Psychiatric Opinion, Vol. 13, No. 2, April 1976, 13-18.
A Physician’s Perspective on the Interdisciplinary Management of Child Abuse
ELI H. NEWBERGER, M.D.
Introduction: The Problem
The management of child abuse is always difficult; for several reasons, it is frequently impossible successfully to bring to bear the efforts of personnel from various disciplines. Among the more important limiting factors on effective interdisciplinary action to help the victims of child abuse and their families are the following:
- Lack of understanding by the members of one discipline of the objectives, standards, conceptual bases, and ethics of the others. For example, physicians in hospitals often see social workers’ professional activities in terms of referring patients to foster homes and carrying on the unpleasant – if necessary – day-to-day contacts with families for whom they have little time.
- Lack of effective communication from members of one discipline to members of another. Possible examples include the important child-development observations that nurses frequently make which, for want of not having been heard, are ignored in the process of diagnostic formulation and decision making by social workers and physicians.
- Confusion as to which personnel can take what management responsibilities at what times. In a hospital, for example, the doctor is accustomed to thinking that he is the boss; he alone decides when the patient is admitted or discharged—perhaps only on the basis of medical criteria. Upon the child’s discharge, he may expect that the protective service’s social worker will obediently knock on his patient’s family’s door, hat in hand, to ask, “Have you been beating your child?”
- Professional chauvinism. A sense of professional pride may lead a social worker in a private family service agency to tell a colleague in a public agency or a public health nurse or physician. “Look, we’ve been in this business a hundred years. Who do you think you are to ask if we made a home visit last week?”
- Too much work for everybody and a sense of hopelessness and despair in the face of overwhelming problems and unsympathetic colleagues. This factor probably accounts for the large yearly turnover of social work personnel in public agencies—with the resulting loss of continuing service to individual families and of precious, experienced manpower. In Massachusetts, the staff turnover in the Division of Family and Children’s Services of the Department of Public Welfare ranges up to 30% a year.
- Institutional relationships which limit effective inter-professional contact. An example with which I am personally impressed is that of hospitals competing for patients and prestige. Their professional staffs (in medicine, social work, and nursing) may be reluctant to communicate with rival institutions’ staffs—much less to collaborate with them in providing coordinated services to families whose individual members may receive continuing services at several clinics and offices. Social workers in public protective service programs are often isolated in state departments of public welfare. The other ancillary components of clinical child abuse management are fragmented, in most cases either into separate departments of public health or mental health or in separate private offices.
The distinguished child psychologist Urie Bronfenbrenner has observed that American service institutions often serve to divide rather than to integrate families.1 In child abuse management, we can often see the destructive consequences of separate institutions which attend to various aspects of welfare, health, and child development, but which cannot—because of their organization—work effectively together to strengthen family life.
- Prevailing punitive attitudes and public policies about child abuse. Many professionals from outside the field turn away from involvement with protective service workers and programs as a result.
- A lack of confidence and trust on the part of personnel from one profession toward colleagues in the others. This problem is made more difficult by the exceeding personal demands on everyone working with families whose children’s lives are in jeopardy. The feelings within oneself generated by the anguish, remorse, anger, and guilt displayed by these families are hard to handle. They prompt serious conflicts among us and try our professionalism enormously.
- Cultural isolation of professional personnel. The traditions and values of child rearing and family life among black, Spanish-speaking, or other minority families—who seem disproportionately represented in child abuse case reports—may be ignored by physicians, social workers, policemen, lawyers, and judges, who tend predominantly to be white. Because professional action on child abuse cases nearly always hinges on assessments of family competency, culture-bound value judgments can be harmful. They also promote conflict among professionals of different cultural backgrounds.
A wise and witty Supreme Court Justice, Felix Frankfurter, in his introduction to Alfred North Whitehead’s book The Aims of Education,2 cautioned against another, last hazard to interdisciplinary work. Concerned lest the boundaries of each professional domain be eroded in a headlong effort to foster mutual enrichment, or cross-fertilization, he warned of a possible “cross-sterilization” of the disciplines, where uncertainty in one profession would be resolved by resorting to a dubious truth in another.
In the interdisciplinary management of child abuse cases, we not infrequently fall into this trap. At the end of a difficult and frustrating case discussion, the only consensus which may be reached is “We need a psychiatric consultation,” when everyone knows that the consultant’s findings may only contribute further to the ambiguity and uncertainty about where to go and how to intervene. Or, also out of fear of making a management mistake, disagreeing parties conclude that the only suitable forum for discussion of conflicting perspectives is the courtroom, putting the judge in the difficult position of having to resolve conflicts among social workers and doctors and putting the family through an exceedingly stressful experience.
In the specific context in which case management takes place, a few more observations are in order.
By and large, physicians, social workers, psychiatrists, public health nurses, and legal personnel operate in relative detachment from one another. Each does what he can, often alone.
From the medical perspective, doctors often just treat the child’s injury and send him on his way; psychiatrists focus on the behavior of an individual who comes to them with a proffered complaint; social workers and public health nurses, who can see the family context in which child abuse occurs, may find themselves powerless to affect the actions of the other professionals with whom the family may be in contact; policemen and judges frequently apply the method most readily available to them to protect a victim of child abuse—separating the child from the parents. Each professional does what he or she can, within the ethical definition of his domain. Yet the family and its individual members can be harmed—not helped—by these well-intended, independent actions.
One is reminded of the comment attributed to the late Abraham Maslow 0908-1970) to the effect that if the only tool you have is a hammer, you tend to treat every problem as if it were a nail.
We now have several excellent studies of foster home care and its consequences; these investigations demonstrate the risks and costs of the most readily available child protective practice.
In the professional practice of child protection, we now know that with the right kind of interdisciplinary cooperation, families can be kept together and made to be safer, more nurturant contexts in which children who have suffered abuse can grow. The recent publication of a landmark volume, edited by Drs. C. Henry Kempe and Ray E. Helfer, Helping the Battered Child and His Family,3 may herald a new era of protective practice. Now professional energies may be invested more in the direction of making families stronger than in simply assuring that children’s risk of repeated injury is reduced. It is especially encouraging to see this interest in the medical community—about a century behind the pioneers of the child welfare movement
The Challenge of Interdisciplinary Child Abuse Management
We professionals in the field face an important challenge in fostering interdisciplinary cooperation and in developing effective and humane child abuse programs. I would like to present a rationale for the clinical management of child abuse in the initial crisis period when interdisciplinary cooperation is most vital.
I will consider interdisciplinary practice—admittedly and unabashedly from a physician’s perspective—in the critical period when a family in crisis presents an abused child for care. A consensus on seven axioms of child abuse management appears in child abuse literature:
- Once diagnosed, a child with inflicted injury or neglect is at great risk for reinjury or continued neglect.
- Protection of the child must be a principal goal of initial intervention, but protection of the child must go hand-in-hand with the development of a program to help the family through its crisis.
- Traditional social casework in itself cannot protect a battered or neglected child in the environment in which he received his injuries. Medical follow-up, too, is necessary, and day-to-day contact with a child care center may help significantly to encourage his healthy development.
- In the event the child is reinjured and medical attention is sought anew, it is likely that the parents or caretaker will seek care at a different facility from the one at which the diagnosis was originally established or suspected.
- The problems of public social service agencies in both urban and rural areas—specifically in numbers of adequately trained personnel and in quality of administrative and supervisory functions—militate against their effective operation in isolation from other care-providing agencies. Simply reporting a case to the public agency mandated to receive child abuse case reports may not be sufficient to protect an abused or neglected child or to help the family.
- Early identification by professional personnel of the immediate agent of the injury, or attempts to determine if neglect was “intentional,” may be ill advised. However strategic the “facts” may be to confirmation of diagnosis and treatment planning clinical experience attaches the greater importance to the establishment of confidence and trust in the intervening professionals. This relationship may be jeopardized by overly aggressive attempts to elicit specific information on the circumstances of the injury. There is rarely any need to establish precisely who it was who injured or neglected a child and why. Lack of evidence for parental “guilt,” furthermore, is emphatically not a criterion for discharge of the patient.
- If there is evidence that the child is at major risk, hospitalization to allow time for assessment of his home setting is appropriate. Infants under a year of age with fractures, burns, or bruises of any kind are especially at risk for reinjury or for serious consequences of neglect. Prompt and effective intervention is vital to assure their survival.
Assessment of The Child and His Family
An adequate general medical history and physical examination are necessary at the time the child is brought to the physician. Photographs and a skeletal X-ray survey are performed when deemed appropriate. A social worker, if available, is called promptly at the time of the family’s presentation; this contact with the family is supported by the physician, who introduces the worker as someone interested and able to help them through this difficult period and who confers with the worker after the initial interview.
In the initial interviews and in subsequent contacts, no direct or indirect attempt is made to draw out a confession from the parent. Denial is a prominent ego defense in virtually all abusing parents, and the bizarre stories often heard from them about how their children got their injuries ought not to be taken as intentional falsifications. These odd accounts often tell how profoundly distressing it is to a parent to acknowledge having inflicted an injury or having failed to protect a child from someone else’s having done so, In the face of such a threatening reality, they repress it, literally to hold themselves together; they may offer blatantly phony stories, which must be accepted for the moment.
A professional does no service to parent and patient with assaults on the parent’s personality structure. The third degree or its gentlemanly equivalent serves often to harden the defense or to promote more primitive defenses—resistance to talking about the problem at all, angry outbursts directed at the interviewer or at the hospital, or threats to take the child home immediately. Such defenses limit both the process of information gathering and the prospects for continuing helpful professional relationships; they may possibly endanger the child. Rather, good interview technique allows parent and child to maintain the integrity of ego and family as it is in each case. Although spoken or suggested skepticism about the proffered explanation also operates deleteriously, it is appropriate to emphasize the child’s need for care—which may include his admission to a hospital—and the need to ensure that he is protected from harm. At this time, the professionals should demonstrate concern and ability to help the parent’s distress as well.
In explaining his legal obligation to report the case, the physician’s compassion and honesty will go far to allay the family’s anxiety. The opportunity to observe parent-child interaction and the child’s physical and psychological milestones (which might yield insight into the familial causes of a child’s injury) may not be available to a physician in his office. Nurses in clinical and public health settings can and do, however, make such observations, which are fundamental in case finding and evaluation. Their competence contributes uniquely to diagnosis, and their perceptions should be shared appropriately with the physician and social worker seeing the family. A description of the child’s development—perhaps augmented by a Denver Developmental Screening Test—and of his interaction with his family, is usually recorded in the nurses’ notes.
A home visit by a public health nurse or social worker is made to develop a reasoned perception of the child’s home environment and to gather data for the discussion of the child’s disposition. A psychiatric consultation is frequently obtained on cases of child neglect and abuse. Often this consultant’s perceptions lead to understanding of what intervention by which personnel can be most effective. Only rarely, however, can a psychiatrist work magic; his consultation—always desirable but often difficult to arrange—should be a helpful adjunct to the planning process for the primary managers, social worker, physician, and nurse. Psychiatric consultation should not substitute for careful history taking and diagnostic assessment by the personnel who will continue to follow the child and his family.4
The development of programs which attend to these principles will require careful thought and planning. In the last analysis, our ability to convince our patients or clients that we mean to help them depends on our ability to mobilize effective services for them. When we do so, case reports from all practitioners will certainly come easier and our ability to enlist our colleagues—some of whom are now reluctant even to report child abuse cases—in an interdisciplinary effort will improve as well.
- Bronfenbrenner, G. Two Worlds of Childhood. Russell Sage Foundation, New York, 1970.
- Whitehead, A. N. The Aims of Education. Mentor Book Ed. New American Library of World Literature. New York. 1949.
- Kempe, C. H., and R. E. Helfer. eds. Helping the Battered Child and His Family. Lippincott. Philadelphia, 1972.
- Newberger. E. H., and J. N. Hyde. “Child Abuse: Principles and Implications of Current Pediatric Practice,” Pediatr. Clin. North Am. Vol. 22, No.3, 1975. pp. 695.715
ELI H. NEWBERGER – Dr. Newberger is Director of Family Development Study and Chief of the Family Development Clinic at the Children’s Hospital Medical Center in Boston. He is an Instructor in Pediatrics at Harvard Medical School.