Develop. Med. Child Neurol. 1975, 17, 64 1-646

Annotations THE INCIDENCE AND NATURE OF CHILD ABUSE DESPITE the considerable evidence to the contrary, we in the developed countries like to think of ourselves as civilized-by which we understand that our behaviour conforms to certain standards of non-violence and that we are kind and considerate to the weaker members of our society, animals, destitute people and children. When faced with evidence that we are transgressing these standards we feel guilty, and society reacts to guilt by anger, by denial and by seeking for a scapegoat-a wicked parent, a negligent social worker or a heedless department. In recent years we have seen all these reactions and we have seen them inflamed and intensified by sensational presentation in the mass-media. If we are going to face the problems of child abuse, it is essential that we do so dispassionately and try to separate the facts from the emotional reaction to them. There have always been cruel or ignorant adults who ill-treat their children. The present wave of interest began when people started to realise that apparently normal and wellintentioned young parents may inflict injury on their children and conceal the fact, even from one another. The introduction of the term ‘battered child’ to describe this sort of situation concentrated attention on the subject but suggested a clear-cut, easily definable clinical entity, which only required to be recognized to be defined. Nothing could be further from the truth. Child abuse is an infinitely complex phenomenon-ranging from fatal assault to deprivation of food or affection-and mental cruelty may be just as damaging to the child as physical injury, though its effects are less obvious. Boundaries are ill-defined and it does not help to think in terms of simple black-and-white stereotypes-innocence and guilt, good and bad, crime and punishment. We must rather cultivate increased understanding of the causes of child abuse and better recognition of the danger signals so that preventive measures can be taken in time. Child abuse is not confined to one section of society, although predisposing stresses are likely to be more severe among the poorer and more deprived in the community. Parents who ill-treat their children are not a homogeneous group and it is unwise to generalise about them. They do not all come from one age-group, one range of intelligence, or one social class. Experience shows that professional workers are ready enough to think the worst of poor, illiterate and ill-clad parents but find it difficult to suspect well-dressed, educated people with whom they readily identify. Even when suspicion is aroused, many find that it takes some effort to believe that the nice young couple who seem so warm towards their child have an enormous potential for aggression when confronted with a crisis from which they cannot escape. It cannot be stated too strongly that whatever the social background and however plausible the story, child abuse must be considered as a possibility in every incident of injury to a young child and wherever a child is failing to thrive or to grow in weight or height. While there are no typical battering parents and no typical battered babies, certain

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characteristics are frequently found among mothers who show aggression towards their children. They are usually young and have often themselves had an unhappy, depriving childhood. While overt mental disease is not common, a high proportion have immature, dependent personalities. They lack self-esteem and need constant reassurance. Such mothers have high expectations of their children and may resort to violence if a child fails to meet their excessive demands. Children who are abused are often no different from others, though they may be perceived as different by their parents. However, child abuse is more frequent among babies of low birth-weight, especially those who have been in special care baby units, and among handicapped children. Infants who are restless, excitable and cry a lot are especially at risk: an infant of this type almost seems to invite physical abuse, especially if he is the only child in the family who behaves in this way. Given these predisposing characteristics, violence is particularly likely to be precipitated by some domestic crisis or series of crises. It is suggested that child abuse is becoming more common, and in our increasingly stressful and violent society this may be so. However, statistics are rather meaningless when we are considering not a clear-cut disease but a whole range of human behaviour. It may be possible to produce figures for recognized cases of significant physical injury inflicted on young children but this is really only the tip of a large iceberg of disturbed family relationships which defy statistical analysis. The more critically we examine cases of accidental injury or poisoning, failure to thrive and delayed development, the more likely are we to disclose further cases of child abuse. If attention is focused only on those clear cases of physical injury inflicted by parents or other adults having custody of the child, we can identify certain recurrent patterns. The classical situation is that of the young respectable couple, one of whom is under emotional stress and ill-treats the child as an expression of his or her disturbed mental state. Often the other partner is aware of or suspects the assault, but experiences a conflict of loyalty and so there is collusion in concealing what has happened. When two adults act together, one may be involved in setting the child up for abuse and then standing back in a passive way while the more aggressive member of the relationship inflicts the injury. This is then presented as an accident to the unsuspecting doctor, who treats it appropriate:y without further enquiry. A succession of assaults are disguised as accidents in this way and escape attention because on each occasion the parents tell a different story, meet a different doctor, or go to a different hospital and the connection between the events is not recognized. The true circumstances are revealed only when suspicion is aroused by incongruity between the history and the injuries, or when a severe or fatal injury leads to full investigation. It is not too difficult to count the number of such cases in a particular hospital o r area and to relate them to the number of children attending as outpatients, to the child population served by the hospital or to the total population of the area, but such data are difficult to interpret or compare because they depend on so many variables, such as the effectiveness of hospital records, the index of suspicion among the staff, and so on. As a rough guide it may be said that for every 1000 babies born about six will come to notice as battered children during the first three years or so of their lives. This means about 5000 recognized cases a year in the United Kingdom. But for every case recognized there are probably several of repeated injury, neglect or mental cruelty which are not and never will be identified. About 5 to 10 per cent of children sustaining non-accidental injury are said to die as a result and about one quarter of the survivors show signs of permanent neurological disability. These rates are mainly derived from series of severe injuries, however, and they

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may be expected to be lower when more cases are recognized early, before repeated assaults cause serious intracranial injuries. Despite these difficulties of definition and recognition, knowledge of the clinical picture of non-accidental injury is rapidly accumulating, indeed more rapidly than it is being absorbed by health workers in general. Certain alarm signals can be discerned-a delay between the injury and attendance at hospital or surgery, the assertion by the parents that they do not know how the injury happened, or the use of mouth-to-mouth resuscitation, which has been described as a panic reaction by the parent. Failure to gain weight and height can be a valuable pointer to possible child abuse. Injuries suggestive of ill-treatment include not only the well-known bruising, multiple fractures and intracranial bleeding, but such things as retinal haemorrhage, bilateral black eyes, cigarette burns, human bite marks, finger and thumb marks, and the torn frenulum of the lip. It is aIso said that many of these babies are quiet, still and unsmiling-behaviour which has been called “frozen watchfu1ness”l. Too much should not be made of this, however, because infant behaviour is so variable, especially in the circumstances of injury and a visit to hospital. It is important to realise that, although levels of recognition vary enormously in different areas, the trend will be more and more towards diagnosis early, when injuries are no more than a few minor bruises or petechial haemorrhages. Even these, insignificant though they may seem, may be highly suggestive in appearance or situation, and when related to circumstances and social background may be sufficient to sound the alert. At the same time it must be remembered that this is mainly a problem of clinical diagnosis in the early stages, for there are many medical disorders which present with such signs and the children of stressed mothers or unhappy homes are not immune from disease. One of the most important things that doctors must do is to increase their index of suspicion, and this applies especially to surgeons and general practitioners. It is noteworthy that in New York, where the majority of sick and injured children are seen by private practitioners, only eight of 3000 cases of child abuse were reported by them2. It is also essential to evolve mechanisms of recording the pattern of repeated incidents. For example, the child-abuse team in Dundee now has a system for cross-referencing every injury to a child who is treated in hospital or clinic and the alert is sounded whenever a potentially dangerous situation is recognized. General practitioners are co-operating in this early-warning system, so that it is increasingly easy to identify repeated incidents or other suspicious circumstances. It may be pertinent to pause for a moment here and consider the significance of repeated visits to hospital with apparently trivial injuries. They are certainly to be regarded as an important indicator of possible child abuse, but in seeking to establish this connection we must not forget that they may also represent repeated cries for help from an unhappy and confused young mother, who may resort to more serious assault if her distress signals are ignored. We have not yet reached the point where such a parent can openly communicate her need for help, and so this appears as a minor injury or a complaint about a non-existent symptom in her infant. The highest priority must be given to improving recognition of the first injuries so that subsequent, more serious incidents can be prevented. But perhaps even more important in the long run is primary prevention, which depends on recognizing the potentially abusing situation before any injury occurs. This is largely a social problem but it is also of concern to medical, nursing and other health staff. Research work is going on in many centres in this and other fields of prevention. One question is ‘Can we identify the mother who is 643

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likely to ill-treat her child?-because if we could do so, preventive measures might well be feasible. Preliminary data from a study in Aberdeen suggest that the rate of non-accidental injury among children attending the Accident and Emergency Department was considerably higher among those cases where the attitude of the mother in the postnatal period had given cause for concern than among the rest, so we already have some suggestion that prediction may be possible. Such studies encourage us to believe that the preventive approach will be the most rewarding in the future, but this is not to imply that arrangements to deal with non-accidental injury as it now exists are not important and urgently requiredthey are. However much we may be concerned about the prevention of future episodes, there are children at risk now and being abused now, so that measures must be taken to protect them. The child’s safety and well-being must be paramount considerations and there are legal and moral aspects which cannot be ignored. Nevertheless, necessary though it is to set up committees and organise case conferences, it is equally important to try to understand the forces which generate child abuse and the reactions to it. The problem should be seen as primarily one of disturbed family relationships and psychologically stressed parents, who need help and treatment rather than the vengeance of an outraged society. Ross G. MITCHELL University of Dundee, Department of Child Health, Ninewells Hospital and Medical School, Dundee DD2 1UD. REFERENCES 1. Ounsted, C., Oppenheimer, R., Lindsay, J. (1975) ‘The psychopathology and psychotherapy of the families: aspects of bonding failure.’ In Franklin, A. W. (Ed.) Concerning Child Abuse. Edinburgh: Churchill Livingstone. 2. Mindlin, R. L. (1974) ‘Child abuse and neglect: the role of the pediatrician and the Academy.’ Pediatrics, 54, 393.

BIRTHWEIGHT OR GESTATIONAL AGE, OR BIRTHWEIGHT FOR GESTATIONAL AGE? LONGITUDINAL studies have shown that postnatal environment has a much greater influence upon development than have prenatal and perinatal events. Thus the long-term effects of severe maternal starvation during pregnancy1 and of breech delivery2may be overshadowed to a great extent by later experiences. Nevertheless, the quality of intra-uterine life does have some long-lasting effects and the concept of the continuum of reproductive casualty is not only logical but true. Deviations from ‘normal’ birthweight and gestational age, for example, are associated not only with increased perinatal mortality but also with impaired school performance 4. As it sometimes is possible to modify the duration of intra-uterine life and some perinatal events, there is proper interest in the relative importance of different early influences upon development. GOLDSTEIN and PECK HAM^, in report from the National Child Development study, have demonstrated that both birthweight and gestational age independently have a relationship with reading ability at the age of 11 years-children whose birthweights were under 2000g had an average reading ability 1.2 years behind those whose birthweights were over 4000g; children born before 35 weeks had a mean reading age 1.0 years below those born at 39 to 41 weeks. Their study shows that birthweight has a greater effect than has gestational age, but confirms that its effect is not as great as that of postnatal experience as measured by social class and maternal age. 39

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The incidence and nature of child abuse.

Develop. Med. Child Neurol. 1975, 17, 64 1-646 Annotations THE INCIDENCE AND NATURE OF CHILD ABUSE DESPITE the considerable evidence to the contrary,...
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