Amer. J . Orthopsychiat. 46(4), October 1976

THEORY AND RSEVIEW THE ROLE OF THE CHILD IN ABUSE: A Review of the Literature William

N. Friedrich, M.P.H., and Jerry A. Boriskin, B.A. University of North Dakota, Grand Forks,

N.D.

Current theories generally emphasize the role of the parent in the etiology of child abuse, and frequently fail to consider other factors, in particular the role oJ the child. This paper reviews the literature and discusses the role of the child in abuse, with special attention to identification of particular types of children who may be most at risk.

number of current theories conA cerning the etiology of child abuse place heavy emphasis on the role of parental psychopathology. Spinetta and Rigler 43 concluded their review of the child-abusing parent by stating that

. . . the great majority of the authors cited . . . have pointed to psychological factors within the parents themselves as of prime importance in the etiology of child abuse. They see abuse as stemming from a defect in character.. (p. 302)

.

Socioeconomic factors were not felt to contribute significantly to abuse. However, Kempe and Helfer stated that only a small number (less than ten percent) of the parents of abused chilSubmitted to the Journal in February 1976.

580

dren are seriously mentally ill. In addition, Steele and Pollock 4 * maintained that psychopaths and sociopaths make up only a small portion of abusers, and that their sample of abusers would not seem much different than a random sample of people on a downtown street. More important to Steele and Pollock than severe psychopathology was the disruption of the “mothering function” in the development of children who later became abusers. Increasingly, research on abused and neglected children suggests that the child plays more than a passive role in abuse. Gelles’s l5 social-psychological model of the causes of child abuse,

FRIEDRICH AND BORlSKlN

which admirably demonstrated the complexity and interrelatedness of the factors leading to abuse, assumes that a certain amount of child abuse is a function of child-produced stress. Helfer’s psychodynamic model of abuse zo holds that, for abuse to occur, three conditions are required: 1) a very special kind of child, 2) a crisis or series of crises, and 3) the potential (in the parent) for abuse. Although the potential may be composed of many characteristics the parent has acquired as he moves through his “world of abnormal rearing,” ?o it is triggered by a “special” child, a crisis, or both. Helfer took great pains to state that the child is either viewed by the parent as being special, or actually is a special, different child. Green l7 offered a four-factor explanation of the etiology of child abuse, similar to Helfer’s, but adding as the fourth factor “a cultural tolerance for severe corporal punishment.” Sandgrund, Gaines, and Green 39 stated that child abuse appears to result from the interaction of three factors: immediate environmental stress, personality traits of the parent, and actual characteristics of the child that make him vulnerable to scapegoating. In this view, theories that focus on only the first two etiological factors would fail to present the complete picture. An early theory on the role of the child in abuse was offered by Milowe and L ~ u r i e who , ~ ~ suggested four possible causal factors of abuse, two of which dealt specifically with characteristics of the child. One category included those cases in which the precipitating factor was a defect in the child (especially a defect that contributed to a lack of responsiveness, resulting in parental frustration). The second category in-

58 I

cluded physical damage resulting from parental neglect or mishandling. Their third category covered a little-researched area of abuse-abuse resulting from assaultive behavior by unsupenvised siblings. The final category included abuse resulting from characteristics in the child’s personality that served to invite others to hurt him. As far as can be determined, these categories are the result of clinical experience, not controlled empirical investigation. It is uncomfortable to think that a child can play a role in his own abuse. Furthermore,

. . . despite the contributions which infants make toward the disappointments and burdens of their parents, they can hardly be used as an excuse or adequate cause for child abuse.“ (P. 115) Nevertheless, the fact remains that the child is not always a benign stimulus to the parent. For example, although it is not necessarily the fault of the child or the mother that a birth is premature, this characteristic of the child has an effect on its caregiver. This paper will survey evidence that particular types of children produce parental stress reactions, some of which might stimulate abuse. It will consider the following points, in turn: 1) prematurity and children at risk lor abuse, 2) mental retardation and children at risk for abuse, 3) physically handicapped and sickly children at risk for abuse, 4 ) genetic contributions to the child at risk for abuse, and 5 ) parents’ perceptions of the abused child as different. PREMATURITY

Although one can only speculate as to cause and effect, the recently revealed association of child abuse and prema-

582

turity cannot be ignored. Elmer and Gregg,lo in a sample of twenty battered children in the Chicago area, found 33% to have been premature. Klein and Stern 24 studied 88 battered children at the Winnipeg Children's Hospital, of whom eleven ( 12.5 % ) were premature. In addition, Klein and Stern reviewed the records of 51 battered children in the Montreal area, and found twelve (23.5 % ) to have been low-birth-weight infants; the rate of premature birth in Montreal is between nine and ten percent. It was suggested that multiple factors (pre-existing mental retardation, maternal deprivation, isolation from mother in the early post-partum period, etc.) may increase the risk for these infants. Conversely, it was suggested that certain social characteristics of the mother (poverty, lack of prenatal care) may result in the delivery of low-birthweight infants. In an unpublished retrospective study of 292 suspected abuse cases in England from 1970, referred to by Martin er u Z , ~it~was noted that 14.5% of the children, or twice the national average, had had a low birth-weight. However, it was not specified whether the children were born prematurely or were of adequate gestation with poor prenatal growth. Fomufod, Sinkford and Louy,12 in a retrospective analysis of child abuse in the District of Columbia, found ten of 36 (27.8%) abused children to be of low birth-weight; the incidence of low birth-weight in the D.C. area is 13.2%. A larger scale prospective study is underway to compare low-birth-weight infants with and without prolonged maternal separation. Martin et a1 31 found that eleven (19% ) of their sample of 58 abused

CHILD ABUSE

children weighed less than 2500 grams at birth. This was in comparison to an incidence rate of only 9.2% of all babies born in 1971 in Colorado. They feel that the normal mean IQs of even their smallest prematurely-born children do not support the hypothesis that mental retardation or brain damage stemming from prematurity elicits abuse by parents. In this study, Martin et a1 took special pains to include children with soft tissue damage, in addition to those who had incurred fractures, so that their sample would be as typical as possible of abused children, since only a small proportion of abused children receive fractures. Bishop supports the view that premature babies are particularly vulnerable. It is suggested that some premature babies are hypersensitive to all stimuli, and may even object to gentle handling. What proportion of abused premature babies fit this hypersensitive handling pattern is still unknown. Mussen, Conger and Kagan36 also stated that the premature child is more likely to be restless, distractible, and difficult to care for than a full-term baby, especially during the first year of life. A reason for this is that prematures are more prone to anoxia and colic, and irritability in the newborn period can result from these conditions. In addition, Dreyfus-Brisac has pointed out that disturbances in sleep organization are very common among premature infants. Ounsted, Oppenheimer and Lindsay 87 reported that the colicky child syndrome was a prominent feature during infancy of most of the abused children in their sample. Maternal attitudes toward premature infants must certainly play a role. Elmer and Gregg lo suggested that the mother

583

FRIEDRICH AND BORlSKlN

may perceive a child as being abnormal simply because it is premature. Leiderman ** has found significant differences in both attitudes and behavior between mothers of premature infants and mothers of full-term infants. He stated that the

.

. . attenuated relationship of mothers of prematures with their infants is consistent with reports in the literature that premature infants are more likely the victims of battering by their parents and are more likely to have behavior problems as children. (p. 154)

ganized, unstable, and more sensitive to stress. Pasamanick 38 speculated that these abnormalities precipitate parental distress, thereby reinforcing abnormal behavior in the child, which may ultimately result in abuse. Whereas maternal perceptions of abnormality, socioeconomic status, prenatal care, and hypersensitivity in the premature infant are interacting variables of as yet unknown significance, current data do indicate significant association of prematurity and child abuse. Unraveling the complex interactions involved has only begun, but the basic point to be noted is that premature infants should be considered “children at risk” within the battered child syndrome.

Klaus and Kennell 23 also raised the question of whether the battered child syndrome is in part related to hospital care practices that frequently separate mothers from their premature infants for prolonged periods of time. Fanaroff, Kennell and Klaus l1 analyzed the frequency of visits of 146 MENTAL RETARDATION mothers of low-birth-weight infants. Several researchers have reported a Thirty-eight mothers visited their babies high incidence of mental retardation less than three times in a two week pe- among battered and neglected children. riod. Follow-up data from six to 23 However, the complexity of the phemonths after release show that, in the nomenon and the large number of intereleven cases of abuse or failure to thrive, acting variables make any position as nine mothers were in the infrequent to cause and effect most tenuous. Elvisiting group. Thus, problems may be mer reported 5 5 % of the childreq in identified early, simply by monitoring her sample had an IQ of less than 80; the frequency of visits to the premature Morse, Sahler and Freidmana4 found child. 43% of their sample of abused children Pasamanick 38 noted a significant were similarly classified-all but one of linear relationship between maternal the nine retarded children in this study tension and signs of brain dysfunction were thought to have been retarded in a longitudinal study of premature in- prior to abuse. fants. Mothers of neurologically normal Brandweiq6 noting the association of premature infants were no more tense abuse and mental retardation, suggested than were mothers of neurologically that brain damage resulting from child normal, full-term infants. abuse was the primary factor in the inIt was the neurologically abnormal child, creased frequency of mental retardawhether full-term or premature, who had a tion. One cannot ignore socioeconomic significantly tense mother. (p. 550) factors, stress, prenatal care or lack of Knobloch and Pasamanick contended it, parental depravity, differences in that these abnormal children are disor- learning and reinforcement contingen@

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584

cies, physical damage to the CNS from abuse, genetic variables, as well as the inherent flaw of intelligence measures in accounting for any of the above variables, when evaluating this relationship. Considering what is known to date, and the difficulties inherent in this area of research, the factors contributing the most weight to the disproportionate retardation associated with abuse will not be readily apparent for some time. But we should not now overlook the distinct possibility that the child born with mental deficiencies may be more “abuse prone;” his unfortunate state may make him highly vulnerable to scapegoating. In a recent study by Sandgrund, Gaines and Green,3e children from the same socioeconomic level were divided into three groups : confirmed abuse, confirmed neglect, and nonabused controls; the neglected group was included to control for the impact of neglect upon the abused children. They found that 25% of the abused sample were classified as retarded, 20% of the neglected children were deemed retarded, and only three percent of the nonabused controls were categorized as retarded. Whereas the relative weights of neglect and abuse are indeterminable from this study, a more careful examination of these variables is warranted. It is in fact impossible to make any statements as to what factors differentiate a neglected and abused child. It is precisely this lack of clarity that highlights current methodological problems and investigational gaps. Sandgrund, Gaines and Green excluded subjects known to have suffered any serious head trauma; on this basis, their findings seriously challenge Brandwein’s 6 organic damage hypothesis. Sandgrund, Gaines and Green’s 39 hypothesis is supported by Martin et al‘s 31

determination that 43% of a sample of 37 abused children with no history of head trauma manifested slight to severe neurologic dysfunctions. However, only 29% of their sample of 21 abused children with a history of skull fracture did not manifest any neurologic dysfunction. Nichamin 36 presented some reasons why the child with neurologic dysfunction can be very difficult to tolerate. He mentioned that these babies appear to be unhappy throughout infancy, and are very difficult to appease. Their crying consists to a great extent of highpitched, disagreeable screaming. While the association of retardation and abuse is clear-cut, etiological factors remain muddled, and there is a dearth of experimental data. Whereas the parental depravity hypothesis is well known and widely accepted, further experimental and clinical attention should be given to the “abuse prone” hypothesis, PHYSICAL HANDICAPS

Johnson and Morsez1 reported on a study the Denver Department of Welfare carried out with 97 abused children. Based on child welfare worker reports, it was noted that nearly 70% of the children exhibited either a mental or physical deviation prior to the reported abuse. In addition, twenty percent were considered unmanageable due to severe temper tantrums, nineteen percent had retarded speech development, and seventeen percent demonstrated either a learning disability or mental retardation. However, the data in this study do not thoroughly substantiate that these behaviors were congenital or had occurred prior to abuse. Freidman,’a on the basis of a retrospective study of 25 cases of abused children, hypothe-

FRIEDRICH AND BORlSKlN

sized that some abused children are hyperactive or intellectually precocious. He reported several instances in which the inquisitive behavior of a child who was intellectually more capable than his parents caused the child to be more vulnerable to abuse. Green l7 found that 23% of 70 school-age schizophrenic children had suffered abuse. It was suggested that because schizophrenic children are generally unrewarding to the parents and are emotionally deviant, there is an increased risk of physical abuse. However, not enough information was provided to choose between this hypothesis, or the alternate possibility that schizophrenic behavior may result from abuse. Gil,I6 from data garnered in a twoyear nationwide study, discovered that 29% of the abused children in his sample of 12,000 children had demonstrated abnormal social interactions in the year preceding the abusive act. He also noted that approximately 22 % were suffering from either a deviation in physical or intellectual function. Among those children of school age, approximately thirteen percent were in special classes or were in grades below their age level; however, at least half of these children had incurred abuse prior to the study year. Ounsted, Oppenheimer and Lindsay 37 cited the case of an abused child who was found to be blind. Upon hearing this, the parents broke down, the mother saying that “he cried and cried and he never looked at me.” (p. 448) Birrell and Bi~-rell,~ in an analysis of 42 cases of abuse, found congenital physical abnormalities (cleft lip, fibrocystic disease, talipes, etc.) in eleven cases (approximately 25 % ) . However, this finding has not been substantiated

585

by other studies; in a study of 58 abused children?’ no children with major abnormalities, or with more than one or two minor abnormalities (clinodactyly, hermis, etc.), were found. Baron, Bejar and Sheaf€ presented the case of an infant with no signs of abuse but with a presenting problem very similar to organic brain disease. The child was treated for a number of months before it was noticed that she had been battered. When the child was admitted to the hospital, her symptoms of organic brain disease cleared up within a week. The point made is that only adequate follow-up can show how often seemingly congenital neurologic abnormalities are the result of physical abuse. In unpublished material from. the National Clearing House on Child Abuse and Neglect at the American Humane Association in Denver, Soeffing 42 reported on preliminary incidence data from 1974. Of 14,083 abused and neglected children, 1680 had one or more “special” characteristics. For example, 288 were classified as mentally :retarded, 195 had been born prematurely, 250 had a chronic illness (e.g., multiple sclerosis, diabetes), 234 were physically handicapped, 130 were either twins or triplets, 180 had a congenital defect, 669 were reported as being emotionally disturbed, and 267 had “other special characteristics.” It was also noted that the number of reported handicaps could increase as social workers learned how to better diagnose a handicap. Lynch found a significantly greater frequency of serious illness in the first year of life among abused children. It has been suggested by Morris33 that sickly infants and premature infants, by virtue of their extended hospital stay,

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make it difficult for “claiming behavior” on the part of the mother to occur, and if this “claiming behavior” (attachment) does not occur, the child is at greater risk for abuse. GENETIC CONTRIBUTIONS

Although not as clearly related as are physical abnormalities, individual differences and behavioral styles present in infants from birth may also contribute to abuse. Thomas, Chess and Birch,45on the basis of data gathered in their New York Longitudinal Project, were able to demonstrate that, seemingly from birth, children display nine different temperament styles. These temperaments tend to be present in clearly defined clusters, giving rise to a minimum of three “types” of children. “Slow-to-warm-up” children have as a significant core of their pattern of activity quiet withdrawal from, and then slow adaptation to, the new. The “difficult” child shows irregularity in biological functions, nonadaptability, predominantly negative (withdrawal) responses to new stimuli, high intensity, and frequent negative mood expressions. At the opposite end of the temperament spectrum from the “difficult” child is the “easy” child, who exhibits regularity in biological functions, approach responses to new stimuli, easy adaptability to change, and predominately positive mood of mild or moderate intensity. In this study, roughly 70% of the “difficult” children developed behavior problems; although they comprised only ten percent of the sample, these children accounted for 23% of the group of children who later developed behavior problems. Milowe and Lourie 32 made reference to children who seem to fall into the

CHILD ABUSE category of “difficult” children. At first, the researchers thought the irritable characteristics of the abused children they came in contact with were a result of their being battered. But after nurses found it difficult to take some of these infants for an eight-hour tour of duty, the researchers began to have second thoughts. The nurses commented on the irritable cry, the difficulty in managing, and the unappealing nature of some of these children. In this study, reference was also made to two children who each received battering in two different homes, presumably because of their “difficult” natures. Silver 41 also cited a case of an abused child who was admitted to the hospital, was subsequently removed to a foster home, and was battered in the foster home. In a vein similar to Thomas, Chess and Birch’s 46 temperament clusters, Schaffer and Emerson 40 isolated two groups of infants-those who actively resisted close physical contact under all conditions (noncuddlers) , and those who accepted close physical contact under all conditions (cuddlers). It was determined that this behavior was not peculiar to the relationship of the child with the mother. Shaffer and Emerson felt that a noncuddling pattern is not clinically a bad sign. Only if the mother is too rigid to attempt alternate methods of relating to the child, or if she feels the noncuddling behavior is a sign of rejection, is there risk of a pathological mother-child relationship. Ounsted, Oppenheimer and Lindsay have pointed out the implications of this risk for abused children. In their study of 24 children, about two-thirds of the mothers complained that the child could not be cuddled, although it was not reported whether this feature of the child’s inter-

FRIEDRICH AND BORlSKlN actional pattern was present from birth. In the area of individual differences in infants, Korner 26 has found differences in crying patterns among infants, and differences in soothability once they begin to cry. She pointed out the implications this could have for a young and inexperienced mother with a difficult to soothe child. These differences can directly affect the mother’s feelings of competence as a caregiver. In addition, Benjamin has suggested that infants with low sensory thresholds are very prone to develop coIic during the first few postnatal weeks, thus aggravating a developing mother-child relationship. Woolf 46 described seven normal infant states: regular sleep, irregular sleep, periodic sleep, drowsiness, alert inactivity, waking activity, and crying. KornerZ7 has suggested a concept of state-immaturity, in which infants exhibit only a limited range of states (e.g. two or three). These children have been shown to be very difficult to care for and will often develop subsequent psychopathological symptoms. For example, Brazelton f3 described a case in which an infant, capable of only two extreme states, so demoralized his mother, a young professional woman, that she became totally ineffectual and depressed. From the start, the mother felt “rejected” by the child. Korner 26 concluded her paper by saying

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focusing on each child‘s particular needs. Consequently, mothers are prone to feel a lot of guilt over deviant behavior in their children.6 Some of this might be reflected in battered children. PARENTS PERCEPTIONS OF THE CHILD AS DIFFERENT

A number of studies *, 14- l6 have shown that generally, even in multi-child families, only one child is abused. This has given rise to suggestions that the abused child is selected as a scapegoat, either because he is truly different from his siblings, or for some other, inexplicable reason. For example, Lynch’s 29 study of 25 abused children and their nonabused siblings reported the nonabused siblings

. . . to have been exceptionally healthy, and, where population figures are available, show a lower than expected incidence of adverse factors. (p. 319)

However, Johnson and Morse noted that, while 36% of the abused children were illegitimate, 40% of the nonabused siblings were also illegitimate. In addition, there were similarities among the siblings in terms of personality and intellectual performance. Morse, Sahler and Friedman 34 noted that the mothers of six abused children who were progressing normally at the time of follow-up saw the parent-child relationship as good. However, the mothers of seven abused children who were quite disturbed at follow-up de. . . the finding that infants differ significantly scribed the parent-child relationship as from each other right from the very start sug- poor. Originally, of the 25 children obgests that there is more than one way of pro- served in this study, fifteen were conviding good child care; . . . the only way to do sidered different by their parents. Nine so is to respond flexibly to . . . each and every of the children were retarded, and three child. (p. 617) of these were thought by their parents to However, parents are trained in the be sickly. Six others were thought by “right” way to raise kids, rather than their parents to be bad, selfish, spoiled

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rotten, or defiant in comparison to siblings. This suggests that, in addition to the child’s abnormalities, the parents’ perception of the child can also be critical. Bishop4 cited four cases of young children overdosed with sedatives by disorganized and depressed mothers who had perceived their child as “damaged.” Physical examinations of the children provided no support of this perceptual bias. Consequently, Bishop claimed that when the parental perception of a “damaged” child is counter to objective evidence, the risk may be even greater. In a similar vein, Martin and Beezley have hypothesized that it is the children with mild or borderline abnormalities who are at greatest risk, while severely handicapped children are at lower risk for abuse. The basis for this hypothesis is unclear. Perhaps it is the ambiguity that introduces the greatest stress to the parent. Whatever the case, more data on parental perception of abnormalities in their abused children is needed. CONCLUSION

On the basis of the evidence presented, it would be fanciful to conclude that the special child is the sole contributor to abuse. But the opposite extreme, the all too prevalent notion that abuse is exclusively a function of a parental defect, seems equally specious. Abuse is the product of a comp!ex set of interactions, and assigning weights to any of its components is premature. A conceivable expansion upon Green’s l7 four-factor equation of the causes of abuse may help to illustrate the problem :

+

+

+

+

-+ +

a) special child special parent crisis cultural tolerance = abuse b) special child + normal parent + crisis cultural tolerance = abuse normal parent cultural c) special child tolerance = abuse

Each equation is feasible and has been clinically demonstrated. While the factors making up the first have been noted by Green and others, the implications of the other two equations have all too often been ignored. Emphasis upon a single factor in abuse (psychopathology of the parent, environmental stresses, etc.) may obscure the importance of relevant variables, and lessen the effectiveness of therapeutic and prevention programs. Popular emphasis on the depraved-parent model of abuse may make other parents more reluctant to seek counseling (for fear of labeling). A broader dissemination of the fact that there are “difficult” children who can induce stress, and that relatively normal mothers can experience severe anxiety with respect to child rearing, could reduce this reluctance and the guilt attached to it. Furthermore, it must be shown that it is not necessary for a special child to be present, but that the parent’s perception of the child as different can be sufficient to instigate abuse. Current research does demonstrate that prematurity, mental retardation, physical handicaps, congenital malformations, and similar conditions are overrepresented in abused populations. Even Martin et U Z , ~ ’ who stress the role of the parent and deemphasize the role of the child, stated that the proportion of premature infants in their population was significantly different from the norms.

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Obviously, a great deal of research is required before the multifaceted aspects of the etiology of child abuse are determined. However, particularly within the realm of present knowledge, we must take into account a relatively consistent correlation-the special child is at greater risk for abuse. In planning prevention and treatment programs, those who deal with child abuse must keep this postulate in mind. REFERENCES 1. BARON,

M., BEJAR, R. AND SHEAFF, P.

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Neurologic manifestations of the battered child syndrome. Pediatrics 45: 1003-1007. 2. BENJAMIN, J. 1961. The innate and the experiential in development. I n Lectures on Experimental Psychiatry, H. Brosin, ed. University of Pittsburgh Press, Pittsburgh. 3.BIRRELL, R . AND BIRRELL, J . 1968. The maltreatment syndrome in children: a hospital survey. Med. J. Austral. 2:10231029. 1971. Children at risk. Med. J. Austral. 1 :623-628. 5. BRANDWEIN, H. 1973. The battered child: a definite and significant factor in mental retardation. Ment. Retard. 11:50-51. 6. BRAZELTON, T. 1961. Psychophysiologic reactions in the neonate: I. the value of observation of the neonate. J. Pediat. 58:

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508-5 12. 7. DREYFUS-BRISAC, c. 1974. Organization of

sleep in prematures: implications for caregiving. In The Effect of the Infant on Its Caregiver, M. Lewis and L. Rosenblum, eds. John Wiley, New York. 8. EBBIN, J. ET AL. 1969. Battered child syndrome at the Los Angeles County General Hospital. Amer. J. Dis. Childhd 118:66& 667. ELMER, E. 1965. The fifty families study: summary of phase-I. neglected and abused children and their families. Children’s Hospital of Pittsburgh, Pittsburgh. 10. ELMER, E. AND GREGG, G. 1967. Developmental characteristics of abused children. Pediatrics 40:596-602.

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1975. Mother-child separation at birth: a contributing factor in child abuse. Lancet 2: 549-550. 13. FRIEDMAN, s. 1972. The need for intensive

follow-up of abused children. In Helping the Battered Child and his Family. C. Kempe and R. Helfer, eds. Lippincott, Philadelphia. 14. FRIEDRICH, w. 1975. A survey of reported physical child abuse in Harris County, Texas. Unpublished Master’s thesis, University of Texas School of Public Health, Houston. 15. GELLES, R. 1973. Child abuse aud psychopathology: a sociological critique and reformulation. Amer. J. Orthopsychiat. 43 : 611-621. 16. OIL, D. 1970. Violence against children:

physical child abuse in the U.S. Harvard University Press, Cambridge, Mass. 17. GREEN, A. 1968. Self-destruction h physically abused schizophrenic children: report of cases. Arch. Gen. Psychiat. 19: 17 1-197.

I ~ . G R E E N , F. 1975. Child abuse and neglect: a priority problem for the private physician. Pediat. Clin. N. A. 22:320-339. 19. HELFER, R. 1973. The etiology of child abuse. Pediatrics 5 1 :777-779. 20. HELFER, R. 1975. The diagnostic process and treatment programs. Office of Child Development, Washington, D. C. 21. JOHNSON, B. AND MORSE, H. 1968. Injured children and their parents. Children 15: 147- 152. 22. KEMPE, C.

AND HELFER,

R.,

4 s . 1972.

Helping the battered child and his family. University of Chicago Press, Chicago. 23. KLAUS, M. AND KENNELL, J. 1970. Mothers separated from their newborn infants. Pediat. Clin. N. A. 17:1015-1037. 24. KLEIN, M. AND STERN, L. 1971. Low birth weight and the battered child syndrome. Amer. J. Dis. Childhd 122:15-18. 25. KNOBLOCH, H.

AND PASAMANICK, B.

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Prospective studies on the epidemiology of reproductive causality: methods, findings, and some implications. Merrill-Palmer Quart. 12:27-43. 26. KORNER, A. 1971. Individual differences a t birth: implications for early experience and later development. Amer. J. Orthopsychiat. 41:608-619. 27. KORNER, A. 1974. Individual differences at birth: implications for child care practices. In The Infant at Risk, D. Bergsma, ed. Stratton Intercontinental, New York. 28. LEIDERMAN, P. 1974. Mothers at risk: a

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590 potential consequence of the hospital care of the premature infant. In The Child in His Family: Children at Psychiatric Risk, E. Anthony and C. Koupernik, eds. John Wiley, New York. 29.LYNCH, M. 1975.Ill-health and child abuse. Lancet 2:3 17-3 19, 30. MARTIN, H. AND BEEZLEY, P. 1974. h e vention and the consequences of child abuse. J. Operational Psychiat. 6:68-77. 31. MARTIN, H. ET AL. 1974. The development of abused children: a review of the literature and physical, neurologic, and intellectual findings. Advances in Pediat. 21:

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AND LOUIUE, R. 1964. The child's role in the battered child syndrome. J. Pediat. 65:1079-1081. 33.MORRIS,M. Detection of High Risk Parents. (unpublished)

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16:447-456. 38.PASAMANICK, B. 1975. Ill-health and child abuse. Lancet 2:550. 39. SANDGRUND, A. GAINES, R . AND GREEN, A. 1974.Child abuse and mental retardation: a problem of cause and effect. Amer. J.

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1964. Patterns of response to physical contact in early human development. J. Child Psychol. Psychiat. 5 : 1-13. 41.SILVER, L. 1968.The psychological aspects of the battered child and his parents. Clinical Proceedings of the Children's Hospital. Washington, D. C. 24:355-364. 42.SOEFFINC, M. 1975. Abused children are exceptional children. Exceptional Children 42:126-133. 43.SPINETTA, J. AND RIGLER, D. 1972. The child-abusing parent: a psychological review. Psychol. Bull. 77:296-304. 44.STEELE, B. AND POLLOCK, C. 1974. A PSYchiatric study of parents who abuse infants and small children. In The Battered Child, R. Helfer and C. Kempe, eds. University of Chicago Press, Chicago. 4 0 . SCHAFFER, H. AND EMERSON, P.

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For reprints: William N. Friedrich, Department of Psychology, University of North Dakota, Grand Forks, N.D. 58201