The Spectrum Of Child Abuse

Assessment, Treatment And Prevention

R. Kim Oates

• Publisher: Routledge
• Year: 2013
• eBook ISBN: 9781135063085
• Topic: Psychology
• Subtopic: Developmental Psychology
• Index: Psychology

First published in 1996. With so much information available today in the area of child abuse, figuring out where to begin quickly becomes overwhelming. But the Spectrum of Child Abuse stands out from current literature in its comprehensiveness and balance. Dr. Oates presents a detailed, thoroughly referenced overview of the entire field- rather than focusing exclusively on one particular professional viewpoint or facet of the problem. The chapters encompass physical abuse, sexual abuse, emotional abuse and neglect. For each of these areas, the text offers a clear historical perspective in addition to pertinent data on incidence and epidemiology, contributing factors, assessment, treatment and prevention. Moreover, a wealth of case studies underscores the important and meaning of various intervention strategies.

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THE DEFINITION OF CHILD ABUSE AND NEGLECT

Almost daily, we are confronted by newspaper reports, magazine articles or television programs describing child abuse. What is child abuse and why is there so much media attention? Is child abuse increasing? Are reports exaggerated? Can we believe what children say? What do we know about the perpetrators of abuse? What happens to abused children—will some become abusers when they grow up? How can abused children be treated? How can scarce resources be best used? How can we reduce the incidence of child abuse? These are typical of the questions that the public, as well as professionals, often ask. Unfortunately, there are no simple answers. Child abuse is a complex problem and complex problems rarely have a simple solution.

This book is an introduction to the problem of child abuse. While it may not be possible to answer all of the above questions fully, much has been learned about the subject. The aim of this book is to provide an understanding of the problem based on current knowledge, as well as to provide references for those who wish to pursue the topic further.

THE SPECTRUM OF CHILD ABUSE

Child abuse can be divided into four broad areas:

•Physical abuse

•Sexual abuse

•Neglect and nonorganic failure to thrive

•Emotional abuse

These are not clear-cut categories. Although in many cases a child will suffer from only one of these types of abuse, for others, the abuse may include two or more of these varieties. And for some, what started as neglect in the first year of life may manifest as another form of abuse, such as physical abuse, in the toddler period. It is common for children to be subjected to more than one type of abuse, particularly when emotional abuse is included, with possibly less than 5% of cases involving only one type (Ney, Fung, & Wickett, 1994). However, for ease of discussion, the four areas of abuse will be considered separately.

PHYSICAL ABUSE

Definition

A simple, early definition of a physically abused child provided by Kempe and Heifer (1972) is still useful:

Any child who receives nonaccidental physical injury as a result of acts, or omissions on the part of his parents or guardians, (p.xi)

This definition has the advantage of recognizing the vulnerability of the child and of placing responsibility on the child's caretaker. It also points out that most physical abuse is caused by people who have responsibility for the care of the child. However, there is no universally accepted definition, which complicates the task of understanding the epidemiology of child abuse in all of its forms. Definitions vary considerably. For example, Swedish law bans all forms of physical punishment and other injurious or humiliating treatment of children. On the other hand, Straus's survey of child abuse in the United States (1980a) used a definition that excluded the “normal” violence of family life, such as pushing, slapping, and throwing objects, but included acts that put the child at risk of serious injury, such as kicking, biting, punching, hitting with an object, or using a knife or gun.

Problems with definitions occur because children's rights evolve over time. What is acceptable in one society may not be acceptable in another and what was regarded as normal in previous generations may be considered unacceptable now. Also, if one simply looks at the physical injuries, the problem in the family may be missed altogether. Physical injuries often depend on the circumstances surrounding the violent act.

A child may be pushed roughly to the floor by his father. He first lands against a soft armchair and then falls to the carpeted floor. No injuries are sustained.

On another occasion, exactly the same amount of force and aggression is used by the same father. This time the child hits his head on a protruding cupboard, sustains a fracture, and then falls to a concrete floor, receiving further head injuries.

In the second incident, the child will present for medical care and is likely to be diagnosed as abused. In the first episode, the boy would not present for medical attention at all. These two scenarios involving the same amount of force and aggression emphasize that the act of violence on the part of the parent is more important than the visible injury.

The physical injury is best thought of as a physical sign of an underlying problem. To use a medical analogy, when a child comes to a physician with a skin rash, the rash presents the physician with a physical sign that there may be an underlying problem. It is the physician's job to consider all the possible causes and to do a thorough assessment. In some cases, the rash may simply be a sign of a mild viral infection. In other cases, it may signify a life-threatening disease. Similarly, in child abuse, the physical injury is the outward sign of an underlying problem and calls for a thorough assessment of the child's family and environment. It is the result of this assessment that will show how the problem can best be managed and the child protected.

Historical Background

Society sometimes pays only lip service to the concept that children are our most precious resource and that they need to be loved, nurtured, and protected. In historical terms, this is a relatively new concept for society as a whole, in contrast to individual families. The psychohistorian Lloyd De Mause (1974) starts his book on the history of childhood with these sentences:

The history of childhood is a nightmare from which we have only recently begun to awaken. The further back in history one goes, the lower the level of child care and the more likely children are to be killed, abandoned, beaten, terrorized and abused, (p. 1).

It is not surprising then that child abuse has been an integral part of children's fairy tales, such as Hansel and Gretel, and of nursery rhymes, such as this well-known example:

There was an old women who lived in a shoe. She had so many children she did not know what to do. She gave them some broth without any bread, and whipped them all soundly and put them to bed.

Even the much-loved puppet show Punch and Judy tells how Judy gives Mr. Punch her baby to mind. At first Mr. Punch rocks the baby on his knee. The baby begins to cry. Mr. Punch responds by rocking the baby harder and, eventually, violently. The crying persists. Mr. Punch then loses control, hits the baby, and throws it out of the window to its death.

Various forms of child abuse have been documented and sometimes condoned in the past. Many cultures used infanticide as an acceptable method of family planning and to dispose of weak, premature, or deformed infants (Bakan, 1971). Sometimes, children were killed for superstitious reasons as it was believed that slain infants would benefit the sterile woman, kill disease, and confer health, vigor, and youthfulness. To ensure durability of important buildings, children were sometimes buried under the foundations (Radbill, 1974). In England, during the industrial revolution in the mideighteenth century, children from poor families provided industry with a cheap work force. Children as young as 5 years of age worked in factories for up to 14 hours each day and often suffered additional cruel treatment during this time. A movement for child labor reform, by Robert Owen and Sir Robert Peel, led to passing the Factory Act by the English Parliament in 1802. However, this Act protected only poor children who had been separated from their parents from being forced to work in appalling conditions in the factories, and did not apply to children still living with their parents. These parents were still legally entitled to send their children to work in factories and to collect their children's wages.

Infanticide was common in England as late as the nineteenth century. In London, 80 percent of illegitimate children who were sent out to wet nurses died, often because they would be killed by the wet nurses, who would continue to collect the nursing fees (Fraser, 1976). Newborn children could be insured for about one English pound under a “burial club” insurance policy. If the child died, the parents could claim between three and five pounds in insurance, which meant that some parents killed their infants or had someone else kill them in order to claim the insurance (Fraser, 1976).

It was not until the late nineteenth century that moves to protect children from abuse began to have some influence. The story of 10-year-old Mary Ellen Wilson in 1874 was a landmark case. Mary Ellen, who had been abandoned by her mother, was beaten and mistreated by her foster parents. Mrs. Wheeler, a church caseworker in the neighborhood, became aware of Mary Ellen's plight. However, the efforts to try to protect Mary Ellen were fruitless. Although there were laws to protect children, there apparently were no means of legal intervention for children living at home. In desperation, Mrs. Wheeler appealed to Henry Bergh, the founder of the American Society for the Prevention of Cruelty to Animals, who was famous for his dramatic rescue of mistreated horses in the streets of New York. Mrs. Wheeler approached Bergh with the contention that Mary Ellen was a member of the animal kingdom. Bergh took the case, which was heard in the New York Supreme Court and resulted in Mary Ellen being removed from her foster parents. She eventually lived with Mrs. Wheeler's family, seemed to recover from her traumatic childhood, was successful as a mother, and lived for 92 years.

As a result of the Mary Ellen case, Henry Bergh, along with Elbridge Gerry, the lawyer in the case, founded the New York Society for the Prevention of Cruelty to Children, the first organization of its kind in the United States (Stevens & Eide, 1990; Lazoritz, 1990). In 1881, an English banker, T. F. Agnew, visited the New York society and was so impressed that, on his return to Liverpool, he established England's first Society for the Prevention of Cruelty to Children in 1883 (Allen & Morton, 1961).

A French physician was the first to describe the medical features of child abuse. Ambrose Tardieu's study of 32 children who had died as a result of abuse (Tardieu, 1860) clearly described not only the medical findings, but also the demographic, social, and psychiatric features of this condition. However, most members of the medical profession had little awareness of the size of the problem.

For example, the American radiologist John Caffey (1946), reported what appeared to be a new syndrome in 1946. He described six children with subdural hematomas who also had multiple long-bone fractures. Some of these children had other injuries, as well, such as bruising and retinal hemorrhages. Some were reported as being undernourished and developmentally delayed. Caffey could not find any evidence of underlying skeletal disease and concluded that the fractures were most likely of traumatic origin. Although he was unable to obtain a history of trauma from the parents, he pointed out that negligence may have been a factor.

The features of child abuse were also slow to be recognized on the other side of the Atlantic. An English orthopedic surgeon (Astley, 1953) described six children with normal bone structure who had metaphyseal fractures. Some of these children were also noted to have bruising, retinal detachment, and bilateral black eyes. The parents were described as normal, sensible individuals who gave no history of trauma. Despite the associated soft tissue injuries, Astley did not appear to consider trauma as a cause but labeled the findings as a new condition, “metaphyseal fragility of bones.”

Radiologist F. N. Silverman (1953) provided a more perceptive answer. He described three children with unusual fractures involving the metaphyseal region and wrote that an adequate history of trauma for fractures of this nature could be obtained by careful questioning of the parents. An important contribution to understanding the cause of these injuries was made by Woolley and Evans in 1955. They reviewed earlier radiological studies and emphasized the traumatic nature of these findings, pointing out that the environments of these incidents were often hazardous and undesirable. However, even as late as 1955, society was not yet ready to accept that parents could intentionally injure their children. Woolley and Evans had to use a euphemism, stating that they believed the children had been subjected to “undesirable vectors of force” (Woolley & Evans, 1955).

Widespread recognition came in the 1960s, but not without difficulty. In 1960, Henry Kempe, professor of pediatrics at the University of Colorado, submitted a paper on child abuse to the American Academy of Pediatrics Scientific Meeting, only to have it rejected. The next year, Kempe was elected chairman of the program committee for the Academy and organized a seminar on child abuse at the Academy meeting (Steele, 1993). The following year, Kempe and colleagues (1962) published some of the data presented at this seminar in the landmark paper, “The Battered Child.” The authors concluded that physical abuse was a significant cause of death and injury among children and suggested that psychiatric factors were likely to be of importance in understanding the disorder. The intense interest in child abuse at a political and media level can be dated from the appearance of this paper. Within 10 years, every -state in the United States had enacted laws about child abuse notification.

Child physical abuse is now accepted as one of the more serious problems of childhood, although the denial of its extent and existence, which resulted in its being so slow to be recognized, still exists. Denial can be a problem for some members of the medical profession, ranging from a disbelief that parents actually can injure their children to not wanting to become involved because recognition may mean reporting and reporting may mean going to court. Some may be reluctant to do more than treat the injury because they erroneously believe that doctor-patient confidentiality may be compromised. At times, there is a tendency to identify with the parents, particularly when the abuser is of a similar professional standing and ethnic background or may not fit the professional stereotype of what a "child abuser" is like. The fact is that child physical abuse is common and should be considered when unexplained or unlikely injuries occur.

Incidence

Although we do not know the incidence of physical abuse, we do know that most abuse occurs within the privacy of the child's home and that as most abusers give a false explanation of injuries that come to medical attention, the reported incidence of physical abuse is underestimated. We also know that not all reports of abuse are genuine. Some may be malicious, while others may be reports of actual abuse that cannot to be substantiated. Thus, there is the situation of simultaneous underreporting of real cases and some degree of overreporting. The reported incidence for all forms of child abuse in the United States was 2,989,000 cases in 1993, of which 1,016,000 cases were substantiated, giving a rate of...

Table of contents

• Cover
• Half Title
• Full Title
• Copyright
• Contents
• Foreword
• Preface
• 1. THE DEFINITION OF CHILD ABUSE AND NEGLECT
• 2. WHY DOES CHILD ABUSE OCCUR?
• 3. PHYSICAL ABUSE
• 4. SEXUAL ABUSE
• 5. EMOTIONAL ABUSE AND NEGLECT
• 6. WHAT HAPPENS TO ABUSED CHILDREN?
• 7. PREVENTION
• Resources
• References
• Name Index
• Subject Index