock-effect term had its origin in a seminar sponsored by the American Academy of Pediatrics in 1961. The participants at this conference were aware that pediatricians were unduly complacent about the problem of child abuse. It was felt that something stark and dramatic had to be done to gain attention and create an impact upon society's universal conscience .3 It remained for another individual to create the third milestone - a sort of trilogy - in the area of awakening our nation's conscience to the problem of child abuse. Kempe published an article which outlined the major components of this heinous syndrome.4 Its essential element was "a clinical condition in young children who have received serious physical abuse, generally from a parent or foster parent." He described, on a single day in November 1963 on the pediatric service of a Colorado General Hospital, four infants suffering from the parentinflicted battered-child syndrome. Two of the four died of their central nervous system pathology and one died suddenly four weeks later, in an unexplained manner, after discharge from the hospital to his parents.4 The results of Kempe's report were truly electrifying. Within a brief span of approximately five years, 1963-1968, all states passed laws dealing with the problem and mandated reporting, by health professionals to state agencies, of suspected cases of child abuse.5 6 817
The initial definition of child abuse was limited to actual, willful, or intentional physical injury inflicted upon the child by the parent or foster parent. The movement now, however, is away from the narrow confines of this limited definition to a more allembracing concept. This one includes acts of omission "or neglect" which interfere with the normal development of the child through Dr. Fontana's expanded definition in his "The Maltreated Child"7 and the broad concepts of Alvy8 of the Center for the Improvement of Child Caring, Los Angeles, California. The comprehensive report defines child abuse as being collective, institutional and individual in nature.
called a community credo which includes the following:
1. All members of the community must recognize their responsibility in the field of child welfare and care.
2. All governmental agencies must subscribe to the essential needs of children in the fields of health, food and nutrition, family and child welfare, education, vocational guidance, and training. 3. There must be a combined effort of governments, international agencies, voluntary agencies, and private citizens to eradicate conditions proving detrimental to the welfare and future of
children.7',12
Definition The strict definition of the phrase "child abuse" in terms of willful, intentional, physical trauma, which reaches its ultimate in the "battered child" syndrome, is too narrow a premise for this very extensive and paramount problem. In contrast to an act of commission, the almost equally shameful acts of neglect or omission are now recognized as major components of the child abuse syndrome. This confusing interchange of definitions accounts for wide discrepancies in the compilation of statistical data and clouds the overall extent of the problem. Because of the confusion of the terms abuse and neglect, the actual number of child abuse cases reported per year in the United States shows a wide range, usually from 300,000 to 600,000, of which an estimated 6,000 or 10 percent die. 9-1 1 Dr. Vincent J. Fontana, Medical Director of New York Foundling Hospital and a tireless worker in the field of child abuse has grown impatient with an effort to distinguish between abuse and neglect. He has now introduced the term "maltreated child" which combines the elements of abuse and neglect but goes further to include all elements of society that affect the emotional, physical, or mental health of the child. He places the responsibility for the abuses, of whatever source, upon the community at large. Indeed he suggests what might be 818
The widest dimension to the term child abuse has been given by Alvy.8 He defines the term in a comprehensive manner consisting of three types of child abuse: (1) collective abuse; (2) institutional abuse; and (3) individual abuse. Collective abuse has as its frame of reference all of those attitudes collectively held by our society that impede the psychological and physical development of children. This would include racial, sex, and social discrimination; substandard child-rearing environments that commonly exist in most racially segregated and economically impoverished neighborhoods in the United States. He quotes the figures from the US Bureau of Census, 1972, which state that seven million children are being raised in the abusive child-rearing conditions of poverty. Institutional abuse includes all abusive and damaging acts perpetrated against children by such stalwart institutions as schools, juvenile courts, child welfare agencies, and correc-
tional facilities. Individual abuse encompasses the traditional physical and emotional abuse and neglect of children that result from willful, intentional acts of commission or deliberate acts of omission or neglect on the part of parents or other individual caretakers which result in physical and emotional trauma to the child.8
Causes The syndrome of physical child abuse is only the symptomatic manifestation of a complex family sickness that breaks under a societal crisis. 1 3 The vast majority of prima facie cases of physical child abuse are composed of three factors: the abusing parent or parents; the abused child; and a crisis situation. The child abusers most often have a history of abuse as a child. An indepth analysis and evaluation of the psychological make-up of the child abuser reveals the following negative factors: (1) low frustration tolerance, (2) low self-esteem, (3) impulsivity, (4) dependency, (5) immaturity, (6) severe depression, and (7) role reversals. The problem of role reversals is extremely interesting in that these individuals expect their children to function as adults while they, the parents, are engaged in an almost childlike preoccupation with self. 14 The typically abused and/or neglected child has the following characteristics: (1) under three years of age, (2) more frequently a male, and (3) somewhat different. This would include the hyperactive child or seemingly apparent personality traits different from the other children.
Crisis Given an unstable parent and the "slightly different child," another factor usually must be added to this equation which acts as the spark to ignite the powder keg. This crisis incident usually is external in origin and societal in nature. In many instances, it is the grinding, relentless, self-demeaning poverty but this, all authorities in the field unanimously agree, is not to infer that low socioeconomic status is the primary crisis problem. Since child abusers are found in all strata of our society, this crisis episode in many cases is unrelated to apparent economic difficulty. The situational stress leading to crisis may take many forms and may be associated with economic stress, job insecurity, and alcohol and drug abuse.
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 69, NO. 11, 1977
Prevention
Comprehensive Programs The approaches to prevention of child abuse, in general, depend on which of the etiological types of child abuse that we are dealing with. This is why I particularly favor the three-tier definition of Alvy.8 The commonly held but narrow view of child abuse from an individual standpoint deals primarily with physical abuse and emotional trauma to the child. Prevention takes two forms: (1) preincidence or before-the-fact intervention and (2) postincidence or afterthe-fact intervention. In the first category, the health professional is concerned with recognizing those telltale symptoms (usually in the abusing parent) that would lead to an explosive outburst. A recent report from the Colorado General Hospital and the University of Colorado Medical Center indicates that potential child abusers sometimes develop "functional" or "psychosomatic" illness to signal their need for help. 1 s One illustrative case was of a 3 1year-old man who was seen in the Emergency Room complaining of chest pains and weakness in the legs. After a thorough physical examination, which was completely negative, a psychiatric evaluation was done. It was then learned that the alleged symptoms had begun two weeks after he had gained custody of a six-year-old stepson. The patient used the term "hateful" to describe the child. Recognizing the potential setting for an impending disaster, the physicians wisely chose to send the child to live with relatives and to have the patient and his wife attend the psychiatric clinic. 1 5 Most authorities in the field of child abuse are of the opinion that preventive measures for individual abuses should begin by prenatal, perinatal, and postnatal observations. Prenatally, the mother's psychological profile in respect to the expected child is observed. The following questions should be considered. Is there an attempt to deny that there is a pregnancy? Is this child going to be one child too many? Could this be the 'last straw'? Is there great depression over this pregnancy? Is the mother alone and frightened, especially by the physical changes caused by the pregnancy? Do careful explanations fail to dissipate these fears? and Is support
lacking from husband and/or family? During delivery, fathers are encouraged to be present. The reaction of the parents to the child is carefully noted. Specifically, are the parents passive, showing no active interest in the baby or not holding it? The postpartum and pediatric checkups are extremely important to note: (1) Does the mother have fun with the baby? (2) Does the mother establish eye contact with the baby? (3) Are most of her verbalizations negative? A broader and relatively novel prevention approach was suggested by Kempe,4 who suggested that the United States develop a system of lay health visitors, probably nurses, who visit every child during the first four years of life. He, in effect, proposes a universal health visitors system. This is patterned on the European visiting nurse system where nurses periodically visit the homes of newborn and presciool children. The unique features of Kempe's preventive report are the following two elements. First, it would be compulsory, and secondly, it would be a universal service. He aptly compares his health visitors system to the present public school system which is, of course, compulsory and universal by law. He expects the anticipated human cry that his system would certainly generate outcry similar tp that of a hundred years ago, when the concept of free compulsory universal public education was first seriously suggested to an unready public. Today, of course, we recognize that basic education is the right of every child. The concept of Kempe has its parallel in the preventive programs of other dedicated workers in this field when they speak of a bill of rights for children. Kempe recognizes the basic common-law tenet of the parent/child relationship with its protected rights from intrusion by the state. However, Kempe, without apparently knowing it, is on very sound grounds when he advocates state interference based on the protection of an overriding public policy. He rightfully points out the many areas in which the state does intervene into what might be called traditional private areas of a free society. He brings up an interesting point - which is that the traditional support of pediatric care depends, in large part, on parental motivation. In effect, a willing mother brings a
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 69, NO. 11, 1977
wanted child to the pediatrician for well-baby care. These healthy, happy people, as he pointed out, are delighted to keep their appointments. They are a joy for us to have in our offices and they make our days pleasant and fulfilling ones. He rightfully points out that these people do deserve excellent care. But, he goes further and, as in Sinclair Lewis' Main Street, disturbs our complacency by treating of alien themes. Specifically he asks us to direct our attention to the isolated families - the unmotivated families, the families who break appointments - the families who are unappreciative and unresponsive. It is to these people he is asking us as health professionals to reach out to protectively. When we are rebuffed by them, instead of uttering the time honored phrase, "well we tried," he is demanding that we say instead, "this behavior is so unusual and worrisome that we must intervene actively." It is at this point he would m,andate active intervention by child protective services initiated on the complaint of the physician or other health professionals. He suggests that such a program be administered by our municipal or state health departments. However, he rightfully points out that if these antiquated and creeky bureaucratic machines are unwilling or unable to handle the task, we should utilize our hospitals as bases from which to establish a system of aftercare. He is asking that we extend our aftercare program for at least five years. He points to such countries as France and Holland where monetary stipends are given to those families with young children that seek health care. In a costconscious society Kempe addresses himself to the cost of such an ambitious program. He asked for a reordering of our priorities with emphasis on spending before, rather than after, the fact. He uses a lower figure of 300,000 cases of annual child abuse and neglect in the United States, with 60,000
children receiving significant injuries, 2,000 dying, and 6,000 having permanent brain damage. The cost of providing institutional care for a severely brain-damaged child in the United States is approximately $700,000 for a lifetime. He sums up his program by stating that (1) in a free society, the newborn child does not belong to the state nor to his 819
parents, but to himself in the charge of his parents; and (2) universal, egalitarian, and compulsory health supervision in the broadest sense of the term is the right of every child.4 Access to regular health supervision should not be left to the motivation of the parents but must be guaranteed by society.1 6 Kempe feels that even though a man's home may be his castle, that does not give him a constitutional protective right to keep his child a prisoner in this dungeon.
Present Partial Program There are currently a number of programs of a limited scope which address themselves to the prevention of child abuse. One of these is the Education for Parenthood Program. This program, which began in 1972 as a joint venture of the US Office of Education and the Office of Child Development, has as its goal the preparation of teenage boys and girls for effective parenthood through high school-based educational experiences about child development and the role of parent, and by participatory observation experiences with young children in day care, nursery school, and kindergarten settings. This program has high potential because (1) it exposes teenagers to the various stages of human development through classroom and field experiences; and (2) it exposes these teenagers to child care workers who are particularly sensitive to the needs of children and who are capable of helping the children to channel their aggression in appropriate ways. 8 The program should be available in all high schools, probably on a compulsory basis. A second excellent prevention program that is already in operation is the Home Start Program of the Office of Child Development. This grew out of the Headstart Program, which of itself has abuse prevention potentials. Specifically, the Home Start Program sends trained caseworkers into the homes of economically disadvantaged families who have three to five-yearold children. These home workers are able to offer counseling and help with a variety of problems. It serves as a link between the family and commu820
nity services such as employment counseling, job training, drug counseling, and psychotherapy. The program should be extended to homes with children under three years of age and should be nationwide. This program is, in effect, a mini-type health visitors system of Kempe. Although not specifically designed as a child abuse prevention program, Headstart projects, which began in the 1960s, were shown to have great primary abuse prevention potentials because their programs served as a catalyst to the communities to improve their educational, health, and social services to the poor. The programs are based in local centers rather than the home. They are directed towards poverty families and consist of one-year programs that provide health, nutritional, educational, social and psychological services to economically d isadvantaged pre-schoolers. Community Mental Health Centers and children's services departments, should and could deliver mental health services to family groups. The adult education programs of the public school system could and should offer parent training programs. The early periodic screening, diagnosis, and treatment programs have excellent records in providing health care for many children. However, these programs are only for Medicaid clients and only those clients who are motivated to present their children for screening. Another program that deserves mentioning is Parents Anonymous. This is a volunteer self-help program composed of child-abusing parents and patterned after Alcoholics Anonymous. Like AA, it provides these parents with an opportunity to talk over their common problems. However, unlike AA, The Parents Anonymous group has as its sponsor a social worker or another professional concerned with child abuse.
Conclusion Child abuse is a symptom complex of a family sickness that has as its etiology the impact of negative societal stresses upon a psychologically inadequate parent which surfaces at a crisis point and results in intentional, willful, physical, emotional, or psychological harm to a child.
Acknowledgment The writer wishes to acknowledge the help and contribution of Mrs. Edith A. Taub, Director of the Library, Methodist Hospital of Brooklyn, for obtaining reprints of the reference articles and Mrs. Marion Paige tor the typing and researching of th is manuscript.
Literature Cited in
1. Noshpitz JD: Issues and approaches child psychiatry. Hosp Community
Psychiatry 25:96-97, 1974 2. Caffey J: Multiple fractures in the long bones of infants suffering from chronic subdural hematoma. Am J Roentgenol 56(2):163-173, 1946 3. Kempe C, Helfer RE: Helping the battered child and his family. In The Battered Child, (ed 2). Chicago, University of Chicago Press, 1974, pp 120-122 4. Kempe CH, Silverman FN, Steele BF, et al: The battered-child syndrome. JAMA 181:(1)17-24, 1962 5. Wilcox DP: Child abuse laws: past, present, and future. Jour Forensic Sciences 21(1):71-75, 1976 6. DeFrancis V, Lucht C: Child abuse legislation in the 1970s, rev ed. Denver, The American Humane Association Childrens Division, 1974 7. Fontana VJ: The Maltreated Child: The Maltreatment Syndrome in Children. Springfield, Illinois, Charles C Thomas, 1971, pp 32-57 8. Alvy KT: Preventing child abuse. Am Psychol, 1975, pp 921-927 9. Solomon T: History and demography of child abuse. Pediatrics, 51(2):773-776, 1973 10. Nagi S: Child abuse and neglect programs: A national overview. Child Today, May-June, 1975 11. Congressional Record-Proceedings and Debates of the 93rd Congress, First Session (Senate). USA 119(39):S4444. pp 1-9. Washington (Tuesday, March 13, 1973) 12. Polansky NA, Hally C, Polansky NF: Profile of Neglect: A Survey of the state of knowledge of child neglect. US Department of Health, Education, and Welfare, Social and Rehabilitation Service, Community Services Administration, 1975 13. Ebeling NB, Hill DA (eds): Child Abuse: Invervention and Treatment. Acton, Massachusetts, Publishing Sciences Group, Inc, 1975, pp 58-65 14. Hindman M: Child abuse and neglect: The alcohol connection. Alcohol Health and Research World, 1977, pp 3-7 15. Child Abusers Often Given Medical Signals. The New York Times, Sunday, April 17, 1977, p 8 16. Kempe CH: Approaches to preventing child abuse: The health visitors concept. Am J Dis Child 130:941-947, 1976
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 69, NO. 11, 1977
.. ..
Child Abuse: Causes and Prevention Arthur T. Davidson, MD New York, New York
In every organized society there are certain sensitive barometers that, if properly evaluated, will indicate the state of the health and general welfare of the society in question. Perhaps the most sensitive barometer in determining the quality of the health care delivery system of a country is its infant mortality rate. In the same vein, the overall health and general welfare of a society can be rather accurately determined by the manner in which it cares for, protects, or abuses its children. Indeed, the noted psychiatrist, N oshpitz stated that "a society succeeds or fails in direct proportion to the way it enhances or impedes the development of its children."1
Historical Background An indepth historical review of the subject of child abuse in the United States reveals three major events: the first was an article appearing in the August 1946 issue of the American Journal of Roentgenology entitled,
"Multiple Fractures in the Long Bones of Infants Suffering from Chronic Subdural Hematoma" by the distinguished Columbia University Roentgenologist, Dr. John Caffey.2 Here he describes six cases of infants whose principal disease was chronic subdural hematoma and who "exhibited 23 fractures and four contusions of the long bones. In not a single case was there a history of injury to which the skeletal lesions could reasonably be attributed and in no case was there clinical or roentgen evidence of generalized or localized skeletal disease which would predispose to pathological fractures."2 Caffey, however, fell into the same trap as many other physicians who see child abuse cases. This was pointed out by Kempe, the second great contributor to the recognition of the problem of child abuse, who stated that "physicians have great difficulty both in believing that parents could have attacked their children and in undertaking the essential questioning of parents on this subject. Many physicians find it hard to believe that such an attack could have occurred and they attempt to obliterate such suspicions from their minds, even in the face of obvious circumstantial
evidence."3 Caffey, after recognizing that the Read at the Sixth Annual Convention and of the Scientific Assembly of Region National Medical Association, Kiamesha Lake, New York, May 27-30, 1977. Requests for reprints should be addressed to Dr. Arthur T. Davidson, 1378 President Street, New York, NY 11213.
complete fractures in the femurs of three of his cases could not have been caused by "trivial unrecognizable trauma," gently suggested "that the question of intentional ill-treatment" must be raised.2 The second historial milestone
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 69, NO. 11, 1977
focusing mass public attention on the area of physical child abuse was the coining of the emotional term, "the battered child." This shock-effect term had its origin in a seminar sponsored by the American Academy of Pediatrics in 1961. The participants at this conference were aware that pediatricians were unduly complacent about the problem of child abuse. It was felt that something stark and dramatic had to be done to gain attention and create an impact upon society's universal conscience .3 It remained for another individual to create the third milestone - a sort of trilogy - in the area of awakening our nation's conscience to the problem of child abuse. Kempe published an article which outlined the major components of this heinous syndrome.4 Its essential element was "a clinical condition in young children who have received serious physical abuse, generally from a parent or foster parent." He described, on a single day in November 1963 on the pediatric service of a Colorado General Hospital, four infants suffering from the parentinflicted battered-child syndrome. Two of the four died of their central nervous system pathology and one died suddenly four weeks later, in an unexplained manner, after discharge from the hospital to his parents.4 The results of Kempe's report were truly electrifying. Within a brief span of approximately five years, 1963-1968, all states passed laws dealing with the problem and mandated reporting, by health professionals to state agencies, of suspected cases of child abuse.5 6 817
The initial definition of child abuse was limited to actual, willful, or intentional physical injury inflicted upon the child by the parent or foster parent. The movement now, however, is away from the narrow confines of this limited definition to a more allembracing concept. This one includes acts of omission "or neglect" which interfere with the normal development of the child through Dr. Fontana's expanded definition in his "The Maltreated Child"7 and the broad concepts of Alvy8 of the Center for the Improvement of Child Caring, Los Angeles, California. The comprehensive report defines child abuse as being collective, institutional and individual in nature.
called a community credo which includes the following:
1. All members of the community must recognize their responsibility in the field of child welfare and care.
2. All governmental agencies must subscribe to the essential needs of children in the fields of health, food and nutrition, family and child welfare, education, vocational guidance, and training. 3. There must be a combined effort of governments, international agencies, voluntary agencies, and private citizens to eradicate conditions proving detrimental to the welfare and future of
children.7',12
Definition The strict definition of the phrase "child abuse" in terms of willful, intentional, physical trauma, which reaches its ultimate in the "battered child" syndrome, is too narrow a premise for this very extensive and paramount problem. In contrast to an act of commission, the almost equally shameful acts of neglect or omission are now recognized as major components of the child abuse syndrome. This confusing interchange of definitions accounts for wide discrepancies in the compilation of statistical data and clouds the overall extent of the problem. Because of the confusion of the terms abuse and neglect, the actual number of child abuse cases reported per year in the United States shows a wide range, usually from 300,000 to 600,000, of which an estimated 6,000 or 10 percent die. 9-1 1 Dr. Vincent J. Fontana, Medical Director of New York Foundling Hospital and a tireless worker in the field of child abuse has grown impatient with an effort to distinguish between abuse and neglect. He has now introduced the term "maltreated child" which combines the elements of abuse and neglect but goes further to include all elements of society that affect the emotional, physical, or mental health of the child. He places the responsibility for the abuses, of whatever source, upon the community at large. Indeed he suggests what might be 818
The widest dimension to the term child abuse has been given by Alvy.8 He defines the term in a comprehensive manner consisting of three types of child abuse: (1) collective abuse; (2) institutional abuse; and (3) individual abuse. Collective abuse has as its frame of reference all of those attitudes collectively held by our society that impede the psychological and physical development of children. This would include racial, sex, and social discrimination; substandard child-rearing environments that commonly exist in most racially segregated and economically impoverished neighborhoods in the United States. He quotes the figures from the US Bureau of Census, 1972, which state that seven million children are being raised in the abusive child-rearing conditions of poverty. Institutional abuse includes all abusive and damaging acts perpetrated against children by such stalwart institutions as schools, juvenile courts, child welfare agencies, and correc-
tional facilities. Individual abuse encompasses the traditional physical and emotional abuse and neglect of children that result from willful, intentional acts of commission or deliberate acts of omission or neglect on the part of parents or other individual caretakers which result in physical and emotional trauma to the child.8
Causes The syndrome of physical child abuse is only the symptomatic manifestation of a complex family sickness that breaks under a societal crisis. 1 3 The vast majority of prima facie cases of physical child abuse are composed of three factors: the abusing parent or parents; the abused child; and a crisis situation. The child abusers most often have a history of abuse as a child. An indepth analysis and evaluation of the psychological make-up of the child abuser reveals the following negative factors: (1) low frustration tolerance, (2) low self-esteem, (3) impulsivity, (4) dependency, (5) immaturity, (6) severe depression, and (7) role reversals. The problem of role reversals is extremely interesting in that these individuals expect their children to function as adults while they, the parents, are engaged in an almost childlike preoccupation with self. 14 The typically abused and/or neglected child has the following characteristics: (1) under three years of age, (2) more frequently a male, and (3) somewhat different. This would include the hyperactive child or seemingly apparent personality traits different from the other children.
Crisis Given an unstable parent and the "slightly different child," another factor usually must be added to this equation which acts as the spark to ignite the powder keg. This crisis incident usually is external in origin and societal in nature. In many instances, it is the grinding, relentless, self-demeaning poverty but this, all authorities in the field unanimously agree, is not to infer that low socioeconomic status is the primary crisis problem. Since child abusers are found in all strata of our society, this crisis episode in many cases is unrelated to apparent economic difficulty. The situational stress leading to crisis may take many forms and may be associated with economic stress, job insecurity, and alcohol and drug abuse.
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 69, NO. 11, 1977
Prevention
Comprehensive Programs The approaches to prevention of child abuse, in general, depend on which of the etiological types of child abuse that we are dealing with. This is why I particularly favor the three-tier definition of Alvy.8 The commonly held but narrow view of child abuse from an individual standpoint deals primarily with physical abuse and emotional trauma to the child. Prevention takes two forms: (1) preincidence or before-the-fact intervention and (2) postincidence or afterthe-fact intervention. In the first category, the health professional is concerned with recognizing those telltale symptoms (usually in the abusing parent) that would lead to an explosive outburst. A recent report from the Colorado General Hospital and the University of Colorado Medical Center indicates that potential child abusers sometimes develop "functional" or "psychosomatic" illness to signal their need for help. 1 s One illustrative case was of a 3 1year-old man who was seen in the Emergency Room complaining of chest pains and weakness in the legs. After a thorough physical examination, which was completely negative, a psychiatric evaluation was done. It was then learned that the alleged symptoms had begun two weeks after he had gained custody of a six-year-old stepson. The patient used the term "hateful" to describe the child. Recognizing the potential setting for an impending disaster, the physicians wisely chose to send the child to live with relatives and to have the patient and his wife attend the psychiatric clinic. 1 5 Most authorities in the field of child abuse are of the opinion that preventive measures for individual abuses should begin by prenatal, perinatal, and postnatal observations. Prenatally, the mother's psychological profile in respect to the expected child is observed. The following questions should be considered. Is there an attempt to deny that there is a pregnancy? Is this child going to be one child too many? Could this be the 'last straw'? Is there great depression over this pregnancy? Is the mother alone and frightened, especially by the physical changes caused by the pregnancy? Do careful explanations fail to dissipate these fears? and Is support
lacking from husband and/or family? During delivery, fathers are encouraged to be present. The reaction of the parents to the child is carefully noted. Specifically, are the parents passive, showing no active interest in the baby or not holding it? The postpartum and pediatric checkups are extremely important to note: (1) Does the mother have fun with the baby? (2) Does the mother establish eye contact with the baby? (3) Are most of her verbalizations negative? A broader and relatively novel prevention approach was suggested by Kempe,4 who suggested that the United States develop a system of lay health visitors, probably nurses, who visit every child during the first four years of life. He, in effect, proposes a universal health visitors system. This is patterned on the European visiting nurse system where nurses periodically visit the homes of newborn and presciool children. The unique features of Kempe's preventive report are the following two elements. First, it would be compulsory, and secondly, it would be a universal service. He aptly compares his health visitors system to the present public school system which is, of course, compulsory and universal by law. He expects the anticipated human cry that his system would certainly generate outcry similar tp that of a hundred years ago, when the concept of free compulsory universal public education was first seriously suggested to an unready public. Today, of course, we recognize that basic education is the right of every child. The concept of Kempe has its parallel in the preventive programs of other dedicated workers in this field when they speak of a bill of rights for children. Kempe recognizes the basic common-law tenet of the parent/child relationship with its protected rights from intrusion by the state. However, Kempe, without apparently knowing it, is on very sound grounds when he advocates state interference based on the protection of an overriding public policy. He rightfully points out the many areas in which the state does intervene into what might be called traditional private areas of a free society. He brings up an interesting point - which is that the traditional support of pediatric care depends, in large part, on parental motivation. In effect, a willing mother brings a
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 69, NO. 11, 1977
wanted child to the pediatrician for well-baby care. These healthy, happy people, as he pointed out, are delighted to keep their appointments. They are a joy for us to have in our offices and they make our days pleasant and fulfilling ones. He rightfully points out that these people do deserve excellent care. But, he goes further and, as in Sinclair Lewis' Main Street, disturbs our complacency by treating of alien themes. Specifically he asks us to direct our attention to the isolated families - the unmotivated families, the families who break appointments - the families who are unappreciative and unresponsive. It is to these people he is asking us as health professionals to reach out to protectively. When we are rebuffed by them, instead of uttering the time honored phrase, "well we tried," he is demanding that we say instead, "this behavior is so unusual and worrisome that we must intervene actively." It is at this point he would m,andate active intervention by child protective services initiated on the complaint of the physician or other health professionals. He suggests that such a program be administered by our municipal or state health departments. However, he rightfully points out that if these antiquated and creeky bureaucratic machines are unwilling or unable to handle the task, we should utilize our hospitals as bases from which to establish a system of aftercare. He is asking that we extend our aftercare program for at least five years. He points to such countries as France and Holland where monetary stipends are given to those families with young children that seek health care. In a costconscious society Kempe addresses himself to the cost of such an ambitious program. He asked for a reordering of our priorities with emphasis on spending before, rather than after, the fact. He uses a lower figure of 300,000 cases of annual child abuse and neglect in the United States, with 60,000
children receiving significant injuries, 2,000 dying, and 6,000 having permanent brain damage. The cost of providing institutional care for a severely brain-damaged child in the United States is approximately $700,000 for a lifetime. He sums up his program by stating that (1) in a free society, the newborn child does not belong to the state nor to his 819
parents, but to himself in the charge of his parents; and (2) universal, egalitarian, and compulsory health supervision in the broadest sense of the term is the right of every child.4 Access to regular health supervision should not be left to the motivation of the parents but must be guaranteed by society.1 6 Kempe feels that even though a man's home may be his castle, that does not give him a constitutional protective right to keep his child a prisoner in this dungeon.
Present Partial Program There are currently a number of programs of a limited scope which address themselves to the prevention of child abuse. One of these is the Education for Parenthood Program. This program, which began in 1972 as a joint venture of the US Office of Education and the Office of Child Development, has as its goal the preparation of teenage boys and girls for effective parenthood through high school-based educational experiences about child development and the role of parent, and by participatory observation experiences with young children in day care, nursery school, and kindergarten settings. This program has high potential because (1) it exposes teenagers to the various stages of human development through classroom and field experiences; and (2) it exposes these teenagers to child care workers who are particularly sensitive to the needs of children and who are capable of helping the children to channel their aggression in appropriate ways. 8 The program should be available in all high schools, probably on a compulsory basis. A second excellent prevention program that is already in operation is the Home Start Program of the Office of Child Development. This grew out of the Headstart Program, which of itself has abuse prevention potentials. Specifically, the Home Start Program sends trained caseworkers into the homes of economically disadvantaged families who have three to five-yearold children. These home workers are able to offer counseling and help with a variety of problems. It serves as a link between the family and commu820
nity services such as employment counseling, job training, drug counseling, and psychotherapy. The program should be extended to homes with children under three years of age and should be nationwide. This program is, in effect, a mini-type health visitors system of Kempe. Although not specifically designed as a child abuse prevention program, Headstart projects, which began in the 1960s, were shown to have great primary abuse prevention potentials because their programs served as a catalyst to the communities to improve their educational, health, and social services to the poor. The programs are based in local centers rather than the home. They are directed towards poverty families and consist of one-year programs that provide health, nutritional, educational, social and psychological services to economically d isadvantaged pre-schoolers. Community Mental Health Centers and children's services departments, should and could deliver mental health services to family groups. The adult education programs of the public school system could and should offer parent training programs. The early periodic screening, diagnosis, and treatment programs have excellent records in providing health care for many children. However, these programs are only for Medicaid clients and only those clients who are motivated to present their children for screening. Another program that deserves mentioning is Parents Anonymous. This is a volunteer self-help program composed of child-abusing parents and patterned after Alcoholics Anonymous. Like AA, it provides these parents with an opportunity to talk over their common problems. However, unlike AA, The Parents Anonymous group has as its sponsor a social worker or another professional concerned with child abuse.
Conclusion Child abuse is a symptom complex of a family sickness that has as its etiology the impact of negative societal stresses upon a psychologically inadequate parent which surfaces at a crisis point and results in intentional, willful, physical, emotional, or psychological harm to a child.
Acknowledgment The writer wishes to acknowledge the help and contribution of Mrs. Edith A. Taub, Director of the Library, Methodist Hospital of Brooklyn, for obtaining reprints of the reference articles and Mrs. Marion Paige tor the typing and researching of th is manuscript.
Literature Cited in
1. Noshpitz JD: Issues and approaches child psychiatry. Hosp Community
Psychiatry 25:96-97, 1974 2. Caffey J: Multiple fractures in the long bones of infants suffering from chronic subdural hematoma. Am J Roentgenol 56(2):163-173, 1946 3. Kempe C, Helfer RE: Helping the battered child and his family. In The Battered Child, (ed 2). Chicago, University of Chicago Press, 1974, pp 120-122 4. Kempe CH, Silverman FN, Steele BF, et al: The battered-child syndrome. JAMA 181:(1)17-24, 1962 5. Wilcox DP: Child abuse laws: past, present, and future. Jour Forensic Sciences 21(1):71-75, 1976 6. DeFrancis V, Lucht C: Child abuse legislation in the 1970s, rev ed. Denver, The American Humane Association Childrens Division, 1974 7. Fontana VJ: The Maltreated Child: The Maltreatment Syndrome in Children. Springfield, Illinois, Charles C Thomas, 1971, pp 32-57 8. Alvy KT: Preventing child abuse. Am Psychol, 1975, pp 921-927 9. Solomon T: History and demography of child abuse. Pediatrics, 51(2):773-776, 1973 10. Nagi S: Child abuse and neglect programs: A national overview. Child Today, May-June, 1975 11. Congressional Record-Proceedings and Debates of the 93rd Congress, First Session (Senate). USA 119(39):S4444. pp 1-9. Washington (Tuesday, March 13, 1973) 12. Polansky NA, Hally C, Polansky NF: Profile of Neglect: A Survey of the state of knowledge of child neglect. US Department of Health, Education, and Welfare, Social and Rehabilitation Service, Community Services Administration, 1975 13. Ebeling NB, Hill DA (eds): Child Abuse: Invervention and Treatment. Acton, Massachusetts, Publishing Sciences Group, Inc, 1975, pp 58-65 14. Hindman M: Child abuse and neglect: The alcohol connection. Alcohol Health and Research World, 1977, pp 3-7 15. Child Abusers Often Given Medical Signals. The New York Times, Sunday, April 17, 1977, p 8 16. Kempe CH: Approaches to preventing child abuse: The health visitors concept. Am J Dis Child 130:941-947, 1976
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