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Journal of the American Medical Association, Vol. 237, No. 19, May 9, 1977, 2086-2088.

Compassion vs Control

Conceptual and Practical Pitfalls in the Broadened Definition of Child Abuse

Alvin A. Rosenfeld, MD, Eli H. Newberger, MD

• A broadened understanding of child abuse has enabled practitioners to think of the parents of abused children not as evil murderers but as human beings caught in a complex web of social Isolation and deprivation. Concomitantly, child abuse laws have changed dramatically in the last decade to include virtually all childhood physical symptoms of family crisis; physical, sexual, and emotional abuse and child neglect are now reportable by nearly all professionals who have contact with children. There has been a dramatic increase in case reports, but the services for which families become eligible do not approach the humane rhetoric and intent of child abuse legislation. Society and the helping professions are caught in a dilemma that we characterize and address clinically as compassion vs control.
(JAMA 237:2086-2088, 1977)

For more than a century, child welfare agencies have undertaken to assure the safety and well-being of children. This important work began as a concern to provide basic life supports for the children of the immigrant poor and focused on providing homes for the homeless.1 More recently, it has progressed to a legally mandated intervention on behalf of children who are suffering from physical, sexual, or emotional traumatization in their homes.2 As the statutory basis for this protection has rapidly evolved in the last two decades, there have developed neither clear-cut legal guidelines for family intervention nor a scientific foundation for protective service work.3-6 The lack of a rigorous practical and theoretical framework for law and for clinical practice has created a muddled and perplexing situation for professionals concerned with the health and welfare of children.

Historical Background

In 1962, Kempe and his co-workers7 dramatized the problem of child abuse with the term "the battered child syndrome" in a paper that precipitated public outrage and deep professional concern. Although the phenomenon was hardly new8 and the existing clinical studies of child abuse were mostly of dubious quality,9 the time was ripe for action. The concern led to the passage of a child abuse reporting statute in every state. In retrospect, it is of note that these laws were enacted in the 1960s, an era of concern for the rights of the disadvantaged. As they have developed (and broadened) to the present day, these statutes oblige all professionals in contact with children to report any symptoms or serious suspicions of physical, sexual, or emotional abuse. Most laws also require signs of neglect to be reported. In 1974, the passage of a national child abuse act (PL 93-247) that makes available to states modest support for protective service work has, through the establishment and administration of federal regulations, effectively expanded the list of reportable conditions.

Since nearly all of the statutes are worded imprecisely, they give the reporter wide latitude in addition to legal immunity. Usually, the department of public welfare or the police are designated to receive the report. Once a report is filed, an investigation may begin to determine whether the child is at risk in his parents' care, and appropriate steps may be taken.

The child abuse statutes are intended to protect children whose lives are in danger and for whom other statutes do not afford protection. They spell out state and professional responsibility toward families who have problems in protecting their children, and state that helpful services (such as counseling, provision of a homemaker, day care, and temporary foster-home care) shall be provided to strengthen family life. Few anticipated the number and variety of cases that would be reported under the child abuse laws. Where in 1967 fewer than 7,000 cases of child abuse came to the attention of the authorities,10 in 1974 there were more than 200,000 (V. De Francis, JD, personal communication, Feb 13, 1976). No child welfare office had resources remotely adequate to deal with this deluge. For example, when Florida introduced a state-wide hot line for child abuse reporting as the centerpiece of its strategy to deal with the problem, the state was overwhelmed with calls. This led to a rapid deterioration of the method of screening cases for service.11

Moreover, the social workers who man these departments, which tender mainly to impoverished children and families, are overworked, underpaid, and poorly supervised, and they have insufficient access to psychiatric, psychological, and medical consultation and treatment.12,13 Staff turnover in welfare departments is enormous, and the prospects for continuing service to troubled families is small. With few clear-cut guidelines for decisions, action can be taken on the basis of exhaustion, emotionalism, or personal values about child rearing; rather than from attention to statutory or administrative guidelines or to commonly understood standards of sound professional practice. At present, services do not approach the humane rhetoric and intent of child abuse legislation. The system may mete out punishment in the guise of help.

Child Abuse and Later Deviant Behavior

It has been noted that child abuse has a multi-generational pattern: the parents of abused children may themselves have been abused and neglected in childhood.14 Violent criminals seem often to have suffered abuse as children; for this reason, Schmitt and Kempe15 strongly suggest that action on the problem of child abuse will prevent crime. The data that form the basis for these conclusions can be accounted for in large part by insufficiently rigorous study design. The studies share a prominent bias that favors poor people. Of the few studies that have comparison groups, nearly none match cases and controls adequately.5 The single controlled follow-up study that matches cases and controls on social class suggests that the developmental consequences of child abuse can be accounted for on the basis of low social class.16 Finally, foster-home care, a common protective service intervention, is associated with an unfortunate and predictable psychiatric morbidity of its own.17

Compassion vs Control

As laws have been passed broadening the list of conditions mandated to be reported as child abuse, a humane philosophy of clinical treatment has evolved.

Newer knowledge has shown social isolation, illness, and parental psychologic symptoms to be associated with child abuse, and our present orientation also acknowledges current life stresses, including unemployment, marital conflict, crises associated with drugs and alcohol, and inadequate access to essential resources and services.18

This broadened understanding of the setting of child abuse enables practitioners to see abusing parents not as evil murderers but as human beings caught in a complex web of personal and social deprivation that inhibits the normal loving relationships between parents and their children. The philosophy of practice has become assertedly humane: Kempe and Helfer's second book19 is entitled Helping the Battered Child and His Family. Behavior that might be characterized by an outside observer as destructive or criminal has come to be seen and interpreted by those involved in its identification and treatrpent in terms of the psychosocial economy of the family.

The more compassionate understanding of the family has changed expectations of the clinician. He or she is expected to approach each case with both an abundance of human kindness and a nonpunitive outlook on intervention, which should be aimed at strengthening the entire family. Compassionate intervention has created a commonly understood language of child abuse treatment, one in which the abusing parents are frequently seen as victims themselves. They may effectively be relieved of responsibility for their actions by a professional who perceives the social and developmental origins of their behavior.

The clinician may find incompatible the dual role suggested by the two models of intervention that we identify as a consequence of our broadened concept of child abuse and call "compassion" and "control."

The compassionate model derives from the need for insight and the formation of a helpful professional-parent relationship to understand and to improve the functioning of abusing families. In practice, when the abusing parents are seen as sad, deprived, and needy human beings (rather than as cold, cruel murderers), one sympathizes with their plight and may proffer help in the form of counseling and other services, such as provision of a homemaker, health and child care, and other supports. One may contemplate with dread strong intervention on behalf of the child, such as court action on his or her behalf, with or without foster-home placement.

The danger implicit in the compassionate approach is that overidentification with an abusive parent can be paralyzing. We have seen injuries and fatalities that are traceable to a physician's, nurse's, social worker's, or judge's inability to act on perceived danger for want of alienating the parents. Fused with utopian' notions about the curative power of love and genuine concern, the compassionate model may also demoralize professionals when the treatment relationship proves hopeless.

One may take it as a personal failure to love sufficiently or appropriately. "Perhaps one more week" or "This time I'm sure she won't do it again. We had a really good talk. . ." are familiar refrains of the professional who has become attached, involved, and overidentified with the family as victim. When an interdisciplinary team approaches a case, there may be reluctance to assume the role of the "bad guy" who will tamper with the therapeutic relationship by taking the drastic step of signing a care and protection petition in the juvenile or family court.

The control model refers to the aggressive use of intervention to limit and, if necessary, to punish deviant behavior. It assumes that an individual must take full responsibility for his actions and the State will hold him accountable.

For several reasons, the human service community may reject the notion of control. First, it is perceived as being in direct conflict with the model of compassion and the ethical mandate to be humane and to refrain from a judgmental posture in one's work. Any threat of force against abusing parents may be seen as cruel. The compassionate approach requires the behaviors of physician and friend, while control requires the action of the not-so-friendly policeman who may blow the whistle on an intolerable situation.

Second, child-care professionals are reluctant to set limits for adults, even if the situation screams for action. Third, the philosophy of helping the family carries in it an implicit standard of professional deportment that does not allow the expression (and for many, we fear, the acknowledged experience) of strong negative feelings towards their clients or patients. The rage that a conscientious professional may feel in a child abuse case cannot be expressed directly. It may be translated to a displacement of anger, so that judges and police who impose criminal sanctions on parents (whose behavior would undoubtedly yield them a long jail sentence if done against an adult) become the villains. Another manifestation of this displacement is the anger that sometimes develops between physicians and social workers on these cases. This can grow so intense that communication and intelligent problem-solving cease. Another way to deflect the rage without acknowledging it is to rationalize it. Thus, under the guise terests, a harsh and punitive approach may be used in all cases, with the unspoken motive of punishing the bad parents.

Giving Compassion and Control

In all cases, there is a need for a balance and coordination of compassion and control, and we suggest that because it is not always humanly possible to maintain objective judgment during intensive work with abusive families, we might assign the functions separately. The assessment of a family referred for child abuse might be done by someone expert in deciding whether the case warrants a therapeutic trial, or whether strict legal intervention, such as a care and protection petition, is required. If a primarily compassionate treatment approach is attempted, the person working with the family would not be the one deciding if, when, or what legal intervention is necessary. A professional who has no interest in forming a helping relationship with the family (an administrator, as opposed to a therapist, in the psychiatric model) would be assigned to the case. The administrator's function would be to make the practical decisions about protective intervention on behalf of a child. Were the administrator an experienced and senior person, one would reasonably anticipate in him or her the maturity to decide calmly and to help the clinician define the relative balance of compassion and control. Furthermore, at times, only the authority and oversight of a court may give sufficient leverage (eg, the threat of a child's being taken away) to make possible a compassionate relationship (or any relationship) between professional and family.

Standard for Decision-Making

There is need for a standard that would guide the choice of the intervention model. While there is no body of empirical data with which to finalize such a standard, we propose six measurements in the form of dualisms to inform professional decisions. No one measurement is sufficient for a decision.

1. Acute vs chronic injury: If the injury is an isolated experience that occurs during situational stress, a more compassionate model might be applicable, whereas recurrent severe injuries might call for intervention

2. The abusive incident acceptable or unacceptable: A parent who continues to manifest guilt and concern after an isolated episode may be more likely to respond to a more compassionate intervention model, whereas the parent who shows lack of concern about the injury may well require control. Prolonged observation may be necessary accurately to assess a parent's reaction. We warn against casual impressions.

3. Social vs dissocial: This measurement addresses the parent's pattern of behavior in reference to the norms of the culture or subculture. In suggesting it, we acknowledge the inability and reluctance of professionals to make such judgments. The greater the degree of social deviance (isolation, alcoholism, drug abuse, criminality), the more likely the need for control.

4. Love vs hate for the child: Of the various symbolic meanings of a child to a parent, the most pertinent to this discussion is valence, or the subjective parental attitude towards the child. If the child is seen as good, a compassionate approach may be more likely to succeed, whereas a child seen as intrinsically bad may need to be protected by a model that emphasizes control of the parent.

5. The child seen as separate from or fused to the parent: This measurement addresses the parent's ability to conceive of the child as a separate entity with needs of its own. A capacity for empathy and appropriate parental behavior is supported by this ability, and a more compassionate model may be apt in a case of abuse. A fused perception of parent and child may support a control intervention.

6. Integrated or disintegrated parental ego: A person with demonstrated (or potential) personality strength sufficient to inhibit destructive impulses may more likely respond to a compassionate approach. The desire to quiet a crying child is universal. The impulse to harm the child if necessary to quiet him is prevalent, if not universal.20 The lack of sufficient ego strength to deflect that impulse into a channel other than abuse may reflect either transient disturbance or serious ego pathology. If it means the latter, at least one aspect of intervention will have to be control.

Obviously there is a great deal of none provides the answer when or how to employ compassion and control. Child abuse, like other clinical problems, calls for sound clinical judgment. The identification of assumptions implicit in present child protective work and the establishment of a rational basis for future thinking about child abuse will promote the development of a more effective and humane practice.

This study was supported in part by grant OCD-CB-141 from the Office of Child Development, US Department of Health, Education, and Welfare.

References

1. Kadushin A: Child Welfare Services. New York, Macmillan Publishers, 1967, pp 36-65.

2. Wald MS: State intervention on behalf of "neglected" children: A search for realistic standards. Stanford Law Rev 27:985-1040, 1975.

3. Gelles RJ: Child abuse as psychopathology: A sociological critique. Am J Orthapsych 43:611621, 1973.

4. Newberger EH, Hyde IN: Child abuse: Principles and implications of current pediatric practice. Ped Clin North Am 22:695-715, 1975.

5. Newberger EH, Daniel JH: Knowledge and epidemiology of child abuse: A critical review of concepts. Ped Ann 5:15-25, 1976.

6. Bourne RD, Newberger EH: "Family autonomy" or "coercive intervention?" Ambiguity and conflict in a proposed juvenile justice standard on child protection. Boston University Law Rev, to be published.

7. Kempe CH, Silverman FN, Steele BF, et al: The battered child syndrome. JAMA 181:17-24, 1962.

8. DeMause L: Our forbears made childhood a nightmare. Psychol Today 8:85-88, 1975.

9. Polansky NA, Polansky NF: The current status of child abuse and child neglect in this country, in Report of Task Force I. Joint Commission on the Mental Health of Children, Washington, DC, 1968.

10. Gil DG: Violence Against Children. Cambridge, Mass, Harvard University Press, 1970. 11. Price M: Child Protection Report, Washington, DC, March 13, 1975.

12. Nagi SZ: Child Maltreatment in the United States: A Cry for Help and Organizational Response. Columbus, Ohio, Ohio State University Publications, 1976.

13. Jenkins S: Child welfare as a class system, in Schorr AL (ed): Children and Decent People. New York, Basic Books Inc Publishers, 1974, pp 3-23.

14. Steele BF, Pollock CB: A psychiatric study of parents who abuse infants and small children, in Helfer RE, Kempe CH (eds): The Battered Child, ed 2. Chicago, University of Chicago Press, 1974, pp 89-133.

15. Schmitt BD, Kempe CH: Neglect and abuse of children, in Vaughn VC, McKay RJ (eds): Nelson Textbook of Pediatrics, ed 10. Philadelphia, WB Saunders Co, 1975, pp 107-111.

16. Elmer E: A followup study of traumatized children. Pediatrics 59:273-274, 1977.

17. Fanschel D, Schinn EB: Dollars and Sense in the Foster Care of Children: A Look at Cost Factors. New York, Child Welfare League of America, 1972.

18. Newberger EH, Reed RB, Daniel JH, et al: Pediatric social illness: Toward an etiologic classification. Pediatrics, to be published.

19. Kempe CH, Helfer RE: Helping the Battered Child and His Family. Philadelphia, JB Lippincott Co, 1972.

20. Chase NF: A Child Is Being Beaten. New York, Holt Rinehart & Winston Inc, 1975.

From the Departments of Psychiatry (Dr Rosenfeld) and Pediatrics (Dr Newberger), Harvard Medical School, and the Children's Hospital Medical Center (Dr Newberger), Boston. Dr Rosenfeld is now with the Child Psychiatry Unit, Naval Regional Medical Center, Portsmouth, Va.

Read in part before the 28th annual meeting of the American Association of Psychiatric Services for Children, San Francisco, Nov 12, 1976.