SPECIAL ARTICLE Family Violence: Impact on Children JAVAD H. KASHANI, M.D., ANASSERIL E. DANIEL, M.D., ALISON C. DANDOY, M.A., AND WILLIAM R. HOLCOMB, PH.D. Abstract. Violence within the family is increasingly being recognized as a serious societal problem in the United States. Four types of family violence are discussed: violence toward children, siblings, women, and the elderly. This paper explores the development of violent relationships in the family from both biological and psychological perspectives, with the latter encompassing four frameworks-the psychopathological model, the social learning model, the aversively stimulated aggression concept, and systems theory. The authors also examine the risk factors for and the effects of violence as well as the characteristics of the aggressor and the victim. Available intervention strategies for various types of violent behavior are then discussed. J. Am. Acad. Child Adolesc. Psychiatry, 1992,31,2:181-189. Key Words: family violence, family abuse, child abuse.

Righteous Heaven, who has permitted All this woe: What fatal crime Was by me, e' en at the time Of my hapless birth, committed? (Calderon, in Feuerbach, 1832) As a result of increasing public awareness and statutory enforcement, family violence has gained much attention during the past few years. The identification of the widespread prevalence of child abuse in the early 1960s was followed by the recognition of other types of violence within the family, such as spouse and elder abuse. Although investigations in this area are relatively recent, familial violence has been recognized since ancient times. In 1985, a medical team of paleopathologists identified a much greater incidence of fractures among women (up to 50%) than among men (up to 20%) in mummies that were 2,000 to 3,000 years old. The fractures were found to result from lethal blows presumably the result of "peacetime personal violence" (Dickstein, 1988). Historians have also documented the activities of Theodora, Justinian's empress and

Accepted April 24, 1991. Dr. Kashani is Professor of Psychiatry, Psychology, Pediatrics, and Medicine; Director of Training in Child Psychiatry; and Director of Children's Services at Mid-Missouri Mental Health Center. Dr. Daniel is Associate Professor of Psychiatry, aforensic child psychiatrist, and Superintendent of Mid-Missouri Mental Health Center. Ms. Dandoy is a research assistant. Dr. Holcomb is Clinical Associate Professor of Psychiatry and Psychology, a forensic psychologist, and Administrator ofRiverside Hospital. All are affiliated with the University of Missouri-Columbia. The authors would like to thank lames M. A. Weiss, M.D., Professor and Chairman ofthe Department ofPsychiatry, University ofMissouri-Columbia, and Bruce Harry, M.D., Associate Professor, for their critical comments about the manuscript. Reprints requests to Dr. Kashani, Department of Psychiatry, University of Missouri-Columbia, 3 Hospital Drive, Columbia, MO 65201. 0890-856719213102-0181$03.0010©1992 by the American Academy of Child and Adolescent Psychiatry. l.Am.Acad. Child Adolesc. Psychiatry, 31:2, March 1992

coleader of Byzantium from A.D. 508 to 548, as a strong advocate of women's causes; she was one of the first to urge the prevention of physical abuse of women by their husbands. Spouse and child abuse-the most common forms of domestic violence-were both legal early in this century. According to the Old English common law doctrines, wife beating was permitted for the purpose of "correcting behavior deemed inappropriate by husbands." For example, the Rule of Thumb Law permitted a husband to beat his wife with a stick no larger than the circumference of his thumb. As recently as the early 1970s, a Pennsylvania town ordinance prohibited a husband from beating his wife after 10 P.M. or on Sundays (Williams-White, 1988). The magnitude of family violence is emphasized in a report by the Department of Justice, which states that there were at least 4.1 million cases of family violence between 1973 and 1981, an average of 450,000 per year (Department of Justice, 1984). The Department also added that the reported figure was probably significantly lower than the actual number of cases, because the estimates reflect only behavior that victims are willing to report as criminal to survey interviewers. Definition No consensus has been reached regarding the appropriate definitions of "violence" and "abuse." Although these terms are often used interchangeably, it is important to note that violent behavior and abusive behavior often exhibit distinct characteristics. Harrington (1972) defined violence as an "endpoint in a continuum of aggressive behavior." This typically consists of hostile beating, slapping, hitting, and other physically aggressive behavior. The American Psychiatric Association task force on the' 'Clinical Aspects of the Violent Individual" (American Psychiatric Association, 1974) defined the violent person as one' 'who acts or has acted in such a way as to produce physical harm or destruction." Abuse has been defined as " ... mistreatment, ipjury, insulting or coarse language; to hurt by treating b¥t(y ..." 181

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(Daniel and Kashani, 1983). Abusive behavior may be psychological or attitudinal and hence may be nonviolent in nature. Emery (1989) suggests that an "abusive" or "violent" act comprises not an objective decision but rather a social judgment. For example, spanking and pushing have been regarded as forms of parent-child violence and spouse abuse, respectively. In actuality, acts such as spanking may not be severe; thus, unclear definitions of violence and abuse can lead to erroneous conclusions. For this paper's purposes, the terms "abuse" and "violence" are used interchangeably because the authors will be referring to a physical and violent act. The current review will outline developmental issues of violence within various theoretical frameworks. Four types of family violence will be described as well as associated risk factors and effects. Finally, the paper will conclude with intervention strategies. Development of Violent Relationships Biological perspective. Violent behavior has been associated with various biological factors. Researchers have examined genetic determinants, central nervous system damage, endocrine systems, neurotransmitters, chromosomal aberrations, and structural and electrical elements in the brain to better understand the genesis and expression of violence (Burrowes et aI., 1988). Human studies on the genetic aspects of aggression have been primarily directed toward chromosomal abnormalities such as XXX, XXY, and XYY patterns. The only finding to date among XXY women has been a high incidence of mental retardation. Because a high frequency of XYY men among institutionalized populations was discovered in the 1980s, some researchers have purported that the extra Y chromosome is related to violent behavior (Goldstein, 1974). Schiavi et aI. (1984) studied behaviors among XYY and XXY men and found no correlation between these genetic abnormalities and violent traits. Nielsen et aI. (1973) reviewed profiles of XYY probands and found that although XYY men were more impulsive in their decision making, more "hot-tempered," and often lower in intelligence than their peers, no positive relationship was documented between the XYY genotype and violent acts. Various hormonal imbalances are also associated with the onset of violent behavior. For example, aggressive behavior has been linked to high testosterone levels, but the hormone's specific role in violence has not yet been determined. Mattsson et aI. (1980) found higher immune plasma testosterone levels among 40 male delinquents than among normal matched adolescents. Kruez and Rose (1972) studied aggression within a young criminal population and found that testosterone levels did not correlate with the violent history documented in criminal prison records. Physical and emotional changes associated with menstrual cycles have been thought to contribute to female violent behavior. Dalton (1961) reported that 49% of all crimes committed by women occur during menstruam and premenstruam. However, in a review of the literature linking menstruation to violent behavior, Horney (1978) reminded us

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that data obtained retrospectively may be unreliable. Likewise, Harry and Balcer (1987) reviewed the world literature on the relationship between menstruation and crime and found the research to have been severely flawed methodologically; they found no evidence linking fluctuations in reproductive hormones to criminal behavior. The relationship between neurotransmitters and aggression is one of the most intensively studied areas in biological psychiatry. The inhibitory neurotransmitters, y-aminobutyric (GABA) and serotonin (5-HT) have each been associated with aggression and impulsivity (Burrowes et aI., 1988). One of the earliest human studies associating serotonin with violence was conducted by Asberg et aI. (1976). These researchers found low cerebrospinal fluid (CSF) concentrations of 5-HIAA (a metabolite of serotonin) in patients who attempted violent suicides, which some view as a form of self-aggressivity (Asberg et aI., 1976). Abnormalities of brain tissue resulting from mass lesions or trauma may also be related to aggressive behavior. Elliot (1982) studied 286 individuals with a history of recurrent rage attacks. Most of them were diagnosed with adult minimal brain dysfunction. Furthermore, most had complex partial seizures. The latter problem is one of the most extensively investigated syndromes associated with violence. Many studies have been conducted in individuals with criminal records, and the evidence points to an increased frequency of epilepsy among prison inmates, although epileptic prisoners seem no more violent than nonepileptic prisoners (Gunn and Bonn, 1971). Although the preceding discussion has described pertinent studies of the biological basis of aggressive behavior, it is important to note that there have been few, if any, prospective investigations indicating an immediate need for biological studies. Furthermore, the complex interplay among these variables limits our present understanding and warrants more systematic research. Theoretical frameworks. Four theoretical frameworks have been advanced to explain the etiology and perpetuation of family violence: 1. the psychopathological model, 2. the social learning model, 3. the aversively stimulated aggression concept, and 4. systems theory. The psychopathological model takes into account a wide variety of intraindividual factors, such as personality and psychiatric disorders, as determinants of family violence. Early studies on child abuse focused on uncovering psychopathology within the parents because it was assumed that such violent behavior must be caused by mental illness. In the majority of cases, however, this model is not applicable to abusive parents (Starr, 1979; Wolfe, 1985). Hence, although no one personality type is reflective of a child or a wife abuser, many common personality types and disorders have received attention in the literature as being associated with violent behavior (Daniel and Kashani, 1983; Maiuro et aI., 1988). The social learning model explains the intergenerational transmission of violence as learned behavior. Thus, past experiences determine if, when, and how often aggression is manifested. Children learn how to behave from the actions they see in their parental role models. Although the social J. Am. Acad. Child Adolesc. Psychiatry, 31:2, March 1992

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learning model has been recognized as having much to say about how family members are socialized into becoming abusive, it has been criticized on the grounds that it has little to add in terms of how people learn to inhibit violence (Emery, 1989). The social learning theory minimizes the role played by mediating emotional and cognitive processes. The third model, aversively stimulated aggression, offers a parsimonious explanation for behavior that is not learned and that apparently has no instrumental value. Berkowitz (1983) stated that although much aggression is maintained through positive and negative reinforcement, the primary goal of aversively stimulated aggression is to inflict pain; aggression is a high probability response to a diverse set of stimuli. Thus, the aversively stimulated aggression concept focuses on the perpetrator's intent. Because violence within the family is not a single causeand-effect phenomenon, a fourth framework based on systems theory has evolved. This theory proposes that dysfunctional relationships exist among violent individuals and their interpersonal, physical, and organizational environments. These relationships, in tum, place all members of the family at risk for abusive or violent interactions (Daughtry, 1981). Hence, the family is viewed as a system of individuals who are actively engaged in reciprocal interactions with each other. Family members are influenced in these interactions by their roles and expectations. This theory provides a framework for assessing how individual characteristics and interpersonal, physical, and organizational environments interact to lead to a violent act within the family. Violence toward Children In 1871, a young girl in New York City was severely beaten by her adoptive parents. Neighbors reported the child's injuries to the Society for Prevention of Cruelty to Animals, the only available legal authority at that time. Soon after this incident was investigated, the Society for Prevention of Cruelty to Children was founded. However, . it was not until 1961, when Henry Kempe described the "battered child syndrome" at a workshop of the American Academy of Pediatrics, that child abuse became recognized as a widespread national problem (Kempe and Helfer, 1972). There is still much uncertainty and debate about the extent of child abuse. Estimates of the number of cases in the United States range from 60,000 (Helfer and Kempe, 1974) to 2.3 million (Straus et al., 1980). In light of the difficulties and inconsistencies regarding the definition of child abuse, it is not surprising that such a range of incidence estimates exist. Furthermore, the information on which these estimates are based comes from many sources such as social agencies, hospitals, and police reports. All are based on different samples and different reporting criteria. Furthermore, many reports are speculative and inferential. There is general concensus, however, that cases of abuse and neglect are significantly underreported (Williams, 1980). Although much abuse is perpetrated by strangers, 85% of child abuse is inflicted by a person the child knows, usually the father or the mother. Children of all ages and demographic status are victims of physical, psychological, and sexual abuse in their own homes, committed by parents, J. Am. Acad. Child Ado/esc. Psychiatry, 31:2, March 1992

step-parents, grandparents, and other family members (Dickstein, 1988). Effects ofabuse on the child. Although considerable attention has been focused on the perpetrators of abuse, recent work has also focused on the children (Barahal et al., 1981; Friedrich and Einbender, 1983; Kashani et al., 1987; Kazdin et al., 1985; Main and George, 1985). The impact of family violence is demonstrated in several spheres including shortterm physical, developmental, and psychiatric effects as well as long-term effects on the intergenerational transmission of violence, criminality, psychiatric disorders, and other psychosocial complications. Because interparental violence and child abuse often coexist, the confounding effects of abuse and exposure to parental violence may have a cumulative negative effect. An abundance of literature exists describing the psychopathology common among abused children. These outcomes of abuse are diverse and include impaired social cognitions (Barahal et al., 1981), low self-esteem (Friedrich and Einbender, 1983; Kashani et al., 1987), lack of empathy (Main and George, 1985), and depression (Kazdin et al., 1985). Symptoms of posttraumatic stress disorder are also common. Nightmares about the violence are common, and children become anxious when reminded about it. They may also become emotionally constricted and inhibited, and their behavior may regress. Other symptoms are sleep disorders and irritability. Such stress also complicates the grief, because the anxiety and intrusive images interfere with normal grieving (Pynous, 1990). It is important to note at the outset that no single behavioral or emotional reaction epitomizes the abused child. Reaction to abuse may be influenced by other factors such as support from other family members, intelligence, and genetic makeup. Also, the experience of being a victim of violence may not be the sole factor for consequent difficulties that have been found among abused children; other aspects of the child's environment may pose a greater negative effect. Regarding the eventual adjustment of abused children, Emery (1989) has proposed two types of predictions. One set of predictions focuses on the caregiver-child relationship, more specifically, disruptions in patterns of attachment. Attachment theorists believe that disruptions in security with primary caretakers and the child's cognitive script for relationships are the primary causes of problems found among abused children (Sroufe and Fleeson, 1986). A second set of predictions is based on social learning theory and suggests that abused children are more aggressive than their nonabused peers because of their learning experiences. Intergenerational transmission studies support this view. Over a quarter century ago, Curtis (1963) expressed his concern that abused and neglected children would "become tomorrow's murderers and perpetrators of other crimes of violence, if they survive" (p. 386). However, in a recent review of empirical studies investigating the intergenerational transmission of violence, Widom (1989) found surprisingly little evidence to support the claim that abuse begets abuse. Kaufman and Zigler (1987) also concluded that acceptance of the intergenerational transmission hypothesis 183

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is unwarranted at present. Many of the studies are weak methodologically and overdependent on self-report and retrospectivedata. Others fail to use baseline data from control groups, employ insufficient sample sizes, and lack appropriate comparison groups. To overcome these methodological problems, Widom (1989) designed a 2-year research project that incorporated a large sample size, unambiguous operational definitions of abuse, a control group, a prospective design, and an assessment of the long-term consequences of abuse. Results of this project provided dramatic support for the notion that violence breeds violence. In this study, physical abuse and neglect as a child led to significantly greater violent criminal behavior at a later point in time. However, the findings also showed that not every abused or neglected child would become either a delinquent, a criminal, or a violent criminal. She concludes that the linkage between childhood victimization and later violent behavior is not universal and that intergenerational transmission is not inevitable. For example, later criminal behavior and abuse may represent indirect by-products of early abusive experiences, thus taking into account the existence of other intervening variables such as familial factors, the environment, intelligence, and social support. Violence toward Spouse

By definition, spouse abuse, more commonly of a woman, is a behavior pattern that occurs in physical, emotional, psychological, and sexual forms. Its purpose is to control and maintain power by the abuser, usually a man (Dickstein, 1988). Women receive the greatest share of violence and batterings, accounting for approximately 95% of all spousal violence victims (Tilden and Shepherd, 1987). The issue of spousal battery emerged in the late 1960s as a consequence of the women's movement and public scrutiny of the family unit in instances of child abuse. Unlike the response to child abuse, however, society was slow to recognize spousal violence as a problem; women were viewed as consenting adults, responsible for their own behavior. Also, a husband's right to control his wife through physical force continued to be socially accepted by many. Although not the only victims of family violence, women are not protected by the same legislation that protects children and the elderly (Tilden and Shepherd, 1987); hence, they are the most vulnerable. Straus et al. (1980) conducted a study of violence in American families in the late 1970s. In a sample of 2,143 families, 16% of the respondents indicated that some type of violence between spouses had occurred during the preceding 12 months; moreover, at least 25% of all couples reported physical violence at some point during their marriage. Appleton (1980) also administered an anonymous questionnaire to adult women seeking care in the emergency department of an urban general hospital. Of the 620 women who completed the questionnaire, 219 or 35% reported having been struck at least once by their intimate partner. Some researchers have suggested that domestic violence occurs in three predictable phases (Drake, 1982; Walker, 1979). In the first phase, tension between the couple builds 184

as a result of minor irritations. Verbal and minor physical abuse occurs. When the tension exceeds the couple's coping capabilities, an acute battering episode ensues. If beaten severely, a woman may respond by withdrawing; this selfimposed seclusion frequently delays medical attention. The third phase is a period of calm during which reconciliation between the partners occurs. As this phase recedes, the tension buildup of phase one recurs and the cycle of violence continues. Battered women may cope by attempting to change the spouse while retaining the relationship, abandoning the relationship, or responding with violence themselves. A few may become assaultive and homicidal; indeed, a number of interspousal murders are precipitated by victims. The murders are likely committed in self-defense, without premeditation (Daniel and Kashani, 1983). Effects of witnessing marital violence on children. Only recently have children who witness parental physical violence been identified as at risk for psychopathology (Hughes, 1988). In general, results comparing characteristics of shelter children with control children seem to depend on the particular personality or behavioral characteristics selected for assessment. Consistently, though, the child who witnesses interparental aggression experiences more internalizing behavior problems, such as anxiety and depression, than does the comparison group child (e.g., Brown et al., 1983). Hughes (1988) improved upon previous child witnessing studies by dividing children into age groups, obtaining information from the children themselves as well as the mothers, and dividing the shelter children into more homogeneous subgroups based on whether they were subjected to multiple abuse. Abused and nonabused child witnesses to parental violence (residing in a shelter) were compared with children from a similar economic background on various measures, using information collected from mothers and self-reports. Results showed significantly greater distress in the abusedwitness children than in the comparison group, with nonabused-witness children's scores falling between the two. Age of the child and the type of violence were mediating factors. Hence, physically abused children who have witnessed parental violence may be less well adjusted than witnesses who have not been physically abused. Children who observe wife assault may also be affected in ways other than those revealed through standard mental health assessment procedures. Their witnessing of violent acts between the parents may have an impact on their selfperceived views of violence as an appropriate mean of resolving conflict (Jaffee et al., 1990). To address these issues, a child interview form called the Child Witness to Violence Interview was developed by Jaffee and his colleagues to better assess the presence of more subtle symptoms (Jaffee et al., 1989). Results of research with this instrument showed that latency-aged children exposed to wife battering have more pronounced inappropriate attitudes about violence as a means of resolving conflict than children not exposed to violence. Furthermore, they indicate a greater willingness to use violence themselves compared with children not exposed to wife assault. Also, these children hold themselves J. Am. Acad. Child Adolesc. Psychiatry, 3J :2, March J 992

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responsible for the violence and, in many cases, responsible for their mother's safety. Elder Abuse

The elderly are the most recently recognized group of individuals as being at risk of victimization within the family. Elder abuse is very rare in cultures exhibiting a great deal of respect for the elders as a societal norm. Unfortunately, at times, American society tends to ignore or ridicule the older members of the family unit, resorting to abuse as a means of control in some cases. It is estimated that about 4% of the elderly are victims of abuse, neglect, or exploitation (Jaffee et aI., 1990). As with other forms of violence, however, far fewer cases appear to be reported than actually occur. Physical abuse of older family members includes a wide variety of acts of both omission and commission. For example, active commission of physical abuse includes withholding of food, medicine, or assistance, overmedicating the elderly with tranquilizers or beating to the point of severe injury or death (Anderson, 1981). Causes of abuse. The most widely cited risk factor in the elder abuse literature is the resentment created by the dependence of an older person on a caretaker (Kosberg, 1988). A study by Pillemet and Finkelhor (1989), however, found substantially more support for the concept that abuse is associated with personality problems rather than with stress placed on the caregiver. According to their findings, elder abusers appear to be severely troubled individuals with histories of antisocial behavior and instability. Theoretical models have been proposed to help explain the cause of elder abuse, the primary one being the "cycle of violence" theory discussed earlier. Johnson (1979) suggests that the abused child, when an adult, abuses his or her parent in return. Other theories include: the Role Theory, which is based on the notion that aged parents put their adult children in parental roles, but fail to release authority to them, thereby creating psychological tension within the caregiver (Gresham, 1976); the Family Systems Theory, which proposes that the family denies recognition of the elder parent's problems to maintain the family system (Beck and Ferguson, 1981); and the Environmental Theory, which focuses on the abuser's environment and personal characteristics as factors that can lead to abusive behavior (Bottom and Lancaster, 1981). Thus far, the impact of elder abuse upon children who witness this violence is not well studied or documented. However, it is likely that such behavior results in much confusion within the child who has previously learned that older people are to be treated with respect and kindness as they become frail. Future studies should investigate the direct effects of elder abuse on children as well as the indirect effects on the family system and environment as a whole. Sibling Abuse

The high frequency of imitation and interaction among siblings suggests that this relationship is of developmental importance, both through the direct impact of siblings upon one another and through the indirect effects of the siblings' J. Am. Acad. Child Adolesc. Psychiatry, 31:2, March 1992

relationships with their parents (Dunn, 1988). Of primary concern to parents and clinicians is the frequent aggression and conflict exhibited between some siblings (Baskett and Johnson, 1982). Detailed observations within the family by Patterson (1984,1986) revealed that siblings do indeed playa shaping role in the development of aggressive behavior in both clinic and normal populations. His results suggest that coercive behavior by siblings makes a significant contribution to the development of coercive behavior that is independent of the contribution of parental behavior. Effects on the child from this sibling aggressiveness are still inconclusive. Patterson's group, however, found that coercive behavior by a sibling toward a target child is systematically linked to impaired peer relationships in the target child. Richman et al. (1982) reported poor relationships with siblings to be more common in children with other behavioral problems; these researchers found that poor relationships with siblings at 4 years of age were related to other problems existing during that time and to a clinical rating of disturbance 4 years later. Sexual and psychological abuse compromise other common types of sibling abuse. Parents are typically unaware of the abuse. The effects on the sibling from sexual abuse might mirror posttraumatic stress symptoms. Intervention Biological treatment. Little attention has been devoted to the biological aspects of treatment, although there is a real need for an increased understanding of the underlying neurophysiologic substrates of human aggression. The biological approach to treatment seeks to modulate aggressive behavior by altering the brain dysfunction and hormonal disturbance through pharmacological intervention (Burrowes et aI., 1988). Dalton (1980) used medroxyprogesterone successfully for three women whose cyclic criminal activity was associated with premenstrual syndrome. However, empirical treatment with neuroleptics, lithium, anticonvulsants, and hortnones seems to be effective only in selected patients. XYY men were also studied for aggressivity and 5-HIAA CSF-concentrations by Bioulac et al. (1980). Six XYY men admitted by court order to a high security setting because of criminally violent behavior were found to have decreased 5-HIAA CSF levels. When treated with a serotonin precursor, five of these six exhibited a reduction in aggressive behavior. The use of neuroleptics in the treatment of aggressive individuals is controversial. Similarly, the target populations of aggressive individuals for whom lithium, benzodiazepines, or carbamazepine would be first-line treatments are unknown. Positive results reported in the use of 13-blockers in aggressive patients with intermittent explosive disorder also need to be replicated (Brizer, 1988). Furthermore, if clinicians make every effort to identify and treat the underlying psychiatric disorders, the aggressive behavior may diminish. Other treatment approaches. The shame and secrecy associated with family violence discourages victims from talking about it, let alone seeking professional help. Efforts

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should be directed toward the identification of high-risk individuals and families. If the family physicians or other clinicians have any grounds for suspicion, they should inquire directly about child abuse, marital violence, criminal history, alcoholism, and psychiatric disorders. Reports in the literature regarding the patterns of intervention in family violence indicate a two-tiered approach. The first involves arresting and prosecuting family members for violent acts, when the physical aggression is of sufficient severity to warrant intervention (Attorney General's Task Force on Family Violence, 1984). It is important to note, however, that the effects of police intervention on domestic violence are poorly understood. The second approach involves treating the abusers with the aid of mental health systems to build adaptive coping skills (Emery, 1989). The latter will be emphasized in the present discussion. Violence toward children. Helfer's (1975) multidisciplinary, coordinated approach to diagnosis, treatment, and management of child victims involves several phases. Initially, someone reports the suspected child abuse to child protection services. The child is then taken to an emergency room so that a medical team can determine whether or not the injuries are accidental. In the meantime, the multidisciplinary team (social worker, nurse, attorney, coordinator, etc.) carries out a multitude of tasks, primarily data gathering. Finally, after the case is recognized as abuse or neglect, a planning conference is held by the team to determine the safety of the home and to delegate various responsibilities for team members. Although most people advocate this multidisciplinary approach, its feasibility in the treatment process has been considered at times inefficient and therefore questionable (Cohn and Miller, 1977). The majority of treatment programs are directed toward working with the abusive parents (Broome and Daniels, 1987). Services are provided in an attempt to ameliorate abusive episodes. They focus on enhancing parental strengths and decreasing stressful environmental elements. Interventions include involving parents in such groups as Parents Anonymous. This organization's goal is to help individuals who abuse their children to learn more about themselves and about alternative methods of dealing with the frustrations of parenting. It provides an atmosphere in which acceptance of the abusing parents is maintained. Another means of providing abusive parents with factual knowledge about the development of children and other child care issues is through parent education classes. These classes aim to increase a parent's awareness of a child's needs through discussion of mutual needs in the parent-ehild relationship (Wolfe et aI., 1981). Although separation from the parents and removal to another location may be the most therapeutic intervention for most abused children, other alternatives do exist. Beezley et al. (1976) and Kempe and Kempe (1978) describe a variety of interventions, such as therapeutic play schools, group therapy, day-care centers, or public schools, where adult caregivers can foster confidence and trust within children. Battered women. When seeking treatment for injuries, battered women are most likely to enter the health care system through emergency rooms because they offer 24186

hour service and relative anonymity (Tilden and Shepherd, 1987). Other common centers of contact include prenatal and maternal care services, child health clinics, community mental health centers, and family service agencies. Clinical research has revealed some evidence that health care providers have been somewhat neglectful in the care of abused women; a common mistake is the failure to question the source of the injury, or worse, to denigrate women after abuse is uncovered (Drake, 1982). There are many factors impeding identification and treatment: the health care staff may be influenced by stereotypes, the right to privacy, the right of husbands to control their wives, feelings of frustration because of the overwhelming problem, ancl/or the risk of personal involvement (Tilden and Shepherd, 1987). At the present time, women's shelters and self-help groups are other options for abused women. Self-help and advocacy programs run within the shelter foster hope. Often the victim is encouraged to leave the marital or quasi-marital situation and is provided with legal help. Because the abusive situation gives way to feelings of hopelessness, confusion, and learned helplessness, these self-help groups facilitate an attitude of taking charge through enhanced decision making. Psychiatrists should take an active role in these facilities to improve the efficacy of such programs. Violent men. Adams (1986) has developed a profeminist effective treatment paradigm for male abusers entitled The Emerge Program. It is based on confronting men's excuses for violence while simultaneously helping to increase the costs of that violence. The legal system is involved initially to ensure that the men enter and complete treatment, which consists of individual sessions followed by group therapy. During the 9- to 12-month group therapy program, men may learn to accept responsibility for their behavior and to change sexist beliefs. Adams and Penn (1979) note that the practice of selfassertion and other skills alone will not necessarily induce batterers to stop their battering. These authors also state that such programs must be accompanied by legal sanctions against continued violence as well as specific attention to the abusers' inherent sexist expectations and behavior. It is essential for mental health professionals not to undermine the effective role that the legal system plays in dealing with abusive men. Child witnesses of violence between parents. Only recently have child witnesses to spousal violence begun to receive attention (Pynous and Eth, 1986). Most of the programs have focused on the value of a group approach that aids children in coping with the trauma and allows them to mutually support each other (Alessi and Hearn, 1984; Wilson et aI., 1989). Also, women's shelters are now becoming staffed with child care workers to deal with needs of the children in the shelter (Jaffee et aI., 1990). At the level of prevention, four suggestions have been set forth (Emery, 1982). First, parents should attempt to keep children out of their angry disagreements so that the parents do not become models of violent interactions. Second, parents should try to agree in front of their child(ren) about discipline. Third, parents should make a special effort to maintain their individual relationship with each child, bel. Am. Acad. Child Adolesc. Psychiatry, 31:2. March 1992

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cause this may buffer the child from interparental conflict. Finally, more parents need to be aware that spousal conflicts can have negative effects on their children. There are inherent difficulties in developing appropriate programs for the child of the abused mother. Although children exposed to violence between parents seem to be "at risk" for future behavior problems and require the help of mental health professionals, it may be premature to develop treatment programs before causative factors are identified and outcome research on model programs has been completed. This difficulty in understanding the impact of witnessing family violence on a child's development warrants prospective studies in the hopes of preventing future generations of violent husbands and battered wives (Jaffee et aI., 1986). Elders. Violence toward elders can be prevented by making families more aware of the problems of the elderly and the options available for their care. Because many families are financially unable to place their older relatives in nursing homes, in-home services, such as home health agencies, should be used so that the care provider does not need to carry the burden alone (Pollick, 1987). Legal intervention is limited by the law. Most states have developed adult protective service programs, and individuals who wish to take action against elder abuse may seek recourse through a state's criminal and civil laws. The study cited earlier, by Pillemer and Finkelhor (1989), found that elder abuse is associated more with personality problems of the caregiver than with the actual burden of care and that stress placed on the caregiver has important treatment implications. Whereas elder abuse treatment programs generally emphasize in-home, long-term care services and caregiver support groups, results from the Pillemer and Finkelhor study suggest the need for other interventions that are oriented toward relationships in which the abuser is the dependent party. Such services could be instituted to reduce abuser dependence. For example, adult children could be assisted in finding employment and separate housing. Psychiatric intervention, greater police involvement, and legal assistance may also be necessary to deter the perpetrators from abusing their elders. As for the victim, benefit could be derived from services similar to those offered to young battered women. Emergency shelters for elder abuse victims would provide safety. Support groups would also be useful for the victims by offering them alternatives, helping to break the bonds of dependence. Conclusion

The home environment is the basis for our view of ourselves and others as well as society and the world in general. Maladaptive interactions within the family unit will thus have negative consequences on a global scale. Psychiatrists, as expert mental health professionals, and their professional organizations need not only to recognize this very significant phenomenon but also to bring it to the attention of government authorities, lawmakers, educators, and the public. Psychiatrists have an important role to play, not least because the law enforcement system inevitably seeks the help of J. Am. Acad. Child Adolesc. Psychiatry, 31:2, March 1992

mental health professionals. Whether psychiatrists' patients are court referred or not, the response of the professional may be characterized as a law enforcement type of response. It is imperative that all professionals who encounter people who are in battering relationships address the violence as a type of behavior that is against the law and cannot be tolerated by a civilized society (Lerman, 1989). If the United States is to have less criminal violence as well as better mental health inside and outside the home, then the crucial role of family interaction must be taken seriously. Because those individuals with few social support networks tend to exhibit high levels of verbal and physical aggression (Kashani and Shepperd, 1990), mental health researchers may direct their attention toward the quality and quantity of social support provided by the extended family and friends. Also, cultures exhibiting more adaptive family systems might be examined to incorporate their positive aspects into our own culture. Communication and cooperation must be promoted between psychiatrists, health care providers, criminal justice agencies, schools, and social service agencies. This networking may result in the identification and early intervention of high-risk individuals. Education of health professionals should include training in the identification, treatment, and referral of victims and perpetrators (Surgeon General's Workshop on Violence and Public Health, 1985). Finally, it is evident that the previously described studies pertaining to family violence have methodological weaknesses. Thus, to increase the validity and reliability of violence research, well-designed studies are needed in this important area. In conclusion, it is clear that the family is the first and most important source for the fostering of mentally healthy individuals. The authors' plea to people everywhere is to focus attention on this basic unit of socialization and to develop policies and practices to support and protect the family.

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Coming in May: From Abuse to Violence: Psychophysiological Consequences of Maltreatment Dorothy Otnow Lewis Special Section: Ethical Issues in Child and Adolescent Psychiatry Guest Editor: David Fassler Attention Deficit Disorder with and without Hyperactivity Dennis P. Cantwell and Lorian Baker Children in the Colorado Adoption Project at Risk for CO Hilary Coon et al. ODD and CO: Issues to Be Resolved for DSM-IV Benjamin Lahey et al.

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