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Amer. J. Orthopsychiat., 47(3), July 1977, 374-376.

Child Abuse and Neglect: Toward a Firmer Foundation for Practice and Policy

Eli H. Newberger, M.D.
Children's Hospital Medical Center, Boston

Only recently have child abuse and neglect been identified as problems requiring state and federal legislative attention. With the seminal paper in 1962, by Kempe and colleagues⁴ on the battered child syndrome, there began an effort to try systematically to identify the victims of child abuse, and neglect. This led to the initial development of child abuse and neglect reporting.

But it soon became clear that the children who were being identified were from poor and socially marginal families, with preferential selection of nonwhite children who received their care in public clinics. The illusion is still prevalent that child abuse and neglect are problems of poor people exclusively -- even though we now have indirect evidence that the cases are more widespread.

Children of more affluent families, who receive their medical care in private practice settings where the relationship of clinician to family, the payment structure, and the ethics of treating personal information are quite different, are more likely to have their injuries characterized as "accidents." While the term accident connotes an isolated, random event, recent research^5,7 suggests that there are important associations between childhood accidents and child abuse and neglect, having to do with a particular child's innate qualities, developmental level, and behavior; the family's ability to protect the child; and the realities of the child's nurturing environment. Accidents at home and in automobiles are the leading cause of childhood morbidity and mortality, and domestic trauma accounts for the greater proportion in preschool children.⁶ Thus, many child abuse and neglect cases in richer homes, misdiagnosed as accidents, may not appear on case report rosters.

The very diagnostic terms "abuse" and "neglect" carry important, implicit judgments, which clinicians are understandably reluctant to make. But, regrettably, it's easier to make the diagnosis of child abuse if you are a physician in an inner-city hospital emergency room or in a clinic for the indigent. Calling a poor or black or Indian or Chicano mother a bad parent -- that's what the diagnosis means -- is acceptable there. It's also less painful to report the case when the family isn't paying you directly, when the family looks very different than your own, and when you may never see them again.

Our concern with child abuse and neglect, and most research on the problems, derives from cases that have come to light through the existing social agencies. In focusing our attention only on those children readily accessible to study, we are working within a very narrow frame and within entirely too limited a population. One of our most important and immediate tasks is to look at the universe of need. I mean this both in the sense of all the children -- rich and poor, white and nonwhite -- and in the sense of all manifestations of child abuse and neglect. Our research and development efforts largely ignore the sexual misuse of children, the abuse of children in and by institutions, and the relationship between violence among adults and violence toward children. To address these problems would, to be sure, oblige looking at some troubling social realities and facing up to the question of whether we really want to deal with the issues beyond the level of individual cases.

Are we willing to look seriously at the values and traditions that shape sexual expression and exploitation? Can we face the widespread cruelty to children in institutions for the retarded and the delinquent -- and even in public schools? Do we really want to know what unemployment and public assistance stipends pegged below the subsistence level do to relations between parents and children? How do battered women, the promotion of violence on television, and the coercive, degrading nature of many jobs bear on child abuse?

As Gil3 and Gelles1 have pointed out, our preoccupation with sensational violence in individual homes creates a kind of smokescreen. Its effects are felt on two levels. There is a "macro" smokescreen that lets us, as a society, ignore uncomfortable problems such as poverty, and sidestep other basic and related issues of health and mental health. (As child abuse and neglect were being highlighted by the Congress and by the previous administration, resources for children's immunizations and mental health were actually being cut back.) And there is a "micro" smokescreen that allows individual families to take comfort in knowing that those parents over there are the bad ones, the ones who abuse their kids. (What we do in our own home is OK, and we needn't think too much about our easy acceptance of corporal punishment or about the emotional poverty of so many of our lives.)

Administrators of any such federally funded statute as Public Law 93-247 (The Child Abuse Prevention and Treatment Act of 1974) are, of necessity, acutely sensitive politically, and their implementation will inevitably reflect the Administration's and the Congress's values. Reading the Congressional Record of 1973, before this bill first passed, gives one a pretty good idea about what we want to do and find out about child abuse and neglect -- and what we don't.

There is no way that this $20 million program can begin to answer the service needs of the million or so children we have reason to believe^2,3 are abused and neglected each year. At present, we do not have an adequate conceptual base for the treatment of child abuse and neglect, nor have we adequately disseminated technology, even to the extent that we know what good practice is. While this has partly to do with limited resources, it involves as well the need for basic "theory building" in this field.

We have yet to develop a theoretical base that enables us to deal competently with the many kinds of family problems that culminate in the physical symptoms of child abuse and neglect. We clearly need not only better knowledge, in terms of understanding the type and distribution of family problems, but also a much more accurate understanding of the relationship of children's symptoms to family dysfunctions. We need to know what enables parents to cope and, importantly, what realities are associated with family competency and strength. This, in turn, will make for a more informed and rational clinical practice.

Dr. Edward Zigler, addressing the national conference on child abuse in Atlanta early last year, noted that we are, in child abuse and neglect, where we were in mental retardation in the 1950s. This assessment was not received happily by many of the assembled experts. But it made us stop for a moment to consider the implications of our headlong action in this field. A stronger and broader foundation for action is urgently needed.

REFERENCES

1. GELLES, R. 1975. The social construction of child abuse. Amer. J. Orthopsychiat. 45(3): 363-371.

2. GELLES, R. 1977. Violence toward children in the United States. Presented to AAAS, Denver, February 1977.

3. GIL, D. 1970. Violence Against Children. Harvard University Press, Cambridge, Mass.

4. KEMPE, C. ET AL. The battered-child syndrome. JAMA 181(1):17-24.

5. MORSE, A. ET AL. 1977. Environmental correlates of pediatric social illness: preventive implications of an advocacy approach. J. Pub. Hlth Assoc. (in press)

6. NEWBERGER, E., NEWBERGER, C. AND RICHMOND, J. 1976. Child health in America: toward a rational public policy. Milbank Mem. Fund Quart./Hlth and Society 54(3): 249-298.

7. NEWBERGER, E. ET AL. 1977. Pediatric social illness: toward an etiologic classification. Pediatrics. (in press)

Excerpted from testimony on child abuse and neglect before the US Senate Subcommittee on Child and Human Development, April 1977. Research cited was supported by a DHEW Office of Child Development grant (Project OCD-CB-141).