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Journal of Clinical Child Psychology, Vol. 12, No. 3, Winter 1983, 307-311.

The Helping Hand Strikes Again - Unintended Consequences of Child Abuse Reporting

Eli H. Newberger
Children's Hospital Medical Center at Boston

Concomitant with the evolution of a humane philosophy of intervention in the first decade after the medical discovery of child abuse in the 1960's came a broadening of the definition of the problem. The assumptions of low frequency, the benevolent role for government, and the competency of child welfare programs must be challenged in light of present data, values, and experience. The promise implicit in the child abuse reporting laws is an empty promise for many children. Hospital recognition of child abuse is defined as much by class and race as by severity. A new propensity to criminalize family problems and the possible advent of government intrusions into the newborn nursery suggest a risk of more harm in the guise of help, which will affect the most vulnerable children and families. A retreat from reporting as the method of getting services to families is suggested as one means to ameliorate this crisis.

Twenty years after the publication of the influential medical report, ''The Battered Child Syndrome'' (Kempe, Silverman, Steele, Droegemueller & Silver, 1962) it seems fitting to reflect on the significance and the effectiveness of the modern child protection movement. The Kempe et al. (1962) paper stimulated an outpouring of editorial concern in professional and lay media. The U.S. Children's Bureau promulgated a model child abuse reporting law. By the late 1960's, all states had laws mandating the identification and reporting of abused children. Although the problem had been documented for as long as we have had records of mankind, and notwithstanding a century-old activism against cruelty to children in the United States, it is notable that it took a medical article, and a recasting of child abuse as a medical syndrome, to stimulate a broad national concern (Newberger & Bourne, 1978).

In retrospect, it is notable that this concern coincided with the civil rights movement of the 1960's, a time of concern for the rights of disadvantaged people, including children, a time when it was widely believed that state and national governments had not only the ability, but the responsibility, to provide, protect, and shelter where families could not.

By the early 1970's, substantial clinical literature and experience had accrued. It came to be generally understood in professional circles that people who abused children only rarely were cruel, sadistic murderers. They were troubled, burdened by psychological and family problems; and they could, and should be helped through treatment to more adequately protect and nurture their offspring (Steele & Pollock, 1974). Case report statistics suggested that by far the majority of the victims lived in poor families (Gil, 1978).

A humane philosophy of intervention evolved in the first decade after the publication of "The Battered Child Syndrome" article. Physical child abuse, and its intervention, were increasingly perceived to be associated with other human problems which could respond to an infusion of professional attention and personal good will and affection: child neglect, child sexual abuse, and deprivation of medical, educational, and moral supports for a child's growth.

In February, 1971, a U.S. Senate Subcommittee on Children and Youth was created. With no authority over existing programs, it became a forum for advancing proposals made at the 1970 White House Conference on Children. The need for a coherent federal role in the identification, prevention, and treatment of abused and neglected children stimulated the drafting of legislation. The discussion, and politics, which culminated in the signing of Public Law 93-247 in 1974 have been described clearly by Ellen Hoffman (1979), who served as Staff Director of this subcommittee. Among the points of conflict at that time were the extent to which resources should be committed to research or services, and the appropriate role of the federal government. In Ellen Hoffman's (1979) words:

Another priority question revolved around whether the limited resources under the Act should be directed primarily at the children who are abused, children who are neglected, or both. The original Senate bill did not even define "abuse" and "neglect." It was felt to be unnecessary because the law was to be a program of services, research and the like, not a punitive or regulatory measure. Moreover, an attempt at a federal definition might work unnecessary hardship on states and localities, which already had widely varying definitions in their own laws. The House, however, did insert a definition that included not only physical but also mental injury.

The authors of the bill had no illusions that it would service all of the families implicated by reports of abuse or neglect so widely defined. This was a political judgment based on the recognition that funds available for the new program would not be adequate to provide services even to those children and families already defined as needing them.

Thus, although there is no statutory statement, the legislative history (testimony, committee reports, and floor statements) reflects the clear intent of Congress that priority be given to helping children who are the victims of physical abuse (pp. 168-69).

This may have been the intention, but many physicians and social workers in this field of practice, and officials in the Children's Bureau, appear to have construed the mandate for the National Center on Child Abuse and Neglect differently. When the time came to stipulate a definition of child abuse in state statutes as a condition for eligibility for the states' shares of federal funds, officials in the Department of Health, Education, and Welfare defined child abuse broadly, and they elaborated a long list of professionals to be mandated to report. This action was taken notwithstanding a growing concern among a different professional community that unless the flow of case reports into the child welfare service system were controlled the system could be overwhelmed. This view was expressed, in fact, in the report of an expert commission to study child abuse reporting (Sussman & Cohen, 1975). The debate between the service idealists, who would open wider the portals of entry in the service system, and the civil libertarians, who were concerned with the prospect of more incompetent and damaging intrusions into family life, appears to have been resolved in favor of the idealists (Zigler, 1979).

At this time, no one could have foreseen that the prevalence of child abuse, however narrowly defined, was far greater than was believed at the time of the publication of the "Battered Child Syndrome" paper or the signing of Public Law 93-247. Where 7000 to 8000 reports were received nationally in 1967 and 1968, over 700,000 were received in 1978 (National Center on Child Abuse and Neglect, 1980). Estimates of severe inflicted injuries to children deriving not from case reports, but from household surveys, range from one to four million incidents per year (Gelles, 1978; Gil, 1970¹).

Nor was it possible to predict that the humane and generous expansion of social programs during the administration of Lyndon Johnson would contract in the years since the national child abuse program was passed. I have no doubt that had professionals, like me, known then what we know now, we would never have urged on Congress, federal officials, and state legislators broadened concepts of child abuse as the basis for reporting legislation.

We now see in every state a vexing and cruel dilemma. In many, if not most, jurisdictions the only way to get social services such as day care, homemakers and counseling to children and parents is to make a child abuse or neglect case report. Child welfare services have to a great degree become "protective services." Are they protecting children? Without question, in many cases they are. A higher level of awareness of child abuse and neglect among professionals, parents, and children has led to the timely identification and certainly the rescue of many families in jeopardy.

But in order to help a family, a physician must, in effect, condemn the parents with a diagnosis that implicitly means they are bad parents. Sometimes, the only resources available are abrasive. In many localities, children reported as victims of neglect or abuse are placed in foster home care as the first, rather than the last resort. There, they may languish for years, often shuttled around from foster home to foster home while their health and emotional needs are often cruelly neglected by the very system designed to serve them.

Or, perhaps more frequently, the reports are unattended or are given the most superficial screening and review. Then, children may suffer more grievous harm until their injuries may come to light in the criminal courts where their parents may be prosecuted.

This scandalous situation has resulted in several class-action law suits. Those initiated in Massachusetts by the Massachusetts Committee for Children and Youth and by Greater Boston Legal Services have recently led to court orders assuring a child's right to a timely investigation when she or he is the subject of a child abuse or neglect case report and specifying the maximum caseloads which protective service social workers can carry.

Ironically, the promise implicit in the child abuse reporting laws has become an empty promise for many children. This is all the more regrettable in light of present knowledge about what we can do to effectively treat child abuse (Cohn, 1979).

The issues we face in this area of practice go beyond the acts and the consequences of reporting. They have to do also with some fundamental realities of the provision of medical care and social services which are uncomfortable to mention aloud in the halls of the Senate.

My colleague Robert Hampton and I are completing a study of hospital recognition and reporting of child abuse which documents the pervasive significance of class and race in defining, identifying, and reporting of child abuse (Hampton & Newberger, 1983). The findings are disturbing.

The study is a secondary analysis of the National Study of the Incidence and Severity of Child Abuse and Neglect of the National Center on Child Abuse and Neglect. The data collected between May 1, 1979 and April 30, 1980. A careful effort was made to collect data on a sufficient number of subjects to permit an extrapolation to the national experience. Eight hundred and five cases of child abuse and neglect came to the attention of the hospitals in the study during the year of examination. A projected estimate of 77,380 cases of abuse and neglect suspected by hospital professionals was derived from this number of weighing and multiplying these reports, employing standard sampling methods. Strict criteria for inclusion in the national-incidence measurement had been articulated, and 35,088 cases fell within the scope of these definitions. Compared to other agencies in the sample, hospitals identified children who were younger, had younger parents, contained relatively higher proportions of families in urban areas (65.8% vs. 42.1%), and who were black (25% vs. 16%). There were no major differences between the hospital and other agencies with respect to income, mode of medical payment (public or private), proportion of single parent families, sex of the child, and other demographic factors.

Nationally, approximately 652,000 children met the operational definitions of abuse and neglect during the study year, of whom 212,400 would have been known to the local child protective service agencies. Hospitals identified many more cases of physical abuse than did other agencies. The proportion of cases in this category alone exceeded the proportion of physical, sexual, and emotional abuse cases recognized by all the other agencies; over half the hospital cases were in one or another category of abuse.

The study was unique in its ability to measure which cases were selected for reporting. Never before had a systematic effort been made to identify cases before reports were made and to ascertain the differences between the cases which were reported and those which were not.

The ethnic and social class distributions for all children reported to child protection agencies as alleged victims of abuse or neglect were similar to the sample distribution, but there was significant underreporting of white and more affluent families. Surprisingly, the fact that hospitals identify more serious cases of child abuse and neglect than other agencies, serious injuries are often unreported. Although hospitals reported cases of abuse and neglect within the scope of the study's definitions more frequently than did other agencies, they failed to report almost half of the cases which should have been reported.

Further analyses studied the differences between reported and unreported cases. The following factors appeared to strongly affect case reporting: income, the role of the mother in maltreatment, emotional abuse, race, employment of the mother, sexual abuse, emotional neglect, the number of victims and the education of the mother. Disproportionate numbers of unreported cases were victims of emotional abuse in families of higher income, whose mothers were alleged to be responsible for the injuries and were also white.

These findings suggest that class and race, but not severity, define who is and who is not reported by hospital personnel to child protection agencies. 

The data also suggest that the reporting process contributes to the widespread mythology that these problems are confined to people who are poor who are members of ethnic minorities. This myth, that families who abuse their children are different from the rest of us, has led this country to identify child abuse and neglect as "poor people's problems," for which we have created traditionally programs of poor quality programs, which like the current national child protection program, may mete out punishment in the guise of help.

We now find across the country a movement to remedy the problems in the overburdened child protection agencies by making it required for professionals to report cases to police departments and to district attorneys. The failures in our ability to provide help to troubled individuals and families are, it would appear, being addressed by criminalizing family problems and, unfortunately, by demeaning those professional groups, especially social workers, who are best able to provide help to abused and neglected children and their parents.

The data from our study suggest that were reports to be mandated to more intrusive, and punitive agencies, even fewer white and more affluent families would be reported. Child abuse and neglect will appear even more to be the poor people's problems than we may want them to appear to be.

To make matters worse, the Department of Health and Human Services has now promulgated a regulation which requires that incidents where severely handicapped infants are denied medical services to assure their survival must be reported on a toll-free number of a national clearing house or to local child protection agencies. Signs are to be posted in all nurseries to announce this policy. Hospitals which do not comply risk losing federal reimbursements for services, training, and research.

This policy imposes an inappropriate burden on agencies which are inadequately equipped to do what they are supposed to do, and which are manifestly unprepared to investigate medical practices, parental suffering and grief, and hospital professional procedures. It represents a further extension of the notion that through the provision of child protective services, we police, and control, family life.

The child protection movement in this country is now at an important crossroads. We must decide whether our objective is, truly, as the laws state, to protect children and to strengthen families by offering help to them.

By its very nature, child abuse and neglect case reporting leads to intrusions into family life. This is necessary to assure the protection of thousands of children each year.

My concern is that reporting as a way of getting services to families may no longer be an effective national policy to treat child abuse. Rather, we should consider the needs of all the children who might be vulnerable to maltreatment. Through a national program focused on prevention, addressed to every family, we should be able effectively to put to use our existing knowledge. (Newberger & Newberger, 1983; Newberger, Newberger & Hampton, 1983).

The essential question with regard to child abuse reporting is not whether to narrow the definitions; it is whether reporting is to be the method we choose to treat the problem. Reporting has not been a wholesale failure; but it has not been an unqualified success. Reporting of child abuse must now be supplanted by a marshaling of resources toward prevention, along with an effort to train, among others, physicians and medical workers, more appropriately and wisely to make use of preventive and therapeutic resources.

References

Cohn, A.H. (1979). Effective treatment of child abuse and neglect. Social Work, 24, 513-519.

Gelles, R.J. (1978). Violence towards children in the United States. American Journal of Orthopsychiatry, 48, 580-592.

Gil, D.G. (1970). Violence against children: Physical child abuse in the United States. Cambridge: Harvard University Press.

Gil, D.G. (1978). Societal violence and violence in families. In 'J.M. Eekelaar & S.N. Katz (Eds.). Family Violence. Toronto: Butterworths.

Hampton, R.L., & Newberger, E.H. (1983). Hospitals as gatekeepers: Recognition and reporting in the National incidence study of child abuse and neglect. Report to the National Center on Child Abuse and Neglect.

Hoffman, E. (1979). Policy and politics: The child abuse prevention and treatment act. In R. Bourne & E.H. Newberger (Eds.). Critical perspectives on child abuse (pp. 157-170). Lexington: D.C. Heath.

Kempe, C.H., Silverman, F.N., Steele, B.F., Droegemueller, W., & Silver, H.K. (1962). The battered child syndrome. Journal of the American Medical Association, 181, 17.

National Center on Child Abuse and Neglect. (1980). National analysis on official child neglect and abuse reporting (1978). U.S. Dept. of Health and Human Services. DHHS Publications (OHDS 80-30271).

Newberger, E.H., & Bourne, R. (1978). The medicalization and legalization of child abuse. American Journal of Orthopsychiatry, 48, 593.

Newberger, C.M., & Newberger, E.H. (1983). Prevention of child abuse: Theory, myth, practice. Journal of Preventive Psychiatry, 1, 1-8.

Newberger, E.H., Newberger, C.M., & Hampton, R.L. (1983). Child abuse: The current theory base and future research needs. Journal of the American Academy of Child Psychiatry, 22, 262-268.

Steele, B.F., & Pollock, C.B. (1974). A psychiatric study of parents who abuse infants and small children. In R. Helfer &: C.H. Kempe (Eds.). The Battered Child, 2nd Edition (pp. 80-133). Chicago: University of Chicago Press.

Sussman, A., & Cohen, S.J. (1975). Reporting child abuse and neglect: Guidelines for legislation. Cambridge: Ballinger.

Zigler, E. (1979). Controlling child abuse in America: An effort doomed to failure? (pp. 171-213). In R. Bourne & E.H. Newberger (Eds.). Critical perspectives on child abuse. (pp. 171-213). Lexington: D.C. Heath.

Received: 6/20/83

Revised: 10/10/83

¹Gil conducted a survey of a representative sample of American citizens in which respondents were asked whether they personally knew of incidents in which children were abused. The 95% confidence interval for the extrapolation to the country as a whole was 2.53 to 4.07 million incidents. Gelles surveyed 1146 two-parent families with at least one child between 3 and 17 in the home and asked, using the "Conflict Tactics Technique," direct questions about family violence. Between 1.4 and 1.9 million children were seen as vulnerable to physical injury; 3.6% of the parental respondents used violence which could have led to injury in the survey year.

Eli Newberger received his M.D. from Yale University and completed his pediatric training at Children's Hospital in Boston. There he organized the interdisciplinary clinical and research program on child abuse and family violence. He directs a training program on family violence, which has as its overal objective the bridging of research and practice in the field, wih a special focus on child psychology. His most recent book is "Child Abuse," published in 1982 by Little, Brown.

Testimony given before the Subcommittee on Family and Human Services, Committee on Labor and Human Resources, United State Senate, April 11, 1983.