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Amer. J. Orthopsychiat. 48(4), October 1978

The Medicalization and Legalization of Child Abuse

Eli H. Newberger, M.D., and Richard Bourne, Ph.D., J.D.
The Children's Hospital Medical Center, Boston

Certain symptoms of family crisis and childhood injury are being "medicalized," "legalized," and called "child abuse"-to be processed and dealt with by a range of professionals who derive their social legitimacy and support in the process. Professional conflicts are considered, and the effects of the system on treatment interventions are discussed. Guidelines are offered to minimize the abuse of power of the professional definers.

Child abuse has emerged in the last fifteen years as a visible and important social problem. Although a humane approach to "help" for both victims of child abuse and their families has developed (and is prominently expressed in the title of one of the more influential books on the subject ²⁹), a theoretical framework to integrate the diverse origins and expressions of violence toward children and to inform a rational clinical practice does not exist. Furthermore, so inadequate are the "helping" services in most communities, so low the standard of professional action, and so distressing the consequences of incompetent intervention for the family that we and others have speculated that punishment is being inflicted in the guise of help.^{3, 28}

What factors encourage theoretical confusion and clinical inadequacy? We propose that these consequences result, in part, from medical and legal ambiguity concerning child abuse and from two fundamental, and in some ways irreconcilable, dilemmas about social policy and the human and technical response toward families in crisis. We call these dilemmas family autonomy versus coercive intervention and compassion versus control.

This paper will consider these dilemmas in the context of a critical sociologic perspective on child abuse management. Through the cognitive lens of social labeling theory, we see symptoms of family crisis, and certain manifestations of childhood injury, "medicalized" and "legalized" and called "child abuse," to be diagnosed, reported, treated, and adjudicated by doctors and lawyers, their constituent institutions, and the professionals who depend on them for their social legitimacy and support.

We are mindful, as practitioners, of the need for prompt, effective, and creative professional responses to child abuse. Our critical analysis of the relationship of professional work to the societal context in which it is embedded is meant to stimulate attention to issues that professionals ignore to their and their clients' ultimate disadvantage. We mean not to disparage necessary efforts to help and protect children and their families.

How children's rights-as opposed to parents' rights-may be defined and protected is currently the subject of vigorous, and occasionally rancorous, debate.

The family autonomy vs. coercive intervention dilemma defines the conflict central to our ambiguity about whether society should intervene in situations of risk to children. The traditional autonomy of the family in rearing its offspring was cited by the majority of the U.S. Supreme Court in its ruling against the severely beaten appellants in the controversial "corporal punishment" case (Ingraham vs. Wright et al).²⁵ The schools, serving in loco parentis, are not, in effect, constrained constitutionally from any punishment, however cruel.

Yet in California, a physician seeing buttock bruises of the kind legally inflicted by the teacher in the Miami public schools risks malpractice action if he fails to report his observations as symptoms of child abuse (Landeros vs. Flood).³² He and his hospital are potentially liable for the cost of the child's subsequent injury and handicap if they do not initiate protective measures.⁷

This dilemma is highlighted by the recently promulgated draft statute of the American Bar Association's Juvenile Justice Standards Project, which, citing the low prevailing quality of protective child welfare services in the U.S., would sharply restrict access to such services.²⁸ The Commission would, for example, make the reporting of child neglect discretionary rather than mandatory, and would narrowly define the bases for court jurisdiction to situations where there is clear harm to a child.

Our interpretation of this standard is that it would make matters worse, not better, for children and their families.⁸ So long as we are deeply conflicted about the relation of children to the state as well as to the family, and whether children have rights independent of their parents', we shall never be able to articulate with clarity how to enforce them.

The compassion vs. control dilemma has been postulated and reviewed in a previous paper,⁴⁷ which discussed the conceptual and practical problems implicit in the expansion of the clinical and legal definitions of child abuse to include practically every physical and emotional risk to children. The dilemma addresses a conflict central to the present ambiguity about how to protect children from their parents.

Parental behavior that might be characterized as destructive or criminal were it directed towards an adult has come to be seen and interpreted by those involved in its identification and treatment in terms of the psychosocial economy of the family. Embracive definitions reflect a change in the orientation of professional practice. To the extent to which we understand abusing parents as sad, deprived, needy human beings (rather than as cold, cruel murderers) we can sympathize with their plight and compassionately proffer supports and services to aid them in their struggle. Only with dread may we contemplate strong intervention (such as court action) on the child's behalf, for want of alienating our clients.

Notwithstanding the humane philosophy of treatment, society cannot, or will not, commit resources nearly commensurate with the exponentially increasing number of case reports that have followed the promulgation of the expanded definitions. The helping language betrays a deep conflict, and even ill will, toward children and parents in trouble, whom society and professionals might sooner punish and control.

We are forced frequently in practice to identify and choose the "least detrimental alternative" for the child²¹ because the family supports that make it safe to keep children in their homes (homemakers, child care, psychiatric and medical services) are never available in sufficient amounts and quality.

That we should guide our work by a management concept named "least detrimental alternative" for children suggests at least a skepticism about the utility of these supports, just as the rational foundation for child welfare work is called into question by the title of the influential book from which the concept comes, Beyond the Best Interests of the Child²¹ More profoundly, the concept taps a vein of emotional confusion about our progeny, to whom we express both kindness and love with hurt.

Mounting attention to the developmental sequelae of child abuse^{16, 33} stimulates an extra urgency not only to insure the physical safety of the identified victims but also to enable their adequate psychological development. The dangers of child abuse, according to Schmitt and Kempe in the latest edition of the Nelson Textbook of Pediatrics,⁵³ extend beyond harm to the victim:

If the child who has been physically abused is returned to his parents without intervention, 5 per cent are killed and 35 per cent are seriously reinjured. Moreover, the untreated families tend to produce children who grow up to be juvenile delinquents and murderers, as well as the batterers of the next generation.

Despite the speculative nature of such conclusions about the developmental sequelae of child abuse,^{6, 10, 11} such warnings support a practice of separating children from their natural homes in the interest of their and society's protection. They focus professional concern and public wrath on "the untreated families" and may justify punitive action to save us from their children.

This professional response of control rather than of compassion furthermore generalizes mainly to poor and socially marginal families, for it is they who seem preferentially to attract the labels "abuse" and "neglect" to their problems in the public settings where they go for most health and social services.³⁶ Affluent families' childhood injuries appear more likely to be termed "accidents" by the private practitioners who offer them their services. The conceptual model of cause and effect implicit in the name "accident" is benign: an isolated, random event rather than a consequence of parental commission or omission.^{37, 38}

TABLE 1 presents a graphic display of the two dilemmas of social policy (family autonomy vs. coercive intervention) and professional response (compassion vs. control). The four-fold table illustrates possible action responses. For purposes of this discussion, it is well to think of "compassion" as signifying responses of support, such as provision of voluntary counseling and child care services, and "control" as signifying such punitive responses as "blaming the victim" for his or her reaction to social realities⁴⁹ and as the criminal prosecution of abusing parents.

CHILD ABUSE AND THE MEDICAL AND LEGAL PROFESSIONS

The importance of a technical discipline's conceptual structure in defining how it approaches a problem has been clearly stated by Mercer:³⁴

Each discipline is organized around a core of basic concepts and assumptions which form the frame of reference from which persons trained in that discipline view the world and set about solving problems in their field. The concepts and assumptions which make up the perspective of each discipline give each its distinctive character and are the intellectual tools used by its practitioners. These tools are incorporated in action and problem solving and appear self-evident to persons socialized in the discipline. As a result, little consideration is likely to be given to the social consequence of applying a particular conceptual framework to problem solving.

When the issues to be resolved are clearly in the area of competence of a single discipline, the automatic application of its conceptual tools is likely to go unchallenged. However, when the problems under consideration lie in the interstices between disciplines, the disciplines concerned are likely to define the situation differently and may arrive at differing conclusions which have dissimilar implications for social action.

What we do when children are injured in family crises is shaped also by how our professions respond to the interstitial area called "child abuse."

"MEDICALIZATION"

Though cruelty to children has occurred since documentary records of mankind have been kept,⁹ it became a salient social problem in the United States only after the publication by Kempe and his colleagues describing the "battered child syndrome."³⁰ In the four-year period after this medical article appeared, the legislatures of all 50 states, stimulated partly by a model law developed under the aegis of the Children's Bureau of the U.S. Department of Health, Education, and Welfare, passed statutes mandating the identification and reporting of suspected victims of abuse.

Once the specific diagnostic category "battered child syndrome" was applied to integrate a set of medical symptoms, and laws were passed making the syndrome reportable, the problem was made a proper and legitimate concern for the medical profession. Conrad has discussed cogently how "hyperactivity" came officially to be known and how it became "medicalized.'⁵ Medicalization is defined in this paper as the perception of behavior as a medical problem or illness and the mandating or licensing of the medical profession to provide some type of treatment for it.

Pfohl⁴¹ associated the publicity surrounding the battered child syndrome report with a phenomenon of "discovery" of child abuse. For radiologists, the potential for increased prestige, role expansion, and coalition formation (with psychodynamic psychiatry and pediatrics) may have encouraged identification and intervention in child abuse. Furthermore,

. . . the discovery of abuse as a new "illness" reduced drastically the intraorganizational constraints on doctors' "seeing" abuse. . . Problems associated with perceiving parents as patients whose confidentiality must be protected were reconstructed by typifying them as patients who needed help. . . The maintenance of professional autonomy was assured by pairing deviance with sickness. . .

In some ways, medicine's "discovery" of abuse has benefited individual physicians and the profession.

One of the greatest ambitions of the physician is to discover or describe a "new" disease or syndrome.²⁴

By such involvement the doctor becomes a moral entrepreneur defining what is normal, proper, or desirable: he becomes charged "with inquisitorial powers to discover certain wrongs to be righted."²⁴ New opportunities for the application of traditional methods are also found-for example, the systematic screening of suspected victims with a skeletal X-ray survey to detect previous fractures, and the recent report in the neurology literature suggesting the utility of diphenylhydantoin* treatment for child abusing parents.⁴⁶

Pfohl's provocative analysis also took note of some of the normative and structural elements within the medical profession that appear to have reinforced a reluctance on the part of some physicians to become involved: the norm of confidentiality between doctor and patient and the goal of professional autonomy.⁴¹ For many physicians, child abuse is a subject to avoid.⁵⁰

First, it is difficult to distinguish, on a theoretical level, corporal punishment that is "acceptable" from that which is "illegitimate." Abuse may be defined variably even by specialists, the definitions ranging from serious physical injury to nonfulfillment of a child's developmental needs.^{13, 19, 30}

Second, it is frequently hard to diagnose child abuse clinically. What appears on casual physical examination as bruising, for example, may turn out to be a skin manifestation of an organic blood dysfunction, or what appear to be cigarette burns may in reality be infected mosquito bites. A diagnosis of abuse may require social and psychological information about the family, the acquisition and interpretation of which may be beyond the average clinician's expertise. It may be easier to characterize the clinical complaint in terms of the child's medical symptom rather than in terms of the social, familial, and psychological forces associated with its etiology. We see daily situations where the exclusive choice of medical taxonomy actively obscures the causes of the child's symptom and restricts the range of possible interventions: examples are "subdural hematoma," which frequently occurs with severe trauma to babies' heads (the medical name means collection of blood under the dura mater of the brain), and "enuresis" or "encopresis" in child victims of sexual assault (medical names mean incontinence of urine or feces).

Third, child abuse arouses strong emotions. To concentrate on the narrow medical issue (the broken bone) instead of the larger familial problem (the etiology of the injury) not only allows one to avoid facing the limits of one's technical adequacy, but to shield oneself from painful feelings of sadness and anger. One can thus maintain professional detachment and avert unpleasant confrontations. The potentially alienating nature of the physician-patient interaction when the diagnosis of child abuse is made may also have a negative economic impact on the doctor, especially the physician in private practice.

"LEGALIZATION"

The legal response to child abuse was triggered by its medicalization. Child abuse reporting statutes codified a medical diagnosis into a legal framework which in many states defined official functions for courts. Immunity from civil liability was given to mandated reporters so long as reports were made in good faith; monetary penalties for failure to report were established; and familial and professional-client confidentiality privileges, except those involving attorneys, were abrogated.

Professional autonomy for lawyers was established, and status and power accrued to legal institutions. For example, the growth in the number of Care and Protection cases** before the Boston Juvenile Court "has been phenomenal in recent years. . . four cases in 1968 and 99 in 1974, involving 175 different children."⁴⁴ Though these cases have burdened court dockets and personnel, they have also led to acknowledgement of the important work of the court. The need for this institution is enhanced because of its recognized expertise in handling special matters. Care and Protection cases are cited in response to recommendations by a prestigious commission charged with proposing reform and consolidation of the courts in Massachusetts. Child protection work in our own institution would proceed only with difficulty if access to the court were legally or procedurally constrained. Just as for the medical profession, however, there were normative and structural elements within law which urged restraint. Most important among them were the traditional presumptions and practices favoring family autonomy.

If individual lawyers might financially benefit from representing clients in matters pertaining to child abuse, they-like their physician counterparts-were personally uncertain whether or how to become involved.

Public concern over the scope and significance of the problem of the battered child is a comparatively new phenomenon. Participation by counsel in any significant numbers in child abuse cases in juvenile or family courts is of even more recent origin. It is small wonder that the lawyer approaches participation in these cases with trepidation.²⁶

Lawyers, too, feel handicapped by a need to rely on concepts from social work and psychiatry and on data from outside the traditional domain of legal knowledge and expertise. As counsel to parents, lawyers can be torn between advocacy of their clients' positions and that which advances the "best interest" of their clients' children. As counsel to the petitioner, a lawyer may have to present a case buttressed by little tangible evidence. Risk to a child is often difficult to characterize and impossible to prove.

Further problems for lawyers concerned with child abuse involve the context of intervention: whether courts or legislatures should play the major role in shaping practice and allocating resources; how much formality is desirable in legal proceedings; and the propriety of negotiation as opposed to adversary confrontation when cases come to court.

CONFLICTS BETWEEN MEDICAL AND LEGAL PERSPECTIVES

Despite the common reasons for the "medicalization" and the "legalization" of child abuse, there are several areas where the two orientations conflict:

1. The seriousness of the risk. To lawyers, intervention might be warranted only when abuse results in serious harm to a child. To clinicians, however, any inflicted injury might justify a protective legal response, especially if the child is very young. "The trick is to prevent the abusive case from becoming the terminal case."¹⁴ Early intervention may prevent the abuse from being repeated or from becoming more serious.

2. The definition of the abuser. To lawyers, the abuser might be defined as a wrongdoer who has injured a child. To clinicians, both the abuser and child might be perceived as victims influenced by sociological and psychological factors beyond their control.^{17, 35}

3. The importance of the abuser's mental state. To lawyers, whether the abuser intentionally or accidentally inflicted injury on a child is a necessary condition of reporting or judicial action. So-called "accidents" are less likely to trigger intervention. To clinicians, however, mental state may be less relevant, for it requires a diagnostic formulation frequently difficult or impossible to make on the basis of available data. The family dynamics associated with "accidents" in some children (e.g., stress, marital conflict, and parental inattention) often resemble those linked with inflicted injury in others. They are addressed with variable clinical sensitivity and precision.

4. The role of law. Attorneys are proudly unwilling to accept conclusions or impressions lacking empirical corroboration. To lawyers, the law and legal institutions become involved in child abuse when certain facts fit a standard of review. To clinicians, the law may be seen as an instrument to achieve a particular therapeutic or dispositional objective (e.g., the triggering of services or of social welfare involvement) even if, as is very often the case, the data to support such objectives legally are missing or ambiguous. The clinician's approach to the abuse issue is frequently subjective or intuitive (e.g., a feeling that a family is under stress or needs help, or that a child is "at risk"), while the lawyer demands evidence.

DOCTORING AND LAWYERING THE DISEASE

These potential or actual differences in orientation notwithstanding, both medicine and law have accepted in principle the therapeutic approach to child abuse.

To physicians, defining abuse as a disease or medical syndrome makes natural the treatment alternative, since both injured child and abuser are viewed as "sick"-the one, physically, the other psychologically or socially. Therapy may, however, have retributive aspects, as pointed out with characteristic pungency by Illich:²⁴

The medical label may protect the patient from punishment only to submit him to in. terminable instruction, treatment, and discrimination, which are inflicted on him for his professionally presumed benefit.

Lawyers adopt a therapeutic perspective for several reasons. First, the rehabilitative ideal remains in ascendance in criminal law, especially in the juvenile and family courts which handle most child abuse cases.¹

Second, the criminal or punitive model may not protect the child. Parents may hesitate to seek help if they are fearful of prosecution. Evidence of abuse is often insufficient to satisfy the standard of conviction "beyond all reasonable doubt" in criminal proceedings. An alleged abuser threatened with punishment and then found not guilty may feel vindicated, reinforcing the pattern of abuse. The abuser may well be legally freed from any scrutiny, and badly needed social services will not be able to be provided. Even if found guilty, the perpetrator of abuse is usually given only mild punishment, such as a short jail term or probation. It the abuser is incarcerated, the other family members may equally suffer as, for example, the relationship between spouses is undercut and childrearing falls on one parent, or children are placed in foster home care or with relatives. Upon release from jail, the abuser may be no less violent and even more aggressive and vindictive toward the objects of abuse

Third, the fact that child abuse was "discovered" by physicians influenced the model adopted by other professionals. As Freidson¹⁵ noted:

Medical definitions of deviance have come to be adopted even where there is no reliable evidence that biophysical variables "cause" the deviance or that medical treatment is any more efficacious than any other kind of management.

Weber, in addition, contended that "status" groups (e.g., physicians) generally determine the content of law.⁴⁵

THE SELECTIVE IMPLEMENTATION OF TREATMENT

Medical intervention is generally encouraged by the Hippocratic ideology of treatment (the ethic that help, not harm, is given by practitioners), and by what Scheff⁵² called the medical decision rule: it is better to wrongly diagnose illness and "miss" health than it is to wrongly diagnose health and "miss" illness.

Physicians, in defining aberrant behavior as a medical problem and in providing treatment, become what sociologists call agents of social control. Though the technical enterprise of the physician claims value-free power, socially marginal individuals are more likely to be defined as deviant than are others.

Characteristics frequently identified with the "battered child syndrome," such as social isolation, alcoholism, unemployment, childhood handicap, large family size, low level of parental educational achievement, and acceptance of severe physical punishment as a childhood socializing technique, are associated with social marginality and poverty

Physicians in public settings seem, from child abuse reporting statistics, to be more likely to see and report child abuse than are those in private practice. As poor people are more likely to frequent hospital emergency wards and clinics,³⁶ they have much greater social visibility where child abuse is concerned than do people of means.

The fact that child abuse is neither theoretically nor clinically well defined increases the likelihood of subjective professional evaluation. In labeling theory, it is axiomatic that the greater the social distance between the typer and the person singled out for typing, the broader the type and the more quickly it may be applied.⁴⁸

In the doctor-patient relationship, the physician is always in a superordinate position because of his or her expertise; social distance is inherent to the relationship. This distance necessarily increases once the label of abuser has been applied. Importantly, the label is less likely to be fixed if the diagnostician and possible abuser share similar characteristics, especially socioeconomic status, particularly where the injury is not serious or manifestly a consequence of maltreatment.

Once the label "abuser" is attached, it is very difficult to remove; even innocent behavior of a custodian may then be viewed with suspicion. The tenacity of a label increases in proportion to the official processing. At our own institution, until quite recently, a red star was stamped on the permanent medical record of any child who might have been abused, a process which encouraged professionals to suspect child abuse (and to act on that assumption) at any future time that the child would present with a medical problem.

Professionals thus engage in an intricate process of selection, finding facts that fit the label which has been applied, responding to a few deviant details set within a panoply of entirely acceptable conduct. Schur⁵⁵ called this phenomenon "retrospective reinterpretation." In any pathological model, "persons are likely to be studied in terms of what is 'wrong' with them," there being a "decided emphasis on identifying the characteristics of abnormality;" in child abuse, it may be administratively impossible to return to health, as is shown by the extraordinary durability of case reports in state central registers.⁵⁸

The response of the patient to the agent of social control affects the perceptions and behavior of the controller. If, for example, a child has been injured and the alleged perpetrator is repentant, a consensus can develop between abuser and labeler that a norm has been violated. In this situation, the label of "abuser" may be less firmly applied than if the abuser defends the behavior as proper. Support for this formulation is found in studies by Gusfield,²² who noted different reactions to repentant, sick, and enemy deviants, and by Piliavin and Briar,⁴² who showed that juveniles apprehended by the police receive more lenient treatment if they appear contrite and remorseful about their violations.

CONSEQUENCES OF TREATMENT FOR THE ABUSER

Once abuse is defined as a sickness, it becomes a condition construed to be beyond the actor's control.³⁹ Though treatment, not punishment, is warranted, the type of treatment depends on whether or not the abuser is "curable," "improvable," or "incurable," and on the speed with which such a state can be achieved.

To help the abuser is generally seen as a less important goal than is the need to protect the child. If the abusive behavior cannot quickly be altered, and the child remains "at risk," the type of intervention will differ accordingly (e.g., the child may be more likely to be placed in a foster home). The less "curable" is the abuser, the less treatment will be offered and the more punitive will society's response appear. Ironically, even the removal of a child from his parents, a move nearly always perceived as punitive by parents, is often portrayed as helpful by the professionals doing the removing ("It will give you a chance to resolve your own problems," etc.).

Whatever the treatment, there are predictable consequences for those labeled "abusers." Prior to diagnosis, parents may be afraid of "getting caught" because of punishment and social stigma. On being told of clinicians' concerns, they may express hostility because of implicit or explicit criticism made of them and their child-rearing practices yet feel relief because they love their children and want help in stopping their destructive behavior. The fact that they see themselves as "sick" may increase their willingness to seek help. This attitude is due at least in part to the lesser social stigma attached to the "sick," as opposed to the "criminal," label.

Socially marginal individuals are likely to accept whatever definition more powerful labelers apply. This definition, of course, has already been accepted by much of the larger community because of the definers' power. As Davis⁸ noted:

The chance that a group will get community support for its definition of unacceptable deviance depends on its relative power position. The greater the group's size, resources, efficiency, unity, articulateness, prestige, coordination with other groups, and access to the mass media and to decision-makers, the more likely it is to get its preferred norms legitimated.

Acceptance of definition by child abusers, however, is not based solely on the power of the labelers. Though some might consider the process "political castration,"⁴³ so long as they are defined as "ill" and take on the sick role, abusers are achieving a more satisfactory label. Though afflicted with a stigmatized illness (and thus "gaining few if any privileges and taking on some especially handicapping new obligations"¹⁵) at least they are merely sick rather than sinful or criminal.

Effective social typing flows down rather than up the social structure. For example, when both parents induct one of their children into the family scapegoat role, this is an effective social typing because the child is forced to take their definition of him into account.⁴⁸ Sometimes it is difficult to know whether an abusive parent has actually accepted the definition or is merely "role playing" in order to please the definer. If a person receives conflicting messages from the same control agent (e.g., "you are sick and criminal") or from different control agents in the treatment network (from doctors who use the sick label, and lawyers who use the criminal), confusion and upset predictably result.⁵⁶

As an example of how social definitions are accepted by the group being defined, it is interesting to examine the basic tenets of Parents Anonymous, which began as a self-help group for abusive mothers:

A destructive, disturbed mother can, and often does, produce through her actions a physically or emotionally abused, or battered child. Present available help is limited and/or expensive, usually with a long waiting list before the person requesting help can actually receive treatment. . . We must understand that a problem as involved as this cannot be cured immediately. . . the problem is within us as a parent. . .²⁹ [emphases added]

To Parents Anonymous, child abuse appears to be a medical problem, and abusers are sick persons who must be treated.

CONSEQUENCES OF TREATMENT FOR THE SOCIAL SYSTEM

The individual and the social system are interrelated; each influences the other. Thus, if society defines abusive parents as sick, there will be few criminal prosecutions for abuse; reports will generally be sent to welfare, as opposed to police, departments

Since victims of child abuse are frequently treated in hospitals, medical personnel become brokers for adult services and definers of children's rights. Once abuse is defined, that is, people may get services (such as counseling, child care, and homemaker services) that would be otherwise unavailable to them, and children may get care and protection impossible without institutional intervention.

If, as is customary, however, resources are in short supply, the preferred treatment of a case may not be feasible. Under this condition, less adequate treatment stratagems, or even clearly punitive alternatives, may be implemented. If day care and competent counseling are unavailable, court action and foster placement can become the only options. As Stoll⁵⁶ observed,

. . . the best therapeutic intentions may be led astray when opportunities to implement theoretical guidelines are not available.

Treating child abuse as a sickness has, ironically, made it more difficult to "cure." There are not enough therapists to handle all of the diagnosed cases. Nor. do most abusive parents have the time, money, or disposition for long-term therapeutic involvement. Many, moreover, lack the introspective and conceptual abilities required for successful psychological therapy.

As Parents Anonymous emphasizes, abuse is the abuser's problem. Its causes and solutions are widely understood to reside in individuals rather than in the social system.^{5, 17} Indeed, the strong emphasis on child abuse as an individual problem means that other equally severe problems of childhood can be ignored, and the unequal distribution of social and economic resources in society can be masked.²⁰ The child abuse phenomenon itself may also increase as parents and professionals are obliged to "package" their problems and diagnoses in a competitive market where services are in short supply. As Tannenbaum 117 observed in 1938:

Societal reactions to deviance can be characterized as a kind of "dramatization of evil" such that a person's deviance is made a public issue. The stronger the reaction to the evil, the more it seems to grow. The reaction itself seems to generate the very thing it sought to eliminate.

CONCLUSION

Dispelling the Myth of Child Abuse

As clinicians, we are convinced that with intelligence, humanity, and the application of appropriate interventions, we can help families in crisis.

We believe, however, that short of coming to terms with-and changing-certain social, political, and economic aspects of our society, we will never be able adequately to understand and address the origins of child abuse and neglect. Nor will the issues of labeling be adequately resolved unless we deal straightforwardly with the potentially abusive power of the helping professions. If we can bring ourselves to ask such questions as, "Can we legislate child abuse out of existence?" and, "Who benefits from child abuse?", then perhaps we can more rationally choose among the action alternatives displayed in the conceptual model (TABLE 1).

Although we would prefer to avoid coercion and punishment, and to keep families autonomous and services voluntary, we must acknowledge the realities of family life and posit some state role to assure the well-being of children. In making explicit the assumptions and values underpinning our professional actions, perhaps we can promote a more informed and humane practice.

Because it is likely that clinical interventions will continue to be class and culture-based, we propose the following five guidelines to minimize the abuse of power of the definer.

1. Give physicians, social workers, lawyers, and other intervention agents social science perspectives and skills. Critical intellectual tools should help clinicians to understand the implications of their work, and, especially, the functional meaning of the labels they apply in their practices.

Physicians need to be more aware of the complexity of human life, especially its social and psychological dimensions. The "medical model" is not of itself inappropriate; rather, the conceptual bases of medical practice need to be broadened, and the intellectual and scientific repertory of the practitioner expanded.¹² Diagnostic formulation is an active process that carries implicitly an anticipation of intervention and outcome. The simple elegance of concepts such as "child abuse" and "child neglect" militate for simple and radical treatments.

Lawyers might be helped to learn that, in child custody cases, they are not merely advocates of a particular position. Only the child should "win" a
custody case, where, for example, allegations of "abuse" or "neglect," skillfully marshaled, may support the position of the more effectively represented parent, guardian, or social worker.

2. Acknowledge and change the prestige hierarchy of helping professions. The workers who seem best able to conceptualize the familial and social context of problems of violence are social workers and nurses. They are least paid, most overworked, and as a rule have minimal access to the decision prerogatives of medicine and law. We would add that social work and nursing are professions largely of and by women, and we believe we must come to terms with the many realities-including sexual dominance and subservience-that keep members of these professions from functioning with appropriate respect and support. (We have made a modest effort in this direction at our own institution, where our interdisciplinary child abuse consultation program is organized under the aegis of the administration rather than of a medical clinical department. This is to foster, to the extent possible, peer status and communication on a coequal footing among the disciplines involved-social work, nursing, law, medicine, and psychiatry.)

3. Build theory. We need urgently a commonly understandable dictionary of concepts that will guide and inform a rational practice. A more adequate theory base would include a more etiologic (or causal) classification scheme for children's injuries, which would acknowledge and integrate diverse origins and expressions of social, familial, child developmental, and environmental phenomena. It would conceptualize strength in families and children, as well as pathology. It would orient intervenors to the promotion of health rather than to the treatment of disease.

A unified theory would permit coming to terms with the universe of need. At present, socially marginal and poor children are virtually the only ones susceptible to being diagnosed as victims of abuse and neglect. More affluent families' offspring, whose injuries are called "accidents" and who are often unprotected, are not included in "risk" populations. We have seen examples of court defense where it was argued (successfully) that because the family was not poor, it did not fit the classic archetypes of abuse or neglect

The needs and rights of all children need to be spelled out legally in relation to the responsibilities of parents and the state. This is easier said than done. It shall require not only a formidable effort at communication across disciplinary lines but a serious coming to terms with social and political values and realities.

4. Change social inequality. We share Gil's²⁰ view that inequality is the basic problem underlying the labeling of "abusive families" and its consequences. Just as children without defined rights are ipso facto vulnerable, so too does unequal access to the resources and goods of society shape a class hierarchy that leads to the individualization of social problems. Broadly-focused efforts for social change should accompany a critical review of the ethical foundations of professional practice. As part of the individual's formation as doctor, lawyer, social worker, or police officer, there could be developed for the professional a notion of public service and responsibility. This would better enable individuals to see themselves as participants in a social process and to perceive the problems addressed in their work at the social as well as the individual level of action.

5. Assure adequate representation of class and ethnic groups in decision-making forums. Since judgments about family competency can be affected by class and ethnic biases, they should be made in settings where prejudices can be checked and controlled. Culture-bound value Judgments in child protection work are not infrequent, and a sufficient participation in case management conferences of professionals of equal rank and status and diverse ethnicity can assure both a more appropriate context for decision making and better decisions for children and their families.

REFERENCES

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2. BECKER, H. 1963. Outsiders: Studies in the Sociology of Deviance. Free Press, New York.

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* Dilantin, a commonly-used seizure suppressant.

** Care and Protection cases are those juvenile or family court actions which potentially transfer, on a temporary or permanent basis, legal and/or physical custody of a child from his biological parents to the state.