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Violence: A Public Health Approach. Mark Rosenberg and Mary Ann Fenley, Editors, Oxford University Press, 1990, 51-78. Child Physical Abuse: Definition, Prevalence, and PreventionELI H. NEWBERGER Despite increasing public awareness, both clinical practice and social policy are constrained by substantial deficits in the knowledge base on child abuse and by gaps in the application of research findings to its prevention and treatment. Newer research demonstrates, for example, that psychopathology is not more prevalent in families where abuse is documented than in the general population, but the focus of clinical protective work remains primarily psychotherapeutic; and talking to an individual parent with a view to changing the parent's behavior remains the paradigm of clinical practice. Clinicians who work with families identified as having abused their children may find it difficult to conceptualize etiology and treatment of problems outside the biomedical, symptom-oriented approach to which their practice and training are oriented. Definitions of child abuse have broadened significantly in the last two decades, expanding from an initial focus on injuries inflicted by caregivers to include the categories of neglect, sexual victimization of children inside and out of the home, and denial of necessary life support to severely handicapped infants. These increasingly broad definitions have brought into the child welfare system an increasing number of case reports, but resources have not grown commensurately. Inadequate numbers of trained personnel within and without the formal child protection system limit the effectiveness of current intervention programs. Every human organ system can be affected by the symptoms of child abuse, and both the physical and psychological implications for child and adult development appear to be grave. Yet insufficient study has been made of the relationships between different kinds of abuse and different outcomes, thus limiting substantially the development of programs and policies. Prevention appears to hold promise for reducing the prevalence and impact of child abuse, and the principal preventive initiatives can be derived from specific theories of causality. In addition to making a commitment toward prevention, further efforts should be made to understand the etiology and epidemiology of child abuse and the effectiveness of interventions. STATEMENT OF THE PROBLEMThe commonsense meaning of the term "child abuse" is a situation where a caregiver, generally a parent, sets out in a systematic way to harm a defenseless child. This is the notion of the problem in most medical settings, deriving from the relatively recent "discovery" by the medical profession of an age-old phenomenon. Attention was drawn to the problem in 1962 by Professor C. Henry Kempe and his associates in an influential article in the Journal of the American Medical Association (JAMA), entitled "The Battered Child Syndrome" (1). This study prompted an outpouring of editorial concern in professional and lay media. It was the stimulus for the drafting by the Children's Bureau, the lead agency for children in the federal government, of a model child abuse reporting statute. Child abuse came to be defined in the state reporting laws as injuries inflicted by caregivers. These, it was widely held, could be diagnosed by physicians and medical institutions. And if physicians could be required to report child abuse cases to public agencies, principally to welfare departments, a response competent to assure the safety of the children would logically ensue (2,3). The year 1962 was a time of great public concern for the rights of disadvantaged citizens in the United States. The success of the civil rights movement in bringing to public attention the suffering of black Americans was reflected in the passage by Congress and state legislatures of laws to open opportunities to vote, to go to school, and to live without fear of violent reprisal for overstepping the codes of segregation. Also prevailing at this time was a sense of the role and responsibility of government in helping disadvantaged citizens, including children. The five years subsequent to the publication of "The Battered Child Syndrome" also saw the advent of several major new programs to benefit children: regional centers for retarded children, stimulated by President John F. Kennedy's own concern for his sister; Project Headstart, which provided child care and related health and family services for disadvantaged children; and Medicaid, a program to provide payment for health services to indigent people, with a special provision for children whose families are dependent on public welfare. This provision stipulated that these children were all to be given early and periodic screening, diagnosis, and treatment services ("EPSDT") for conditions that might limit their health or development. The time was ripe for the medical discovery of child abuse, and the title of the Kempe article in JAMA telegraphed a vivid sense of its meaning and of the professions' and agencies' roles: it was for physicians to make the "diagnosis," and, as formalized in the child abuse reporting statutes, it was the responsibility of the agencies mandated to receive the reports to provide the "treatment." But the article's perpetrator-victim model of etiology and the notion of a syndrome of physical examination findings in the child and psychopathology in the caregiver led to several problematic consequences. These persist to the present day. Physicians confuse the ethics of making a diagnosis and giving care with the functions of investigation (to find out who did what to whom and how); a mythology persists that all adults who harm children in their care are mentally ill; and agencies that receive the reports maintain a conflicted sense of responsibility. Although the legal mandate may be to offer services to protect the children and help their families, the persistence of the perpetrator-victim model substantially inhibits the range of perceived diagnostic and therapeutic possibilities in these agencies; in the face of enormous caseloads and shortened resources, whether or not to separate a child from his or her parents' care becomes the informing question of practice, and punishment may be meted out in the guise of help (4). The public and professional activism of the 1960s stimulated studies of the child abuse phenomenon, and these studies affected the efforts during the early 1970s to revise the laws mandating the reporting of child abuse. Parents of abused children were acknowledged to be people who could be helped, and child abuse came to be seen as a form of human trouble not unrelated to other family disturbances, with implications for the health and welfare of children. This humane perspective was reflected in the title of an influential book edited by Professor Kempe and his colleague, pediatrician Ray Helfer, Helping the Battered Child and His Family (5). In this view, government's role was to provide timely help to troubled families whose children might bear physical and behavioral symptoms that could be acknowledged not only by doctors, but by other observers as well. A new model child abuse reporting law was promulgated by the Children's Bureau of the U.S. Department of Health, Education, and Welfare, the agency that was given the responsibility to house the National Center on Child Abuse and Neglect. This center was created by Public Law 93-247 and signed into law by President Richard M. Nixon early in 1973. This draft statute proposed broadening the definition of child abuse to include neglect, emotional injury, parental deprivation of medical care, and factors injurious to a child's moral development. It lengthened the list of professionals required by law to make child abuse case reports to include virtually anyone responsible for the care of children. The committee that drafted the model statute was cautioned by the federal officials of the sponsoring agency against including any language that might link the reporting process to budgeting for services. Although a dramatic increase in reports was foreseen, the assumption was that the good consciences of the state legislators would contend with the cost implications of the statutes (6). Further, the states were given an important incentive by the National Center to bring their laws into conformity with the new model reporting statute: unless their statutes conformed, they would not be eligible for their share of the federal monies that P. L. 93-247 stipulated should go for improving state services. The resulting broadening of the public definitions, associated with public awareness campaigns by the National Center and by the private National Committee for the Prevention of Child Abuse, reflected the understanding of child abuse held by professionals working in the field as well as much of the general public, that "child abuse" was not restricted to parents setting out to destroy their defenseless offspring. In retrospect, one unforeseen consequence of that effort was a changing sense of the government's responsibility for children and families in trouble. States such as Florida, which introduced the new reporting legislation with public service announcements in the major electronic media, were promptly deluged with more reports than could be managed by the limited numbers of child welfare personnel (7). A subsequent study of a random sample of Florida child abuse case reports was stimulated in part by press inquiries into reinjuries and deaths associated with superficial screenings of reports. At this screening stage, reports were either "screened in" as "valid" and referred to a caseworker for investigation, or "screened out" as "invalid" and no investigation pursued. This study showed that it was the professional status of the reporter and not the contents of the report on the child that determined whether a report would be screened in as valid (8). Reports from physicians were far more frequently screened in than those, for example, from child care workers. Child welfare agencies are now overburdened in every state. The expanded definition of child abuse has led to another paradoxical and troubling issue at a time when resources to support families are in increasingly short supply. In many jurisdictions, the only way to get publicly funded child care or residential psychiatric treatment services is to file a child abuse case report, because these services are no longer available as child welfare services per se. As a result, many professionals face the dilemma that in order to help a family, they may have to condemn the parents as "bad" by reporting them as child abusers. This notion of a professional duty to protect child victims from their bad and abusive parents is reflected in the new name for these services: child welfare services have become child protection services in most states. The submission by the Attorney General's Task Force on Family Violence of a report urging an increased use of criminal prosecution in all such cases indicates a strong dissatisfaction with the failures of child protection services (9). In the 1985 reauthorization of the National Center on Child Abuse and Neglect, child abuse was conceived still more broadly to include situations where handicapped infants may be denied medical care necessary to assure their survival. The regulations promulgated by the Children's Bureau required states to set up specialized units within their protective service programs to investigate and pursue reports of such denials of care. These stimulated a huge amount of correspondence, including protests from the principal associations of medical specialists, including the American Academy of Pediatrics (10). They objected strenuously to this intrusion by the government into the judgments of practice. The mounting public awareness of child sexual victimization and the highly publicized cases of sexual abuse of children in day care centers have led to yet another initiative to expand the concept of child abuse and the role of child protection agencies. Federal regulations (1985) require the investigation by child protection agencies of reports of abuse in institutional settings such as day care centers (11). The definition of what constitutes a "case" of child abuse has been changed dramatically in the last quarter-century. Although to many if not most medical professionals, the "battered child syndrome" model appears to prevail, other professions, caregiving institutions, and agencies of government have defined the problem more expansively. But the notion of fault, whether it be the caregiver's active or passive hurting or denying necessary care to the child, remains implicit in the definitions, narrow or broad. This leads to a practice of making burdensome judgments and involving in children's and families' lives agencies that are not always seen as helpful and in many cases may be seen by them and by others as inept, intrusive, hurtful, and punitive. The physician is trained to avoid making value judgments about the people he or she serves, to hold confidential information given in the setting of practice, and to keep in mind two universal doctrines of good practice. The doctrine of informed consent obliges the physician to make known any risks or adverse outcomes that might result from the physician's work, and indeed not to proceed with any interventions that might carry the possibility of harm without the patient's explicit agreement. The Hippocratic axiom states, first of all, do no harm. Both of these ethical doctrines are challenged in nearly every aspect of conforming to the requirements of the reporting statutes. For many doctors, the decision not to report a case of child abuse, however child abuse might be conceived, is taken with great seriousness and attention to the high principles of ethical care. The problem, then, is not simply a set of injuries that parents may inflict through passive or active means on their children. The conception of child abuse is affected importantly by the political and social meaning of the protection of children in the United States at the end of the twentieth century. Child protection, and by inference child abuse, has become a vehicle to influence medical practice, for example, to assure the provision of life support to severely handicapped newborns; it has become the device to justify the distribution of scarce family support resources at a time when it is no longer possible to make them available on the basis of need alone; and it is proposed as a mechanism to police proliferating child care institutions as more and more women enter the workforce and leave their children in these settings. The picture of child abuse seen in medical practice depends on how the problem is understood. In the words of the radiologists, "You see what you look for, and you look for what you know." For practitioners oriented to a perpetrator-victim model, the field of vision may be restricted to such major findings as fractures, bruises to portions of the body that would not ordinarily occur in play (bruises not over bony prominences and conforming to the shapes of sticks, looped electric cords, teeth, and fingers will generally raise suspicion), scalds (especially in glove or stocking distributions), collections of blood around, above, or beneath the dense lining of the brain (which may be due to direct trauma or to violent shaking), poisonings, lacerations, and contusions to internal organs. These injuries evoke greater concern when children are younger and when different forms of trauma occur simultaneously or over time (12). A more embracing medical concept of child abuse, which proposes to go beyond the perpetrator-victim model and to foster a practice in which the process of diagnosis is not jeopardized by the need to assign blame, draws attention to the relationships among the "pediatric social illnesses," unintentional injuries, poisonings, and the condition known as "failure to thrive," where children fail to gain weight and length at adequate rates, but where no definable illness can be found to explain the growth failure (13,14). The child's physical symptoms are understood in an ecologic framework that includes these interacting elements: the given child's unique developmental qualities and risk; the parents' adaptation to the child's caregiving needs, and particularly their capacities to nurture and to protect the child from harm; the psychological attributes of the family, both with respect to the individual's vulnerabilities and strengths and to their relationships with a family system; the realities and exigencies of the nurturing or holding environment, including hazards, the perceived quality of the neighborhood, and the family's connections to or isolation from kin and other supports; and the favorable and unfavorable qualities of professional personnel, service programs, and institutions with which they may have contact. Practice should focus more on family strengths and on prevention rather than on perceived pathologies to be treated by health care professionals. This may necessitate abandoning the highly pejorative characterizations of family life suggested by the name "child abuse." Ultimately as well, the notions of "reporting" a family for treatment by a state agency may give way to a more generous and humane sense of how a child's symptoms reflect particular family relationships and caregiving practices (15). Given the present trend toward criminalization of family disturbances in the United States, there is concern that the promise of help in the child abuse reporting statutes may turn out to be an empty promise for many children. Recent attention has also been drawn to two entities of particular concern to physicians and other medical workers, the "Munchausen syndrome by proxy" and the problem of sexual victimization of children by professionals, including physicians (16-20). Munchausen syndrome has been used to describe the adult patient who falsifies medical history and physical examination findings. In its pediatric manifestation, it is the parent (the "designated culprit of deceit," in the uncharitable words of an article in Pediatrics, the official journal of the American Academy of Pediatrics [21]) who is posited to make the child ill, presumably to draw attention to his or her problems. Children are described in the case reports who have had their skin scratched with needles to give the impression of a bleeding disorder, who have been given injections of fecal matter to produce bizarre patterns of fever, and who have been subjected repeatedly to intrusive diagnostic procedures. These cases stimulate many conflicts for physicians because the childrens' mothers often seem like ideal parents who are especially grateful for the doctor's interest and care, and because it is often more convenient to perform diagnostic studies than it is to question the validity of the proffered history. Many of the mothers have worked as nurses or nursing aides or cared for chronically ill relatives. The medical office is the favored entry point for these patients. The victimization of children by nonparental caretakers is a subject of increasing concern, perhaps as a consequence of the broad attention given to child sexual abuse in day care centers. In some cases, especially when several staff members are involved, this may reflect the larger, linked problems of pedophilia, child pornography, and sex rings (22,23). Many pedophiles are oriented to children in a particular age bracket and sex. They may memorialize their experiences in photographs, journals, letters, and videotapes in order to maintain stimuli for fantasy as the children grow out of the preferred ages. Sex rings involve adults with similar orientations who may exploit large numbers of children by sexual acts and by the trading and selling of mementos. The association between child abuse and other forms of family violence has been highlighted by tragedies, such as the murder of Lisa Steinberg in New York City, which drew attention to the connection between the problems of battered women and child abuse (24). There also appears to be an important link with the family issues associated with homelessness (25). DATA SOURCESThere are few data sources on child abuse that permit useful inferences to be drawn on prevalence, incidence, risk factors, outcomes, and the effectiveness of interventions. This is a consequence of the selective nature of case ascertainment for clinical research, the limitations of study design in nearly every clinical study, and of a reluctance in the formation of national policy on child abuse to make use of standard methods of measurement and program evaluation. Clinical studies are rarely controlled and thus are nearly entirely confounded by socioeconomic class and age artifacts. Few samples are ascertained from any but institutional settings. The generalizability of most of the clinical reports is severely restricted (26). The major data sets on child abuse, all established with the support of federal government grants, give some useful estimates of reported prevalence, and four studies demonstrate the utility of methodologies that do not rely on case reports. The first major data set was established by Professor David Gil of Brandeis University and is the first systematic treatment of child abuse case reports to agencies mandated by the initial wave of reporting statutes in the early and middle 1960s (27). Gil also purchased under his contract with the Children's Bureau several questions on a public opinion poll conducted by the National Opinion Research Center at the University of Chicago. Respondents in a national probability sample (i.e., representative of the major demographic attributes of the national population) were asked, for example, whether they personally knew of a case of child abuse; from this Gil extrapolated an incidence estimate of between two and a half million cases per year. Gil's analysis of 1967 and 1968 case reports serves as the benchmark study of its kind. The study's conclusion that poverty is the principal determinant of abuse has been criticized on the grounds that the demographic attributes of the reported cases reflect the class and other biases of the reporting process. The Gil data were used productively by Light, who explored the possible utility of parent education and risk-screening policies (28). The American Humane Association contracts with the Children's Bureau to compile official reports of child abuse and neglect, but for several reasons these annual compilations are of less value than the original study performed by Gil. The absence of standardized definitions, dependence on the individual states' data aggregation methods, and inability to gauge the meaning of the case reports in reference to any sampling methodology means that these reports describe mainly who it is who gets into the child protection system bearing the tag of abuse or neglect. These reports present a confusing picture with regard to time trends, for example, as state statutes have broadened the definitions of reportable conditions and, in the face of budgetary retrenchments for other child welfare services, many cases flow into the system because a child abuse case report is the only device available to attract publicly funded services. Notwithstanding these limitations, the AHA data give a lively impression of the number and nature of "caught" cases and a sense of how the child abuse problem has grown. Where in 1967 and 1968, Gil documented only 6,000 to 7,000 case reports a year, the 1986 AHA survey of state reports yielded an estimated prevalence of 1,928,000 abused children (29). As with the Gil data, most of the reports were on behalf of children in indigent families, reflecting in part the bias of ascertainment that favors poor children to be reported to agencies of the state that are seen as poor people's agencies. AHA data also document an increasing number of cases of child sexual victimization, perhaps in response to elevated public and professional awareness generated by extensive media attention to sexual abuse. These increased levels of reporting may also reflect the trends in divorce and the improvised child care arrangements of single working mothers that may place their children at risk of sexual victimization by boyfriends, relatives, or other caregivers out of the parental home. Unfortunately, an effort has never been made to assemble and to integrate the case report data with a survey of the population in such a way as to permit an estimate of the true prevalence of child abuse, neglect, and sexual victimization. Nor has there been an analysis of the year-to-year case report data with information collected by the Bureau of the Census and other agencies on the changes in the structure of the American family, especially with regard to divorce, women in the workforce (1985 data suggest that over half the women with preschool children work full time [30]), and child-care arrangements. Neither have the data been compared with the Uniform Crime Reports of the Department of Justice, nor injury or hospital data collected by the National Center for Health Statistics and other units of the U.S. Public Health Service. Representative sampling methodologies have been used to estimate the incidence and prevalence of child abuse. Murray Straus and his associates have pioneered the use of direct interview methods in which people are asked about their practices and experiences. Straus's collaboration with Richard Gelles and Suzanne Steinmetz produced the first national survey of family violence. This survey utilized a scale to measure the techniques family members used to resolve conflicts among themselves; in turn, this scale provided the entry point for a series of questions about violent practices (31). Using a national sample of families with two adults and at least one child between three and seventeen years of age, Straus and his colleagues produced the first systematic and reliable projections of the frequency of particular incidents of violence, such as using or threatening to use a knife or a gun in resolving conflict with another specific family member in the last year or ever. Their study also yielded some of the first family-level insights into the meaning of violence. For example, women who were victims of severe violence at the hands of their spouses were 150 percent more likely to use severe violence in resolving conflicts with their children. Their sample, however, was not representative of American families with children. Because of the investigators' interest in acts of violence between adults and among children and adults, infants were not represented, and neglect or sexual victimization was not explored. The study yielded a prevalence estimate suggesting that in 1975 there were 1.4 million children ages three to seventeen years who had been abused. Gelles and Straus have recently reported the findings of a second national family violence survey, which yielded a much lower prevalence estimate. The extent to which nonscientific issues may affect public discourse on the prevalence and incidence of child abuse is described in their book-length report of the survey: The shock we felt when we first examined our data was echoed when we presented the results at professional meetings. The data on violence toward children were presented at the Seventh National Conference on Child Abuse and Neglect, whichwas sponsored by the National Center on Child Abuse and Neglect and the National Committee for Prevention of Child Abuse. In preparing for the conference, the National Committee had set an almost unprecedented goal by calling for the reduction of child abuse by 20% by 1990. Hundreds of conferees wore buttons that said 20% by /990 while we presented data that reported that the rate of severe violence had already dropped by 47%. Not surprisingly, our results were received with great skepticism (32, p. 109). Gelles and Straus review the principal methodological artifacts that may have led to an underestimate of prevalence: 1975 data were collected using in-person interviews; 1985 interviews were conducted over the telephone. Families without telephones were not studied, thus excluding 5% of the population, a group more likely to experience social isolation and economic adversity. Respondents were perhaps less willing to report family violence in 1985 than they were in 1975. The authors of the study assert their belief, however, that there has been a decline in the rates of violence toward children and, to a lesser extent, women (32, p. III). A so-called national incidence study of child abuse and neglect was funded by the Children's Bureau in response to a congressional mandate under the terms of the reauthorization of the National Center on Child Abuse and Neglect. A study was designed to delineate the dimensions of the "iceberg" of child abuse, only the tip of which was believed to show in child abuse case reports. Levels of visibility of child abuse were postulated and then plumbed by gathering data from child protective agencies (the figurative tip) and such other sources as hospitals, police departments, and mental health agencies (33). Systematic definitions were promulgated, and cases from the various reporting sources were ascertained by telephone or by form. Data from the various sources were then aggregated. A weighting system was devised to generalize to the national experience. For the 26-county sample, 17,645 cases of child abuse and neglect came to attention between May 1, 1979, and April 30, 1980; it was projected that nationwide 1,151,600 cases were suspected by professionals. Of these projected cases, 562,000 were considered as likely to meet the study's criteria, i.e., represented true cases of child abuse and neglect. The method of study has been criticized discerningly by Finkelhor and Hotaling. They noted that child sexual victimization was rarely reported at the time of the incidence study. Because 95 percent of these cases came to the study's attention through child protection or other investigatory agencies (for example, the police), there were likely to have been a far greater number of sexual abuse cases than the study measured (34). Sexual victimization prevalence and the characteristics of victims and their families have been studied using survey methodology by Finkelhor and his coworkers (35-37). The findings suggest a far greater frequency than the case reporting compilations would suggest, with prevalence estimates between 8 percent and 62 percent of women, and 5 percent and 30 percent of men, depending on the breadth of definition, the ages surveyed, and the sampling methods. The first national incidence study data are now available for others' use and are especially useful for studies of agency practice, for example, with regard to the case attributes that drive the reporting practices of hospitals, especially class and race (38). A second national incidence study employed a similar methodology and the same contractor (Westat, Inc.) (39). The data for 1986 are presented in the recently published report, along with perceived changes since the earlier study. The estimated 1986 national incidence of abuse and neglect was 1,584,700. There was a 74 percent increase in the incidence of abuse (to 657,000 cases), within which there was an increase of 58 percent for child physical abuse (to 358,300 cases) and over 300 percent for child sexual abuse (to 155,900 cases). No changes were noted in the incidence of emotional abuse or neglect. Physical abuse was the most frequent type of abuse identified in the study, followed by emotional abuse and by sexual abuse, with respective incidence rate estimates of 5.7, 3.4,and 2.5 cases per thousand children. With regard to the shape of the child abuse "iceberg," there were no changes in the proportion of cases that were reported to state child protection agencies, but more stringent screening standards by these agencies indicate "that some of the children who would, in the past, have had their cases substantiated (and possibly received services as a result) are now excluded as unfounded" (39, p. xxv). Data sources on child abuse are constrained by inconsistent definitions, a relentless focus on the study of reported or "caught" cases, confounding by social class and other uncontrolled attributes, inadequate generalizability of the findings, the theoretical and disciplinary biases of funding agencies and scholars, and by an absence of linkage between demonstration programs, research funding, and efforts to make sense of the findings for program development and public policy. The measurement and analysis of the prevalence and incidence of the many problems now identified under the rubric of "child abuse" would seem to require consistent attention to epidemiologic concepts and methods, regular and systematic review of measurement alternatives and their relationships to the mechanisms for official case identification and reporting, and an orientation to current theory and knowledge of etiology and prevention. By contrast, the present approach to this vital public health function is to assign the tasks of measurement on an occasional basis to contractors who submit bids for specified pieces of work. A specific governmental unit, charged with the responsibility for assessing the magnitude and severity of child abuse, might be better able to attend appropriately to the issues of technique, as the National Center on Child Abuse and Neglect with its overburdened staff and lack of epidemiologic expertise cannot do. This might assure the availability of data and reasoned interpretation at a level of quality commensurate with the seriousness of the problem. CAUSES AND RISK FACTORSInitial efforts to understand child abuse focused on the psychological problems of the parents of the victims. The influential study by Steele and Pollock pointed to abusing parents' distorted expectations of their children, frustrated dependency needs, personal isolation, and histories of having themselves been abused as children (40). Helfer has suggested that risk to a child for abuse may be understood as having three fundamental dimensions: a child with qualities that are provocative; a parent with the psychological predisposition; and a stressful event that triggers a violent reaction (41). In addition to causes originating in the family, social and cultural factors have also been described, dispelling the widely held myth that it is exclusively individual deviant behavior that culminates in child abuse (42-45). The psychoanalytic approach posits that unconscious parental drives and conflicts determine the behavior we characterize as abuse (40,46). This theory organizes the knowledge gathered by many psychologically minded clinicians, and, indeed, informed Kempe's perceptions of the parents of the victims of the "battered child syndrome." The abusive caregiver was characterized in that work as the "psychopathological member of the family." Social learning theory suggests that child abuse is learned behavior and that individuals who have experienced violent and abusive childhoods are more likely to grow up to become child and spouse abusers than individuals who experienced little or no violence in their childhood years (47). Violence in one's family of origin is seen as predictive of violence in one's family of procreation. Environmental stress theory posits that the child abuse results from social and environmental stress. Stressful life conditions and events, including poverty, unemployment, social isolation, inadequate housing, and a violent social milieu are prominent factors considered with this theoretical orientation (48). This perspective suggests that factors in the context of family life that are felt as overwhelmingly stressful facilitate the expression of violence or interfere with a parent's ability to care for his or her children. Cognitive-developmental theory proposes that child abuse reflects an immature parental understanding of the child and of the parental role (49). Four levels of parental thinking about children and the parent-child relationships have been described, some of which are associated with child abuse, especially when coupled with family stresses. Labeling theory presumes social inequality and suggests that the interests of dominant power groups are served by defining as deviant a class of socially marginal individuals (the "child abusers") whose individual problems become the proper concerns of the helping professionals (50). Each of the above theories can be described as a unitary theory since each offers an explanation of child abuse from a single point of view. Each theory has power and adherents because it explains some part of the data, but each also has clear limitations. Psychoanalytic explanations, for example, have guided much of the work in this field, but when abusive parents have been studied, only one parent in ten has been found to have a definable psychiatric condition, a figure comparable to the rest of the population (51). Further, child abuse has been found to be associated with several personality types, and no particular psychiatric diagnosis can predict abuse (52). Other unitary theories share comparable limitations. For example, environmental stress theory does not take into account intraindividual and interindividual sources of strength and weakness that may render families more or less vulnerable to environmental experiences and conditions. Nor do they account for child abuse in seemingly affluent homes. And labeling theory, although helpful in pointing out pervasive biases with respect to who gets identified and reported as abusive, is of scant help in the emergency room when addressing the needs of a family whose child has cigarette burns on its body. Professionals and researchers are becoming more alert to the conceptual underpinnings of empirical research on child abuse and critically evaluating the utility of unitary theories of etiology, and, as a result, they are integrating the more helpful parts of these theories into interactive, multicausal theories. These multicausal theories seek to understand how aspects of an individual's personality or environment may interact with his or her particular experience. Are particular personality types more susceptible to the stresses of certain kinds of environmental experiences? Are there features of the social environment, or ways of understanding a child, that enable families to cope with stress without resorting to violence? Several studies have attempted to integrate causal factors for child abuse from multiple levels: individual, family, and society (53-56). At the individual level, an important and consistent finding is the prevalence of acute or chronic illness in victims of child abuse (57-60). This causal association has systematically been neglected in child protection agency practice, because case workers have limited and fixed notions of the etiology of child abuse and because service agencies are already overburdened and do not have the requisite resources for medical diagnosis and treatment. When North Carolina and Florida made medical consultation available to social workers in child protection agencies, medical antecedents and concomitants of child abuse became increasingly acknowledged (61-62). Certain individual and family factors that have been accepted as "causes" of child abuse must now be contemplated with skepticism. Among these are low birth weight of the infant, young maternal age, and inadequate mother-infant "bond formation" (63-64). Gelles has documented a pervasive, uncritical acceptance by professionals of empirical assertions about child abuse (65). He draws on the "woozle" metaphor from Winnie the Pooh, in which two characters stalk an imaginary beast around a tree, tracking one another's footprints. Many "woozles" are found in the literature on child abuse: simple, empirical results or statements, reiterated by many authors, gain the status of axioms or laws, even though the findings may be in error. Clinical practice based on oft repeated but essentially erroneous findings may be ineffective or even harmful. A familiar example to those who work in the clinical environment is the tidy home woozle. A case report of inflicted injury is made, and the social worker who visits the family notes that the house is clean and orderly. Referring to page 55 of the Massachusetts 1985 "Reference Guide for Child Abuse and Neglect Investigations," he or she will note under Condition of the Home the following: "An example of a home which poses a low risk to a child is one which is clean, with no apparent safety hazards such as exposed wiring or rodent infestation, and structurally sound" (66). The focus of child protection services on poor families has led to a sense of connection between a home in poor repair and a child in danger, although the fact that a home is neat may bear no relationship to a child's risk of abuse. A social worker using the cited reference guide may wrongly conclude that the risk of reinjury to the child is small. Academic behavioral and social science research has not, in general, produced results that are applicable in clinical settings. Much survey research, for example, applies a factor-by-factor approach in attempting to statistically explain the child abuse phenomenon. Both the method of study and the format in which the results are reported may ignore the complexity of individual cases—each of which involves interactions among personal history, general social context, and immediate situational factors. The conclusions drawn from statistical analysis of large sample surveys, when they are communicated to clinicians, may be swallowed eagerly as tools for simple clinical decision making or dismissed as glib and useless. Other social science theories such as social exchange theory may take into account the complexity of individual interaction with families, but their relevance to clinical application may not be immediately apparent; the usual focus of the academic researcher is on the formulation of universal rules ("nomothetic" principles) that govern behavior, whereas the clinician's concern is with executing particular treatment programs appropriate to individual cases. Despite such differences between clinical practice and academic research, there are important points of fruitful interchange and shared development. Structural family therapy, with its emphasis on the family as a system of independent actors, contains assumptions similar to those of social exchange theory, which emphasizes interaction, coalition formation, and the exchange of rewards and punishments. Discussions between academic researchers and clinicians permit cross-fertilization between such perspectives. Clinicians from various fields of practice and researchers from different disciplines can benefit from working together on the study of treatment of child abuse. Such cooperation should help develop a taxonomy of violent acts, a more reliable body of etiologic explanations, indications for different therapeutic interventions, effective prevention programs based on understandings of etiology, and relevant family policies. Unless and until such cooperation and a shared sense of mission can develop, knowledge of the causes and risks associated with child abuse will be restricted. OUTCOMESChild abuse is costly in both human and fiscal terms, but neither the medical nor the psychological sequelae have been studied sufficiently well to allow a conclusive assessment of their costs. This is partly a consequence of policies regarding the funding of research. The principal federal agency responsible for research on child health, the National Institute of Child Health and Human Development in the National Institutes of Health, has taken the position since the early 1970s that it will not support studies of child abuse; the National Center on Child Abuse and Neglect, after funding three shortterm studies of the impact of child physical abuse, announced in its July 1985 priority statement additional support for studies of the impact of child sexual victimization. These projects were not to exceed three years. The documented medical consequences of child abuse include injuries inflicted on every organ system, not infrequently causing chronic impairment (67). Injuries to the central nervous system from direct trauma or shaking appear to be responsible for many cases of cerebral palsy and profound neurologic impairment (68). The costs of treatment and of lost productivity have not been studied. Homicide, one of the five leading causes of death for children between the ages of I and 18 years, is another outcome of child abuse. Homicides involving infants are not always accurately classified and are probably underreported (69,70). The impact of homicide is more fully appreciated when one considers the number of years of potential life lost and lost productivity; the 501 child homicides committed in 1980 account for 93,000 years of potential life lost (71). Child sexual victimization culminated in the transmission of venereal disease in 13 percent of the 409 children in one study, and included gonorrhea, syphilis, condyloma acuminata, and trichomoniasis (72). Herpes genitalis and chlamydia are also documented sequelae of child sexual abuse (73). The long-term psychological effects of child abuse have been described in various case compilations, but varying definitions of abuse, problematic investigative methodologies, and differences in outcome criteria yield a mixed impression of the impacts. In recent reviews there appears to be a consensus on a profound and serious set of effects (74-76). For child physical abuse, these include disturbances in social and emotional development, including a propensity to aggression in adolescence; violence toward intimates; language disorders; and lower performance on standardized tests of intelligence. Unfortunately, however, a prevalent sampling bias that favors the selection of impoverished children for study makes it impossible to separate the developmental attrition associated with low social class from the presumed effects of abuse (77). McCord's 40-year follow-up of children in the Cambridge-Somerville youth study suggested insidious long-term effects of "treatment" as well as abuse and has stimulated critical discussion of classification and intervention (78-80). He found that the clinicians' characterizations of the 49 men who were said to have been abused as children carried predictive meaning (81). Abused boys were more likely than others to have been exposed to high demands for adult behavior; about half of the abused or neglected boys had subsequently been convicted for serious crimes, became alcoholic or mentally ill, or died when unusually young. They had higher rates of juvenile delinquency than those boys who were classified as having had loving parents. Although paternal alcoholism and criminal behavior were not associated with the occurrence of child abuse, they were associated with higher frequencies of later antisocial behavior. Maternal self-confidence seemed to cushion the impact of early adversity. Although the immediate and long-term effects of child sexual victimization are the focus of much current concern, they have not been systematically studied. Such studies are needed to help develop practices and programs that could cushion the impact of child sexual victimization. From clinical case series, changes described as concomitant and subsequent to sexual abuse include hypervigilance, specific phobias, nightmares, feelings of guilt and shame, and changes in sleeping and eating patterns (82-84). Psychosomatic disorders include abdominal pain, headaches, and loss of appetite. When force is used to coerce a child into participating in sexual acts, the subsequent symptoms appear to be more severe, and the behavioral outcomes are more fully explained by analyses that simultaneously examine several variables and their interactions (85-87). Among the more important variables are the existence of antecedent behavioral problems, the family's support of the child after disclosure, the extent to which the child may have been blamed or stigmatized, and the nature and quality of the interventions on behalf of the child. So-called dissociative responses may be associated with the subsequent development of multiple personality (88,89). Additional outcomes have been reported to follow child sexual abuse, but without controlled studies it cannot be said with certainty that they were caused by the victimization. Boys' sexual victimization may be associated with a developmental propensity to violence toward others; turning from victim to victimizer may assure the person that he is no longer vulnerable, and the sense of mastery over others may compensate for the recurrent sense of helplessness (90,91). Childhood sexual victimization appears as a frequent finding in studies of the histories and psychological characteristics of incarcerated pedophiles, rapists, and murderers (92). Women who have been sexually victimized as children appear to have an unusual frequency of depression and self-destructive behavior, as well as disturbances in adult sexual functioning and in protecting themselves from subsequent victimizing relationships (93,94). INTERVENTIONSFor the individual practitioner, implicit in the clinical diagnosis of child abuse is a sense of parental failure. In the formulation of an intervention program, the clinician must first contend with the feelings of despair, sadness, rage, and anxiety that the case may stimulate. Many professionals and many more laypeople retain the belief that once the diagnosis of abuse is made, there is no hope for the child in his or her family. Additionally, there is often a strong impulse toward retribution against the designated perpetrator, as well as toward whomever might have been responsible for protecting the child from harm. Swift and effective punishment is now also favored by an influential report, which suggests that marital violence recidivism was reduced most effectively by the police arresting the offender (as compared to the other customary police methods of attempting to counsel both parties or sending the alleged assailant from the home for a short time) (95). This report was the basis of the recommendation for criminal process in all cases of family violence, child abuse included, promulgated in the Attorney General's Task Force on Family Violence. Although child abuse may indeed be defined by many people as a crime, most social policy in the United States has inclined toward a human service model for most victims. An awkward tension now prevails between the advocates of the criminal process and the advocates of professional clinical services. Those who support the criminal process are skeptical of the utility of helping approaches and believe in the social deterrent functions of the criminal system; the advocates of professional service to children are mindful of the value of good clinical work and are concerned about the unpredictable nature of a criminal system that may itself victimize children. The paradigmatic case is that of a 12-year-old California girl whose family sought help in 1983 for an undisclosed problem of a sexual nature. The child's stepfather, a physician, was alleged in a mandated child abuse case report to have sexually abused her. The case was referred to the district attorney, who initiated a criminal action against the physician. When the girl refused to testify against her stepfather, the district attorney asked the court to find her in contempt of court. The judge ordered her held in solitary confinement until she agreed to testify. A higher court to which the matter was appealed ordered her released. The system designed to protect this child victimized her further (96). Recently, mounting numbers of child abuse case reports have combined with local, state, and national budgetary retrenchments to seriously overburden child protection services. Efforts to shore up the protective service system have been met with resistance on the part of the politicians who are worried about the costs of meeting the needs of the numbers of children who are coming to attention through the reporting process, and on the part of the administrators who are trying to protect the integrity of their agencies from outside criticisms, however well intended. Effective use of a tool from the civil rights movement, the class action suit, has proved successful in Massachusetts in lowering caseloads (to 18 cases per social worker), investigations (to 12 cases per social worker), and the burden of paperwork to which all welfare employees are subjected. As a result of this class action suit, training has been increased in quality and amount, and needs assessments will be performed, aggregating disparities between what children and families are perceived to need and what the Department of Social Services can provide and folding the needs into the annual budget proposal; a modern, computer-supported management information system is being set in place; medical and health needs of children in substitute care will be addressed; and recruitment and training of foster parents will be made more systematic and effective (97). Before the signing of the agreement that brought these changes into being in 1984, the case was litigated for seven years. The decisions made by the personnel responsible for protecting children are, regrettably, often made in haste and without sufficient attention to family strengths that might be supported by homemakers, child care, parent aides, self-help groups such as Parents Anonymous, or specialized medical or psychiatric interventions. One study documented that the unavailability or cost of these supports often drives the decision to remove a child from his or her family; a strong accompanying editorial comment by a leading student of child welfare services, Professor David Fanshel of Columbia University, suggested an implicitly punitive mission of current social policies in the United States: "Given the current abandonment of federal support for social programs in the guise of block grants, the inability to show appropriate compassion for failing parents must be seen as another example of blaming the victim. There is strong indication that these parents, particularly those who are black, Hispanic, or native American, suffer from gross failure of society to adequately deliver health, mental health, and addiction services as well as suffering major deficits in income, housing, and social resources" (98,99). Even knowledge about the family context of child abuse is too often ignored in practice. Examples are the presence of interspousal violence; the unique characteristics of a particular child; the attributes of the family and the environment, including individual roles and the family power structure; access to other people; crises in the ecologic setting (for example, with regard to housing); and the extent to which intrusions by social and health agencies may exacerbate family problems. A doctor may suspect child abuse based on the physical examination, but if the child's mother does not appear to be mentally ill, he or she may set aside the findings and take no action, say, to report the case. A physician's practice may be constrained by popular myth (that all abused parents are mentally ill or poor or nonwhite), by past experience with protective service personnel (for whom removing a child from parental care may be the only action in the therapeutic armamentarium), by financial realities and concerns (the time spent in lengthy conversation with a family in making a case report to a protective service agency and in testifying in a custody hearing will almost certainly not be compensated), by a fear of a malpractice action deriving from the family's dissatisfaction, by class and cultural biases (a reluctance to take action to protect a child when the family is affluent or a zeal to wrest a child from the family's care when the family is poor or nonwhite), and by the emotional impact of the case. (The sadness and rage that child abuse stimulates in all of us may be intolerable to the physician, for whom an objective and dispassionate professional image may be transcendent. Faced with unpleasant feelings, it may be easier to deny the data and forget the case, in the interest of preserving emotional equilibrium.) Interventions on behalf of victims of child abuse must attend to their needs for protection, but a widely held principle of present practice stipulates that efforts to protect a child must go hand in hand with the development of a program to help his or her family (100), including those situations where a child's future offspring need also to be considered. An analysis of a child abuse program at one children's hospital suggests that interdisciplinary review of individual cases, coupled with a systematic program to follow up child abuse case reports with telephone calls to the agencies designated to provide services to the children and families, is associated with lowering both the duration of hospitalization and the dollar cost of the medical treatment of child abuse, and with a reduction of the reinjury rate (101). Of the evaluations of child abuse demonstration programs, two studies stand out. Cohn and her associates enlisted the cooperation of the grantees under a 1973 child abuse initiative (funded, interestingly, by the Nixon administration as part of an effort to convince Congress that the legislation to create a National Center on Child Abuse and Neglect was unnecessary) in documenting the process of the projects' development and their success in attaining their objectives. For the first and only time, data on individual cases served to assess the work of the projects. A salient finding particularly relevant to present-day approaches to child abuse was that lay intervention agents appeared to be as effective as child welfare professionals (102). Daro recently reported the findings of the National Clinical Evaluation Study, which measured costs of services as well as certain indicators of outcome (103). Among the more important findings were the following: "The most cost-effective treatment plan in instances of child sexual abuse involving family members seems to be a combination of family and group counseling for the victim, the victim's siblings, the perpetrator and perpetrator's spouse. In cases of child neglect, the most efficient interventions will combine family counseling with parent education and basic care services such as babysitting, medical care, clothing and housing assistance" (p. 197). The author voices despair over the vast needs of victims of child abuse and their families and the paucity of resources committed to them and emphasizes the efficiencies implied in preventive approaches: "However, the prevailing evidence suggests that treatment efforts, at best, are successful with only half of their clients and that the poorest, most dysfunctional families are least likely to achieve successful outcomes. Given the high cost of treatment services and their limited promise for remediating the consequences of maltreatment, prevention efforts appear to be a more efficient alternative. Approximately $1.3 billion would purchase two years of weekly parenting education and supervised parent-child interactions for all adolescent mothers" (p. 198). The opening sentence of Tolstoy's Anna Karenina frames the principal issue with which individual practitioners and architects of social policy must contend in contemplating what to do with victims of child abuse and family violence: "Happy families are all alike; every unhappy family is unhappy in its own way" (104). The many symptoms, and the multiplicity of causes, call for individualized responses once violence has occurred, both for the victim and for the family (104). These include
When the choice of the appropriate interventions is made with thought and care, and when the services are indeed available, the outcomes for the children appear to be favorable (105). When they are not, damage both to child and family can ensue. The paucity of resources for victims of child abuse and the prevailing low quality of child protection services in the United States have stimulated debate whether to restrict both the social welfare agencies and the courts in their decision prerogatives. With a view to protecting children and families from the possibly incompetent intrusions of state workers, restrictive standards for practice have been proposed, and the American Civil Liberties Union initiated two unsuccessful class action suits challenging the child welfare agencies' abilities to enter homes and to examine children without search warrants issued by courts (106-108). More restrictive and procedure bound practices, however, might lead to further conflicts in the delivery of services to individual children and could culminate ultimately in a more intrusive pattern of practice as the courts-with attorneys arrayed in adversarial postures on behalf of agencies, parents, and children--would have to sort through the data on each case (109). Prevention holds promise for reducing the impact and cost of child abuse, and with the appropriate evaluative effort should frame a national policy, in the view of many professional bodies, including an advisory committee to the National Center on Child Abuse and Neglect. Given the risks of reinjury and the consequences of child abuse, treatment can be understood also as a tertiary form of prevention, but no longer can we afford to neglect primary and secondary preventive initiatives. These can be organized in relation to theories of etiology. Several theories of prevention are outlined in the paragraphs that follow. PREVENTIONFrom Psychoanalytic Theory1. Acknowledge the importance of mental health to the functioning and well-being of children and families by formalizing a conception of health that includes emotional as well as biological health. This can be achieved through the training of physicians and others to recognize and attend to emotional as well as physiological issues in practice, and by providing third party reimbursement for serving as the patient's advisor, counselor, and health advocate (110). From Learning Theory2. Give parents access to information and understanding of child development, including nonviolent methods of socializing their children. From Attachment Theory3. Elevate the parent-child relationship to an appropriate position of respect and importance in clinical practice, by preventing prematurity through prenatal care, humanizing the delivery experience, bringing fathers into the delivery room and emphasizing their supportive role toward mothers and their participation in child care, and by encouragement of paternity leaves as well as maternity leaves from employment (111). From Stress Theory4. Provide hotlines to ensure quick telephone access for parents at times of distress with their children (112). 5. Make available to all children health and mental health services including well child care, diagnosis, and treatment. 6. Make available emergency homemaker and/ or child care services to families in crisis. 7. Reduce social isolation by ensuring universal access to telephones and public transportation to facilitate social interactions. 8. Support existing community institutions (such as churches and women's organizations) that offer support, a sense of community, and feelings of self-worth to their members. 9. Empower women. Acknowledge the extent to which sexual dominance and subservience figures both in the abuse of women and children and in professional settings where male-dominated professions (medicine, surgery, law) hold sway over professions composed mainly of women (social work, nursing, child care). From Labeling Theory10. Remove the stigma associated with getting help for family problems by detaching protective service programs from public welfare agencies. Abandon the heavily value-laden nomenclature of the "battered child syndrome," "child abuse," and "child neglect" in favor of a broader and more humane conception of childhood social illness. Increase the sensitivity, timeliness, and competency of medical and social work practice. 11. Expand public awareness of the prevalence of child abuse and domestic violence, and disassemble the conventional wisdom attaching child abuse to deviant and minority individuals and groups; emphasize that the potential for violence is in all of us; and put a priority on individual and social action to intervene when violence occurs. These recommendations for the prevention of child physical abuse have been elaborated elsewhere in relation to the existing theory base on child abuse (113). From Present PracticeThe following steps to prevent child sexual abuse derive from the somewhat more limited present understanding of etiology, symptoms, and consequences: 1. Develop programs to educate children and professionals about sexual abuse. Children can be empowered to say no and to get help. Physicians, other medical workers, education, social service, and mental health professionals, if acquainted with the physical and behavioral signs of sexual victimization, can act early to prevent its serious consequences. 2. Diminish the culturally sanctioned sexual exploitation of children. The use of children as sexual lures to sell products by advertisers or to attract viewers to movies and other media should be discouraged by parents, professional organizations, and trade associations. Governmental initiatives must take cognizance of the constraints imposed by the first amendment of the Constitution, realizing that as with child pornography, when these efforts begin, they will almost certainly be challenged in the courts. 3. Screen professionals who work with children. Individuals who seek to exploit children through employment as day care and health workers, teachers, or clergy can be identified through careful interviewing and subsequent supervision on the job. Because most pedophiles do not have criminal records, fingerprints and criminal record screens will probably be unavailing. These methods may, indeed, discourage talented people from careers in child care. References can be obtained and checked, and reasons for choosing the work and special preferences for ages and genders of children can be explored. To date, no specific and sensitive methods for identifying adults who may sexually abuse children have been developed. 4. Protect child victims from traumatic court procedures. Only a third of the jurisdictions in the United States have promulgated guidelines for examining and interviewing sexually abused children. The education of prosecutors and judges might well include the development of lines of referral and consultation with skilled medical and mental health professionals (114). REFERENCES1. Kempe CH, Silverman FN, Steele BF, et al. The battered child syndrome. JAMA 1962; 181:17-24. 2. Gershenson CP. 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