Child Abuse & Neglecl, Vol. 15, PP. 437-445, Printed in the U.S.A. All rights reserved.
1991 Copyright
0145-2134/91 $3.00 + .OO Q I99 Pergamon Press plc
I
CHILDREN HOSPITALIZED WITH CHILD ABUSE AND NEGLECF A CASE-CONTROL STUDY J. A. S. SMITH AND R. G. ADLER Department of General Pediatrics, Royal Children’s Hospital, Parkville, Australia
Abstract-A case-control study of 45 hospitalized abused children was conducted to reassess the risk factors for child abuse when confounding by social class was minimized. Cases were matched for age, sex, family structure, and social class with children admitted to hospital for an acute illness. Abused children were more likely to have younger parents, fewer siblings, and to have been separated from their mothers during the first year of life. Their parents were more likely to have been abused as children and to have a poor relationship with the child’s other parent. The families of abused children had encountered more stressful life events in the preceding 12 months. Other previously recognized “risk factors” were not shown to have a statistically significant association with child abuse. Because child abuse is more prevalent in lower socioeconomic families, the association with many of these factors has been accepted as implying a causal relationship. Matching procedures which attempted to eliminate confounding by social class and family structure cast doubts on some previously held beliefs about the risk factors for child abuse. Key Words-Child abuse, Risk factors, Physical abuse, Neglect, Social class.
INTRODUCTION ALTHOUGH ABUSIVE ACTS towards children have varied over the centuries and between cultures, some children have been subjected to violence, neglect, or maltreatment since earliest recorded history. As in 19th century Britain where children of the poor made up the child labor work force, tales of physical abuse and neglect have centered on the maltreatment of children predominantly from lower social class families. Early descriptions of “battered babies” included details of the higher incidence of physical abuse in lower social class families. Gil ( 1969) commented on the pattern of more severe abuse in poorer families with most abuse being in the extremely disadvantaged social class. He addressed the issues of reporting bias, the additional life stresses associated with poverty, and the tendency of lower class socialization to accept a more direct expression of aggressive impulses. Some of the initial papers on child abuse and neglect disputed the association between social class and child abuse. Kempe (1962) claimed that physical abuse and neglect occurred across all strata of society; thus the incidence of child abuse was much higher than was suggested by the available data. He postulated that private physicians were less likely to diagnose nonaccidental injury or neglect. If the diagnosis was made, they were less likely to report middle and upper class families to the authorities. Families living in poverty were under closer scrutiny from a variety of agencies; thus nonaccidental injuries were more likely to be detected. Garbarino and Crouter (1978) noted a tendency for institutions to report lower socioeconomic families more readily. However, they also noted a strong positive relationship between higher income and the likelihood that maltreatment will be reported by family, Received for publication March 9, 1989; final revision received June 1 I, 1990; accepted June 12, 1990. Requests for reprints should be sent to Dr. J. Anne S. Smith, Department of General Pediatrics, Royal Children’s Hospital, Flemington Rd., Parkville, Victoria, Australia 3052. 43-l
438
J. A. S. Smith and R. C. Adler
friends, and neighbors. They concluded that these two factors balanced each other out and discounted the theory that biased reporting accounted for the negative correlation between social class and child maltreatment. Pelton (1978) strongly rejected the “myth of classlessness.” He also noted the strong association between social class and childhood neglect and commented on “the hazardous poverty environment that heightens the dangerousness of child neglect.” Data from other studies supported the theory that physical abuse and neglect is associated with poverty, Johnson and Morse (1968) described the poor economic conditions of their study group in Denver where “most families lived in the city’s slums.” Creighton ( 1985) noted the high incidence of criminality, marital instability, mobility and unemployment in the parents of abused children. A disproportionate number of parents in the Toronto study were from lower socioeconomic families (Caplan 1984). In 1986, Krugman analyzed the data for child abuse and unemployment in Denver from 1964 to 1985 and found a strong correlation between the unemployment rate and the number of physical abuse cases seen (? = .66, p =c .OOl) (Krugman, Lenherr, Betz, & Fryer, 1986). Childhood accidents (both accidental and nonaccidental) have been shown to be more prevalent in children of lower social class families. Brown and Davidson (1978) concluded that accident risk to children is associated with both a working-class status and depression in the mother. All of the children who died from nonaccidental injuries in Nixon’s Queensland study (Nixon, Pearn, Wilkey, & Petrie, 1981) were from lower socioeconomic groups. Much of the literature published over the last 20 years on child abuse has been descriptive in nature and has suffered from a number of methodological flaws (Plotkin, Azar, Twentyman, & Perri, 198 1). Leventhal’s assessment ( 198 1) of 22 case-control studies investigating two risk factors, ( 1) prematurity or low birth weight of the abused child and (2) young maternal age of the mother of the abused child, revealed that no study satisfied all of the criteria to minimize bias or distortion of the results. Much of the research has been retrospective, has involved nonspecific control groups, and has introduced significant bias. Prospective studies have been plagued by difficulties with follow-up of this highly mobile and often uncooperative population. This study was performed in an attempt to assess the risk factors for child abuse when children were matched for age, sex, family structure, and social class with children admitted to hospital for acute illness. We hypothesized that many previously reported “risk factors” for child abuse are related to social class and family structure. The close matching procedures were undertaken in an attempt to minimize confounding by these two variables.
METHOD Between April 1987 and April 1988, 6 1 children were admitted to the Royal Children’s Hospital, Melbourne, because of suspected maltreatment. These cases were identified by one of three methods. First, hospital records were screened for an admission diagnosis of “nonaccidental injury” and “child at risk.” Children were considered for the study if the child had injuries which were considered by the admitting officer to be nonaccidental or showed physical signs of neglect, Second, records from the social work department were scrutinized and contact with social workers of the child abuse team was maintained to detect children admitted to specialist departments with nonaccidental injuries. For example, children admitted to neurosurgery or orthopedic wards may not be readily identified as abused from either the admission or discharge diagnoses. Third, a vigil was maintained on admissions to the general medical wards to identify children admitted because of nonaccidental injuries or neglect. In no instance was a child admitted because of suspected abuse but further investigation revealed
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Table 1. The Abused children Age Sex
Social Class Family Structure
Range 1 month- 14 years 2 months, median 17 months 60% males 82% in the lowest 2 (of 6) levels 25 dual parents-20 biological, 5 reconstituted 20 single parents, I9 single mothers
the injury to be definitely accidental. Children were included in the study, however, if the injury remained unexplained or if professionals associated with the case considered the injury might have been nonaccidental. Of the 6 1 identified children, 45 parents agreed to participate in the study. These families were representative of the group as a whole with respect to the age and sex of the child, family structure, social class, and severity of injury. Each child was matched with another in-patient of the same age (within 2 months for children under 2 years and within 6 months for older children), sex, family structure and social class. Controls were selected as the next child of the appropriate age, sex, and family structure, and of the same social class group as the index child. Family structure was defined as either single-parent or two-parent family at the time of the child’s admission to the hospital. Broom’s criteria for defining social class based on the occupation of the major wage earner was used (Broom, Jones, & Zubrzycki, 1965). Each control child had an acute illness (defined as less than three admissions to the hospital for the same condition). All of the control children were admitted under the general medical teams which investigated and managed the abused children. None of the control children were known to have been abused, although because of matching for social class, many lived in socioeconomically deprived families. A semistructured interview lasting one hour was conducted with a parent, usually the mother, and the child was examined in the ward. The interview was conducted in a private room on the medical ward. An initial questionnaire was completed by the researcher to assess the recognized risk factors for child abuse. Most questions were coded as direct responses, but several risk factors were coded as an assessment made by the interviewer. For example, a history of abuse in the parent’s childhood was addressed by the interviewer after three approaches. In different parts of the interview the parent was asked, “When you were young, did anyone ever beat you or treat you badly? What was it like for you when you were a child? and How did you get on with your Mum and Dad when you were little?” If the parent disclosed physical injuries or discipline with an instrument, this was judged to be abuse. Abuse was also recorded if the mother said, “My father treated me badly. . .but I’d rather not talk about it.” Included in the assessment was a “stress score” of events experienced by the families during the preceding 12 months. The score used was a modification of Beautrais and Fergusson’s stress score used in New Zealand (Beautrais, Fergusson, & Shannon, 1982). The major factors considered related to health, occupational stability, and stability of living conditions of the families, as well as interpersonal relationships of the parents. Consent was obtained from all participating families. All interviews and questionnaires were completed by the principal author. This report is the first stage of a prospective study of children admitted to hospital because of physical abuse and neglect. The list of risk factors was compiled after an extensive review of the literature but did not include an assessment of the psychological profile of the parents. Statistical analysis was conducted using SPSS (Statistical Package for the Social Sciences) with the 5% level chosen as the arbitrary level of significance. RESULTS The general characteristics of the sample are set out in Table 1. First or second born children accounted for 79% of the abused group: 45% first born, and 34% second born. There
J. A. S. Smith and R. G. Adler
440 Table 2. Significant
Difference
Between Abused and Control Families
Risk Factor
Abused (n = 451
Control (n = 45)
D value
Age of Mother Age of Father Mother Abused as Child Father Abused as Child Number of Separations (Mean) Child Described as Frequently or Usually Aggressive Parental Relationship (Mean) Stress Factors n = 19 (Mean)
25.9 + I 28.1 + 8 21 15 1.222
29.6 + 6 32.2 f 9 I 6 0.444
0.0208 0.0302 0.0029 0.0370 0.0193
10 2.46 4.9
2 3.64 3.4
0.0456 0.0045 0.0084
was a statistically significant difference between the abused and control groups when the presence of other children in the house was assessed. Abused children were likely to have fewer other children in the house than controls (Kruskall-Wallis; p = .0039). Comparison of abused and control families revealed a number of statistically significant differences. These are detailed in Table 2. Mothers and fathers of abused children were younger than control parents. A maternal history of child abuse was noted in 47% of mothers of abused children and 16% of control mothers. A paternal history of child abuse was noted in 33% of fathers of abused children and 13% of control fathers. The number of separations (of more than 24 hours) between the child and mother in the first 12 months of life was significantly different (r, = .0193) with abused children being separated on more occasions and for a longer duration of time 0, = .002 1). When separations occurred, the caretakers were similar for both groups of children. The reasons for separations were also not detectably different. (These were assessed as maternal or child ill-health, custody arrangements, parental relief, or involuntary separations at the instigation of an outside agency.) When parents were asked to rate their current relationship with the child’s other biological parent on a 5-point scale, abusive parents rated their relationships significantly worse than the control group (Mann-Whitney; p = .0045). Many abusive parents no longer had any contact with the child’s other parent or regarded their relationship as extremely poor or fair. Physical arguments between parents were reported more often in abusive parents ( 13 abusive families compared to 5 control families), but this did not reach statistical significance. A stress score of stressful life events encountered by the families over the 12 months prior to presentation to hospital was significantly different between the two groups (p = .0084). Of the abusive families, 27 had recently changed residences compared to 12 of the control families. A recent assault was reported by 12 parents of abused children compared to 3 of the control parents. However, some factors were similar between the two groups: For example, 26 of the abusive parents and 22 of the control parents reported a recent pregnancy. There was no significant difference between groups on many measures. These are set out in Table 3. The trend towards abusive parents being more likely to state that they had housing problems ( 17 abusive families and 8 controls.) but not financial difficulties was noted. When parents in both groups were asked about the family history of drug or alcohol abuse, nine abusive parents and six control families admitted to this problem. Psychiatric treatment had been received by 14 abusive parents and 6 control parents. Criminal activity resulting in the involvement of the police was reported for 17 abusive parents and 8 control families. Although conflict with the law approached statistical significance, none of these three factors was statistically significant at the 5% level. The antenatal course, perception of labor, and the incidence of complications during the perinatal period were not statistically different in the abused and control populations. Of
Hospitalized child abuse and neglect cases
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Table 3. No Significant Difference Between Abused and Control Families Risk Factor
Abused cn = 45)
Control (n = 45)
15 15 17 19 13 9 14 17 39 32 30 27
10 9 8 14 5 6 6 8 39 27 29 29
33
41
No Supportfrom Family No Suooort from Friends Housing Problems Financial Problems (Debts) Physical Arguments
Drilguse Psvchiatric Treatment C&lict with Law No Problems at Birth No Colic No Feeding Problems No Sleeping Problems No Markers of Concern for Any Child in the Family
equal importance, both groups were similar in their assessments of whether the pregnancy was planned and also whether the child was “wanted” even if not planned. The prevalence of prematurity, growth retardation, and congenital abnormalities was similar for both groups. Previous concern about the welfare of any of the children in the family was noted slightly more frequently in the families of abused children, but this was not statistically significant. This included children who had been recognized as being “at risk,” children who had been fostered or given up for adoption, and those who had been suspected previously of being victims of child abuse.
DISCUSSION The age of children admitted to hospital because of nonaccidental injury was similar to that of the population of hospitalized abused children described by Kempe ( 1962) in his original article. Other centers throughout the world have also noted the vulnerability of children under two years of age and the disproportionate frequency with which these children suffer significant injury. Although some studies have shown an equal sex distribution of children admitted with nonaccidental injuries, a male predominance was also noted by Birrell and Bin-e11in 1968. Analysis of the reports of child abuse and neglect between 1977 and 1984 in the state of Oklahoma also found that among victims aged 12 years or younger, boys outnumbered girls in all categories except sexual abuse (Rosenthal, 1988). The association of diagnosed child abuse with poverty and low socioeconomic class was noted with 22 (49%) children living in families of social class 5 (unskilled or semiskilled workers) and 15 (33%) living in families from social class 6 (unemployed/pensioners). Thus a total of 82% of families were within the lowest two socioeconomic groups. Nixon and Peam’s ( 1980) reference data on the distribution of social class in Australia based on the 6-point scale of Broom, Jones, and Zubrzycki indicated that 40% of Australian families belong to this strata. However, the general hospital population was skewed towards the lower socioeconomic groups because it was situated in an inner urban region providing primary care to predominantly low income families. Referral patterns for secondary and tertiary care did not show this trend. Also, illnesses such as acute respiratory infections and gastroenteritis were shown to be more prevalent in children of lower socioeconomic families. Single and two-parent families were represented in approximately equal proportions. Kor-
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J. A. S. Smith and R. G. Adler
bin (1977) commented that “mothers who were unable to break continuous interaction with their children were most likely to react negatively to their children.” Solomon (1973) noted that most abused children came from families where the parents were married and living together. Family structure per se has not been shown to be a risk factor for chiId abuse. Demographic data from the Australian Year Book 1985 reveals that 83% of children are either first- or second-born children which is similar to the 79% noted in our study. This contrasts with the majority of previously published reports which link abuse with large families, especially where there is a low birth interval. Creighton ( 1985) noted an increased incidence of child abuse in families with four or more children. Rowan (1979) also described a high incidence of maltreatment in first- and second-born children. A maternal average age of 26 years was reported by Solomon (1979) who also commented on the high incidence of teenage pregnancy. A similarly lower-than-average age of fathers of abused children has also been noted by Oates (Oates, Davis, Ryan, & Stewart, 1979) (25% aged 16-21 when child born). The findings from this study are consistent with accepted theory that abuse is more commonly detected in families where parents are younger than average. Although the intergenerational propensity for child abuse has been recognized for some years, (Adler, 1986) this remains a most worrying concern. The strong correlation between both maternal and paternal histories of child abuse and the detection of child abuse in the ofhspring has been confirmed once again in this case-control study. We noted that seven of the control mothers and six of the control fathers also admitted to being victims of child abuse. The factors which have allowed these parents NOT to repeat the abusive cycle are of interest for prevention of child abuse of the next generation. Also of note, nearly 50% (23 of 4.5) mothers and the same number of fathers of abused children denied being victims of maltreatment during their own childhoods. Factors other than learned patterns of behavior or identification with the aggressor must be operating in these situations. Egeland ( 1988) described 12 characteristics of mothers with a history of maltreatment during childhood not mahreating their children. The identification of factors which interrupt the intergenerational cycle of abuse may encourage appropriate intervention aimed directly at the victims of child abuse, rather than at their parents. Doubt has been expressed about the significance of separations between a mother and her baby during the first year of life and the influence of the separations on the maternal-infant dyad. Early evidence of the risks to the mother-infant bond associated with separations arose from the research of Elmer and Greg8 ( 1967), who reported an increased incidence of child abuse in premature infants. The association between prematurity and child abuse has been subsequently questioned by Leventhal (198 1). This study revealed a strong association between an increasing number ofoccasions (prior to admission to hospital) on which the mother and child were separated from each other for more than 24 hours as well as the total duration of time they spent apart. The inte~ption to the mother-infant bond during this critical time may have devastating effects on the quality of the developing parent-child relationship. Intervention aimed at improving the quality of parent-infant bonding is currently receiving publicity and funding in the United States (Helfer, 1987). The parental perception of the child as “different” has been noted in a number of previous studies, (Freidrich & Boriskin, 1976) but was not detected by this study. The only difference in behavior or temperament was in the parental perception of the child’s behavior as frequently or usually aggressive. Since two-thirds of the children in the study were aged less than two years, their parents may have had unrealistic expectations of normal childhood behavior or they may have been attempting to justify “retaliatory” aggression. A highly significant difference between the stress scores of the two groups reinforces the concept that child abuse may be the result of “the straw that broke the camel’s back.” While
Hospitalized child abuse and neglect cases
443
recognize that individual events which may be stressful to one person may lead to a reduction of stress in another, the overall score indicated that a number of stressful life events may have a cumulative deleterious effect (Leventhal, 198 1). Helfer (1987) described the crisis as one of three conditions contributing to the abusive event. Straus ( 1980) noted the increasing child abuse rate as the number of stresses increased and also noted the greater effect of stress on the fathers, Factors which enable an individual to continue to function effectively as a parent are related to individual resilience and personality as well as the effects of stressful events. Personality factors of abusive parents have been studied in detail, but there is a paucity of information about factors contributing to an individual’s resilience to stressful events. This is obviously of importance in terms of the prevention of child abuse and neglect and highlights the need for further research in this area. Social isolation, lack of support, and a reluctance to seek or use child care facilities has been noted by other researchers (Seagull, 1987). In this study, where cases were matched to controls of the same family structure and social class, statistically significant differences were not detected. Widespread poverty within families of the lower socioeconomic groups was noted, but there was no difference in the perception of financial difficulties between the abusive and control families. Housing problems and lack of satisfaction with current housing were noted more frequently by the parents of abused children when compared to control parents of the same social class, although the differences did not reach statistical signihcance. The use of physical violence between parents was recorded by I3 parents of abused children and 5 parents of control children. More mothers of abused children reported assault by their partners, but this was not statistically significant. Many of these women were also the victims of incest (this latter question was not specifically addressed in the questionnaire, but comments were recorded where appropriate). Oates and Forrest (1985) have reported the low regard in which a population of abusive mothers held their fathers, which may be a reflection of this previous abuse. Of Goodwin’s group of mothers of abused children, 24% reported a prior incest experience {Goodwin, McCarthy, & DiVasto, 1981). Her data indicated that the incidence of incest was similar in mothers of physically and sexually abused children but this was eight times greater than the control mothers. Oates (1985) also commented on the low opinion most abusive mothers expressed towards their partners. This study demonstrated a poorer relationship between the parents of abused children. This may have importance in terms of misplaced aggression but may also reflect the difficulties these individuals have in forming and maintaining harmonious interpersonal relationships. Althou~ the associations between mental illness (Bishop, 1975), drug abuse (Starr, 1978), alcoholism (Kempe, 1960) and parental intellectual handicap (Seagull & Schemer, 1986) with child abuse have been frequently reported, this study did not confirm a statistically significant difference between the two groups. The higher frequency of criminal activity seen in our abusive families was not as high as reported by Creighton (1985) who found 45.3% of the males and 18.2% of the females in her study group had a criminal record. We observed a similar trend but were unable to demonstrate a statistical significance, probably due to the relatively small sample size. Families with a child recognized as being “at risk”, subject to abuse, or fostered or adopted, will be under greater scrutiny from a variety of individuals and agencies. Therefore it may be assumed that episodes of neglect or abuse will be more likely to come to the attention of authorities. This may explain the marginally greater number of families of abused children where there had been concern about at least one of the siblings. An alternative explanation may be that these are “problem families,” the histories of other children acting as markers of increased risk for child abuse.
we
444
J. A. S. Smith and R. G. Adler
The influence of social class appears to have far reaching effects which have infrequently been taken into account in prior research. In this case-control study of hospitalized abused children of lower socioeconomic families, few of the widely accepted risk factors for child abuse reached statistical significance. Many of the recognized risk factors for child abuse which were described in the early literature may reflect features common to lower socioeconomic families rather than pertaining specifically to abusive families. Subsequent papers will describe the follow-up of these families 12 months tier the index admission. This will enable factors associated with good and poor outcome to be identified more accurately.
REFERENCES Adler, R. G. (1986). Physical maltreatment of children. Ausfrulian and New Zealand Journal of Psychiatry, 20, 404-412. Beautrais, A. L., Fergusson, D. M., & Shannon, F. T. (1982). Life events and chiidhood morbidity: A prospective study. Pe~atr~cs, 70(6f, 935-939. Birreil, R. G., & Birrell, J. H. W. (1968). The maltreatment syndrome in children; A hospital survey. MedjcalJ~rna~ ofAustralia, 2, 1023-1029. Bishop, F. I. (I 9‘75). The abusive parent: Perceptions, memories, and pathological identifications as precipitants in the attack. The Child in His Family, (Vol. IV, pp. 239-245). Broom, L., Jones, L., & Zubrzycki, J. (1965). An occupational classification ofthe Australian work force. Australian and New Zealand Juu~aI of S~jolo~, l(Supp1. I), 1. Brown, G. W., & Davidson, S. (1978, February 18). Social class, psychiatric disorder of mother, and accidents to children. Lance& 378-380. Caplan, P. 11984). Toronto multiagency child abuse research project: The abused and the abuser. Child Abuse & Negfecf, 8, 343-35 1. Creighton, S. J. (1985). An epidemiological study of abused children and their families in the United Kingdom beiween 1977 and 1982. Child Abuse-& Negleci, 9,441-448. Egeland, B. (1988). Breaking the cycle of abuse. In K. Browne, C. Davies, & P. Stratton (Eds.), Earl.yprediction and prevention of child abuse. New York: John Wiley and Sons. Elmer, E., & Greg& G. S. (1967). Developmental characteristics of abused children. Pediatrics, 40, 596. Freidrich. W. N., & Boriskin, J. A. ( 1976). The role of the child in abuse: A review of the literature. American Journal of U~h~ps~h~at~, 46(4) 580~Sk. Garbarino. J.. & Crouter. A. 09781. Definina the communitv context for aarent-child relations: The correlates of child m&tr&tment. &Id &ve&pment, 4@,604-6 16. r Gil, D. G. (1969). Physical abuse of children: Findings and implications of a nationwide survey. Pedintrics, 44, 857-864. Goodwin, J., McCarthy, T., & DiVasto, P. ( 198 1). Prior incest in mothers of abused children. Child Abuse & Neglect, 5, 87-95. Helfer, R. E. (1987). The perinatal period, a window of opportunity for enhancing parent-infant communication: An approach to intervention. Child-Abuse & Neglect, 11,mi65-579: Johnson. B.. & Morse. H. A. f 19681. Iniured children and their parents. Children. 15(4), 147- 152. Kempe, ‘C. H., Silver&an, F: N., k&e, B. E, Droegemuefle~, W., & Silver, H. K..( 1962). The battered child syndrome. Journal of the American Medical Association, 181, 17-24. Korbin, J. (1977). Anthropological contributions to the study of child abuse. Child Abuse & Neglect, 1, 7-24. Krugman, R. D., Lenherr, M., Betz, L., & Fryer, G. E. (1986). The relationship between unemployment and physical abuse of children. Ch~Id Abuse & Neglect, 10,4 1S-4 18. Leventhal, J. M. (198 1). Risk factors for child abuse: Methodological standards in case-controi studies. Pediatrics, 68(5), 684-690. Nixon, J., & Peam, J. (1980). Norms for the social class distribution. Medical Journal qfAustralia, 2, 27 l-273. Nixon, J., Peam, J., Wilkey, I., & Petrie, G. (198 1). Social class and violent child death: An analysis of fatal nonaccidental injury, murder, and fatal child neglect. Child Abuse & Neglect, 5, I 1 l-l 16. Oates, R. K., Davis, A. A., Ryan, M. G., & Stewart, L. F. (1979). Risk factors associated with child abuse. ChildAbuse & Neglect, 3, 547-553. Oates, R. K., & Forrest, D. (1985). Self-esteem and early background of abusive mothers. Child Abuse & Neglect, 9, 89-93. Pelton. L. H. (1978). The myth of &sslessness. American Journal O~O~hops~~iatry, 4lK608-617. Plotkin, R. C.; AZ&~S., Twentyman, C. T., & Perri, M. G. ( I98 1). Acritical evaluation of the research methodology employed in the investigation of causative factors of child abuse and neglect. ChildAbuse & Neglect, 5,449-455. Rosenthal, J. A. (1988). Patterns of reported child abuse and neglect. Child Abuse & Neglect, 12, 263-27 1. Rowan, J. M. (1979). Possible early warning sign of non-accidental injury to children. Child Abuse & Neglect, 3, 767-776.
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Seagull, E. A. W. (1987). Social support and child maltreatment: A review ofthe evidence. ChildAbuse & Neglecf, 11, 41-52. Seagull, E. A., & Scheurer, S. L. (1986). Neglected and abused children of mentally retarded parents. Child Abuse & Neglect, 10, 493-500. Solomon, T. (1973). History and demography of child abuse. Pediatrics, 51, 773-776. Starr, R. H. (1978). The controlled study of the ecology of child abuse and drug abuse. Child Abuse & Neglect, 2, 19-28. Straus, M. A. (1980). Stress and physical child abuse. Child Abuse & Neglect, 4, 75-88.
Resume-Une etude de cas control&e a ttt me&e pour &valuer de nouveau les facteurs de risques par rapport aux mauvais traitements des enfants, lorsque le facteur de la couche sociale est controlt. Quarante-cinq enfants hospitalis& qui avaient subi des mauvais traitements ont ttt apparies selon I’age, le sexe, la structure familiale et la classe sociale avec un m&me nombre d’enfants hospital&s a cause dune maladie aigtie. On a constatt que les enfants maltraites avaient moins de f&es et soeurs, que leun parents ttaient plus jeunes, plus aptes a avoir CtCdes enfants maltraites eux-m&mes et qu’ils eprouvaient des difficult&s dans leur relation avec le conjoint. Les enfants maltraites Ctaient plus aptes a avoir &Cs&pares de leur mere durant la premiere annte suivant la naissance. Dans leurs families, il s’etait produit plus d’evtnements critiques durant les 12 mois prectdant l’entree a L’hopital. L’Ctude n’a pas Ctabli une correlation significative avec les autres facteurs qu’on associe habituellement aux mauvais traitements. Etant don& que les enfants maltraites se retrouvent plus souvent dans les couches sociales socio-Cconomiquement faibles, ceci Porte a Ctablir une relation cause-effet entre ces deux n&alit&s.Cette etude ayant controle le facteur de la couche sociale, ses conclusions remettent en question ce que constitue les facteurs de risques par rapport a I’enfance maltraitee. Resumen-Se realizb una investigacibn de cases y grupos control de 45 nifios abusados hospitalizados para reevaluar 10s factores de riesgo del abuso despues que la influencia de la clase social es minimizada. Los cases fueron comparados de acuerdo con la edad, el sexo, la estructura de la familia y la clase social, con nihos hospitalizados por una enfermedad aguda. Los nifios abusados m&s a menudo tenian padres mh jbvenes, menos hermanos/as, y habian sido separados mas a menudo de su madre durante el primer afio de vida. Los padres mas a menudo, habian sido abusados cuando nifios y tenian una relaci6n poco satisfactoria con el otro miembro de la pareja. Las familias de 10s niiios abusados experimentaron mas eventos con stress en 10s Cltimos 12 meses. Qtros “factores de riesgo” previamente reconocidos no presentaron una asociacibn estadisticamente signiticativa con el abuso a 10s nifios. Como el abuso a 10s nifios es m&s frecuente en las clases socio-econbmicas mas bajas, la asociacion con estos otros factores ha sido interpretada coma una relaci6n causal. Los procedimientos de comparacibn que intentaron eliminar confusiones debidas a la clase social y a la estructura familiar, ponen en duda muchas creencias previas acerca de 10s factores de riesgo en el abuso a 10s niiios.
1991 Copyright
0145-2134/91 $3.00 + .OO Q I99 Pergamon Press plc
I
CHILDREN HOSPITALIZED WITH CHILD ABUSE AND NEGLECF A CASE-CONTROL STUDY J. A. S. SMITH AND R. G. ADLER Department of General Pediatrics, Royal Children’s Hospital, Parkville, Australia
Abstract-A case-control study of 45 hospitalized abused children was conducted to reassess the risk factors for child abuse when confounding by social class was minimized. Cases were matched for age, sex, family structure, and social class with children admitted to hospital for an acute illness. Abused children were more likely to have younger parents, fewer siblings, and to have been separated from their mothers during the first year of life. Their parents were more likely to have been abused as children and to have a poor relationship with the child’s other parent. The families of abused children had encountered more stressful life events in the preceding 12 months. Other previously recognized “risk factors” were not shown to have a statistically significant association with child abuse. Because child abuse is more prevalent in lower socioeconomic families, the association with many of these factors has been accepted as implying a causal relationship. Matching procedures which attempted to eliminate confounding by social class and family structure cast doubts on some previously held beliefs about the risk factors for child abuse. Key Words-Child abuse, Risk factors, Physical abuse, Neglect, Social class.
INTRODUCTION ALTHOUGH ABUSIVE ACTS towards children have varied over the centuries and between cultures, some children have been subjected to violence, neglect, or maltreatment since earliest recorded history. As in 19th century Britain where children of the poor made up the child labor work force, tales of physical abuse and neglect have centered on the maltreatment of children predominantly from lower social class families. Early descriptions of “battered babies” included details of the higher incidence of physical abuse in lower social class families. Gil ( 1969) commented on the pattern of more severe abuse in poorer families with most abuse being in the extremely disadvantaged social class. He addressed the issues of reporting bias, the additional life stresses associated with poverty, and the tendency of lower class socialization to accept a more direct expression of aggressive impulses. Some of the initial papers on child abuse and neglect disputed the association between social class and child abuse. Kempe (1962) claimed that physical abuse and neglect occurred across all strata of society; thus the incidence of child abuse was much higher than was suggested by the available data. He postulated that private physicians were less likely to diagnose nonaccidental injury or neglect. If the diagnosis was made, they were less likely to report middle and upper class families to the authorities. Families living in poverty were under closer scrutiny from a variety of agencies; thus nonaccidental injuries were more likely to be detected. Garbarino and Crouter (1978) noted a tendency for institutions to report lower socioeconomic families more readily. However, they also noted a strong positive relationship between higher income and the likelihood that maltreatment will be reported by family, Received for publication March 9, 1989; final revision received June 1 I, 1990; accepted June 12, 1990. Requests for reprints should be sent to Dr. J. Anne S. Smith, Department of General Pediatrics, Royal Children’s Hospital, Flemington Rd., Parkville, Victoria, Australia 3052. 43-l
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friends, and neighbors. They concluded that these two factors balanced each other out and discounted the theory that biased reporting accounted for the negative correlation between social class and child maltreatment. Pelton (1978) strongly rejected the “myth of classlessness.” He also noted the strong association between social class and childhood neglect and commented on “the hazardous poverty environment that heightens the dangerousness of child neglect.” Data from other studies supported the theory that physical abuse and neglect is associated with poverty, Johnson and Morse (1968) described the poor economic conditions of their study group in Denver where “most families lived in the city’s slums.” Creighton ( 1985) noted the high incidence of criminality, marital instability, mobility and unemployment in the parents of abused children. A disproportionate number of parents in the Toronto study were from lower socioeconomic families (Caplan 1984). In 1986, Krugman analyzed the data for child abuse and unemployment in Denver from 1964 to 1985 and found a strong correlation between the unemployment rate and the number of physical abuse cases seen (? = .66, p =c .OOl) (Krugman, Lenherr, Betz, & Fryer, 1986). Childhood accidents (both accidental and nonaccidental) have been shown to be more prevalent in children of lower social class families. Brown and Davidson (1978) concluded that accident risk to children is associated with both a working-class status and depression in the mother. All of the children who died from nonaccidental injuries in Nixon’s Queensland study (Nixon, Pearn, Wilkey, & Petrie, 1981) were from lower socioeconomic groups. Much of the literature published over the last 20 years on child abuse has been descriptive in nature and has suffered from a number of methodological flaws (Plotkin, Azar, Twentyman, & Perri, 198 1). Leventhal’s assessment ( 198 1) of 22 case-control studies investigating two risk factors, ( 1) prematurity or low birth weight of the abused child and (2) young maternal age of the mother of the abused child, revealed that no study satisfied all of the criteria to minimize bias or distortion of the results. Much of the research has been retrospective, has involved nonspecific control groups, and has introduced significant bias. Prospective studies have been plagued by difficulties with follow-up of this highly mobile and often uncooperative population. This study was performed in an attempt to assess the risk factors for child abuse when children were matched for age, sex, family structure, and social class with children admitted to hospital for acute illness. We hypothesized that many previously reported “risk factors” for child abuse are related to social class and family structure. The close matching procedures were undertaken in an attempt to minimize confounding by these two variables.
METHOD Between April 1987 and April 1988, 6 1 children were admitted to the Royal Children’s Hospital, Melbourne, because of suspected maltreatment. These cases were identified by one of three methods. First, hospital records were screened for an admission diagnosis of “nonaccidental injury” and “child at risk.” Children were considered for the study if the child had injuries which were considered by the admitting officer to be nonaccidental or showed physical signs of neglect, Second, records from the social work department were scrutinized and contact with social workers of the child abuse team was maintained to detect children admitted to specialist departments with nonaccidental injuries. For example, children admitted to neurosurgery or orthopedic wards may not be readily identified as abused from either the admission or discharge diagnoses. Third, a vigil was maintained on admissions to the general medical wards to identify children admitted because of nonaccidental injuries or neglect. In no instance was a child admitted because of suspected abuse but further investigation revealed
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Table 1. The Abused children Age Sex
Social Class Family Structure
Range 1 month- 14 years 2 months, median 17 months 60% males 82% in the lowest 2 (of 6) levels 25 dual parents-20 biological, 5 reconstituted 20 single parents, I9 single mothers
the injury to be definitely accidental. Children were included in the study, however, if the injury remained unexplained or if professionals associated with the case considered the injury might have been nonaccidental. Of the 6 1 identified children, 45 parents agreed to participate in the study. These families were representative of the group as a whole with respect to the age and sex of the child, family structure, social class, and severity of injury. Each child was matched with another in-patient of the same age (within 2 months for children under 2 years and within 6 months for older children), sex, family structure and social class. Controls were selected as the next child of the appropriate age, sex, and family structure, and of the same social class group as the index child. Family structure was defined as either single-parent or two-parent family at the time of the child’s admission to the hospital. Broom’s criteria for defining social class based on the occupation of the major wage earner was used (Broom, Jones, & Zubrzycki, 1965). Each control child had an acute illness (defined as less than three admissions to the hospital for the same condition). All of the control children were admitted under the general medical teams which investigated and managed the abused children. None of the control children were known to have been abused, although because of matching for social class, many lived in socioeconomically deprived families. A semistructured interview lasting one hour was conducted with a parent, usually the mother, and the child was examined in the ward. The interview was conducted in a private room on the medical ward. An initial questionnaire was completed by the researcher to assess the recognized risk factors for child abuse. Most questions were coded as direct responses, but several risk factors were coded as an assessment made by the interviewer. For example, a history of abuse in the parent’s childhood was addressed by the interviewer after three approaches. In different parts of the interview the parent was asked, “When you were young, did anyone ever beat you or treat you badly? What was it like for you when you were a child? and How did you get on with your Mum and Dad when you were little?” If the parent disclosed physical injuries or discipline with an instrument, this was judged to be abuse. Abuse was also recorded if the mother said, “My father treated me badly. . .but I’d rather not talk about it.” Included in the assessment was a “stress score” of events experienced by the families during the preceding 12 months. The score used was a modification of Beautrais and Fergusson’s stress score used in New Zealand (Beautrais, Fergusson, & Shannon, 1982). The major factors considered related to health, occupational stability, and stability of living conditions of the families, as well as interpersonal relationships of the parents. Consent was obtained from all participating families. All interviews and questionnaires were completed by the principal author. This report is the first stage of a prospective study of children admitted to hospital because of physical abuse and neglect. The list of risk factors was compiled after an extensive review of the literature but did not include an assessment of the psychological profile of the parents. Statistical analysis was conducted using SPSS (Statistical Package for the Social Sciences) with the 5% level chosen as the arbitrary level of significance. RESULTS The general characteristics of the sample are set out in Table 1. First or second born children accounted for 79% of the abused group: 45% first born, and 34% second born. There
J. A. S. Smith and R. G. Adler
440 Table 2. Significant
Difference
Between Abused and Control Families
Risk Factor
Abused (n = 451
Control (n = 45)
D value
Age of Mother Age of Father Mother Abused as Child Father Abused as Child Number of Separations (Mean) Child Described as Frequently or Usually Aggressive Parental Relationship (Mean) Stress Factors n = 19 (Mean)
25.9 + I 28.1 + 8 21 15 1.222
29.6 + 6 32.2 f 9 I 6 0.444
0.0208 0.0302 0.0029 0.0370 0.0193
10 2.46 4.9
2 3.64 3.4
0.0456 0.0045 0.0084
was a statistically significant difference between the abused and control groups when the presence of other children in the house was assessed. Abused children were likely to have fewer other children in the house than controls (Kruskall-Wallis; p = .0039). Comparison of abused and control families revealed a number of statistically significant differences. These are detailed in Table 2. Mothers and fathers of abused children were younger than control parents. A maternal history of child abuse was noted in 47% of mothers of abused children and 16% of control mothers. A paternal history of child abuse was noted in 33% of fathers of abused children and 13% of control fathers. The number of separations (of more than 24 hours) between the child and mother in the first 12 months of life was significantly different (r, = .0193) with abused children being separated on more occasions and for a longer duration of time 0, = .002 1). When separations occurred, the caretakers were similar for both groups of children. The reasons for separations were also not detectably different. (These were assessed as maternal or child ill-health, custody arrangements, parental relief, or involuntary separations at the instigation of an outside agency.) When parents were asked to rate their current relationship with the child’s other biological parent on a 5-point scale, abusive parents rated their relationships significantly worse than the control group (Mann-Whitney; p = .0045). Many abusive parents no longer had any contact with the child’s other parent or regarded their relationship as extremely poor or fair. Physical arguments between parents were reported more often in abusive parents ( 13 abusive families compared to 5 control families), but this did not reach statistical significance. A stress score of stressful life events encountered by the families over the 12 months prior to presentation to hospital was significantly different between the two groups (p = .0084). Of the abusive families, 27 had recently changed residences compared to 12 of the control families. A recent assault was reported by 12 parents of abused children compared to 3 of the control parents. However, some factors were similar between the two groups: For example, 26 of the abusive parents and 22 of the control parents reported a recent pregnancy. There was no significant difference between groups on many measures. These are set out in Table 3. The trend towards abusive parents being more likely to state that they had housing problems ( 17 abusive families and 8 controls.) but not financial difficulties was noted. When parents in both groups were asked about the family history of drug or alcohol abuse, nine abusive parents and six control families admitted to this problem. Psychiatric treatment had been received by 14 abusive parents and 6 control parents. Criminal activity resulting in the involvement of the police was reported for 17 abusive parents and 8 control families. Although conflict with the law approached statistical significance, none of these three factors was statistically significant at the 5% level. The antenatal course, perception of labor, and the incidence of complications during the perinatal period were not statistically different in the abused and control populations. Of
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Table 3. No Significant Difference Between Abused and Control Families Risk Factor
Abused cn = 45)
Control (n = 45)
15 15 17 19 13 9 14 17 39 32 30 27
10 9 8 14 5 6 6 8 39 27 29 29
33
41
No Supportfrom Family No Suooort from Friends Housing Problems Financial Problems (Debts) Physical Arguments
Drilguse Psvchiatric Treatment C&lict with Law No Problems at Birth No Colic No Feeding Problems No Sleeping Problems No Markers of Concern for Any Child in the Family
equal importance, both groups were similar in their assessments of whether the pregnancy was planned and also whether the child was “wanted” even if not planned. The prevalence of prematurity, growth retardation, and congenital abnormalities was similar for both groups. Previous concern about the welfare of any of the children in the family was noted slightly more frequently in the families of abused children, but this was not statistically significant. This included children who had been recognized as being “at risk,” children who had been fostered or given up for adoption, and those who had been suspected previously of being victims of child abuse.
DISCUSSION The age of children admitted to hospital because of nonaccidental injury was similar to that of the population of hospitalized abused children described by Kempe ( 1962) in his original article. Other centers throughout the world have also noted the vulnerability of children under two years of age and the disproportionate frequency with which these children suffer significant injury. Although some studies have shown an equal sex distribution of children admitted with nonaccidental injuries, a male predominance was also noted by Birrell and Bin-e11in 1968. Analysis of the reports of child abuse and neglect between 1977 and 1984 in the state of Oklahoma also found that among victims aged 12 years or younger, boys outnumbered girls in all categories except sexual abuse (Rosenthal, 1988). The association of diagnosed child abuse with poverty and low socioeconomic class was noted with 22 (49%) children living in families of social class 5 (unskilled or semiskilled workers) and 15 (33%) living in families from social class 6 (unemployed/pensioners). Thus a total of 82% of families were within the lowest two socioeconomic groups. Nixon and Peam’s ( 1980) reference data on the distribution of social class in Australia based on the 6-point scale of Broom, Jones, and Zubrzycki indicated that 40% of Australian families belong to this strata. However, the general hospital population was skewed towards the lower socioeconomic groups because it was situated in an inner urban region providing primary care to predominantly low income families. Referral patterns for secondary and tertiary care did not show this trend. Also, illnesses such as acute respiratory infections and gastroenteritis were shown to be more prevalent in children of lower socioeconomic families. Single and two-parent families were represented in approximately equal proportions. Kor-
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bin (1977) commented that “mothers who were unable to break continuous interaction with their children were most likely to react negatively to their children.” Solomon (1973) noted that most abused children came from families where the parents were married and living together. Family structure per se has not been shown to be a risk factor for chiId abuse. Demographic data from the Australian Year Book 1985 reveals that 83% of children are either first- or second-born children which is similar to the 79% noted in our study. This contrasts with the majority of previously published reports which link abuse with large families, especially where there is a low birth interval. Creighton ( 1985) noted an increased incidence of child abuse in families with four or more children. Rowan (1979) also described a high incidence of maltreatment in first- and second-born children. A maternal average age of 26 years was reported by Solomon (1979) who also commented on the high incidence of teenage pregnancy. A similarly lower-than-average age of fathers of abused children has also been noted by Oates (Oates, Davis, Ryan, & Stewart, 1979) (25% aged 16-21 when child born). The findings from this study are consistent with accepted theory that abuse is more commonly detected in families where parents are younger than average. Although the intergenerational propensity for child abuse has been recognized for some years, (Adler, 1986) this remains a most worrying concern. The strong correlation between both maternal and paternal histories of child abuse and the detection of child abuse in the ofhspring has been confirmed once again in this case-control study. We noted that seven of the control mothers and six of the control fathers also admitted to being victims of child abuse. The factors which have allowed these parents NOT to repeat the abusive cycle are of interest for prevention of child abuse of the next generation. Also of note, nearly 50% (23 of 4.5) mothers and the same number of fathers of abused children denied being victims of maltreatment during their own childhoods. Factors other than learned patterns of behavior or identification with the aggressor must be operating in these situations. Egeland ( 1988) described 12 characteristics of mothers with a history of maltreatment during childhood not mahreating their children. The identification of factors which interrupt the intergenerational cycle of abuse may encourage appropriate intervention aimed directly at the victims of child abuse, rather than at their parents. Doubt has been expressed about the significance of separations between a mother and her baby during the first year of life and the influence of the separations on the maternal-infant dyad. Early evidence of the risks to the mother-infant bond associated with separations arose from the research of Elmer and Greg8 ( 1967), who reported an increased incidence of child abuse in premature infants. The association between prematurity and child abuse has been subsequently questioned by Leventhal (198 1). This study revealed a strong association between an increasing number ofoccasions (prior to admission to hospital) on which the mother and child were separated from each other for more than 24 hours as well as the total duration of time they spent apart. The inte~ption to the mother-infant bond during this critical time may have devastating effects on the quality of the developing parent-child relationship. Intervention aimed at improving the quality of parent-infant bonding is currently receiving publicity and funding in the United States (Helfer, 1987). The parental perception of the child as “different” has been noted in a number of previous studies, (Freidrich & Boriskin, 1976) but was not detected by this study. The only difference in behavior or temperament was in the parental perception of the child’s behavior as frequently or usually aggressive. Since two-thirds of the children in the study were aged less than two years, their parents may have had unrealistic expectations of normal childhood behavior or they may have been attempting to justify “retaliatory” aggression. A highly significant difference between the stress scores of the two groups reinforces the concept that child abuse may be the result of “the straw that broke the camel’s back.” While
Hospitalized child abuse and neglect cases
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recognize that individual events which may be stressful to one person may lead to a reduction of stress in another, the overall score indicated that a number of stressful life events may have a cumulative deleterious effect (Leventhal, 198 1). Helfer (1987) described the crisis as one of three conditions contributing to the abusive event. Straus ( 1980) noted the increasing child abuse rate as the number of stresses increased and also noted the greater effect of stress on the fathers, Factors which enable an individual to continue to function effectively as a parent are related to individual resilience and personality as well as the effects of stressful events. Personality factors of abusive parents have been studied in detail, but there is a paucity of information about factors contributing to an individual’s resilience to stressful events. This is obviously of importance in terms of the prevention of child abuse and neglect and highlights the need for further research in this area. Social isolation, lack of support, and a reluctance to seek or use child care facilities has been noted by other researchers (Seagull, 1987). In this study, where cases were matched to controls of the same family structure and social class, statistically significant differences were not detected. Widespread poverty within families of the lower socioeconomic groups was noted, but there was no difference in the perception of financial difficulties between the abusive and control families. Housing problems and lack of satisfaction with current housing were noted more frequently by the parents of abused children when compared to control parents of the same social class, although the differences did not reach statistical signihcance. The use of physical violence between parents was recorded by I3 parents of abused children and 5 parents of control children. More mothers of abused children reported assault by their partners, but this was not statistically significant. Many of these women were also the victims of incest (this latter question was not specifically addressed in the questionnaire, but comments were recorded where appropriate). Oates and Forrest (1985) have reported the low regard in which a population of abusive mothers held their fathers, which may be a reflection of this previous abuse. Of Goodwin’s group of mothers of abused children, 24% reported a prior incest experience {Goodwin, McCarthy, & DiVasto, 1981). Her data indicated that the incidence of incest was similar in mothers of physically and sexually abused children but this was eight times greater than the control mothers. Oates (1985) also commented on the low opinion most abusive mothers expressed towards their partners. This study demonstrated a poorer relationship between the parents of abused children. This may have importance in terms of misplaced aggression but may also reflect the difficulties these individuals have in forming and maintaining harmonious interpersonal relationships. Althou~ the associations between mental illness (Bishop, 1975), drug abuse (Starr, 1978), alcoholism (Kempe, 1960) and parental intellectual handicap (Seagull & Schemer, 1986) with child abuse have been frequently reported, this study did not confirm a statistically significant difference between the two groups. The higher frequency of criminal activity seen in our abusive families was not as high as reported by Creighton (1985) who found 45.3% of the males and 18.2% of the females in her study group had a criminal record. We observed a similar trend but were unable to demonstrate a statistical significance, probably due to the relatively small sample size. Families with a child recognized as being “at risk”, subject to abuse, or fostered or adopted, will be under greater scrutiny from a variety of individuals and agencies. Therefore it may be assumed that episodes of neglect or abuse will be more likely to come to the attention of authorities. This may explain the marginally greater number of families of abused children where there had been concern about at least one of the siblings. An alternative explanation may be that these are “problem families,” the histories of other children acting as markers of increased risk for child abuse.
we
444
J. A. S. Smith and R. G. Adler
The influence of social class appears to have far reaching effects which have infrequently been taken into account in prior research. In this case-control study of hospitalized abused children of lower socioeconomic families, few of the widely accepted risk factors for child abuse reached statistical significance. Many of the recognized risk factors for child abuse which were described in the early literature may reflect features common to lower socioeconomic families rather than pertaining specifically to abusive families. Subsequent papers will describe the follow-up of these families 12 months tier the index admission. This will enable factors associated with good and poor outcome to be identified more accurately.
REFERENCES Adler, R. G. (1986). Physical maltreatment of children. Ausfrulian and New Zealand Journal of Psychiatry, 20, 404-412. Beautrais, A. L., Fergusson, D. M., & Shannon, F. T. (1982). Life events and chiidhood morbidity: A prospective study. Pe~atr~cs, 70(6f, 935-939. Birreil, R. G., & Birrell, J. H. W. (1968). The maltreatment syndrome in children; A hospital survey. MedjcalJ~rna~ ofAustralia, 2, 1023-1029. Bishop, F. I. (I 9‘75). The abusive parent: Perceptions, memories, and pathological identifications as precipitants in the attack. The Child in His Family, (Vol. IV, pp. 239-245). Broom, L., Jones, L., & Zubrzycki, J. (1965). An occupational classification ofthe Australian work force. Australian and New Zealand Juu~aI of S~jolo~, l(Supp1. I), 1. Brown, G. W., & Davidson, S. (1978, February 18). Social class, psychiatric disorder of mother, and accidents to children. Lance& 378-380. Caplan, P. 11984). Toronto multiagency child abuse research project: The abused and the abuser. Child Abuse & Negfecf, 8, 343-35 1. Creighton, S. J. (1985). An epidemiological study of abused children and their families in the United Kingdom beiween 1977 and 1982. Child Abuse-& Negleci, 9,441-448. Egeland, B. (1988). Breaking the cycle of abuse. In K. Browne, C. Davies, & P. Stratton (Eds.), Earl.yprediction and prevention of child abuse. New York: John Wiley and Sons. Elmer, E., & Greg& G. S. (1967). Developmental characteristics of abused children. Pediatrics, 40, 596. Freidrich. W. N., & Boriskin, J. A. ( 1976). The role of the child in abuse: A review of the literature. American Journal of U~h~ps~h~at~, 46(4) 580~Sk. Garbarino. J.. & Crouter. A. 09781. Definina the communitv context for aarent-child relations: The correlates of child m&tr&tment. &Id &ve&pment, 4@,604-6 16. r Gil, D. G. (1969). Physical abuse of children: Findings and implications of a nationwide survey. Pedintrics, 44, 857-864. Goodwin, J., McCarthy, T., & DiVasto, P. ( 198 1). Prior incest in mothers of abused children. Child Abuse & Neglect, 5, 87-95. Helfer, R. E. (1987). The perinatal period, a window of opportunity for enhancing parent-infant communication: An approach to intervention. Child-Abuse & Neglect, 11,mi65-579: Johnson. B.. & Morse. H. A. f 19681. Iniured children and their parents. Children. 15(4), 147- 152. Kempe, ‘C. H., Silver&an, F: N., k&e, B. E, Droegemuefle~, W., & Silver, H. K..( 1962). The battered child syndrome. Journal of the American Medical Association, 181, 17-24. Korbin, J. (1977). Anthropological contributions to the study of child abuse. Child Abuse & Neglect, 1, 7-24. Krugman, R. D., Lenherr, M., Betz, L., & Fryer, G. E. (1986). The relationship between unemployment and physical abuse of children. Ch~Id Abuse & Neglect, 10,4 1S-4 18. Leventhal, J. M. (198 1). Risk factors for child abuse: Methodological standards in case-controi studies. Pediatrics, 68(5), 684-690. Nixon, J., & Peam, J. (1980). Norms for the social class distribution. Medical Journal qfAustralia, 2, 27 l-273. Nixon, J., Peam, J., Wilkey, I., & Petrie, G. (198 1). Social class and violent child death: An analysis of fatal nonaccidental injury, murder, and fatal child neglect. Child Abuse & Neglect, 5, I 1 l-l 16. Oates, R. K., Davis, A. A., Ryan, M. G., & Stewart, L. F. (1979). Risk factors associated with child abuse. ChildAbuse & Neglect, 3, 547-553. Oates, R. K., & Forrest, D. (1985). Self-esteem and early background of abusive mothers. Child Abuse & Neglect, 9, 89-93. Pelton. L. H. (1978). The myth of &sslessness. American Journal O~O~hops~~iatry, 4lK608-617. Plotkin, R. C.; AZ&~S., Twentyman, C. T., & Perri, M. G. ( I98 1). Acritical evaluation of the research methodology employed in the investigation of causative factors of child abuse and neglect. ChildAbuse & Neglect, 5,449-455. Rosenthal, J. A. (1988). Patterns of reported child abuse and neglect. Child Abuse & Neglect, 12, 263-27 1. Rowan, J. M. (1979). Possible early warning sign of non-accidental injury to children. Child Abuse & Neglect, 3, 767-776.
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Seagull, E. A. W. (1987). Social support and child maltreatment: A review ofthe evidence. ChildAbuse & Neglecf, 11, 41-52. Seagull, E. A., & Scheurer, S. L. (1986). Neglected and abused children of mentally retarded parents. Child Abuse & Neglect, 10, 493-500. Solomon, T. (1973). History and demography of child abuse. Pediatrics, 51, 773-776. Starr, R. H. (1978). The controlled study of the ecology of child abuse and drug abuse. Child Abuse & Neglect, 2, 19-28. Straus, M. A. (1980). Stress and physical child abuse. Child Abuse & Neglect, 4, 75-88.
Resume-Une etude de cas control&e a ttt me&e pour &valuer de nouveau les facteurs de risques par rapport aux mauvais traitements des enfants, lorsque le facteur de la couche sociale est controlt. Quarante-cinq enfants hospitalis& qui avaient subi des mauvais traitements ont ttt apparies selon I’age, le sexe, la structure familiale et la classe sociale avec un m&me nombre d’enfants hospital&s a cause dune maladie aigtie. On a constatt que les enfants maltraites avaient moins de f&es et soeurs, que leun parents ttaient plus jeunes, plus aptes a avoir CtCdes enfants maltraites eux-m&mes et qu’ils eprouvaient des difficult&s dans leur relation avec le conjoint. Les enfants maltraites Ctaient plus aptes a avoir &Cs&pares de leur mere durant la premiere annte suivant la naissance. Dans leurs families, il s’etait produit plus d’evtnements critiques durant les 12 mois prectdant l’entree a L’hopital. L’Ctude n’a pas Ctabli une correlation significative avec les autres facteurs qu’on associe habituellement aux mauvais traitements. Etant don& que les enfants maltraites se retrouvent plus souvent dans les couches sociales socio-Cconomiquement faibles, ceci Porte a Ctablir une relation cause-effet entre ces deux n&alit&s.Cette etude ayant controle le facteur de la couche sociale, ses conclusions remettent en question ce que constitue les facteurs de risques par rapport a I’enfance maltraitee. Resumen-Se realizb una investigacibn de cases y grupos control de 45 nifios abusados hospitalizados para reevaluar 10s factores de riesgo del abuso despues que la influencia de la clase social es minimizada. Los cases fueron comparados de acuerdo con la edad, el sexo, la estructura de la familia y la clase social, con nihos hospitalizados por una enfermedad aguda. Los nifios abusados m&s a menudo tenian padres mh jbvenes, menos hermanos/as, y habian sido separados mas a menudo de su madre durante el primer afio de vida. Los padres mas a menudo, habian sido abusados cuando nifios y tenian una relaci6n poco satisfactoria con el otro miembro de la pareja. Las familias de 10s niiios abusados experimentaron mas eventos con stress en 10s Cltimos 12 meses. Qtros “factores de riesgo” previamente reconocidos no presentaron una asociacibn estadisticamente signiticativa con el abuso a 10s nifios. Como el abuso a 10s nifios es m&s frecuente en las clases socio-econbmicas mas bajas, la asociacion con estos otros factores ha sido interpretada coma una relaci6n causal. Los procedimientos de comparacibn que intentaron eliminar confusiones debidas a la clase social y a la estructura familiar, ponen en duda muchas creencias previas acerca de 10s factores de riesgo en el abuso a 10s niiios.
