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Current Medical Dialog, Vol. XXXX, No. 4, April 1973, 327-334.

The Myth of the Battered Child Syndrome

Focus on parents' inability to nurture child.

Condensation of "The Myth of the Battered Child Syndrome: A Compassionate Medical View of the Protection of Children," by Eli H. Newberger, M.D. Paper presented in a panel discussion, "The Medical Aspects of Child Abuse," at the 95th Anniversary Symposium, American Humane Association, October 1971.

RECENT WORK on childhood accidental injuries leads us to a more enlightened conception of child abuse from the one implied in the diagnosis of "the battered child syndrome," to a more humane view which focuses on the parent's capacity to protect a particular child rather than any "intent" he may have had to injure him. Studies by J. D. Holter and S. B. Friedman (Pediatrics, 42: 128, 1969), G. S. Gregg and E. Elmer (Pediatrics, 44: 434, 1969), and R. Sobel (Pediatric Clinics of North America, 17: 653, 1970) demonstrate that there is a common causal background behind childhood accidents-so called "intentional" accidents and otherwise-which has to do with a variety of real life as well as psychologic factors, including poor, crowded housing, accessible hazards, low social class, large family size, alcoholism and drugs, illness, prematurity, and unemployment.

We are coming to see that the essential element in child abuse is not the intention to destroy a child but rather the inability of a parent to nurture his offspring - a failing which can stem directly from ascertainable environmental conditions which may not necessarily be accessible to the intervention of social workers, physicians, nurses, psychiatrists, and others who offer the traditional modalities of care to distressed families.

When we at the Children's Hospital in Boston reformulated our definition for trauma X, our house euphemism for child abuse, we decided to define this diagnostic entity not as inflicted injuries brought on defenseless children by willfully destructive parents, the concept implicit in the "battered child syndrome" diagnosis, but as an illness, with or without inflicted injury, stemming from situations in his home setting which threatened a child's survival.

Francis Sargent, the Governor of Massachusetts, convened an advisory committee on child abuse which proposed a similar definition, also intended to be compassionate and non punitive. The definition read as follows: "a family crisis which threatens the physical or emotional survival of a child." The object was to define in a helpful way where intervention is to be directed; to identify the causes of the problem (which are nearly always multiple and very rarely stem from simple, destructive intent of a parent which you can see); to focus less on the symptoms of the child than on what problems seemed to lead to those symptoms; to allow one to commit one's resources in such a way as to exert some positive impact on the family's ability to prevent them from happening again.

Each individual medical practitioner, or center, has to work at his own style of management. The model which we have been introducing in Children's Hospital over the last year has a basic idea, i.e., to come to grips with the complexity of each case and to tackle its specific important components directly. There is, of course, an important relationship between the personnel who are providing care and those who are receiving it. It may be, however, that effective, lasting intervention is less a function of successful treatment relationships than a matter of defining and resolving specific problems of parents' lives, problems such as poor health, inadequate housing, no child care, and legal and monetary difficulties. Our primary function may be improving, to the extent that we can determine, what Julius Richmond (American Journal of Public Health, 60: 23, 1970) has called "a family's ecology of health." This means, for a physician, a somewhat different professional role from his customary one. It means, for us at the Children's Hospital, becoming advocates for these children and families. It means cooperating constructively with our colleagues in public and voluntary agencies to reach the objective which concerns us all, enhancing a family's capacity to care for its children.

For us, creating an interagency, multidisciplinary consultation group with weekly meetings at the hospital has worked well. We meet together to explore the needs of the 3 to 5 children who are referred to us each week bearing physical symptoms of severe family distress. We try to help families function better by finding services which will make a difference in their ability to be parents. These services include medical, dental, social services, legal help, child care, homemaker services, psychiatric treatment, and, very often, haggling on their behalf, with landlords, the police, and the welfare department.

Our ability to intervene effectively is challenged by many situations where one cannot simply offer services, but where one has to go out, find the people, and effectively change the environments where they live before they can come to grips with their problems of nurturing their children. The ethical and political implications of this kind of professional activism have been explored in the recent social work literature by Martin Rein (Social Work, 13: April, 1970) and in the medical literature by Julius Richmond (Pharos, 35: 17, 1972).

Even when more adequate resources become available, many of the current problems of management will persist. Not the least of these are the exceeding difficulties which public welfare departments are having in coping with dramatically increasing numbers of reported cases. In Boston, for example, the inflicted injury unit of our Division of Child Guardianship, at the time of this writing, has an uncovered backlog of 35 new cases. And in Massachusetts under current law, only bona fide battered babies get reported by doctors. This is a situation which will grow worse when we have better reporting laws.

In New York, the problem was utterly out of control until a few spectacular murders galvanized the community to action. Mayor Lindsay appointed a task force, the report of which is available from his office. Inasmuch as Mayor Lindsay's task force report underlines the need for 24-hr. intervention, a child abuse registry and adequate coordination between public and private agencies, this report is a useful document. Many of its recommendations were heeded, with a resulting upsurge in case reports, as well might be expected. Still, however, the New York City Mayor's Task Force Report pins the blame on the parents and touts the old "battered child," "inflicted injury" jargon as the key to the understanding and control of the problem of children in jeopardy in their own homes. Governor Sargent's committee report, on the other hand, emphasizes that the way to prevent such a tragic symptom of family distress as child abuse is to strengthen family life. Its recommendations include a dial-a-parent hotline for families in crisis, the coordination of human services with a view to maintaining physical and emotional health, as opposed to treating artifacts of disease, as well as other specifically "protective" services such as a registry, legal services, and more action-oriented case workers. Functions of welfare departments in child protection are unfortunately tarred by the same brush as their relief and medicaid functions when the time comes for legislative scrutiny of budgets. There is also more than a suggestion that their child protection activities may convey many of the same values toward the poor, or toward people in trouble, as do their relief policies, such as taking their children away as the final "protective" service. Two superb, book-length analyses of welfare have come out recently, and a citation from each one may help us see how the agencies to whom we physicians have to report cases of child abuse may themselves be part of the problem, which in my view is a profound deficiency in our public policy toward children and families who need help.

G. Y. Steiner, whose book The State of Welfare (Brookings Institution, 1971) has a brilliant chapter called "Tireless Tinkering with Dependent Families," makes it plain that Welfare Departments mess around with some aspects of poverty but have an investment in maintaining it. He quotes Representative Martha Griffiths describing a mother's life on welfare:

"Can you imagine any conditions more demoralizing than those welfare mothers live under? Imagine being confined all day every day in a room with falling plaster, inadequately heated in the winter and sweltering in the summer, without enough beds for the family, and with no sheets, the furniture falling apart, a bare bulb in the center of the room as the only light, with no hot water most of the time, plumbing that often does not work, with only the companionship of small children who are often hungry and always inadequately clothed - and, of course, the ever-present rats. To keep one's sanity under such circumstances is a major achievement, and to give children the love and discipline they need for healthy development is superhuman. If one were designing a system to produce alcoholism, crime and illegitimacy, he could not do better.

One could also do no better to design a system to make parents fail. Insofar as our established "service" structure in public welfare departments allows these conditions to persist, Steiner demonstrates, our human service system is implicated in many cases of child abuse and neglect.

F. F. Piven and R. A. Cloward's Regulating the Poor (Pantheon, 1971) develops a historical argument to show that "relief policies are cyclical-liberal or restrictive, depending on the problems of regulation in the larger society with which government must contend... this view clearly belies the popular supposition that government social policies, including relief policies, are becoming progressively more responsible, humane and generous." The authors document several situations where the threat of applying "protective services" has been used to intimidate welfare rights demonstrators. This is a scary and impressive scholarly work to which we professionals interested in salvaging families and protecting children should attend.

We physicians face a dilemma with respect to cases of child abuse. We have an ethical obligation to intervene in situations where a child's life may be in danger. Yet the technologic tools of intervention can be incompetent or destructive. Fortunately, there is evidence that specific, vigorous activity directed at the causes of an individual family's particular crisis can make a difference in the safety of a child in jeopardy.

Physicians and medical institutions can work toward making public agencies' activities with regard to children more adequate to the task of sustaining families.

Just as I think we should reject the punitive taxonomy of illness which fixes the blame for a child's injuries on his parent (because it makes no scientific sense and doesn't help in case management) I think we can offer cooperation, consultation, and support to the personnel in public protective agencies. This could lead, ultimately, to a coherent and humane approach to the control of child abuse. The crux of the matter is that child abuse is a complex phenomenon which requires the investment of diverse and coordinated professional energies. It is a symptom of distress in a complicated family ecosystem with many interacting variables. To recognize and act appropriately on the really important ones requires more than simple definitions and isolated professional activities.

Children's Hospital Medical Center

Boston, Massachusetts