New England Journal of Medicine, Vol. 301, November 29, 1979, 1205-1212.

Child Abuse in the International Year of the Child

LESLI TAYLOR AND ELI H. NEWBERGER, M.D.

Children have been documented as victims of violence, neglect, abandonment, slavery, and murder since records of mankind have been kept.1-3 Only within the past century has the notion developed that children have rights apart from those that adults choose to grant them. In 1959, the United Nations Declaration of the Rights of the Child stated, “The child shall be protected from all forms of neglect, cruelty and exploitation.”4

The child-welfare movement began in the United States during the middle and late 19th century when the exploitation of children and adults during the Industrial Revolution led to undeniable signs of childhood suffering: homeless and starving, children wandered the streets. The sight of these children led, in turn, to concern for the moral growth of the children of the poor. Home was believed to be a haven for children and the setting where their spiritual development into upright and productive citizens should be nurtured.5

Not until the 1950’s did the medical community begin systematically to note that many children were in fact harmed by their parents. Radiologists noted fractured bones associated with head injuries in infants and speculated that the injuries might have been inflicted by parents or other persons responsible for the children’s care.

But it was the article that appeared in 1962 in the Journal of the American Medical Association by Professor C. Henry Kempe and his colleagues that coined the diagnosis, the battered-child syndrome. The article was written with the explicit intention of arousing public concern and spurring professional action for the protection of children.6 This publication was associated with an editorial outcry in both professional and lay media, and it led directly to the promulgation by the United States Children’s Bureau of a model statute for the reporting by physicians of victims of child abuse. By the middle 1960’s, every state in the country had laws mandating the reporting of battered children. Today, all professionals with responsibility for the care of children are obliged to report suspected cases of child abuse.

Other Western industrialized nations have involved agencies of the state in the protection of children in their homes. The countries where child abuse and neglect appear most visibly to be the targets of professional action are those where the organic or biologic sources of illness and death in children have largely been controlled.

With the celebration of the International Year of the Child, the rights of children to be free from maltreatment have again been recognized worldwide. As of May, 1979, the following countries had identified child abuse and neglect as worthy of special concern: Austria, Belgium, Bermuda, Ghana, Guyana, Hong Kong, India, Ireland, Liberia, Sudan, the United States, and Zambia. According to information supplied by the International Year of the Child Secretariat, many countries have also been involved in studies relating to the rights of the child. These include Barbados, Finland, France, the Federal Republic of Germany, the German Democratic Republic, Hungary, Indonesia, Nicaragua, Nepal, Poland, Senegal, and the Syrian Arab Republic.

DEFINITION

There is no consensus among professionals about the definition of child abuse and neglect. There is controversy about whether the definition should be narrow or broad. The original paper on the battered child syndrome by Professor Kempe and his colleagues described the syndrome as resulting from harmful acts by parents or foster parents.6,7 Here, the notion was of injuries inflicted on children; a concept of intent to harm the child was implicit.

A broadened definition, which is suitable for medical diagnosis but does not presuppose a desire to harm the child, is “an illness stemming from situations in his home setting which threaten a child’s survival.”8

Professor David Gil, whose book, Violence Against Children, was the first systematic study of case reports on child abuse, proposed yet a broader definition of child abuse in hearings before the United States Senate on what ultimately became legislation establishing a Center on Child Abuse in the Department of Health, Education; and Welfare. Gil described child abuse as “any act of commission or omission by individuals, institutions, or society as a whole and any conditions resulting from such acts or inaction, which deprive children of their equal rights and liberties and/or interfere with their optimal development, constitute by definition abusive or neglectful acts or conditions.”9

Whether child abuse should be seen in terms of the plight of individual children or whether the problem should be recognized as an issue for society is the subject of vigorous, frequently rancorous debate. There are, furthermore, culturally accepted methods of childrearing that result in physical harm to a child. How these situations should be dealt with is by no means clear. The following examples drawn from several countries show the range of practices that may be considered child abuse. In America, a three-year old boy was admitted to the hospital after being beaten by his father. Physical examination showed a broken arm and bruises all over the child’s body. An operation performed after the child vomited blood revealed abdominal visceral injuries.10 In Czechoslovakia, identical twins were isolated from human contact and treated cruelly by their stepmother from their 18th month until they were seven years old, resulting in subnormal intelligence, rudimentary speech, rickets, inability to walk, and terror of people and normal objects.11 In Nigeria, a seven-year-old child died after being shot by an angry guardian. The child had a history of three previous hospitalizations for trauma.12 Most people would agree that the aforementioned cases constitute child abuse. But what about the following cases, in which the intent to do harm is not apparent?

In Vietnam, a four-year-old child was forced to submit to the practice of Cao Gio (“scratch the wind”), or coin-rubbing, in which a child’s oiled back is stroked with a coin until bruises appear, to help rid the body of “bad winds.” It is unclear how painful or harmful this is to the child.13,14 In America, a Little League baseball pitcher, eight years old, injured his elbow because he was pressured by his parents to excel in sports.15-17 In Latin America, a folk remedy for depression of the soft spot on an infant’s head (caida de mollera) prescribes holding the infant by the ankles while dipping the crown of his head into very hot water. This practice may cause both scalded skin and hemorrhage around the brain.18

These examples show the diversity of maltreatment of children and suggest some cultural practices and values associated with child abuse: corporal punishment, superstition and the concern that twin babies may be evil, the right of the parent to harm or destroy his offspring, the infliction of pain and injury as healing, and the traumatic consequences of competitive athletics. Each country has values and practices that may culminate in injury or suffering to children. In the industrialized world and especially in the United States, the dramatic manifestations have led to awareness and to a probing of the origins of child abuse and neglect. After initial recognition of the problem, more formalized professional and governmental action may follow.

MANIFESTATIONS OF CHILD ABUSE

As described in the medical literature, the clinical signs of the battered-child syndrome include bruises, welts, lacerations, abdominal injuries, ocular damage, burns, and bone fractures. Skull fracture and bleeding around the lining of the brain have been frequently noted and reported.19-21 Shaking an infant may cause injury to the child’s neck, bleeding within the skull, and brain injury that may be associated with early death or with profound and continuing neurologic and psychologic disturbances.22 Frequently, the diagnosis of severe child abuse is supported by the simultaneous presence of new injuries to bone and soft tissue and by signs of previous trauma, often detected on physical examination or on an x-ray film. Some victims of child abuse are found to have only recent injuries. Others, however, have such diverse symptoms of mistreatment as to give the impression of a longstanding pattern of abuse. This has led to expressions of concern that if action is not taken promptly, the consequences may be fatal.

Infanticide has a long history. Its persistence to the latter part of the 20th century may have to do with the same cultural and economic realities that appear to have been associated with the killing of infants in the past: the wish to destroy illegitimate offspring, the belief in ritual sacrifice, the desire to destroy defective babies, and the need to control population growth. In some cultures, the last born in a set of twins or triplets may be killed if the mother is feared to be unable to care for the child; if a mother dies in childbirth, her child may be buried alive with her.23 A grim reminder of the relation between infanticide and economics is the practice recently reported in Thailand of buying a baby from unknowing parents, killing the child, and using the body to smuggle heroin.24 It has been asserted that at one or another time every culture has practiced infanticide.24-28 Infanticide has also been associated with unwanted births and with mothers’ psychiatric problems after delivery.29,30

The syndrome called “failure to thrive” has been associated with the neglect of children. Here, the children fall below the third percentile for weight and height; their neurologic and psychologic growth has also slowed, and no signs of organic illness account for the deficiencies. Characteristically, children who fail to thrive show marked improvement when separated from their parents, either in the hospital or in foster homes.31 Failure to thrive has frequently been described in families in which mothers cannot fulfill their children’s emotional and nutritional needs. There may have been a failure to form an adequate mother-infant bond at birth or the mother may have serious psychiatric problems; the child, too, may have special qualities that inhibit expressions of normal nurturing by the parent. 32-34

Failure to thrive can be distinguished from kwashiorkor and marasmus, which are nutritional disorders frequently found in developing countries.35 Occasionally, a child may starve to death because of deliberate action or neglect by a parent.36 It has been proposed that failure to thrive, neglect, and abuse form a continuum of symptoms, perhaps from the same causes.37

Neglect may be defined as a parent’s failure to meet a child’s needs for food, clothing, shelter, hygiene, medical care, education, or supervision. It is important to take into account the parent’s economic ability to provide these items and thus the parent’s intent when a child appears neglected.38 Obviously, in many underdeveloped countries where poverty is rampant, people of all ages suffer for want of basic necessities. In these situations, a parent cannot be blamed for the child’s symptom, but action must still be taken to help the child.

Emotional or psychologic abuse of children is difficult to define. The psychologist James Garbarino has proposed the definition, “the willful destruction or significant impairment of the child’s competence.”39

The problems of sexual exploitation of children have received increasingly greater attention in the past five years, and Professor C. Henry Kempe has noted that we are now discovering sexual abuse, just as in the early 1960’s we discovered child abuse. He defines sexual abuse as, “the involvement of dependent and developmentally immature children and adolescents in sexual activities that they do not fully comprehend, to which they are unable to give informed consent, or that violate social taboos of family roles.”40

Cultural factors may also figure in the sexual abuse of children. In Muslim countries, children may be taken as brides, whereas in Western countries, sexual interaction between adults and children may be construed as a criminal act or as a symptom of psychologic disturbance. Incest and less traumatic and invasive sexual acts toward children have been blamed for various levels of physical and psychologic harm to the child.”41-44 Brandt and Tisza have proposed the concept of “the sexual misuse of children” to draw attention to the fact that normal and necessary physical relations between children and their parents or guardians can sometimes become more intense and sexual than society will tolerate.

A newly recognized form of child abuse is Munchausen’s syndrome by proxy. Munchausen’s syndrome is a psychiatric illness in which the patient creates a physical illness in order to gain attention and medical treatment. A case has been reported in the United States of a mother injecting fecal material into her daughter and, after widespread infection was diagnosed in the child, withholding antibiotics. This caused serious recurrent infections and several hospitalizations.” In England, a mother falsified her child’s medical history and substituted contaminated urine samples for the child’s own urine so that the child was admitted to the hospital on several occasions.” In these situations, the child is the unwitting victim of a serious psychiatric problem in the parent.

CAUSES OF CHILD ABUSE

Just as there are many symptoms of child abuse, there appear to be many causes. The child may have qualities that provoke abuse. He or she may be small at birth and difficult to care for. “47-48 It may be difficult for parents and child to form an emotional bond. The child may be hyperactive or precocious and thus demand a great deal from parents; physical handicaps or a mismatch in the child’s and parents’ temperaments may make it especially difficult to cope with the angry feelings that all parents have at one time or another. Mental retardation has been described in association with child abuse, although it may be difficult to determine whether violence against the victim preceded or succeeded the disability.” The parent may perceive the child as different or unusual in relation to other children; parents’ perception of a child may be distorted if a child is unwanted, illegitimate, or adopted.50-51

Abusive parents have been characterized as immature and unable to see their children as children. They may think that a baby, for example, is crying just to make them angry. They may believe that a child should be toilet trained by the age of six months or that the child should be able to help cook and clean the house at the age of 18 months. When parents of abused children are interviewed, many indicate that they as children were abused themselves. They may know no other method of child rearing than violence. Drug and alcohol addiction and major mental illness have been described in relation to child abuse, but many parents who abuse their children are psychologically normal. They may have suffered recent serious stresses, such as the loss of a loved one or a recent move to an unfamiliar community. It has been asserted that psychologic analyses of child abuse are inadequate, and that the presence or absence of social supports and stresses may better explain the individual case and indicate the route to prevention.52

Families in which child abuse or neglect have occurred often appear to have suffered serious environmental stresses, such as crises in housing and in access to essential services and supports. These problems may be associated with less parental tolerance of children and with explosions of violence.53 Child abuse may also be seen as a subset of a larger set of family problems involving violence, including abuse by one spouse of the other, violence among siblings, and attempts by children to harm their parents.54

Values of a society may influence methods of child rearing at home. The acceptance of corporal punishment in schools may encourage parents to use harsh discipline. In his article, “Controlling Child Abuse in America: An Effort Doomed to Failure,” the distinguished American psychologist Edward Zigler contends that so long as corporal punishment is sanctioned, child abuse will be inevitable.55

Many societies sanction violence as an acceptable method of controlling behavior and of solving conflicts. Whether child abuse results from individual or social causes is the subject of much discussion in the literature on the problem. Although individual cases cry out for action on behalf of particular children, the prevention of child abuse must involve reassessing the values, practices, and realities of family life.

THE SEQUELAE OF CHILD ABUSE

Child abuse may have far-reaching consequences.’ Both abuse and neglect of children have been described as causes of brain damage and mental retardation.56,57 A child may be left with permanent physical deformities. There may be major emotional and psychologic consequences.58-60 The only controlled follow-up study published to date, however, indicates that poverty may be as important as maltreatment in causing psychologic deficits in children.61

Concern has also been expressed about the long-term impact of child abuse. Violent juvenile delinquents have been described as having suffered or witnessed great amounts of violence in their lives.62,63 It has been further proposed that victims of child abuse may become the abusers of the next generation.64

CURRENT PROBLEMS IN DEALING WITH CHILD ABUSE

The great conflict in developing programs for the protection of children has to do with whether children have rights of their own. Article 17 of the International Covenant on Civil and Political Rights (United Nations, December 16, 1966) states, “No one shall be subjected to arbitrary or unlawful interference with their privacy, family, home…Everyone has the right to the protection of the law against such interference.”65 The privacy of the home, however, may make it difficult to fulfill the United Nations Declaration of the Rights of the Child: “The child shall be protected from all forms of neglect, cruelty and exploitation.”4

In present practice, professional services aim to protect the child and simultaneously help the parents to understand their own problems. Most programs to protect children involve social workers who are trained in counseling parents. Often, homemaker and child-care services are offered to help allay the stresses that may make it difficult for a parent to care for a child.

Frequently, however, parents are reluctant to cooperate. In these situations, more intrusive and coercive actions may be taken. These actions sometimes involve juvenile, family, or criminal courts. Although the child may be separated from the parents, the action is usually justified in terms of providing the child and the parent with professional assistance. Often the parent is portrayed as “sick” and in need of treatment.66 In the best present practice, professionals expert in child protection work together to provide coordinated medical, social, psychiatric, and child development services to families in which children have been abused and neglected. Frequently, however, it is difficult for workers in separate institutions to collaborate in serving families with many problems. The past decade has seen the development in many places of interdisciplinary teams that work from different bases—hospitals or community social service agencies, for example—and that provide many services to families whose children are reported as victims. Many social-welfare programs for victims of child abuse are crippled by too many cases for too few workers and a heavy emphasis on separating children from their parents.67 Frequently, doctors ignore child abuse or resist dealing with other professionals because the problems are so emotionally distressing to them or because they do not have the time or interest to do more than care for a wound.68-70

Sometimes the cure for child abuse can be worse than the disease. Children have been reported often as victims of abuse and neglect in the foster homes in which they have been placed for protection.71 Not only do professionals have to be trained to recognize child abuse and to treat the victims sensitively and humanely, but the agencies assigned by the state to care for the problems of abused and neglected children need to be staffed sufficiently; foster homes, when they are needed, must themselves be safe, nurturant, and well supervised.

CROSS-CULTURAL COMPARISONS

Children are still seen as chattel in many countries. Some are forced to be beggars, and they may be mutilated to make them more effective at it.72 Children are still used as soldiers, and they are often victims of wars that they did not choose to fight.73 Child labor remains extensive throughout the world, with current estimates approaching 52 million children under the age of 15 years in the work force; 42 million of them work without pay.74 In the practice of jeetah in India, children are sold to the parents’ landlord, by whom they may be mistreated.75

Aggressiveness toward children appears to vary according to culture. German adults in one study were found to be more aggressive toward their children than were Danes or Italians.76 Child rearing among the Alorese was consistently seen in another study to rely heavily on shaming and aversive discipline, and such methods were accepted within that culture by all adults.77 A study in Ireland indicated that alcoholism among fathers may be linked to abuse of mothers and children, especially among the poor.78 In one area on the Gulf of Guinea in West Africa, corporal punishment of children may include use of a switch or a whip, and cuts received from a beating may be made more painful by the rubbing of pepper into the wounds and into other sensitive parts of the child’s body.79

Corporal punishment is a time-honored and socially sanctioned form of discipline. Forty-six states in America permit corporal punishment in the schools, as do Australia, Barbados, Canada, Ireland, New Zealand, South Africa, Swaziland, Trinidad, Tobago, and the United Kingdom.80,81 Most Western and Eastern European countries, including the Communist bloc countries, have outlawed corporal punishment in the schools. Sweden has made corporal punishment at the hands of the parents illegal as well; Norway plans to do the same. Although the law is unenforceable for practical purposes, its effect is intended to be pedagogic and to change social attitudes.82 Corporal punishment is frowned on as a method of discipline in Japan, modern China, and the Soviet Union.83-85 If the person administering corporal punishment in a school wants to humiliate or harm a child as well as to maintain order, serious injuries may occur.86,87

Some socially sanctioned customs may hurt a child, and whether these practices should be labeled child abuse depends on the observer. Such practices as scarification, binding of the skull or feet, and a variety of painful pubertal initiation rites may do lasting harm.88-90 Male and female circumcision have been called abusive, although they clearly have religious and cultural meaning that make them widespread practices.91,92 In the light of current concerns about the right of children to be protected from cruelty, it is anticipated that these practices will be reevaluated.

Child abuse has been identified as a problem in many countries: Australia, Canada, East Africa, India, Malaysia, New Zealand, and South Africa, as well as most Western European countries.93-99 Child abuse is said not to exist or to be very rare in modern China, Russia, Poland, and Japan.84,100-103 Whether or not a country acknowledges the problem depends on its local definition and priority. For many, the problem would be too embarrassing to admit; for some, serious violence against children may seem normal.

Some societies have values and standards of child rearing that appear to lower the likelihood of child abuse. The birth of a child in the Papago Indian culture brings great prestige to the parents and may mark their transition to full adult status; the child is valued and cherished.77 In Russia, children are held in high esteem by all adults; strangers may show concern for children as if the children were their own.83 In societies in which extended families are the norm, young parents are relieved from constant care of the child. Children also learn as they grow up about the care of other children, and they may learn at an early age to deal with the problems of parenthood by other than violent means.104 Child care in China, Russia, and Israel is provided by the state. In some cultures in China, a custom called “doing the month” results in a 30-day period in which a mother and her infant are apart. There would seem to be little opportunity for the establishment of normal mother-child attachment.105 Yet this Western concept of bonding, the lack of which has recently been suggested to have predictive value, may be of limited usefulness in a crosscultural comparison. There is apparently no child abuse in cultures in which this separation of mother and child takes place. China’s state policy strongly favors late marriage and the spacing of children.85 Family supports that may reduce the prevalence of child abuse and neglect in the United Kingdom, France, Israel, and Poland include universal healthcare programs for mother and child.103

In cultures in which infants are given great amounts of physical affection and adult sexual proscriptions are few, there appear to be fewer violent acts by adults toward children.106,107

SUGGESTIONS FOR ACTION

The first step in coming to terms with child abuse is to recognize it. When child abuse is defined, assumptions about the care of children and about injurious but socially accepted practices will come under scrutiny. Only then can legislation and policy be formulated to deal with child abuse and neglect.

Many areas of contention remain. Who has the ultimate responsibility for children—their parents or the state? Should parents retain power over the life and death of their offspring? Is childbearing an inalienable right, or should governments determine who can be parents? These questions go beyond the cultural position of children, to the political status of individuals and families. They demonstrate the extent to which defining child abuse and elaborating a social policy to deal with it are linked to the country’s values and social and political structures. The following recommendations for action are intended to stimulate discussion regarding the prevention and treatment of child abuse at several levels: community, government, and worldwide.

Community Actlon

At the community level, both families with children and professionals who care for children need to be aware of the problem of child abuse. Schools of medicine, law, and social work should include child abuse in their curriculums and encourage professional work to prevent and treat the problem. It must be understood, however, that professionals alone will not solve the problem of child abuse.

Personnel in hospitals with pediatric departments frequently see injured children and are in a position to identify child abuse and neglect. Educating the staff and forming links to other supportive services in the community will permit identification of individual cases and help ensure that the children return to safe, nurturant homes.

Plans to prevent child abuse at the local level must take into account the socioeconomic status of the community and the institutions that serve parents and children. In less affiuent communities, it may be possible only to educate parents about the development of children and nonviolent means of raising them. Violence against children can be outlawed in public schools.

In more affluent communities, such family supports as child-care centers and health programs for mothers and children that include counseling and help for marital problems will go far to prevent child abuse. The mobility of families throughout the world in response to war, rural poverty, and the attraction of jobs in the cities may isolate parents and children and rupture the ties to extended family and friends that make it possible to tolerate the demands of children.108,109 Attention must be paid to the needs of families in transition; the special problems of political refugees, victims of famine and war, and linguistically isolated parents and children must be acknowledged forthrightly and compassionately by all who care for children.

Hospitals can revise routines to help make childbirth a favorable experience. Breast feeding can be encouraged and made more socially acceptable by professionals educating the public about its benefits.

Churches and other community organizations can organize programs to support families. Housing programs can be planned to avoid the segregation of people by age, race, and social class, which leads to isolation, frustration, and stress.110

Local services today strive to keep children with their parents, even after abuse has occurred. Keeping the home together requires the development of professional skills and the availability of such supports as child care and homemaker services; it also requires a commitment to maintain the integrity of the family even in the face of serious adversity and the presence of great risk.

Government Action

Nearly all governments now have laws that address the welfare of children, if not statutes requiring the reporting of child abuse and neglect. To prevent child abuse, several initiatives are possible at the government level. A “family-impact statement” has been proposed as a counterpart to the environmental impact statement required for all major government funded programs in the United States. Rigmor von Euler of Sweden’s Save the Children Federation has suggested the appointment of a children’s ombudsman who could act on the behalf of any child.111

Corporal punishment by parents and by institutions that deal with children can be reduced through policies, laws, and vigorous efforts to educate parents and teachers in other methods of socializing children. Recent studies of the impact of violence in the media on children’s behavior suggest a need to reduce the extent to which violence is presented as a legitimate way of resolving conflict.112 Government regulation may be required, although respect for individual civil liberties and freedom of the press must be considered in the formulation of national policy.

In countries where child abuse has been studied systematically, there appears to be a prevalence of unwanted children in the reports. The development of more liberal family-planning programs should make it possible for parents to have children only when they want them and feel prepared to care for them.

The association of child abuse with poverty suggests that one of the most important government initiatives to control child abuse will be to make available to young families certain basic necessities, including adequate housing, employment, and health care. Countries with universal health-care systems in which the programs for maternal and infant care include regular visits by a nurse at certain points in infancy appear to prevent child abuse more effectively.103 Child abuse is not inevitable. Governments can have an important role in its perpetuation or its eradication. Governments can encourage the study of child abuse. This task will entail compiling an analysis of case reports, evaluating and guiding preventive and therapeutic efforts, promoting communication between social scientists and clinical workers, and funding pertinent research on child development and the family.

World Action

Although all will agree that children represent the future of the world, it is clear that throughout most of the world the welfare of children lags behind as a priority. Of particular concern is the extent to which defense budgets outstrip allocations for services to children and families. Implements of destruction seem everywhere to be more important than supports to ease the suffering of the young. It is encouraging to note that the Socialist Republic of Romania has reduced its military expenditures by $42 million, approximately one fifth of its 1977 defense budget. Part of this money will be used to increase state allowances for children.113

An important worldwide action that will help to prevent child abuse is the international exchange of information through conferences and journals, already under way during the International Year of the Child. A better understanding of how children are reared in other cultures will help us to understand how we can make life better for children in our own.

Though much will be done to further the rights of children during the International Year of the Child, this effort will have to be sustained and increased in the years to come. At a time when enough weaponry exists to destroy the population of the world, we have everything to gain by rearing the next generation in peace.

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©Copyright. 1979, by the Massachusetts Medical Society Printed in the U.S.A.

From the Department of Medicine, Children’s Hospital Medical Center, and the Department of Pediatrics, Harvard Medical School, Boston. Supported in part by a grant (#ITOIMHI5517-0IA2CD) from the National Institute of Mental Health. The paper was prepared at the invitation of the International Year of the Child Secretariat, UNICEF Headquarters, New York.