Child Abuse-What the Pharmacist Should Know By Michael W. McKenzie, Ronald B. Stewart and Sally S. Roth
There was an old woman who lived in a shoe; She had so many children, she didn't know what to do. She gave them some broth without any bread Then whipped them all soundly and sent them to bed.
harmacists, who daily meet most of . the public seeking medical care, occupy a unique position among the health-related professions. With proper alertness to the problem of child abuse, they can perform a valuable health service to their communities by identifying children who are suspected of being at risk of abuse and then reporting them to an agency which can provide appropriate treatment for these children and their parents.
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findings on the national incidence of child abuse and coined the term "Battered Child Syndrome." These findings and a symposium held by the American Academy of Pediatrics provided the stimulus and attention needed to involve the medical profession to a greater degree. During the next five years more than 300 papers were published focusing on the incidence, clinical manifestations, social and psychological characteristics of the battered child and the responsible parent and the physician's responsibilities. 6
Background of Child Abuse Definition of the Battered Child West! in 1888, described several infants in a family suffering from acute periosteal swelling and was unable to associate these findings conclusively with any disease entity. Stone 2 in 1907, reported several cases of unexplained subperiosteal elevations seen on X-ray, and suggested there were many incidences of unexplained injuries to bones which are not recognized clinically. As recently as 1946, Caffey 3 noted multiple long bone fractures of unexplained origin in six children with subdural hematomas . He associated oile case as possible intentional abuse, but was unable to obtain a history of violence and did not make any conclusions as to etiology in all the cases. In 1953, Silverman 4 finally related metaphyseal fragmentation to unadmitted trauma and described the child abuse syndrome. In 1961, a group led by Kempe 5 published its
The term "Battered Child," intended to make an emotional impact on pediatricians, other health professionals and the public, was highly successful in focusing attention on the problems of child abuse, now reflected by the existence of reporting laws in all 50 states. The term "child abuse" is more comprehensive than severe physical abuse to children. It should encompass the entire spectrum of abuse; from parents who have the potential to abuse their children to the child who is severely beaten, neglected or killed. Delaney 7 defined child abuse as " . any Injury to the child's good health through physical violence, gross neglect or parental ignorance or unconcern. A child is physically abused if a parent willfully physically injures him; a child is physically abused if through parental
neglect he is not fed and becomes malnourished; a child is physically a bused if through parental neglect or unconcern in providing a protective environment, he suffers physical injuries; a child is emotionally abused if physical cruelty is allowed to continue; a child is intellectually abused if, as a result of his physical injuries, he suffers permanent brain damage a child (is) .. . emotionally abused if he does not receive the affection and guidance of his parents . . . " Kempe et al. 8 prefer the term "battered child" and define him as "any child who received nonaccidental physical injury (or injuries) as a result of acts (or o!TIissions) on the part of his parents or guardians." Many of the state reporting laws define child abuse more specifically. In Florida, the law defines child abuse or maltreatment as any person under 17 years of age who is exposed to neglect, malnutrition, severe physical injury other . than accidental means, and not provided with food, clothing, shelter or medical attention. Incidence of Child Abuse Accurate data on the incidence of child abuse are lacking. Estimates of the incidence range between 250 to 300 cases reported per million per population per year .9 These figures are based on two intensive reporting programs sponsored by the cities of Denver and Vol. NS 15, No. 4, April 1975
Z13
New York. In 1966 Zalba lo extrapolated on data from California and Colorado, and arrived at a conservative estimate ranging between 200,000 and 250,000 children in the U.S. needing protective services each year. Although reporting laws exist in all 50 states, not all make reporting mandatory. Four states-New Mexico, North Carolina, Texas and Washington, have made their laws permissive. II People cited in their laws "may report." The existence of mandatory reporting laws does not insure compliance, however. Other reasons why accurate data on the incidence of child abuse are difficult to obtain include-(l) varying definitions of child abuse, (2) many cases never come to the attention of medical personnel, (3) many cases which do come to the attention of health personnel are not suspected or diagnosed and (4) medical personnel do not want to "get involved" and do not report suspected cases of child abuse. Tables I- V (pages 215 and 216) provide information on child abuse statistics obtained from the Division of Family Services, Department of Health and Rehabilitative Services, State of Florida. These statistics were accumulated through a statewide child abuse registry system during the period October 1, 1971, to September 28, 1973, and include information on 48,814 reports. * The results of the investigations on 29,291 of the 48,814 reported children have been received in the ' Central Registry. The investigation revealed that reports on 17,662 of the children are valid and a variety of social services such as working with the parents to alleviate the social pro )lem, foster home care, emergency shelter care, placement with relatives and referral to other social agencies were initiated. Although accurate data are lacking, child abuse represents a significant hazard and may be one of the most common causes of injury and death in children. General Pattern of Child Abuse Cl}ild abuse can occur at any age, but Kempe et al. I2 have stated that the abused child is usually less than three years old. In another study by Elmer, 13 over one-half of the suspected cases were children under one year of age. The statistics from the Florida Child Abuse Registry show a fairly even distribution among all ages for reported cases. Age and sex distribution statistics for
*
The authors w ould like to acknowledge the asS"istance of the Division of Family Services, D ep artm ent of H ealth , and R ehabilitative Services, State of Florida, for making thei r dat a available.
214
Michael W. McKenzie, MS, is assistant professor of clinical pharmacy at the University of Florida college of pharmacy in Gainesville. He received his BS in pharmacy from Samford University in 1969 and his MS in pharmacy from the University of Florida in 1972. He has worked as a researcher in pediatrics on the epidemiologic study of adverse drug reactions conducted jointly by the University of Florida college of pharmacy and department of medicine. He is a member of APhA, ASHP, AACP, Rho Chi, Florida Pharmaceutical Association and the Florida Society of Hospital Pharmacists.
Ronald B. Stewart, MS, has been assistant professor of clinical pharmacy at the University of Florida since 1970. He earned his BS and MS in pharmacy from that school as well. Since 1969 he has served as a research associate on an epidemiologic study of adverse drug reactions conducted jointly by the University of Florida college of pharmacy and department of medicine. He serves on the scientific review panel of the APhA Drug Interactions Evaluation Program. He is a member of APhA, ASHP and AA CPo
Sally S. Roth, MD, is on the staff of the National 1nstitute of Arthritis, Metabolism and Digestive Diseases, National Institutes of Health, Bethesda, Maryland. A graduate of Case Western Reserve University school of medicine, Roth completed her internship and residency in pediatrics at Yale University . She served as a f ellow in ambulatory pediatrics at the University of Florida. There she also was on the faculty and codirector of the outpatient clinic and founder and chairperson of the child abuse program at Florida.
validated cases could not be obtained. Child abuse is not confined to the lower socio-economic population. Abused children come from all levels of the population. Fathers were responsible for about 38 percent of injuries in a study of 662 cases by De Francis,1 4 while mothers were responsible for about 29 percent of injuries. The primary caretaker, whoever he may be, is usually responsible. Parents inflicted about 73 percent of all injuries and were responsible for three of the four children who died. Kempe et al. 15 identify three major criteria for a child to be abused. First, a parent (or parents) must have the potential to abuse. This potential is composed of at least four factors1. The parents themselves were raised in a system in which they were, to an excessive degree, expected to perform well to gratify parental needs early in life, and then were punished severely for failure to do so. 2. The parents are isolated, often physically, with little capacity to love or trust others. They have little awareness of being loved and are in constant need of reassurance. When this reassurance from adults does not occur, they turn to their children for response to restore self-esteem. This is the socalled "role reversal."
Journal of the AMERICAN PHARMACEUTICAL ASSOCIATION
3. The spouse is usually very passive. They are unusually vulnerable to criticism or abandonment by the spouse. Correspondingly, one parent is usually the active batterer, while the other passively accepts and permits the child abuse. 4. The parents have unrealistic expectations from their child (or children). They have a style of child rearing characterized by an excessive demand for the child to perform to satisfy their needs. If the child does not meet these needs, then severe punishment occurs to discipline the child for proper behavior.
The second major criterion in the pattern of child abuse is the concept of a special child. This child is not considered normal by the parents although he or she may be quite normal. The child is seen as too stubborn, too smart, hyperactive, retarded, ugly, spoiled, blond, freckled, etc. There is a tendency for the parents to select one child and to repetitively abuse this child. The last major criterion must be a crisis (or series of crises), that initiates the abuse. The crisis can be major or minor, such as a broken-down car, broken window, divorce, lost job, no food and t;Specially illness. The crisis is probably the precipitating factor which leads to abusive action. A
TABLE I
TABLE II
Comparison of Reported Abuse by Sex and Race
Age Distribution by Reported Cases
1.
White male
19,030
Less than 1 year
3 , 311
9 years
2,693
1 year
3,378
10 years
2,913 2,481
2.
White female
18,803
2 years
3,721
11 years
3.
Black male
5,193
3 years
3,191
12 years.
2,760
4.
Black female
5,377
4 years
2,922
13 years
2,672
5.
Spanish surname male
6. Spanish surname female
145
5 years
2,858
14 years
2,684
141
6 years
2, 829
15 years
2,441
7.
Other male
68
7 years
2,919
16 years
1,942
8.
Other female
57
8 years
3,004 Total
17 years
95
popular misconception by the lay public is that child abuse is caused by parents who do not know their own strength when disciplining their child. Child abuse can be triggered by a combination of events and factors occurring at the right time and order. Using the analogy of firing a gun, the parent's childhood loads the gun, the child's failure to meet the parent's needs aims the gun, and life's problems and conflicts stimulate the parent to pull the trigger. 16 Types of Abuse
Physical abuse to children can take many forms. Beatings with pipes, electrical cords and ropes are frequent. Slamming the child against a wall or throwing him into the air and letting him fall can cause multiple bone fractures, bruises and internal bleeding. Physical torture has been reported- scalding water, cigarette burns, twisted fingers and arms, biting, shaking, etc. Intentional drug administration by par~nts to harm children has been reported . Dine 17 described a case of a 19-month old who presented in the emergency room with hyperpyrexia, convulsion and extrapyramidal signs which would disappear after two or three days of hospitalization. Investigation of the etiology of this condition revealed that the parents were administering the child perphenazine (Trilafon). Acts of neglect are reflected by maternal deprivation, failure to thrive and starvation. . Other acts of neglect protective include failure to provide environment for the child. Children may ingest toxic substances such as kerosene, bleach and drain cleanser that are left in readily accessible areas for children. A chjld was admitted to the Pediatric Intensive Care Unit of the Shands Teaching Hospital at the University .o f Florida following ingestion of an unknown amount of Darvon Compound-65. Upon investigation by the pharmacist, it was learned that the mother "allowed" the child to "play"
a
with prescription drug vials. The child had opened a drug vial and ingested the colorful Darvon Compound-65 capsules. These acts of omission and neglect are much more difficult to identify and rectify. Morbidity and Mortality Repetitive episodes of child injury are the rule rather than the exception in child abuse cases. If there is no intervention and a child returns home after a child abuse episode, Helfer 18 estimates that child to be at a 25 to 50-percent risk of permanent injury or death from another episode. Brain injury is a frequent consequence of physical abuse. In one study 43 percent of 42 physically abuse children had some neurologic dysfunction. 19 Two-thirds of the 43 percent had evidence of partial paralysis, blindness and decreased neurological reflexes. Mental retardation also is associated with severe head trauma. In the above study, 93 percent of the mental retarded children had a history of head trauma, and/or some abnormality on neurological examination. Retardation can also result from environmental deprivation. 20 Failure to love, feed, clothe and shelter children can re!mlt in profound physical and mental abnormalities. . The number of children who die from abuse cannot be accurately determined. Difficulties in diagnosis, reporting and definition of child abuse make estimated figures conservative. The first nationwide survey in 1962 found that 33 of 302 children died (11 percent). 21 The mortality has been determined by others 2 2,23 to be from 5 to 27 percent. However, it must certainly be low considering the expanded definition of child abuse. The prospect that violence breeds violence may be an outcome of child abuse. Curtis 24 has proposed that abused children would have an excessive degree of hostility toward their parents and society. In studies of murderers, a common history of violence in childhood was uncovered. There is much
48,814
evidence to demonstrate that children may grow up to become adults with violence as a prominent aspect of their behavior. Steele and Pollock 25 have stated that most parents of abused children were themselves abused as children. This supports the theory that violence is a self-perpetuating lifestyle. This is probably the most important sequela of child abuse: These children make poor parents, poor spouses and
A "battered child"
A photo of physical abuse to the back of a child. The wounds are the result of teeth bites. Vol. NS 15. No.4. April 1975
215
TABLE III
poor citizens requIrIng abnormal external ego supports throughout life ~hich perpetuate their weaknesses.
Prevention and Treatment The effects of physical battering on a child may be catastrophic- including permanent brain damage, retardation and death. Rehabilitation is very difficult once the central nervous system has incurred serious damage, therefore, emphasis is on prevention. With repeated attacks more damage may occur, so that intervention after early identification can be lifesaving. Identification of potentially abusive parents is the ideal prevention procedure so that psychotherapeutic intervention may be provided to prevent damage to unborn or born. Legislation of reporting laws, in itself, does not prevent child abuse. These laws bring the problem to the attention of the public and stimulate a mechanism for possible prevention. Other laws which provide punishment for offenders of criminal acts against children do not directly prevent or treat child abuse. The criminal process in law is not a solution to child abuse. It probably has some deterrent effect on parents capable of controlling their own conduct. Child abuse prevention and treatment requires cooperation from legal, social, psychiatric and medical workers . The fear of "getting involved" must be overcome. This fear is the principal cause of failure in reporting by front-line observers, such as teachers, physicians, pharmacists, nurses and private citizens. For this reason education is a prime instrument for prevention. People can become involved without fear of civil damage actions . The police usually are inclined to investigate a child abuse case only on criminal grounds. Protective welfare agencies have the trained personnel to intervene and determine the source of the problem. Trained volunteers, social workers, psychologists and psychiatrists are the referral personnel abused children and their parents must come in contact with. After identification of suspected child abuse, reporting to protective service agencies is the next step. Criminal action, if necessary, can be instituted later. The first priority is ensuring the safety of the child. It is important that efforts to identify child abuse do not supersede the emphasis for effective programs to treat parents of abused children. An effective community identification and referral system with cooperation among social, legal and medical personnel is mandatory for proper handling of child abuse cases. While 216
Types of Abuse Reported I.
Disorganized family life
12 ,899
10.
Sexual abuse
2.
Unattended
10,634
II.
Malnutrition
459
3.
Beatings
7,3 17
12.
Burns
323
4.
Lack offood, clothing and shelter
4,435
13.
Cuts
257
5.
Medical neglect
2,835
14.
Unknown
254
6.
Other
2,690
15 . Broken bones
7.
Abandonment
1,888
16.
Skull fracture
63
8.
Bruises
1,848
17.
Dea th on arrival
22
9.
School problems
1,379
18.
Death due to injury
15
1, 320
176
TABLE IV
Alleged Abusers I.
Mother
24,868
10.
Babysitter
429
2.
Both parents
10,642
II.
Aunt
285
3.
Father
7,520
12.
Grandparents
179
4.
Stepfather
1,607
13.
Uncle
159
5.
Other
949
14.
Grand father
138
6.
Grandmother
623
15 . Foster mother
99
7.
Mother's boyfriend
621
16.
Neighbor
82
8.
Unknown
429
17. Foster father
33
9.
Stepmother
294
TABLE V
Reporters of Child Abuse Nurse
I.
Neighbor
9,933
10.
2.
Relatives
6,561
3.
Police
4,776
II. Physician 12. Court Hospital
920 789 696 605
4.
Parent
4,754
13 .
5.
Other
4,674
14. Institutions
525 226
6.
Social worker
4,414
15.
7.
Anonymous
4,203
16. Clergy
163
8.
School
3,496
17. Attorney
144
9.
Division of youth services
1,935
the child is being treated for physical injuries, a rehabilitative program should be instituted for the parents. A reasonable goal of therapy described by Kempe et al. 26 would be that at least 75 percent of the children reported to have been abused should be residing safely in their homes within one year after the report was made . A small number of parents (less than 10 percent) of abused children are actually seriously mentally ill, i.e., psychotics and psychopaths. 27 These parents should be recognized early in a therapeutic program and referred to a mdre intensive psychiatric approach to their problems. The remaining majority can respond to therapeutic programs initiated by social workers, clinical psychologists and trained volunteers.
Journal of the AMERICAN PHARMACEUTICAL ASSOCIATION
D ay care center
Therapy is instituted to solve the problems of the parents. A positive therapeutic communicative rapport between therapist and patient is necessary for beneficial results. The needs of the parents are studied and evaluated and psychotherapy instituted in meeting everyday problems. It is essential that the therapist establish a trusting, communicative relationship so that the parent will turn to the therapist for help and not turn to a child who cannot meet his or her needs . Children may have to be temporarily removed from the home for their safety and placed in foster homes. Selection of foster parents should be done with great care to insure the proper environment, and that behavior characteristics of the child and foster parents do not
References
Glossary Sub-Periosteal Elevation-the portion of the bone (rich in blood su pply) ju st beneath the bone-forming, specialized connective tissue (periosteum) which surrounds all bones is elevated; in this case, trauma has caused bleeding and inflammation beneath the periosteum causing increased pressure and consequent swelling_ Periosteal Swelling-same as sub-periosteal elevation_ Subdural Hematoma-the tumor-like mass produced by bleeding and subsequent coagulation of blood beneath the dura mater covering of the brain_ Metaphyseal Fragmentation-the wider part at the end of the shaft of a long bone is shattered or fragmented; usually due to trauma.
hinder a growing, trusting attitude for the child. Foster parents who permit the abnormal adaptive behavior of an abused child to continue because it also satisfies their needs do not benefit the child_ Grandparents usually are not good choices for homes for abused children since the tendency for the parents to abuse their children may have been fostered from their parents. In summary, the foci of work for the cases of battered children are 28_ 1. Understanding the dynamics of the syndrome 2. Decreasing the resistance of professionals to consider the diagnosis 3. Protection of the life and neurologic integrity of the child 4. Legal, medical and social maneuvers to manage the child and family
Role of the Pharmacist Identification of abused children and reporting cases to a child protective service agency is the main role pharmacists can perform. Early identification may be life-saving, since some studies appear to demonstrate that severe permanent injury may not occur until of child after several episodes abuse. 29 - 31 Pharmacists should report cases even when there is only suspicion of child abuse. Abusive parents frequently seek medical care from multiple sources (physician offices, clinics, emergency rooms), which may be an attempt to conceal repetitive acts of abuse or may represent the parents' unrecognized "cry for help." 32 One of the sources parents may utilize is a pharmacist. The pharmacy may be utilized to purchase first aid material to treat cuts, bruises, burns and other injuries. Pharmacists can develop an index of suspicion by observing and communicating with children and /or parents in their pharmacy. Some of the factors to consider could be 33_
Parent1. Presents a contradictory history of
injury to the child
2. Shows detachment 3. Has delayed in bringing child in for
care 4. Reveals inappropriate awareness of seriousness of situation (either overreaction or underreaction) 5. Gives a history of repeated injury to the child 6. Has unrealistic expectations of the child 7. Is reluctant to give information 8. Projects cause of injury onto a sibling or third party
Child1. Has an unexplained injury 2. Shows evidence of dehydration and/or
malnutrition without obvious cause 3. Has been given inappropriate food ,
drink and/or drugs 4. Shows evidence of overall poor care 5. Shows evidence of repeated injury 6. Is seen as "different" or "bad" by the parents 7. Shows evidence of repeated skin injuries 8. Dressed inappropriately for degree or type of injury When some of these signs and symptoms are present , the pharmacist should be alerted to the possibility of child abuse. A suspected case should be reported to a local or state welfare protective service immediately. Although reporting laws vary from state to state, most grant immunity from civil liability to any person reporting a case of suspected abuse in good faith . As respected citizens in their community, pharmacists can greatly influence governmental and medical leaders to develop comprehensive, organized protective health services for families with the problem of child abuse. The establishment of a reporting system with a statewide toll free telephone number to call for registering cases of child abuse deserves support from the pharmacy profession. This registry can be most helpful to physicians, pharmacists, nurses, or other health professionals in determining if a child is being abused, since most cases of child abuse are multiple. Reference to this registry may be all that is needed to confirm a diagnosis which starts a child and his family on the road to rehabilitation. •
1. West} S., "Acute P eriosteal Swelling in Several Y?ung ~nfa nts of the Same Family, Probably Rickety In Nature," Brit. "fed. J., 1, 856 (1888) 2. Stone, J.S. , "Acu te Epiphyseal a nd Periosteal Infec::tions in Infants and C hil dren," Boston M ed. and Surg. J., 156, 842 (1907 ) ,). Caffey, J., "Multiple Fractu res in the Long Bones of Infa nts Suffering from Chronic Subdural H ematoma," Amer. J. Roentgenol., 56, 163 (1946 ) 4. Silverman, F.N. , " The Roentgen Manifestations of Un recognized Skeletal Trauma in Infa nts" Amer. J. Roentgenol., 69, 413 (1953) ,
5. Kempe, C. H. et al., "The Battered Child S yndrome," JAMA, 181,1 7 (1962) 6. Bibliography on the Battered Child, Clearinghouse for R esearch in Child Life, C hildren 's Bureau Department of H ealth, Education, and Welfare ( M ay 1966 ) 7. Delaney, D.W., " The Physically Abused Child," World M ed. J ., 13, 145 (Sept.-Oct. 1966) 8. Kempe, C. H. , and H elfer, R.E., cds., Helping the Battered Child and His Family, J .B. Lippincott Company, Philadelphia, Pa., XI (1972) 9. Ibid., XIII 10. Zalba, S.R. , The Abused C hild; l. A Survey of the Problem, Social Work, 11 , 3- 16 (Oct. 1966) 11. De Francis, V., " The Sta tus of C hild Protective Services," in rielping the Battered Child and His Family, Kempe, C.H . and Helfer, R.E., eds., 1.B. Lippincott Company, Philadelphia, Pa., 139 (1972) 12. Kempe, C.H. et al ., "The Battered Child Syndrome," op. cit. 13 . Elmer, E., " Identifica tion of Abused Children," Children, 10, 183 (Sept.-Oct. 1963 ) 14. De Francis, V., "Child Abuse- Preview of a N a ti onwid e Survey," Denve r, Colorado, Children 's Division, America n Humane Association (1963) 15. K empe, C .H., and Helfer, R.E., cds., Helping the Battered Child and His Family, op. cit., XIV 16. Milowe, LD., " Patterns of Pare n tal Be havior L eading to Physical Abuse of Chil dren." Presented a t workshop sponsored by the Children's Bureau in Coll aboratio n with the University of Colorado, Colorado Springs, Colorado, March 21-22, 1966 17. Dine, M.S., "Tranq uili ze r Poisoning- An Example of Child Abuse," Pedi atrics , 36, 782 (Nov. 1965) 18. Helfer, R.E., and Kempe, C.H., eds., The Battered Child, U niversity of Chicago Press, Chicago, III., 51 (1968) 19. Martin, H., "The Child and His D evelopment," in Helping the Battered Child and His Famiiy, Kempe, C.H. and Helfer, R.E. , eds., op. cit ., 95 20 . Patton, R.G., and Gardner, L.l., " Influence of Famil y Environment on Growth- The Syndrome of Maternal Deprivation," Pediat rics, 30, 957 (Dec. 1962 ) 21. Kempe, C.H. et al., " The Battered Child Syndrome," op. cit. 22. Helfer, R.E. , and Pollock, C.B., "The Battered Child Syndrome," in Advances in Pediatrics, V ol. 15, Yr. Bk. Pub., Chicago, 9 (1968) 23 . Radbill , S.x., "A History of Child Abuse and Infa nticid e," in The Battered Child, Helfer, R.E. and Kempe, C. H., eds., Universit y of Chicago Press, Chicago, III. , 16 (1968) 24. Cu r tis, G.C., "Violen ce Breeds Violence-Perhaps," Am. J. Psychiatry, 120, 386 (Oct. 1963) 25 . Steele, B.F., and Pollock, C.B. , ," A Psychiatric Study of Parents Who Abuse Infants a nd Small Children," in the B atte red Child, Helfer, R.E. a nd Kempe, C.H., (eds.), U niversity of Chic. Press, Chicago a nd London, III. (1968) 26. Kempe, C.H., and Helfer, R.E. , cds., Helping the Battered Child and His Family, op . cit., XII 27 . I bid. 28. Ibid., III 29. Holter, J.C., and Friedman, S.B., "PrincipJ es of Management in Chil d Abuse Cases," Amer. J. Orthopsychiat., 38, 127 (1968) 30. Holter, J.C., and Friedman,· S.B., "Child AbuseEarly Case Finding in the Emergency D e p a rt~ ment," Pediatrics , 42, 131 (1968) 31. Kempe, C.H. , a nd H elfer, R.E., eds. Helping the Battered Child and His Family, op . cit., 79
32. Ibid., 85 33 . Ibid., 73
Vol. NS 15, No . 4, April 1975
217
There was an old woman who lived in a shoe; She had so many children, she didn't know what to do. She gave them some broth without any bread Then whipped them all soundly and sent them to bed.
harmacists, who daily meet most of . the public seeking medical care, occupy a unique position among the health-related professions. With proper alertness to the problem of child abuse, they can perform a valuable health service to their communities by identifying children who are suspected of being at risk of abuse and then reporting them to an agency which can provide appropriate treatment for these children and their parents.
P
findings on the national incidence of child abuse and coined the term "Battered Child Syndrome." These findings and a symposium held by the American Academy of Pediatrics provided the stimulus and attention needed to involve the medical profession to a greater degree. During the next five years more than 300 papers were published focusing on the incidence, clinical manifestations, social and psychological characteristics of the battered child and the responsible parent and the physician's responsibilities. 6
Background of Child Abuse Definition of the Battered Child West! in 1888, described several infants in a family suffering from acute periosteal swelling and was unable to associate these findings conclusively with any disease entity. Stone 2 in 1907, reported several cases of unexplained subperiosteal elevations seen on X-ray, and suggested there were many incidences of unexplained injuries to bones which are not recognized clinically. As recently as 1946, Caffey 3 noted multiple long bone fractures of unexplained origin in six children with subdural hematomas . He associated oile case as possible intentional abuse, but was unable to obtain a history of violence and did not make any conclusions as to etiology in all the cases. In 1953, Silverman 4 finally related metaphyseal fragmentation to unadmitted trauma and described the child abuse syndrome. In 1961, a group led by Kempe 5 published its
The term "Battered Child," intended to make an emotional impact on pediatricians, other health professionals and the public, was highly successful in focusing attention on the problems of child abuse, now reflected by the existence of reporting laws in all 50 states. The term "child abuse" is more comprehensive than severe physical abuse to children. It should encompass the entire spectrum of abuse; from parents who have the potential to abuse their children to the child who is severely beaten, neglected or killed. Delaney 7 defined child abuse as " . any Injury to the child's good health through physical violence, gross neglect or parental ignorance or unconcern. A child is physically abused if a parent willfully physically injures him; a child is physically abused if through parental
neglect he is not fed and becomes malnourished; a child is physically a bused if through parental neglect or unconcern in providing a protective environment, he suffers physical injuries; a child is emotionally abused if physical cruelty is allowed to continue; a child is intellectually abused if, as a result of his physical injuries, he suffers permanent brain damage a child (is) .. . emotionally abused if he does not receive the affection and guidance of his parents . . . " Kempe et al. 8 prefer the term "battered child" and define him as "any child who received nonaccidental physical injury (or injuries) as a result of acts (or o!TIissions) on the part of his parents or guardians." Many of the state reporting laws define child abuse more specifically. In Florida, the law defines child abuse or maltreatment as any person under 17 years of age who is exposed to neglect, malnutrition, severe physical injury other . than accidental means, and not provided with food, clothing, shelter or medical attention. Incidence of Child Abuse Accurate data on the incidence of child abuse are lacking. Estimates of the incidence range between 250 to 300 cases reported per million per population per year .9 These figures are based on two intensive reporting programs sponsored by the cities of Denver and Vol. NS 15, No. 4, April 1975
Z13
New York. In 1966 Zalba lo extrapolated on data from California and Colorado, and arrived at a conservative estimate ranging between 200,000 and 250,000 children in the U.S. needing protective services each year. Although reporting laws exist in all 50 states, not all make reporting mandatory. Four states-New Mexico, North Carolina, Texas and Washington, have made their laws permissive. II People cited in their laws "may report." The existence of mandatory reporting laws does not insure compliance, however. Other reasons why accurate data on the incidence of child abuse are difficult to obtain include-(l) varying definitions of child abuse, (2) many cases never come to the attention of medical personnel, (3) many cases which do come to the attention of health personnel are not suspected or diagnosed and (4) medical personnel do not want to "get involved" and do not report suspected cases of child abuse. Tables I- V (pages 215 and 216) provide information on child abuse statistics obtained from the Division of Family Services, Department of Health and Rehabilitative Services, State of Florida. These statistics were accumulated through a statewide child abuse registry system during the period October 1, 1971, to September 28, 1973, and include information on 48,814 reports. * The results of the investigations on 29,291 of the 48,814 reported children have been received in the ' Central Registry. The investigation revealed that reports on 17,662 of the children are valid and a variety of social services such as working with the parents to alleviate the social pro )lem, foster home care, emergency shelter care, placement with relatives and referral to other social agencies were initiated. Although accurate data are lacking, child abuse represents a significant hazard and may be one of the most common causes of injury and death in children. General Pattern of Child Abuse Cl}ild abuse can occur at any age, but Kempe et al. I2 have stated that the abused child is usually less than three years old. In another study by Elmer, 13 over one-half of the suspected cases were children under one year of age. The statistics from the Florida Child Abuse Registry show a fairly even distribution among all ages for reported cases. Age and sex distribution statistics for
*
The authors w ould like to acknowledge the asS"istance of the Division of Family Services, D ep artm ent of H ealth , and R ehabilitative Services, State of Florida, for making thei r dat a available.
214
Michael W. McKenzie, MS, is assistant professor of clinical pharmacy at the University of Florida college of pharmacy in Gainesville. He received his BS in pharmacy from Samford University in 1969 and his MS in pharmacy from the University of Florida in 1972. He has worked as a researcher in pediatrics on the epidemiologic study of adverse drug reactions conducted jointly by the University of Florida college of pharmacy and department of medicine. He is a member of APhA, ASHP, AACP, Rho Chi, Florida Pharmaceutical Association and the Florida Society of Hospital Pharmacists.
Ronald B. Stewart, MS, has been assistant professor of clinical pharmacy at the University of Florida since 1970. He earned his BS and MS in pharmacy from that school as well. Since 1969 he has served as a research associate on an epidemiologic study of adverse drug reactions conducted jointly by the University of Florida college of pharmacy and department of medicine. He serves on the scientific review panel of the APhA Drug Interactions Evaluation Program. He is a member of APhA, ASHP and AA CPo
Sally S. Roth, MD, is on the staff of the National 1nstitute of Arthritis, Metabolism and Digestive Diseases, National Institutes of Health, Bethesda, Maryland. A graduate of Case Western Reserve University school of medicine, Roth completed her internship and residency in pediatrics at Yale University . She served as a f ellow in ambulatory pediatrics at the University of Florida. There she also was on the faculty and codirector of the outpatient clinic and founder and chairperson of the child abuse program at Florida.
validated cases could not be obtained. Child abuse is not confined to the lower socio-economic population. Abused children come from all levels of the population. Fathers were responsible for about 38 percent of injuries in a study of 662 cases by De Francis,1 4 while mothers were responsible for about 29 percent of injuries. The primary caretaker, whoever he may be, is usually responsible. Parents inflicted about 73 percent of all injuries and were responsible for three of the four children who died. Kempe et al. 15 identify three major criteria for a child to be abused. First, a parent (or parents) must have the potential to abuse. This potential is composed of at least four factors1. The parents themselves were raised in a system in which they were, to an excessive degree, expected to perform well to gratify parental needs early in life, and then were punished severely for failure to do so. 2. The parents are isolated, often physically, with little capacity to love or trust others. They have little awareness of being loved and are in constant need of reassurance. When this reassurance from adults does not occur, they turn to their children for response to restore self-esteem. This is the socalled "role reversal."
Journal of the AMERICAN PHARMACEUTICAL ASSOCIATION
3. The spouse is usually very passive. They are unusually vulnerable to criticism or abandonment by the spouse. Correspondingly, one parent is usually the active batterer, while the other passively accepts and permits the child abuse. 4. The parents have unrealistic expectations from their child (or children). They have a style of child rearing characterized by an excessive demand for the child to perform to satisfy their needs. If the child does not meet these needs, then severe punishment occurs to discipline the child for proper behavior.
The second major criterion in the pattern of child abuse is the concept of a special child. This child is not considered normal by the parents although he or she may be quite normal. The child is seen as too stubborn, too smart, hyperactive, retarded, ugly, spoiled, blond, freckled, etc. There is a tendency for the parents to select one child and to repetitively abuse this child. The last major criterion must be a crisis (or series of crises), that initiates the abuse. The crisis can be major or minor, such as a broken-down car, broken window, divorce, lost job, no food and t;Specially illness. The crisis is probably the precipitating factor which leads to abusive action. A
TABLE I
TABLE II
Comparison of Reported Abuse by Sex and Race
Age Distribution by Reported Cases
1.
White male
19,030
Less than 1 year
3 , 311
9 years
2,693
1 year
3,378
10 years
2,913 2,481
2.
White female
18,803
2 years
3,721
11 years
3.
Black male
5,193
3 years
3,191
12 years.
2,760
4.
Black female
5,377
4 years
2,922
13 years
2,672
5.
Spanish surname male
6. Spanish surname female
145
5 years
2,858
14 years
2,684
141
6 years
2, 829
15 years
2,441
7.
Other male
68
7 years
2,919
16 years
1,942
8.
Other female
57
8 years
3,004 Total
17 years
95
popular misconception by the lay public is that child abuse is caused by parents who do not know their own strength when disciplining their child. Child abuse can be triggered by a combination of events and factors occurring at the right time and order. Using the analogy of firing a gun, the parent's childhood loads the gun, the child's failure to meet the parent's needs aims the gun, and life's problems and conflicts stimulate the parent to pull the trigger. 16 Types of Abuse
Physical abuse to children can take many forms. Beatings with pipes, electrical cords and ropes are frequent. Slamming the child against a wall or throwing him into the air and letting him fall can cause multiple bone fractures, bruises and internal bleeding. Physical torture has been reported- scalding water, cigarette burns, twisted fingers and arms, biting, shaking, etc. Intentional drug administration by par~nts to harm children has been reported . Dine 17 described a case of a 19-month old who presented in the emergency room with hyperpyrexia, convulsion and extrapyramidal signs which would disappear after two or three days of hospitalization. Investigation of the etiology of this condition revealed that the parents were administering the child perphenazine (Trilafon). Acts of neglect are reflected by maternal deprivation, failure to thrive and starvation. . Other acts of neglect protective include failure to provide environment for the child. Children may ingest toxic substances such as kerosene, bleach and drain cleanser that are left in readily accessible areas for children. A chjld was admitted to the Pediatric Intensive Care Unit of the Shands Teaching Hospital at the University .o f Florida following ingestion of an unknown amount of Darvon Compound-65. Upon investigation by the pharmacist, it was learned that the mother "allowed" the child to "play"
a
with prescription drug vials. The child had opened a drug vial and ingested the colorful Darvon Compound-65 capsules. These acts of omission and neglect are much more difficult to identify and rectify. Morbidity and Mortality Repetitive episodes of child injury are the rule rather than the exception in child abuse cases. If there is no intervention and a child returns home after a child abuse episode, Helfer 18 estimates that child to be at a 25 to 50-percent risk of permanent injury or death from another episode. Brain injury is a frequent consequence of physical abuse. In one study 43 percent of 42 physically abuse children had some neurologic dysfunction. 19 Two-thirds of the 43 percent had evidence of partial paralysis, blindness and decreased neurological reflexes. Mental retardation also is associated with severe head trauma. In the above study, 93 percent of the mental retarded children had a history of head trauma, and/or some abnormality on neurological examination. Retardation can also result from environmental deprivation. 20 Failure to love, feed, clothe and shelter children can re!mlt in profound physical and mental abnormalities. . The number of children who die from abuse cannot be accurately determined. Difficulties in diagnosis, reporting and definition of child abuse make estimated figures conservative. The first nationwide survey in 1962 found that 33 of 302 children died (11 percent). 21 The mortality has been determined by others 2 2,23 to be from 5 to 27 percent. However, it must certainly be low considering the expanded definition of child abuse. The prospect that violence breeds violence may be an outcome of child abuse. Curtis 24 has proposed that abused children would have an excessive degree of hostility toward their parents and society. In studies of murderers, a common history of violence in childhood was uncovered. There is much
48,814
evidence to demonstrate that children may grow up to become adults with violence as a prominent aspect of their behavior. Steele and Pollock 25 have stated that most parents of abused children were themselves abused as children. This supports the theory that violence is a self-perpetuating lifestyle. This is probably the most important sequela of child abuse: These children make poor parents, poor spouses and
A "battered child"
A photo of physical abuse to the back of a child. The wounds are the result of teeth bites. Vol. NS 15. No.4. April 1975
215
TABLE III
poor citizens requIrIng abnormal external ego supports throughout life ~hich perpetuate their weaknesses.
Prevention and Treatment The effects of physical battering on a child may be catastrophic- including permanent brain damage, retardation and death. Rehabilitation is very difficult once the central nervous system has incurred serious damage, therefore, emphasis is on prevention. With repeated attacks more damage may occur, so that intervention after early identification can be lifesaving. Identification of potentially abusive parents is the ideal prevention procedure so that psychotherapeutic intervention may be provided to prevent damage to unborn or born. Legislation of reporting laws, in itself, does not prevent child abuse. These laws bring the problem to the attention of the public and stimulate a mechanism for possible prevention. Other laws which provide punishment for offenders of criminal acts against children do not directly prevent or treat child abuse. The criminal process in law is not a solution to child abuse. It probably has some deterrent effect on parents capable of controlling their own conduct. Child abuse prevention and treatment requires cooperation from legal, social, psychiatric and medical workers . The fear of "getting involved" must be overcome. This fear is the principal cause of failure in reporting by front-line observers, such as teachers, physicians, pharmacists, nurses and private citizens. For this reason education is a prime instrument for prevention. People can become involved without fear of civil damage actions . The police usually are inclined to investigate a child abuse case only on criminal grounds. Protective welfare agencies have the trained personnel to intervene and determine the source of the problem. Trained volunteers, social workers, psychologists and psychiatrists are the referral personnel abused children and their parents must come in contact with. After identification of suspected child abuse, reporting to protective service agencies is the next step. Criminal action, if necessary, can be instituted later. The first priority is ensuring the safety of the child. It is important that efforts to identify child abuse do not supersede the emphasis for effective programs to treat parents of abused children. An effective community identification and referral system with cooperation among social, legal and medical personnel is mandatory for proper handling of child abuse cases. While 216
Types of Abuse Reported I.
Disorganized family life
12 ,899
10.
Sexual abuse
2.
Unattended
10,634
II.
Malnutrition
459
3.
Beatings
7,3 17
12.
Burns
323
4.
Lack offood, clothing and shelter
4,435
13.
Cuts
257
5.
Medical neglect
2,835
14.
Unknown
254
6.
Other
2,690
15 . Broken bones
7.
Abandonment
1,888
16.
Skull fracture
63
8.
Bruises
1,848
17.
Dea th on arrival
22
9.
School problems
1,379
18.
Death due to injury
15
1, 320
176
TABLE IV
Alleged Abusers I.
Mother
24,868
10.
Babysitter
429
2.
Both parents
10,642
II.
Aunt
285
3.
Father
7,520
12.
Grandparents
179
4.
Stepfather
1,607
13.
Uncle
159
5.
Other
949
14.
Grand father
138
6.
Grandmother
623
15 . Foster mother
99
7.
Mother's boyfriend
621
16.
Neighbor
82
8.
Unknown
429
17. Foster father
33
9.
Stepmother
294
TABLE V
Reporters of Child Abuse Nurse
I.
Neighbor
9,933
10.
2.
Relatives
6,561
3.
Police
4,776
II. Physician 12. Court Hospital
920 789 696 605
4.
Parent
4,754
13 .
5.
Other
4,674
14. Institutions
525 226
6.
Social worker
4,414
15.
7.
Anonymous
4,203
16. Clergy
163
8.
School
3,496
17. Attorney
144
9.
Division of youth services
1,935
the child is being treated for physical injuries, a rehabilitative program should be instituted for the parents. A reasonable goal of therapy described by Kempe et al. 26 would be that at least 75 percent of the children reported to have been abused should be residing safely in their homes within one year after the report was made . A small number of parents (less than 10 percent) of abused children are actually seriously mentally ill, i.e., psychotics and psychopaths. 27 These parents should be recognized early in a therapeutic program and referred to a mdre intensive psychiatric approach to their problems. The remaining majority can respond to therapeutic programs initiated by social workers, clinical psychologists and trained volunteers.
Journal of the AMERICAN PHARMACEUTICAL ASSOCIATION
D ay care center
Therapy is instituted to solve the problems of the parents. A positive therapeutic communicative rapport between therapist and patient is necessary for beneficial results. The needs of the parents are studied and evaluated and psychotherapy instituted in meeting everyday problems. It is essential that the therapist establish a trusting, communicative relationship so that the parent will turn to the therapist for help and not turn to a child who cannot meet his or her needs . Children may have to be temporarily removed from the home for their safety and placed in foster homes. Selection of foster parents should be done with great care to insure the proper environment, and that behavior characteristics of the child and foster parents do not
References
Glossary Sub-Periosteal Elevation-the portion of the bone (rich in blood su pply) ju st beneath the bone-forming, specialized connective tissue (periosteum) which surrounds all bones is elevated; in this case, trauma has caused bleeding and inflammation beneath the periosteum causing increased pressure and consequent swelling_ Periosteal Swelling-same as sub-periosteal elevation_ Subdural Hematoma-the tumor-like mass produced by bleeding and subsequent coagulation of blood beneath the dura mater covering of the brain_ Metaphyseal Fragmentation-the wider part at the end of the shaft of a long bone is shattered or fragmented; usually due to trauma.
hinder a growing, trusting attitude for the child. Foster parents who permit the abnormal adaptive behavior of an abused child to continue because it also satisfies their needs do not benefit the child_ Grandparents usually are not good choices for homes for abused children since the tendency for the parents to abuse their children may have been fostered from their parents. In summary, the foci of work for the cases of battered children are 28_ 1. Understanding the dynamics of the syndrome 2. Decreasing the resistance of professionals to consider the diagnosis 3. Protection of the life and neurologic integrity of the child 4. Legal, medical and social maneuvers to manage the child and family
Role of the Pharmacist Identification of abused children and reporting cases to a child protective service agency is the main role pharmacists can perform. Early identification may be life-saving, since some studies appear to demonstrate that severe permanent injury may not occur until of child after several episodes abuse. 29 - 31 Pharmacists should report cases even when there is only suspicion of child abuse. Abusive parents frequently seek medical care from multiple sources (physician offices, clinics, emergency rooms), which may be an attempt to conceal repetitive acts of abuse or may represent the parents' unrecognized "cry for help." 32 One of the sources parents may utilize is a pharmacist. The pharmacy may be utilized to purchase first aid material to treat cuts, bruises, burns and other injuries. Pharmacists can develop an index of suspicion by observing and communicating with children and /or parents in their pharmacy. Some of the factors to consider could be 33_
Parent1. Presents a contradictory history of
injury to the child
2. Shows detachment 3. Has delayed in bringing child in for
care 4. Reveals inappropriate awareness of seriousness of situation (either overreaction or underreaction) 5. Gives a history of repeated injury to the child 6. Has unrealistic expectations of the child 7. Is reluctant to give information 8. Projects cause of injury onto a sibling or third party
Child1. Has an unexplained injury 2. Shows evidence of dehydration and/or
malnutrition without obvious cause 3. Has been given inappropriate food ,
drink and/or drugs 4. Shows evidence of overall poor care 5. Shows evidence of repeated injury 6. Is seen as "different" or "bad" by the parents 7. Shows evidence of repeated skin injuries 8. Dressed inappropriately for degree or type of injury When some of these signs and symptoms are present , the pharmacist should be alerted to the possibility of child abuse. A suspected case should be reported to a local or state welfare protective service immediately. Although reporting laws vary from state to state, most grant immunity from civil liability to any person reporting a case of suspected abuse in good faith . As respected citizens in their community, pharmacists can greatly influence governmental and medical leaders to develop comprehensive, organized protective health services for families with the problem of child abuse. The establishment of a reporting system with a statewide toll free telephone number to call for registering cases of child abuse deserves support from the pharmacy profession. This registry can be most helpful to physicians, pharmacists, nurses, or other health professionals in determining if a child is being abused, since most cases of child abuse are multiple. Reference to this registry may be all that is needed to confirm a diagnosis which starts a child and his family on the road to rehabilitation. •
1. West} S., "Acute P eriosteal Swelling in Several Y?ung ~nfa nts of the Same Family, Probably Rickety In Nature," Brit. "fed. J., 1, 856 (1888) 2. Stone, J.S. , "Acu te Epiphyseal a nd Periosteal Infec::tions in Infants and C hil dren," Boston M ed. and Surg. J., 156, 842 (1907 ) ,). Caffey, J., "Multiple Fractu res in the Long Bones of Infa nts Suffering from Chronic Subdural H ematoma," Amer. J. Roentgenol., 56, 163 (1946 ) 4. Silverman, F.N. , " The Roentgen Manifestations of Un recognized Skeletal Trauma in Infa nts" Amer. J. Roentgenol., 69, 413 (1953) ,
5. Kempe, C. H. et al., "The Battered Child S yndrome," JAMA, 181,1 7 (1962) 6. Bibliography on the Battered Child, Clearinghouse for R esearch in Child Life, C hildren 's Bureau Department of H ealth, Education, and Welfare ( M ay 1966 ) 7. Delaney, D.W., " The Physically Abused Child," World M ed. J ., 13, 145 (Sept.-Oct. 1966) 8. Kempe, C. H. , and H elfer, R.E., cds., Helping the Battered Child and His Family, J .B. Lippincott Company, Philadelphia, Pa., XI (1972) 9. Ibid., XIII 10. Zalba, S.R. , The Abused C hild; l. A Survey of the Problem, Social Work, 11 , 3- 16 (Oct. 1966) 11. De Francis, V., " The Sta tus of C hild Protective Services," in rielping the Battered Child and His Family, Kempe, C.H . and Helfer, R.E., eds., 1.B. Lippincott Company, Philadelphia, Pa., 139 (1972) 12. Kempe, C.H. et al ., "The Battered Child Syndrome," op. cit. 13 . Elmer, E., " Identifica tion of Abused Children," Children, 10, 183 (Sept.-Oct. 1963 ) 14. De Francis, V., "Child Abuse- Preview of a N a ti onwid e Survey," Denve r, Colorado, Children 's Division, America n Humane Association (1963) 15. K empe, C .H., and Helfer, R.E., cds., Helping the Battered Child and His Family, op. cit., XIV 16. Milowe, LD., " Patterns of Pare n tal Be havior L eading to Physical Abuse of Chil dren." Presented a t workshop sponsored by the Children's Bureau in Coll aboratio n with the University of Colorado, Colorado Springs, Colorado, March 21-22, 1966 17. Dine, M.S., "Tranq uili ze r Poisoning- An Example of Child Abuse," Pedi atrics , 36, 782 (Nov. 1965) 18. Helfer, R.E., and Kempe, C.H., eds., The Battered Child, U niversity of Chicago Press, Chicago, III., 51 (1968) 19. Martin, H., "The Child and His D evelopment," in Helping the Battered Child and His Famiiy, Kempe, C.H. and Helfer, R.E. , eds., op. cit ., 95 20 . Patton, R.G., and Gardner, L.l., " Influence of Famil y Environment on Growth- The Syndrome of Maternal Deprivation," Pediat rics, 30, 957 (Dec. 1962 ) 21. Kempe, C.H. et al., " The Battered Child Syndrome," op. cit. 22. Helfer, R.E. , and Pollock, C.B., "The Battered Child Syndrome," in Advances in Pediatrics, V ol. 15, Yr. Bk. Pub., Chicago, 9 (1968) 23 . Radbill , S.x., "A History of Child Abuse and Infa nticid e," in The Battered Child, Helfer, R.E. and Kempe, C. H., eds., Universit y of Chicago Press, Chicago, III. , 16 (1968) 24. Cu r tis, G.C., "Violen ce Breeds Violence-Perhaps," Am. J. Psychiatry, 120, 386 (Oct. 1963) 25 . Steele, B.F., and Pollock, C.B. , ," A Psychiatric Study of Parents Who Abuse Infants a nd Small Children," in the B atte red Child, Helfer, R.E. a nd Kempe, C.H., (eds.), U niversity of Chic. Press, Chicago a nd London, III. (1968) 26. Kempe, C.H., and Helfer, R.E. , cds., Helping the Battered Child and His Family, op . cit., XII 27 . I bid. 28. Ibid., III 29. Holter, J.C., and Friedman, S.B., "PrincipJ es of Management in Chil d Abuse Cases," Amer. J. Orthopsychiat., 38, 127 (1968) 30. Holter, J.C., and Friedman,· S.B., "Child AbuseEarly Case Finding in the Emergency D e p a rt~ ment," Pediatrics , 42, 131 (1968) 31. Kempe, C.H. , a nd H elfer, R.E., eds. Helping the Battered Child and His Family, op . cit., 79
32. Ibid., 85 33 . Ibid., 73
Vol. NS 15, No . 4, April 1975
217
