Primary Prevention of Child Abuse: Focus on the Special Child WILLIAM N. FRIEDRICH, JERRY A. BORISKIN, B.A. University of North Dakota Grand Forks, North Dakota
M.P.H.
The authors review the literature on child abuse and present evidence demonstrating that children who are born prematurely or who are sickly or handicapped are at high risk for child abuse. The authors describe ways to identify such children and suggest a number of primary prevention techniques that can reduce parental stress and help prevent child abuse. The techniques include day-care programs for handicapped children, mothers’ social clubs, and lay health visitors to give support and impart proper maternal attitudes. Cunnent theories of the etiology of child abuse and neglect have focused primarily upon the parent.’ Howeven, evidence indicates that psychopathology does not typically describe abusing parents, and that many abusens seem no different from any random cross section of parents.2” Recent data have shown that certain children are overrepresented in abused populations. In a netrospective study of 292 suspected abuse cases in England, it was reported that 14.5 per cent of the children, or twice the national average, were of low birth weight.4 Another study found ten of 36, or 27.8 per cent, of a sample of abused children in the District of Columbia were of low birth weight, which is twice the incidence The
authors
are
psychology Dakota 1
J J
at the
clinical
psychology
University
students
of North
in
Dakota,
the
department
Grand
Forks,
of
North
58202.
Spinetta
chological
and
Review,”
D.
Rigler,
Psychological
“The Child-Abusing Bulletin, Vol.
77,
Parent: A PsyApril 1972, pp.
296-304. R. E. HeIfer, Helping the Battered Child and Philadelphia, 1972. ‘B. F. Steele and C. B. Pollock, “A Psychiatric Study of Parents Who Abuse Infants and Small Children,” in The Battered Child, R. E. HeIfer and C. H. Kempe, editors, University of Chicago Press, Chicago, 1974, pp. 89-133. H. P. Martin et al., “The Development of Abused Children: A Review of the Literature and Physical, Neurologic, and Intellectual Findings,” Advances in Pediatrics, Vol. 21, I. Schulman, editor, Yearbook Medical Publishers, Chicago, 1974, pp. 25-73. 2
His
248
C. H. Kempe Family,
and Lippincott,
HOSPITAL
& COMMUNITY
of low birth weight in the surrounding D.C. area.’ Researchers have noted a high incidence of mental retardation among battered and neglected children, and report that between 43 and 53 per cent had an IQ of less than In a review of 97 cases of abuse, it was noted that nearly 70 per cent of the children exhibited either mental on physical anomalies prior to the reported abuse. Twenty per cent were considered unmanageable because of severe temper tantrums, 19 per cent had retarded speech development, and 17 per cent demonstrated either a learning disability or mental retardation.’ In a considerably larger nationwide sample, 22 pen cent were found to be suffering from some deviation.’ A study of 357 abused children noted that children who were blind, retarded, crippled, or otherwise handicapped seemed to incur the most severe abuse, accounting for significantly greater percentages of fractures, burns, and cuts.’#{176} It is conceivable that individual differences and behavional styles present in infants from birth can also contribute to abuse. Researchers have referred to children who seem to fit the rubric of “difficult” children. Initially it was thought that the irritable characteristics of the abused children they came in contact with were the result of their being battened. When nurses found it difficult to withstand some of the infants for an eighthour tour of duty, they began to have second thoughts. The nurses noted the irritable cry, the difficulty in managing, and the unappealing nature of some of these children. Two children who received battering in two different homes, presumably in part because of their
PSYCHIATRY
I A. K. Fomufod, S. Sinkford, and V. Louy, “ Mother-Child Separation at Birth: A Contributing Factor in Child Abuse,” Lancet, No. 7934, September 20, 1975, pp. 549-550. 3 E. Elmer, Children In Jeopardy: A Study of Abused Minors and Their Families, University of Pittsburgh Press, Pittsburgh, 1967. C. W. Morse, 0. J. Sahler, and S. B. Friedman, “A Three-Year
Follow-up
of Abused
and
Neglected
Children,”
American
Journal
of
Diseases of Children, Vol. 120, November 1970, pp. 439-446. ‘B. Johnson and H. A. Morse, “Injured Children and Their Parents,” Children, Vol. 15, July-August 1968, pp. 147-152. ‘D. G. Gil, Violence Against Children: Physical Abuse in the United States, Harvard University Press, Cambridge, Massachusetts, 1970. 10
Lancet,
W.
Friedrich No. 7960,
and
J. Boriskin,
March 20, 1976,
“Ill pp.
Health and Child 649-650.
Abuse,”
difficult nature, were also noted.” Parental Derception of the child as being different or special is undoubtedly a significant factor, since a number of studies have shown that in the majority of abusing families with more than one child, only one child is abused.” The etiology of abuse is decidedly multifaceted, with contributions from the child, the parent, and the envinonment in which they live. The fact that special children often comprise a greaten percentage of abused children than their over-all percentage of the population does not negate the roles parents, stress, and cultural tolerance for physical punishment play in the abuse of children. However, we cannot ignore a relatively consistent correlation-the special child is at risk for abuse. The abuse of special children can arise from a lack of maternal-child bonding as a result of an early and prolonged separation of mother and child, a lack of knowledge about how to care for a tiny, prematurely born baby, and the increased stress a special on handicapped child can introduce into a family. Indeed, abusing families have been shown to have high stress levels as measured by the Rahe-Holmes scale.’4 Any reduction in this stress would seem conducive to better family relations. AVENUES
FOR
PREVENTION
The realization that the child can contribute to abuse opens up a number of avenues for primary prevention, many of which could result from the expansion of existing programs. Because abuse is typically chronic and transmitted from one generation to the next, primary prevention would seem to be the answer. On that basis, the following suggestions are set forth. Assessing maternal attitudes. Mothers of premature infants have been found to have more negative attitudes toward pregnancy, more hostility toward the infant, and less emotional maturity than mothers of fullterm babies.” In addition, unmarried mothers and mothers with multiple births may feel overwhelmed by the birth event. Early detection of feelings of hostility and despair is necessary. A standardized attitudinal assessment for mothers of special children could be adopted, possibly one akin to that used by Leidenman with mothers of premature infants.” The instrument would measure maternal 11
I. D.
Milowe
and
R. S. Lourie,
Child Syndrome,”JournalofPedkztrics, 1079-1081. 12
“A.
Gil,
op.
“The
Child’s Vol.
General
Role
in the
December
Battered 1964,
pp.
cit.
J.Ebbin
et al.,
“Battered Child Syndrome
American Journal Vol. 118, October 1969, pp. 660-667. 14 B. Justice and D. Duncan, “Life Crisis County
65,
Hospital,”
at
the Los Angeles
of Diseases as a Precursor
perceptions of abnormality in the child and the degree of anxiety associated with the mental and physical wellbeing of the child. Such an instrument not only would serve as a screening device, but also would provide valuable information for health care personnel in establishing a supportive framework for the parents. A more informal method involves assessment of ten areas of maternal attitudes by a nurse or physician at the prenatal clinic. Some of the questions include whether or not the mother is overconcerned with the baby’s sex; whether she is receiving adequate moral support from her husband, close relatives, and friends; whether the child will be one too many; or whether the mother is denying hen pregnancy by refusing to gain weight on talk about the upcoming birth. The answers to any of the questions can indicate a potential prob-
lem.’7 Assessing maternal claiming behavior. Maternal claiming behavior is an active process mothers go through with each new baby whereby the infant is fitted into already existing relationships.1’ Immediately upon birth, the mother begins to interact with the infant in ways that ensure the claiming process. Several criteria can be used to assess the adequacy of maternal claiming behavior early in the child’s life. The motherinfant bond can be said to be successful when a mother can find pleasure in her infant and in tasks done for and with the child, can understand the child’s emotional states and comfort him appropriately, and can read the child’s cues for new stimuli and sense his fatigue points. Behavior to the contrary could be predictive of highrisk parent-child relations. Three sets of questions that could be asked by the attending physician at the birth of the child have been suggested. First, how does the mother look at the child? Is eye contact established? Second, what does the mother say? Is she hostile toward the child? Third, what does the mother do with the child? Does she cuddle the child or hold it rigidly? If the father is present at the delivery, what are his reactions?1’ Empirical evidence for the importance of claiming behavior at the moment of delivery has been demonstrated on a videotape available from the National Center for the Prevention and Treatment of Child Abuse and Neglect. Delivery interactions depicting the first encounter between mother and child were taped. Potential problems with mother-child interaction were easy to identify.2#{176} Mothers who are denied early interaction with their babies because of illness or low birth weight have been found to be less skillful in caring for the child and have
of Children, to Child
Abuse,” Public Health Reports, Vol. 91, March-April 1976, pp. 110115. “A. Blau et al., “The Psychogenic Etiology of Premature Births,” Psychosomatic Medicine, Vol. 25, May-June 1963, pp. 201-211. “P. H. Leiderman, “Mothers at Risk: A Potential Consequence of the Hospital Care of the Premature Infant,” in The Child in His Family: Children at Psychiatric Risk, E. J.Anthony and C. Koupernik, editors, Wiley, New York City, 1974, pp. 149-156.
17
C. H. Kempe,
lishing the
Children’s Health
Visitors
“
Predicting
Rights
and
Concept,”
Child
Preventing
by Assuring
Access
Armstrong
to Health
Lecture
at the
Abuse:
Care annual
EstabThrough meet-
ing of the Ambulatory Pediatric Association, June 9, 1975, Toronto. 18 M. G. Morris, Detection of High Risk Parents, unpublished paper, Children’s Hospital of Philadelphia, 1968. Kempe, June 9, 1975, op. cit. ‘#{176} National Center for the Prevention and Treatment of Child Abuse and Neglect, Mother-Infant Interaction, Denver, 1974.
VOLUME
29 NUMBER
4
APRIL
1978
249
It has been stated that there are four conditions necessary for child abuse: a special parent, a special child, a crisis, and cultural tolerance for physical punishment. demonstrated less attachment behavior, such as looking at and smiling at the infant, than mothers who were not separated from their infants.’1 PACER (Parent and Child Effective Relations), a federally funded child abuse project, is currently sponsoning a pilot project in one hospital in which parentchild interaction is observed on maternity wards. The plan is to follow up families identified as high risk and to direct them to services that play a preventive role.2’ Monitoring visits of mothers to premature infants in the nursery. A simple way to identify potential abusers of premature infants involves recording each time a mother visits hen infant or calls the nursery to inquire about the child. The records can be inspected regularly, and special attention can be given to those whose visits fall below the norm.”4 In one instance, on a follow-up ranging from six to 23 months, nine of the 38 mothers who visited their babies less than three times in a twoweek period were involved in abuse on failure-to-thrive cases.”
Establishing day-care programs for special children. Even very mature mothers can experience increasing tension and stress as a result of the presence of a retarded or physically handicapped child in the family. Often the mother feels hesitant to go out, feels guilty about the handicap, and feels inadequate to near the child.” Perhaps the support given to the parents in the earliest months after birth are most important in their long-term acceptance of the child, but it cannot be denied that a continuing measure of support is also crucial. One way that can be done is to arrange for the mother to leave the child at a specially staffed and
equipped day-cane center a number of times each month in order to give hen time off. The intervention strategies that can be used for infants in day-care centers have already been outlined.” The use of day cane for the primary prevention of neglect and for assistance in shoring up a deteriorating home situation has also been urged.”#{176} Organizing mothers’ groups at centers for handicapped children. In many large cities, national organizations for handicapped children, such as Cerebral Palsy and March of Dimes, maintain centers that mothers attend regularly during the first years after the birth of the child. Neurologic evaluations and physical therapy are pant of the day-to-day life of the children. Since families with handicapped children are often embarrassed to go out in public, they tend to become isolated, a common characteristic of abusive parents.” Administrators of the centers should make active efforts to form social clubs among the mothers. Instead of sitting idly at the center while their children undergo testing on therapy, groups of mothers can go shopping, visit the zoo, have Tupperware parties, or plan other activities. A social club would offer a sense of belonging and an opportunity to develop new interests and provide mutual support for members.” Using lay health visitors. Lay health visitors may be successful mothers who can share their experiences with young families” on elderly people in foster grandparent roles. The lay visitors could focus on mothers who have been identified as being at high risk for child abuse, and could provide support and impart proper maternal attitudes. Enlisting aid from physicians and parent educators. Physicians should not only be alert to early signs of abnormal mother-child interaction, but should also let parents of high-risk children know that the anxiety and frustration they experience is normal and should not arouse guilt. Similarly, parent educators should instruct parents to expect individual differences in their children and should not espouse any one way that supposedly works for all children. It has been suggested that all parents have an inherent potential for abuse that ranges from very low to rather high.’4 However, there are some children-the 27
D. S. Huntington,
Care
Centers
editor, 28 21
NI. H. Klaus
J.
and
H.
Kennell,
“Mothers
Separated
From
Their
Infants,” Pediatric Clinics of North America, Vol. 17, No1970, pp. 1015-1037. 22 C. J. Nofen, PACER Project, St. Petersburg, Florida, personal communication, January 1976. 23 C. Caplan, E. A. Mason, and D. M. Kaplan, “Four Studies of Crisis in Parents of Prematures,” Community Mental Health Journal, Vol. 1, Summer 1965, pp. 149-161. 24 A. Fanaroff, J. Kennell, and M. Klaus, “Follow-up of Low Birth Newborn vember
Weight Infants:The Predictive Value of Maternal Visiting Patterns,” Pediatrics, Vol. 49, February 1972, pp. 287-290. 2$
Ibid.
28
R. MacKeith,
capped Vol.
250
Children,” 15, August
“The
Feelings
Developmental 1973,
pp.
and
Behavior
Medicine
of Parents
and
Child
of Handi-
Neurology,
524-527.
HOSPITAL
& COMMUNITY
PSYCHIATRY
Stratton
E.
29
B. M.
Intervention
Institutions,”
“
American Caldwell,
An
Strategies for Infants in Day Infants at Risk, D. Bergsma, York City, 1974, pp. 109-117.
in
Intercontinental,
Pavenstedt,
Risk Homes,” pp. 393-395.
“
and
New
Intervention
Journal “The
Program
of Public Effect
of
for
Health, Psychosocial
Human Development in Infancy,” Merrill-Palmer Jtilv 1970, pp. 260-270. N. A. Polansky, C. Hally, and N. F. Polansky, A Survey of the State of Knowledge of Child Rehabilitation Service, Washington, D.C., 1975. 31 Steele and Pollock, op. cit.
Infants Vol.
High
From 63,
May
1973,
Deprivation
Quarterly, Profile Neglect,
on
Vol.
16,
of Neglect: Social
and
‘ L. J.Webb, “The Therapeutic Social Club,” American Journal of Occupational Therapy. Vol. 27, March 1973, pp. 81-83. “Kempe, June 9, 1975, op. cit. ‘ H. P. Martin and P. Beezley, “Prevention and the Consequences of Child Abuse,” Journal of Operational Psychiatry, Vol. 6, FallWinter 1974, pp. 68-77.
number is impossible to estimate-who because of some special condition will trigger their parents’ or caretakers’ abuse potential in a way that normal children do not. We are not suggesting that children with defects and disabilities necessarily provoke abuse. It has been stated that there are four conditions necessary for abuse: a special parent, a special child, a crisis, and cultural tolerance for physical punishment.” Ideally, none of these factors should be ignored when considering inter-
vention techniques in cases of child abuse and neglect. The approaches listed here have all been shown. to have a certain degree of success, although very few have focused on the detection of early warning signs or the prevention of child abuse. Many of them will fit very well into existing and established programs.I “F.
C.
the Private May 1975,
“Child Physician,” pp. 329-339.
Green,
Abuse Pediatric
and Neglect: Clinics of
A Priority
North
Problem
America,
for
Vol. 22,
Assess ing Co m m u n ity Attitu des Toward Mental Illness WILLIAM T. BOWEN, Research Social Worker Veterans Administration Topeka, Kansas STUART
W.
Topeka,
M.S.W. Hospital
TWEMLOW,
M.D.
BOQUET,
M.S.W.
Kansas
RUDOLPH
E.
Staff of a Veterans Administration hospital combined recruitment offamily-care sponsors with an assessment of community attitudes toward mental illness. They mailed questionnaires to 989 persons in a small community 35 miles from the hospital. Most of the 235 respondents believed that mental illness is caused by a lack either of physical health or of proper nurturing, rather than seeing it as punishment for sins. Respondents were generally optimistic about the chances of recovery. Respondents with no children at home were more receptive to the idea of accepting a family-care patient, while those with children at home were highly ambivalent. From the responses, the staff were able to locate several family-care sponsors. UPlacement of mental patients in family-care homes is limited by a lack of community sponsors. Morrissey says that community attitudes about family-care homes are largely unknown. But he believes the insufficient number of sponsors may be a reflection of the resistance of Mr. Bowen’s Topeka, the
VA
practice. hospital.
Kansas Hospital
Mr.
address 66622. when
Boquet,
at
the VA Hospital Dr. Twemlow was
the
now
study
was
deceased,
is 2200 Gage chief of research
conducted;
was
chief
he
is now
social
Boulevard, service
at
in private
worker
at the
both the community and the hospital staff to expansion of family-care programs.’ In addition, many psychiatric hospitals that have good candidates for family care are hampered in their placements because they do not effectively recruit sponsors in the community. We attempted to combine the assessment of community attitudes with the recruitment of family-care sponsons. A questionnaire was developed and sent to each of the 989 persons with a listing in the telephone directory of a city of 2608, located about 35 miles from the hospital. Through the questions, many of which had been drawn from an earlier study,’ we tried to determine the residents’ attitudes toward the mentally ill, including their views of the cause of mental illness and the chances of recovery from it. We also asked about their attitudes toward family care and accepting a patient into their own home. That particular city was selected because it met the criteria we had laid out for the family-care project. It was within an hour’s drive of the hospital so that followup could be provided, yet it was far enough away to discourage continued dependency on the hospital for services such as canteen supplies and recreation. We believed the ideal community should have a population of between 2000 and 4000 and should contain a broad array of facilities, including a bowling alley, public library, drug store, grocery, restaurants, and churches, each of which could be reached by foot from any part of the city. We also wanted a community that was not in the process of rapid growth, since such communities are ‘J. R. Therapeutic pp. 63-71. 2
Morrissey, Resource,”
“Family
Social
Care
for
Service
the
Review,
Mentally
Ill:
Neglected 1965,
Vol. 39, March
W. T. Bowen and C. J. Fischer, “Community Attitudes Toward Care,” Mental Hygiene, Vol. 46, July 1962, pp. 400-407.
Family
VOLUME
29 NUMBER
4 APRIL
1978
251
M.P.H.
The authors review the literature on child abuse and present evidence demonstrating that children who are born prematurely or who are sickly or handicapped are at high risk for child abuse. The authors describe ways to identify such children and suggest a number of primary prevention techniques that can reduce parental stress and help prevent child abuse. The techniques include day-care programs for handicapped children, mothers’ social clubs, and lay health visitors to give support and impart proper maternal attitudes. Cunnent theories of the etiology of child abuse and neglect have focused primarily upon the parent.’ Howeven, evidence indicates that psychopathology does not typically describe abusing parents, and that many abusens seem no different from any random cross section of parents.2” Recent data have shown that certain children are overrepresented in abused populations. In a netrospective study of 292 suspected abuse cases in England, it was reported that 14.5 per cent of the children, or twice the national average, were of low birth weight.4 Another study found ten of 36, or 27.8 per cent, of a sample of abused children in the District of Columbia were of low birth weight, which is twice the incidence The
authors
are
psychology Dakota 1
J J
at the
clinical
psychology
University
students
of North
in
Dakota,
the
department
Grand
Forks,
of
North
58202.
Spinetta
chological
and
Review,”
D.
Rigler,
Psychological
“The Child-Abusing Bulletin, Vol.
77,
Parent: A PsyApril 1972, pp.
296-304. R. E. HeIfer, Helping the Battered Child and Philadelphia, 1972. ‘B. F. Steele and C. B. Pollock, “A Psychiatric Study of Parents Who Abuse Infants and Small Children,” in The Battered Child, R. E. HeIfer and C. H. Kempe, editors, University of Chicago Press, Chicago, 1974, pp. 89-133. H. P. Martin et al., “The Development of Abused Children: A Review of the Literature and Physical, Neurologic, and Intellectual Findings,” Advances in Pediatrics, Vol. 21, I. Schulman, editor, Yearbook Medical Publishers, Chicago, 1974, pp. 25-73. 2
His
248
C. H. Kempe Family,
and Lippincott,
HOSPITAL
& COMMUNITY
of low birth weight in the surrounding D.C. area.’ Researchers have noted a high incidence of mental retardation among battered and neglected children, and report that between 43 and 53 per cent had an IQ of less than In a review of 97 cases of abuse, it was noted that nearly 70 per cent of the children exhibited either mental on physical anomalies prior to the reported abuse. Twenty per cent were considered unmanageable because of severe temper tantrums, 19 per cent had retarded speech development, and 17 per cent demonstrated either a learning disability or mental retardation.’ In a considerably larger nationwide sample, 22 pen cent were found to be suffering from some deviation.’ A study of 357 abused children noted that children who were blind, retarded, crippled, or otherwise handicapped seemed to incur the most severe abuse, accounting for significantly greater percentages of fractures, burns, and cuts.’#{176} It is conceivable that individual differences and behavional styles present in infants from birth can also contribute to abuse. Researchers have referred to children who seem to fit the rubric of “difficult” children. Initially it was thought that the irritable characteristics of the abused children they came in contact with were the result of their being battened. When nurses found it difficult to withstand some of the infants for an eighthour tour of duty, they began to have second thoughts. The nurses noted the irritable cry, the difficulty in managing, and the unappealing nature of some of these children. Two children who received battering in two different homes, presumably in part because of their
PSYCHIATRY
I A. K. Fomufod, S. Sinkford, and V. Louy, “ Mother-Child Separation at Birth: A Contributing Factor in Child Abuse,” Lancet, No. 7934, September 20, 1975, pp. 549-550. 3 E. Elmer, Children In Jeopardy: A Study of Abused Minors and Their Families, University of Pittsburgh Press, Pittsburgh, 1967. C. W. Morse, 0. J. Sahler, and S. B. Friedman, “A Three-Year
Follow-up
of Abused
and
Neglected
Children,”
American
Journal
of
Diseases of Children, Vol. 120, November 1970, pp. 439-446. ‘B. Johnson and H. A. Morse, “Injured Children and Their Parents,” Children, Vol. 15, July-August 1968, pp. 147-152. ‘D. G. Gil, Violence Against Children: Physical Abuse in the United States, Harvard University Press, Cambridge, Massachusetts, 1970. 10
Lancet,
W.
Friedrich No. 7960,
and
J. Boriskin,
March 20, 1976,
“Ill pp.
Health and Child 649-650.
Abuse,”
difficult nature, were also noted.” Parental Derception of the child as being different or special is undoubtedly a significant factor, since a number of studies have shown that in the majority of abusing families with more than one child, only one child is abused.” The etiology of abuse is decidedly multifaceted, with contributions from the child, the parent, and the envinonment in which they live. The fact that special children often comprise a greaten percentage of abused children than their over-all percentage of the population does not negate the roles parents, stress, and cultural tolerance for physical punishment play in the abuse of children. However, we cannot ignore a relatively consistent correlation-the special child is at risk for abuse. The abuse of special children can arise from a lack of maternal-child bonding as a result of an early and prolonged separation of mother and child, a lack of knowledge about how to care for a tiny, prematurely born baby, and the increased stress a special on handicapped child can introduce into a family. Indeed, abusing families have been shown to have high stress levels as measured by the Rahe-Holmes scale.’4 Any reduction in this stress would seem conducive to better family relations. AVENUES
FOR
PREVENTION
The realization that the child can contribute to abuse opens up a number of avenues for primary prevention, many of which could result from the expansion of existing programs. Because abuse is typically chronic and transmitted from one generation to the next, primary prevention would seem to be the answer. On that basis, the following suggestions are set forth. Assessing maternal attitudes. Mothers of premature infants have been found to have more negative attitudes toward pregnancy, more hostility toward the infant, and less emotional maturity than mothers of fullterm babies.” In addition, unmarried mothers and mothers with multiple births may feel overwhelmed by the birth event. Early detection of feelings of hostility and despair is necessary. A standardized attitudinal assessment for mothers of special children could be adopted, possibly one akin to that used by Leidenman with mothers of premature infants.” The instrument would measure maternal 11
I. D.
Milowe
and
R. S. Lourie,
Child Syndrome,”JournalofPedkztrics, 1079-1081. 12
“A.
Gil,
op.
“The
Child’s Vol.
General
Role
in the
December
Battered 1964,
pp.
cit.
J.Ebbin
et al.,
“Battered Child Syndrome
American Journal Vol. 118, October 1969, pp. 660-667. 14 B. Justice and D. Duncan, “Life Crisis County
65,
Hospital,”
at
the Los Angeles
of Diseases as a Precursor
perceptions of abnormality in the child and the degree of anxiety associated with the mental and physical wellbeing of the child. Such an instrument not only would serve as a screening device, but also would provide valuable information for health care personnel in establishing a supportive framework for the parents. A more informal method involves assessment of ten areas of maternal attitudes by a nurse or physician at the prenatal clinic. Some of the questions include whether or not the mother is overconcerned with the baby’s sex; whether she is receiving adequate moral support from her husband, close relatives, and friends; whether the child will be one too many; or whether the mother is denying hen pregnancy by refusing to gain weight on talk about the upcoming birth. The answers to any of the questions can indicate a potential prob-
lem.’7 Assessing maternal claiming behavior. Maternal claiming behavior is an active process mothers go through with each new baby whereby the infant is fitted into already existing relationships.1’ Immediately upon birth, the mother begins to interact with the infant in ways that ensure the claiming process. Several criteria can be used to assess the adequacy of maternal claiming behavior early in the child’s life. The motherinfant bond can be said to be successful when a mother can find pleasure in her infant and in tasks done for and with the child, can understand the child’s emotional states and comfort him appropriately, and can read the child’s cues for new stimuli and sense his fatigue points. Behavior to the contrary could be predictive of highrisk parent-child relations. Three sets of questions that could be asked by the attending physician at the birth of the child have been suggested. First, how does the mother look at the child? Is eye contact established? Second, what does the mother say? Is she hostile toward the child? Third, what does the mother do with the child? Does she cuddle the child or hold it rigidly? If the father is present at the delivery, what are his reactions?1’ Empirical evidence for the importance of claiming behavior at the moment of delivery has been demonstrated on a videotape available from the National Center for the Prevention and Treatment of Child Abuse and Neglect. Delivery interactions depicting the first encounter between mother and child were taped. Potential problems with mother-child interaction were easy to identify.2#{176} Mothers who are denied early interaction with their babies because of illness or low birth weight have been found to be less skillful in caring for the child and have
of Children, to Child
Abuse,” Public Health Reports, Vol. 91, March-April 1976, pp. 110115. “A. Blau et al., “The Psychogenic Etiology of Premature Births,” Psychosomatic Medicine, Vol. 25, May-June 1963, pp. 201-211. “P. H. Leiderman, “Mothers at Risk: A Potential Consequence of the Hospital Care of the Premature Infant,” in The Child in His Family: Children at Psychiatric Risk, E. J.Anthony and C. Koupernik, editors, Wiley, New York City, 1974, pp. 149-156.
17
C. H. Kempe,
lishing the
Children’s Health
Visitors
“
Predicting
Rights
and
Concept,”
Child
Preventing
by Assuring
Access
Armstrong
to Health
Lecture
at the
Abuse:
Care annual
EstabThrough meet-
ing of the Ambulatory Pediatric Association, June 9, 1975, Toronto. 18 M. G. Morris, Detection of High Risk Parents, unpublished paper, Children’s Hospital of Philadelphia, 1968. Kempe, June 9, 1975, op. cit. ‘#{176} National Center for the Prevention and Treatment of Child Abuse and Neglect, Mother-Infant Interaction, Denver, 1974.
VOLUME
29 NUMBER
4
APRIL
1978
249
It has been stated that there are four conditions necessary for child abuse: a special parent, a special child, a crisis, and cultural tolerance for physical punishment. demonstrated less attachment behavior, such as looking at and smiling at the infant, than mothers who were not separated from their infants.’1 PACER (Parent and Child Effective Relations), a federally funded child abuse project, is currently sponsoning a pilot project in one hospital in which parentchild interaction is observed on maternity wards. The plan is to follow up families identified as high risk and to direct them to services that play a preventive role.2’ Monitoring visits of mothers to premature infants in the nursery. A simple way to identify potential abusers of premature infants involves recording each time a mother visits hen infant or calls the nursery to inquire about the child. The records can be inspected regularly, and special attention can be given to those whose visits fall below the norm.”4 In one instance, on a follow-up ranging from six to 23 months, nine of the 38 mothers who visited their babies less than three times in a twoweek period were involved in abuse on failure-to-thrive cases.”
Establishing day-care programs for special children. Even very mature mothers can experience increasing tension and stress as a result of the presence of a retarded or physically handicapped child in the family. Often the mother feels hesitant to go out, feels guilty about the handicap, and feels inadequate to near the child.” Perhaps the support given to the parents in the earliest months after birth are most important in their long-term acceptance of the child, but it cannot be denied that a continuing measure of support is also crucial. One way that can be done is to arrange for the mother to leave the child at a specially staffed and
equipped day-cane center a number of times each month in order to give hen time off. The intervention strategies that can be used for infants in day-care centers have already been outlined.” The use of day cane for the primary prevention of neglect and for assistance in shoring up a deteriorating home situation has also been urged.”#{176} Organizing mothers’ groups at centers for handicapped children. In many large cities, national organizations for handicapped children, such as Cerebral Palsy and March of Dimes, maintain centers that mothers attend regularly during the first years after the birth of the child. Neurologic evaluations and physical therapy are pant of the day-to-day life of the children. Since families with handicapped children are often embarrassed to go out in public, they tend to become isolated, a common characteristic of abusive parents.” Administrators of the centers should make active efforts to form social clubs among the mothers. Instead of sitting idly at the center while their children undergo testing on therapy, groups of mothers can go shopping, visit the zoo, have Tupperware parties, or plan other activities. A social club would offer a sense of belonging and an opportunity to develop new interests and provide mutual support for members.” Using lay health visitors. Lay health visitors may be successful mothers who can share their experiences with young families” on elderly people in foster grandparent roles. The lay visitors could focus on mothers who have been identified as being at high risk for child abuse, and could provide support and impart proper maternal attitudes. Enlisting aid from physicians and parent educators. Physicians should not only be alert to early signs of abnormal mother-child interaction, but should also let parents of high-risk children know that the anxiety and frustration they experience is normal and should not arouse guilt. Similarly, parent educators should instruct parents to expect individual differences in their children and should not espouse any one way that supposedly works for all children. It has been suggested that all parents have an inherent potential for abuse that ranges from very low to rather high.’4 However, there are some children-the 27
D. S. Huntington,
Care
Centers
editor, 28 21
NI. H. Klaus
J.
and
H.
Kennell,
“Mothers
Separated
From
Their
Infants,” Pediatric Clinics of North America, Vol. 17, No1970, pp. 1015-1037. 22 C. J. Nofen, PACER Project, St. Petersburg, Florida, personal communication, January 1976. 23 C. Caplan, E. A. Mason, and D. M. Kaplan, “Four Studies of Crisis in Parents of Prematures,” Community Mental Health Journal, Vol. 1, Summer 1965, pp. 149-161. 24 A. Fanaroff, J. Kennell, and M. Klaus, “Follow-up of Low Birth Newborn vember
Weight Infants:The Predictive Value of Maternal Visiting Patterns,” Pediatrics, Vol. 49, February 1972, pp. 287-290. 2$
Ibid.
28
R. MacKeith,
capped Vol.
250
Children,” 15, August
“The
Feelings
Developmental 1973,
pp.
and
Behavior
Medicine
of Parents
and
Child
of Handi-
Neurology,
524-527.
HOSPITAL
& COMMUNITY
PSYCHIATRY
Stratton
E.
29
B. M.
Intervention
Institutions,”
“
American Caldwell,
An
Strategies for Infants in Day Infants at Risk, D. Bergsma, York City, 1974, pp. 109-117.
in
Intercontinental,
Pavenstedt,
Risk Homes,” pp. 393-395.
“
and
New
Intervention
Journal “The
Program
of Public Effect
of
for
Health, Psychosocial
Human Development in Infancy,” Merrill-Palmer Jtilv 1970, pp. 260-270. N. A. Polansky, C. Hally, and N. F. Polansky, A Survey of the State of Knowledge of Child Rehabilitation Service, Washington, D.C., 1975. 31 Steele and Pollock, op. cit.
Infants Vol.
High
From 63,
May
1973,
Deprivation
Quarterly, Profile Neglect,
on
Vol.
16,
of Neglect: Social
and
‘ L. J.Webb, “The Therapeutic Social Club,” American Journal of Occupational Therapy. Vol. 27, March 1973, pp. 81-83. “Kempe, June 9, 1975, op. cit. ‘ H. P. Martin and P. Beezley, “Prevention and the Consequences of Child Abuse,” Journal of Operational Psychiatry, Vol. 6, FallWinter 1974, pp. 68-77.
number is impossible to estimate-who because of some special condition will trigger their parents’ or caretakers’ abuse potential in a way that normal children do not. We are not suggesting that children with defects and disabilities necessarily provoke abuse. It has been stated that there are four conditions necessary for abuse: a special parent, a special child, a crisis, and cultural tolerance for physical punishment.” Ideally, none of these factors should be ignored when considering inter-
vention techniques in cases of child abuse and neglect. The approaches listed here have all been shown. to have a certain degree of success, although very few have focused on the detection of early warning signs or the prevention of child abuse. Many of them will fit very well into existing and established programs.I “F.
C.
the Private May 1975,
“Child Physician,” pp. 329-339.
Green,
Abuse Pediatric
and Neglect: Clinics of
A Priority
North
Problem
America,
for
Vol. 22,
Assess ing Co m m u n ity Attitu des Toward Mental Illness WILLIAM T. BOWEN, Research Social Worker Veterans Administration Topeka, Kansas STUART
W.
Topeka,
M.S.W. Hospital
TWEMLOW,
M.D.
BOQUET,
M.S.W.
Kansas
RUDOLPH
E.
Staff of a Veterans Administration hospital combined recruitment offamily-care sponsors with an assessment of community attitudes toward mental illness. They mailed questionnaires to 989 persons in a small community 35 miles from the hospital. Most of the 235 respondents believed that mental illness is caused by a lack either of physical health or of proper nurturing, rather than seeing it as punishment for sins. Respondents were generally optimistic about the chances of recovery. Respondents with no children at home were more receptive to the idea of accepting a family-care patient, while those with children at home were highly ambivalent. From the responses, the staff were able to locate several family-care sponsors. UPlacement of mental patients in family-care homes is limited by a lack of community sponsors. Morrissey says that community attitudes about family-care homes are largely unknown. But he believes the insufficient number of sponsors may be a reflection of the resistance of Mr. Bowen’s Topeka, the
VA
practice. hospital.
Kansas Hospital
Mr.
address 66622. when
Boquet,
at
the VA Hospital Dr. Twemlow was
the
now
study
was
deceased,
is 2200 Gage chief of research
conducted;
was
chief
he
is now
social
Boulevard, service
at
in private
worker
at the
both the community and the hospital staff to expansion of family-care programs.’ In addition, many psychiatric hospitals that have good candidates for family care are hampered in their placements because they do not effectively recruit sponsors in the community. We attempted to combine the assessment of community attitudes with the recruitment of family-care sponsons. A questionnaire was developed and sent to each of the 989 persons with a listing in the telephone directory of a city of 2608, located about 35 miles from the hospital. Through the questions, many of which had been drawn from an earlier study,’ we tried to determine the residents’ attitudes toward the mentally ill, including their views of the cause of mental illness and the chances of recovery from it. We also asked about their attitudes toward family care and accepting a patient into their own home. That particular city was selected because it met the criteria we had laid out for the family-care project. It was within an hour’s drive of the hospital so that followup could be provided, yet it was far enough away to discourage continued dependency on the hospital for services such as canteen supplies and recreation. We believed the ideal community should have a population of between 2000 and 4000 and should contain a broad array of facilities, including a bowling alley, public library, drug store, grocery, restaurants, and churches, each of which could be reached by foot from any part of the city. We also wanted a community that was not in the process of rapid growth, since such communities are ‘J. R. Therapeutic pp. 63-71. 2
Morrissey, Resource,”
“Family
Social
Care
for
Service
the
Review,
Mentally
Ill:
Neglected 1965,
Vol. 39, March
W. T. Bowen and C. J. Fischer, “Community Attitudes Toward Care,” Mental Hygiene, Vol. 46, July 1962, pp. 400-407.
Family
VOLUME
29 NUMBER
4 APRIL
1978
251
