Pediatric Dentistry, Vol. 8, Special Issue 1, May 1986, 88-92.

Sequelae of reporting child abuse

Howard Dubowitz, MD
Eli Newberger, MD

In the last 20 years each of the 50 States has developed and refined legislation that mandates professionals who have contact with or who are responsible for children to report suspected cases of child abuse or neglect. The language in these laws varies markedly, with different states defining their own criteria for intervention. All states have expanded their focus beyond physical abuse and neglect to include psychological and sexual abuse. In view of these differences, this article will examine the most common policies and practices.

An important role for professionals has been to identify and report suspected cases of abuse. A requirement of medical screening is that early detection of the problem is beneficial to the patient; diagnosis alone does not justify a screening test. Therefore, it is important that we critically evaluate what happens to the more than 1 million children and their families who now are being reported to state child protection agencies each year.

Before focusing on details of clinical management, it is helpful to identify important recent philosophical approaches. These are central to an appreciation of what underlies specific programs and policies.

Philosophical Approaches to Child Abuse and Neglect

It is important to recognize that attention to the needs and rights of children is relatively recent. Concern about child abuse developed in the 1960s, an era of heighten’d social awareness and concern about the disenfranchised, disadvantaged, poor, and powerless. Conciousness also was raised about the rights of children.

For many centuries children were perceived as the property of their parents, and especially of their fathers.1 Generally, families we’re at liberty to raise their children as they deemed appropriate. Understanding the child’s perspective and needs has been revolutionary.

Efforts to resolve family difficulties such as child abuse and custody disputes weigh the best interests of the child versus the best interests of the parents.2,3 Examples of this are the parents’ right to choose a means of discipline versus the child’s right to be safe from nonaccidental injury, or the parents’ right to have custody of their children, versus a placement that better satisfies the child’s needs. A more useful concept may be to refer to the best interests of the family; the needs of children are dependent upon their parents and intertwined with the needs of the family.

This not only has been an intellectual trend, federal and state legislation has authorized child protection services to ensure the safety of children. This mandate obligates responsible agencies to enter private homes when there is reasonable cause for concern. The sanctity of the family privacy is now opened to public scrutiny. Social work and the judicial system have been influenced strongly by this new perspective.

Primacy of the Biological Family

A central tenet of practice is the primacy of the biological family. The criteria for removing children from their biological families and placing them out of the home have become more rigid. This is due to disillusionment with the major alternative, foster care.

Then, studies in the mid-1970s found that foster parents were screened poorly and inadequately trained and supported – both emotionally and financially.4,5

Although foster care was intended to be a temporary arrangement, more than one-third of children placed were still wards of the state after 5 years. Foster children were found to have lived in 6 different homes on average. Their educational and mental health needs were sadly neglected. The future of abused children in the home was not good, and the foster care system was seen as a dismal alternative. Currently, the first approach is to keep the biological family intact and to support it so that the child is adequately nurtured and protected. The child is removed only when he is at major risk for further injury or where serious harm already has occurred.

Long-term Planning

Long-term planning for these children and families is a major concern. This has been a problem in the foster care system where, until recently children were in stressful and confusing circumstances for protracted periods of time. The lack of an organized, thoughtful, and sensitive social service plan along with officials’ hesitancy in making difficult decisions concerning adoption, termination of parental rights, or return of a child to the biological family compounded the problem. Held in limbo, and frequently trapped between 2 sets of hostile parents, the foster child has been in an unenviable position. Increasingly, some state agencies are requiring comprehensive service plans that are reviewed periodically, and have set time limits for final decisions.6 For example, after an agency has custody of a child for 1 year, definite plans for the long-term placement of that child are required.

Criminalization of Child Abuse

Another major trend has been more legislation concerning child abuse along with greater involvement of law enforcement personnel and the criminal justice system. This contradicts a social work tradition of almost 100 years that has advocated a supportive and therapeutic approach to family difficulties. This shift in approach is a result of public outrage at the extreme abuse cases reported by the media and a frustration at the limited success of supportive and therapeutic approaches. The national mood may be reflected in the recent report by the Attorney General’s Task Force on Family Violence wherein family violence is declared a crime.7 Thus, prosecution and punishment are recommended. In Massachusetts, a recent law mandates social workers to report the more severe categories of abuse to the district attorney who then can decide how to pursue the case.8

It is unclear what effect this will bear on clinical practice. Clinicians, particularly in the area of sexual abuse, feel that court authority is valuable to confront perpetrators and mandate therapy. The threat of prosecution has been argued to serve as a deterrent to likely abusers. New laws and more prosecution convey the clear message that child abuse or neglect is unacceptable. Many believe that punishment is deserved and necessary even though the effects on adult, child, and family remain uncertain.

On the other hand, other professionals consider the court process unlikely to benefit those who need help. Lawyers and judges generally have little education and experience in fields relevant to child abuse such as child development, psychology, and pediatrics. Another problem is that fear of prosecution may deter persons from seeking help, and those in psychotherapy might resist disclosing their abusive behavior due to legal consequences. For most persons, and especially children, court appearances can be very traumatic experiences.

There is another facet to emphasis on prosecution. It allows us to point a finger at a perpetrator. We now recognize a multifactorial or ecological process in the etiology of child abuse with contributions at the individual, family, community, and broader cultural levels.9,10 Nonetheless, the spotlight has been maintained largely on the parent(s). The individual parent is held culpable and other important contributing factors are ignored. This approach is unfair and inadequately narrow as we attempt to grapple properly with the endemic problem of child abuse.

The trend toward greater judicial involvement in addressing family difficulties is an effort to exert a measure of social control. This is a sensitive issue since a disproportionately high number of poor and minority groups are diagnosed and reported as abusive.11 Professional biases in this direction clearly have been shown.12

Depicting the therapeutic approach as compassionate and judicial involvement as controlling is too simplistic. Imposed counseling or therapy can be understood as controlling; this is partly inherent in any effort to modify behavior. However, the courts can serve a compassionate role, particularly if the wellbeing of the victim is safeguarded. The courts also can mandate services which provide constructive and ultimately compassionate assistance.

Compassionate versus Controlling Approaches

A debate over compassion versus control does not appear helpful. What is indicated is a sensitive and constructive application of measures that is compassionate and controlling. We need to recognize the pain and difficulties confronting many families, and then to offer constructive assistance. The goal is to be helpful-compassionate. l’punitive measures seem to be a response to the outrage that professionals and society feel when a child is abused. We should acknowledge these feelings, but keep clear the needs of the children and families we seek to help.

When society and professionals establish laws and guidelines stipulating that certain behaviors are not permissible, controlling measures are applied. For example, social workers might request that parenting classes be attended, pediatricians might insist on follow up for a medical problem, or a judge might mandate psychotherapy for an incestuous father. There are no ready formulas and each case warrants individual consideration. Rosenfeld and Newberger have offered useful guidelines on how this principle can be applied.13

Evaluation of Child Abuse and the Treatment Process

Having discussed certain cure tenets underpinning clinical practice, our focus now shifts to a detailed description of the evaluation and treatment process. Matters pertaining to diagnosis and reporting will be mentioned only briefly, as they are addressed elsewhere in this issue. All 50 states have laws that mandate professionals working with children to report cases of suspected abuse or neglect. In addition, lay persons can be voluntary or mandated reporters. Such reports are on behalf of the child, and not against an alleged perpetrator. In many institutions, especially schools and hospitals, teams have been set up to discuss management of cases and whether or not a report to the state agency ought to be filed. Ideally, such teams consist of representatives of different disciplines and different ethnic groups. A team offers the ideal approach to deal with the complex and frequently painful situations. They offer a shared responsibility and remove some of the burden placed on the individual. Such a team process has been described comprehensively.14

When a report is made, it goes through a screening process in the state agency. In some states, mandated reports by professionals are investigated automatically. Depending on the urgency of the circumstances, the agency then investigates the case immediately or within a set time period (e.g., 7 days). This evaluation generally includes meeting with key family members, a home visit, and contact with professionals involved with the family such as a physician and teacher. The investigation determines whether or not the report is substantiated. If not, there still remains the possibility that services can be offered on a voluntary basis, which the family can choose to accept or reject. When the case is substantiated, a service plan is developed, and family members are expected to cooperate.

There has been a steep rise in professional awareness and reporting of child abuse or neglect. Generally, state laws have been revised so as to cast the net more widely. As a result the number of case reports has increased steadily. Unfortunately, legislative concern has not been matched by appropriation of funds to provide resources to meet identified needs. Social service agencies are overwhelmed and social workers overworked, inadequately trained and supported, and they have a high “burn-out” rate.15 Their ability to offer critical services such as satisfactory housing, day care, or access to medical, mental health, and dental services often is limited severely.

The restricted abilities of child protection services has compromised their ability to protect children, perhaps hurting instead of helping. Consequently, many states have been able to offer services only to the highest risk families. They are constrained to efforts at tertiary prevention – primary and secondary preventive approaches are impossible. To some, this approach seems necessary given the limited resources, but it is extremely costly in human terms. At all levels of prevention and treatment we need to evaluate what works best for whom in which circumstances. It has become clear however that a focus on primary and secondary prevention sorely is needed.

Once a report has been substantiated, the social worker needs to assess the degree of the child’s immediate risk so as to determine the appropriate placement. In the majority of cases the child will remain in the home, but when there is serious concern about the child’s safety, he will be removed. Placement in the extended family is pursued first, but if unavailable, a foster family is found. In some instances, hospitalization or placement in a residential rental setting is warranted. The wisdom of removing the child has been challenged because of the possible deleterious psychological impact when an abused child is taken out of the home and placed away from the security of loved family members. For example, this could exacerbate the guilt felt by a child for “provoking” family problems. Thus, it might be argued that it is preferable for the adult perpetrator to move out.

In many states, law enforcement personnel are involved from the outset, and some areas, such as southern California, have dual reporting to both police and child protection agencies. Removing a child from the family and transferring custody to the state always requires court action, often including an appearance of the family in court. However, an emergency placement can be made prior to the court hearing by phoning a judge or designated court official.

When children are placed out of the home reunification of the family is nearly always the ultimate goal – the foster care is seen as temporary. Visits with the biological family are arranged. At first, these might be supervised by a social worker in an office or play area of the agency. 5hould these contacts progress satisfactorily, visits gradually might be increased in frequency, length, and become unsupervised. In contrast, if visits present major difficulties for the child they might be shortened, less frequent, or terminated. In addition, specific interventions (outlined later) could be offered to improve family functioning and enhance parenting abilities.

A comprehensive social service plan should be developed as soon as possible that identities the needs of the family and implements the appropriate services to meet these needs. In addition, clear goals should be articulated to the family in a supportive but forthright manner. The types of services vary from family to family, and should match the specific needs of each situation. It is critical that difficulties be addressed, both for individuals and the family as a whole. Frequently, a graduated step-wise approach is necessary.

The social worker can be valuable in helping the family obtain services and welfare benefits that they might be entitled to. These include, for example, SSI payments for disabled children, or nutrition supplements for pregnant women, infants, and young children. Guidance in securing reasonable housing, help with transportation to important intervention programs, and information on work opportunities might be needed.

Although poverty is certainly a bias in reporting, it appears likely that there is a real association between the stress of poverty and child abuse and neglect.16 Indeed, to be raised in poverty per se can be construed as a form of abuse at the community or societal levels. Whether the effect is direct or indirect, alleviating some of the burdens of poverty is key to enhancing family functioning. (In no way does this suggest that most poor parents abuse their children, or that wealth provides immunity from abuse or neglect.)

The population with a high prevalence of family violence is known to have disproportionately high rates of medical, mental health, and dental problems.17 Frequently, poverty prevents access to health services. Children in the custody of the state usually are issued Medicaid cards, but this offers only some help in improving access to health care; many health care providers refuse to accept Medicaid patients, so inadequate health care of abused children remains a significant problem.

Some children require skilled, individual therapy, while others can benefit from group treatment. The social worker can facilitate the development and learning of abused children by placing them in early intervention programs, therapeutic day care centers or advocating a suitable school program. Even if the active toddler is in a program only a few hours in the week, that can offer valuable respite to a stressed parent. It is valuable to include the parents in any plan, to support and improve their parenting abilities. Classes or small groups that teach parenting skills are a useful adjunct. The challenge is both to enhance the parents’ capabilities to nurture their child and meet the needs of parents as individual adults. Often the former is not possible without the latter. A parent who is depressed is hard-pressed to interact in a responsive and competent manner with the child.

Social isolation is known to be an important correlate of child abuse.18 so it is important to facilitate supportive relationships within the extended family, neighborhood and community. Many parents have found the self-help group Parent Anonymous to be helpful. Parents at high risk for abusing their children voluntarily participate in weekly group meetings which are held without professional involvement.

Monitoring the family situation and coordinating services are the crucial functions of the social worker. He must be empathetic and supportive, persistent in pursuing needed services, and astute and sensitive in working with families.

Since professional biases lead to poor families being more likely to be diagnosed as abusive, there is a clear stigma attached to these agencies. Families frequently are angry and resistant to working with the social worker. Denial, an important unconscious mechanism to avoid painful realities, might preclude parents from acknowledging their difficulties and accepting help. Also, social service agencies usually become involved only when the circumstances are already quite desperate. Working in this area can be a formidable challenge.

It is evident that social workers are often not adequately equipped to meet these challenges. Limited training, low social status, little supervision, poor facilities (such as private office space, a desk, and phone), large case loads, and unsatisfactory secretarial support, all contribute to poor quality work, frustration, and a high burn-out rate. The best intentions, might not endure under such conditions.

The legal mandate is clear. Professionals are to report suspected cases of abuse or neglect. Yet many professionals have been concerned with the possible negative outcomes following a report of child abuse. They are then reluctant to report, particularly if they have a close relationship with the family. They may prefer to help the family themselves or to maintain a safe distance from the problem. There is not an easy answer to these dilemmas. There is a need to consider carefully each case and to fulfill the obligation to ensure the child’s protection.

The Fate of Abused Children

What ultimately happens to abused children? The vast majority will remain with or be returned to their biological families. Some will linger in the foster care system for years, often shunted from one home to another, and others finally will be adopted. Aside from the mortality figures that crudely estimate several thousand deaths in the United States each year, the morbidity is immense. This results nol only from the abuse per se, but also from those contributing factors that are associated with it. Many children will bear long lasting physical and psychological scars, while others demonstrate remarkable resilience and lead relatively healthy lives.

What then is our professional role? This paper has surveyed the array of resources that can help abused children and their families. It also has pointed to the problems and shortcomings of current approaches. It is reasonable to question the overall intent and design of the welfare system, which has been assailed as “a poor system for poor people.”19 Yet it is important not to be nihilistic. We need to fulfill our professional mandate concerning the protection of children. We should file a report if that is indicated and then maintain our involvement. We have the potential to be very effective advocates for children and families.

There are too many children being abused and neglected, and too many families in distress. There are also too few services and programs to treat these problems. Expanding these resources is essential, but unlikely to be sufficient. We need to be imaginative and creative to devise new policies and approaches. At the local, state, and national levels, much work is needed to improve the health and welfare of children and their families.

Dr. Newberger is an assistant professor, pediatrics, Harvard Medical School, and director, Division of Family Development at Children’s Hospital, Boston. Dr. Dubowitz is an assistant professor, pediatrics, University of Maryland Medical School.

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