PSYCHIATRIC TREATMENT FOR THE ABUSING PARENT AND THE ABUSED CHILD Some Problems and Possible Solutions*
SIMON KREINDLER,
Physically abusive behaviour towards children appears to represent only one extreme of a continuum of aggressive behaviour, for which we all have a certain potential. Therefore, it is not surprising that abusing parents may manifest virtually any type of psychopathology. Notwithstanding this fact, they do show certain psychological characteristics in common. Morris and Gould (8) have described the phenomenon of role reversal seen in these parents where they tum to the child for nurturance and protection. Steele and Pollock (14) have noted how there are two basic elements involved in this kind of behaviour, , ,... a high expectation and demand by the parents for the infant's performance and a corresponding parental disregard of the infant's own needs, limited abilities and helplessness." They also note that" ... the difference between the non-abusing and the abusing parent is that the latter implements such standards with exaggerated intensity, and most importantly, at an inappropriate early age." These authors (14) have pointed out that abusing parents have a history of having been raised in much the same way which they then recreate in the rearing of their own children. * A modified version of a contribution to a Position Paper on
"Service Delivery in Child Abuse" presented at an InterProfessional Seminar on Child Abuse. sponsored by the Ontario Ministry of Community and Social Services, Toronto, February 1976. Manuscript received April 1976. 'Department of Psychiatry, University of Toronto and Hospital for Sick Children, Toronto, Ontario. Can. Psychiatr. Assoc. J. Vol. 21 (1976)
M.D.!
Apart from other diagnostic considerations abusing parents demonstrate pathological deviations in personality development which are manifested in: • failure of the adult to develop a capacity for motherliness - an essential parental attribute which includes" ... the more subtle ingredients of tenderness, of awareness and consideration of the needs and desires of the infant, and of appropriate emotional interaction with it"; • failure to develop what Benedek has called a "sense of confidence" or what Erikson has called ."basic trust" - an essential prerequisite for the development of satisfying relationships with others; • failure to develop what Erikson describes as a sense of personal identity - a sense of him or herself as a "unique, separate individual with a continuity of personal character and ability to maintain solidarity with social groups" (14). Instead, these parents develop an identity based on a loose collection of unintegrated, disparate concepts of the self. They can " ... feel like a confident parent and quickly change to being nothing but a helpless, ineffectual, inadequate child. They can be a kindly adult and shift suddenly to being a punitive adult. They know they are men and women but are not really sure of it. They have one firm concept of what they should be and another of what they actually are. Any sense of being reasonably good can be easily displaced by a conviction of badness. They
275
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are usually quite uncertain about allying with whom no amount of help seems to prevent a group even if they join it."( 14) recurrent abuse (9) it would appear that there These deviations in personality develop- is a far larger percentage of families who are ment culminate in adults who neither believe amenable to help but who are not receiving that others can help them nor that they are it. Just as is the case of the abusing parent, worth helping. Consequently, abusing parents usually expect relationships with other the abused child may manifest any type of adults to be disappointing, if not frankly psychopathology, depending on his age, rejecting. While these parents may speak of constitutional and genetic factors, his unique having many friends, they usually turn out to life experiences, and the nature and severity of the abuse to which he has been subjected. be friends in name only. The psychotherapeutic treatment of abus- Some of the more common forms of ing parents presents a number of challenges, presenting psychopathology, especially some of which are technical, others logisti- among young children, include developmencal. In the first place, abusing parents are not tal delays which may have an organic basis but quite frequently are functional; behaviour 'good patients' in the classical sense many refuse to be involved in treatment or . disorders of an aggressive, pseudoshow only a superficial motivation to get hyperkinetic type, often associated with help. Others are unreliable in keeping learning difficulties; and frightened, anxiappointments or they abruptly discontinue ous, chronically depressed children. Although it is now fairly well accepted treatment. Changes occur slowly in these that abuse occurs within all socioeconomic patients especially the core problems of their classes of society the majority of cases are severely damaged self-esteem and their punitive superego. For the therapist, a major among the lower socioeconomic groups. obstacle is the feeling of anger these parents These children have often faced such addiprovoke, and which he must learn to handle tional stresses as being raised by a single parent; the presence of one or more effectively if treatment is to proceed. common-law partner for their single parent; Although some investigators have expres- foster placement(s); parental abandonment; sed extreme pessimism about the prospects frequent geographic moves, and so on. for rehabilitating abusing parents (11), others Martin (7) has suggested that the delay in have indicated more favourable results (12). language development seen in so many of What types of treatment have these parents these children may well be multifactorial in been receiving? Unfortunately only a very etiology but it is probably related to the small percentage receive individual child's recognition that it is potentially psychotherapy, primarily because few dangerous to express himself verbally in an therapists are interested in working with abusive environment. these people. A further small percentage As Martin (7) has pointed out, if the receive help from groups such as Parents abused child is recognized early enough, Anonymous or community agencies provid- functional retardation can be reversed by ing marital counselling, family therapy, and providing him with a loving environment, so on. A significant percentage receive help where he receives previously missing stimuof variable duration and quality from the lation, but the longer he goes unrecognized Children's Aid Society (C.A.S.) or its the harder it is to alleviate this problem. equivalent, but there is reason to suspect that Even where the child has been recognized a significant number of these parents receive early, it is important to remember that it either no help or grossly inadequate help, sometimes takes several months before either because they are never recognized or, improvement is seen. For instance, it has once diagnosed, cannot be provided with the been noted that over a three-month to necessary helping services. six-month period a previously abused child, Although it is known that there are certain with what appears to be a normal intellectual seriously disturbed abusing families for potential, will start to demonstrate increas-
August, 1976
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ing attention span; increasing interest in problem solving; a more positive response to praise; more creative play; and a greater interest in the people and things around him. Once these new behaviours start to appear the child seems capable of an accelerated development, although a further three-month to six-month period may be needed to demonstrate changes on the basis of psychological test scores. The author has noted a similar improvement in those neglected and abused children who presented as behaviour disorders or as withdrawn and depressed. This is particularly so if the home situation can be made more stable, or where a consistent,loving, foster placement can be arranged. Stephenson (13) has recently reported encouraging results with a group of very young (one-and-a-half years to two-and-ahalf years old), high-risk children who were seen over a two-year period for a daily four-hour enrichment program, and whose parents were simultaneously seen at least weekly by the child's nursery teacher. It would appear that the abused child does not develop a normal sense of basic trust because the environment in which he lives is so unpredictable. Prolonged exposure to this type of environment paves the way for the damaged self-esteem these children later develop as adults. The lack of a sense of basic trust seriously impairs the child's ability to develop adequate peer relationships and, later on, precludes the development of truly intimate relationships with other adults. Regardless of whether -the abused child remains in his home or is placed in a foster home, the provision of psychological treatment needs to be considered both for the child and for his parents or caretakers. Parents need help in understanding the child's behaviour and feelings and in knowing how to react to him. If the child is in foster placement it is important to recognize that this, by itself, is not sufficient for many abused children. Foster parents also need to be helped to understand the abused child's behaviour and reactions: his lack of trust; his withdrawal; his tendency to test, and so on. Without adequate support many foster parents react with disappointment when an
277
abused child does not demonstrate rapid progress. They often feel that the child's slow progress implies some deficiency in their own parenting abilities. If they are not helped to understand the reasons for this the placement frequently breaks down and the child is moved to another placement, with his already impaired self-esteem further eroded by what he perceives as yet another rejection. Another type of problem occurs when a foster parent finds it difficult to permit the child to become more independent, sensing in this a rejection of him/her personally. These parents also need understanding and assistance if they are to help the child appropriately. For the abused child in foster care it is eventually necessary to face the question of the child's possible return home, and generally, it is not safe to return him to his natural parents until there is strong evidence that they have found sufficient sources of satisfaction and pleasure in life that they no longer have to turn to the child to meet their own emotional needs. If the parents are able to help each other and can find support from others in their environment, especially in times of crisis, it is a good indication of the safety of the home, but if they continue to misperceive the child and to have unrealistic expectations of him, return home is contraindicated. Parents who pressure the C.A.S. and/or Court to return their child because of fears of public or family disapproval should alert us to the likelihood that the home environment has probably not changed significantly. Helfer and Kempe (3) have developed a useful set of guidelines which can be used to assess the safety of the home when return of the child is contemplated. However, they note that when all has gone well, when the parents have improved and when the child has returned home, there is often a tendency for either parent(s) or worker to consider terminating treatment. This should not be done since this is the time to consolidate gains and to see that whatever improvement has taken place in both parents and child is maintained. It must be remembered that the purpose of treatment is not just to return the
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child home, but to influence the basic quality of the relationship between the parents and between them and their child(ren). The prognosis for the child depends on many variables. Gil (2) has suggested that probably more than 50 percent of the children have been physically abused prior to the incident which brings them to attention. In fact, it has been suggested that physical abuse of children is often an indication of a prevailing pattern of caretaker-child interaction in a given home rather than being an isolated incident. Helfer( 4) has estimated that there is a 25 percent to a 50 percent risk of permanent injury or death if an abused child is returned home without there being any intervention. Where there is intervention, the prognosis depends not only on the type and severity of the injury sustained by the child but also on the prognosis for rehabilitating the parents. Those parents who actively and repeatedly resist all manner of therapeutic involvement have the poorest prognosis. These are generally the least stable families in terms of marital relationship; abuse of drugs and/or alchohol; unemployment; frequent moves, and so on. The prognosis becomes more and more guarded as the number of these adverse variables increases, and is probably poorest in the very small percentage of cases where the abusing parent is either sociopathic or frankly psychotic. For those parents who can be involved in a therapeutic relationship and can learn to reach out to 'helping individuals' in times of crisis the prognosis is probably good. It is even better if they can come to have a more realistic view of the child and be able to accept him or her as an individual with certain capabilities and needs of his own. The prognosis is best if, in addition to the aforesaid, the individual parent can develop a more worthwhile self-concept and can be helped to be less severely critical of his/her shortcomings. The following are some of the major problems encountered in providing treatment for abusing parents and their children: • The need for all individuals involved
Vol.21,No.5
in working with these parents and their children to recognize that changes in patterns of behaviour generally take a long time (often years). • Intensive, individual psychotherapy is realistically available to only a very small percentage of these parents and their children because of manpower problems, especially in rural areas, and a disinterest on the part of many therapists in working with these patients . • Self-help groups such as Parents Anonymous can play an important role in helping some abusing parents, but these groups are currently located only in larger population centres and attract a type of parent who already has the strength to recognize that he/she has a problem and also is willing to discuss it with others. • Adequate case-work treatment for abusing parents (as provided by C.A.S.) is repeatedly hampered by: an agency philosophy that strongly discourages development of a dependent relationship between client and worker; workers who are unable to see designated families frequently enough because of too large case-loads; inexperienced workers being given the most difficult cases to handle; worker's inadequate technical understanding of the problem of abuse; the understandable wish on a worker's part to believe that even the most superficial changes which he/she sees in these parents represent something lasting, rather than just an accommodation on the part of the parent to what he knows the worker wants to see; the far too frequent transferring of cases (often because of worker burn-out) without adequate appreciation of the detrimental effects of a poorly handled transfer; the far too frequent premature closing of cases; poor supervision of workers by senior colleagues who ought to be more knowledgeable about the problem but who are often not. • The lack of a sufficient number of adequately staffed treatment centres to deal with the very large numbers of young, abused and neglected children who are in need of psychotherapeutic help. • The unavailability of a .sufficient number of good foster homes and the lack
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of adequate supportive services to help foster parents to understand the pathology of the abused child. The following are some possible approaches to remedying these problems: • Educational programs for professionals both in practice and in training (especially social workers, physicians, psychologists, teachers, early childhood education specialists, and child-care workers) to help improve skills in identifying, understanding, and managing the problems of the abusing parent and the abused child. • The organization and coordination of programs which could integrate diagnostic and acute-care hospital services with a variety of long-term, community-based treatment services (5) such as: Intensive Individual or Family Case Work; Lay Therapists (6) or Parent Aid's Programs; Parents Anonymous Groups; specialized Parent-Child Centres (1,10) which, in addition to providing therapeutic help for the abused child, would offer parent education courses, individual and group counselling for parents, and so on. • Greater emphasis on the recruitment and training of specialized volunteers, homemakers, and others, whose services may be particularly appropriate in smaller communities. • Greater emphasis on the recruitment and training of a larger, more highly skilled pool of foster parents capable of providing both short-term and long-term care for abused children. References I. Galdston, R.: Violence begins at home. The parents' centre project for the study and prevention of child abuse. J. Am. Acad. Psychiatry, /0: 336-350, 1971. 2. Gil, D.G.: Violence Against Children Physical Child Abuse in the United States. Cambridge, Mass., Harvard University Press, 1970. 3. Helfer, R.E .. Kempe, C.H.: "The child's need for early recognition, immediate care and protection." In: Helping the Battered Child and His Family, Philadelphia and Toronto: LB. Lippincott, 1972. 4. Helfer, R.E.: Personal Communication. 5. Helfer, R.E., Schmidt, Rc.Unpublished Manuscripts.
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6. Kreindler, S.: "The Toronto Lay Therapist Project - The Role of the Para-professional in the Rehabil itation of the Abusing Parent." Paper presented at a Workshop on Child Abuse sponsored by the Laidlaw Foundation. Toronto, April 1975. 7. Martin, H.: "The child and his development" In: Helping the Battered Child and his Family. Eds. Kempe, C.H. and Helfer, R.C., Philadelphia and Toronto: 1.B. Lippincott, 1972. . 8. Morris, M.G., Gould, R.W.: "Role reversal: A concept in dealing with the neglected/battered child syndrome." In: The NeglectedBattered Child Syndrome. New York, Child Welfare League of America, 1963. 9. Oliver, 1.E., Cox 1.: A family kindred with ill-used children: The burden on the community,Br. J. Psychiatry, 123: 81-90,1973. 10. Ounsted, C.; Oppenheimer, R., Lindsay, J.: Aspects of bonding failure: the psychopathology and psychotherapeutic treatment. Del'. Med. Child Neurol., /6: 447-456, 1974. II. Polansky, N., Polansky, N.: "The current status on child abuse and child neglect in this country." Report to the Joint Commission on Mental Health for Children, Washington, D.C., University of Georgia typescript, 1968. 12. Pollock, Carl, Steele, Brandt: In: Helping the Battered Child and his Family. Eds. Kempe, C.H. and Helfer, R.E., Philadelphia and Toronto: 1.B. Lippincott, 1972. 13. Stephenson, P. Susan: "Project Toddler: Early Intervention with High Risk Families and Their Children." Paper presented at the Canadian Psychiatric Association Annual Meeting, Banff, Alberta, 1975. 14. Steele, B.F., Pollock, C.B.: "A psychiatric study of parents who abuse infants and small children." In: The Battered Child, Eds. Helfer, R.E. and Kempe, C.H., Chicago, University of Chicago Press, 1968
Resume Offrir des soins psychiatriques aux parents qui maltraitent physiquement leurs enfants et Ii ces enfants, demeure un probleme tres complexe. Toute therapie devrait etre centree vers le parent implique, dont le problerne initial est un manque de confiance fondamental en lui-rneme et un surmoi punitif. Toutefois, il est difficile d'inciter ces parents a suivre un traitement therapeutique de relations parent-enfant. DO a cette difficulte,
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peu de psychotherapeutes sont interesses a travailler avec ces patients. II en resulte alors, que cette responsabilite premiere de rehabilitation, retombe sur les epaules d'un travailleur social de la Societe de protection de I'enfant, qui, tres sou vent manque d'experience ou de formation pour aider ce genre de client. Les enfants maltraites physiquement, parviennent difficilernent a avoir confiance aux autres et la mauvaise projection qu'ils font de leur image, empechent Ie developpement normal des relations avec ses pairs et contribuent asa vie isolee et pseudo-mature. II importe peu que l' enfant demeure au
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foyer ou soit separe de sa famille, car on devrait egalement traite l'enfant et les parents ou les gardiens, car ils ont pareillement besoin d'aide pour comprendre et pour savoir reagir, face au comportement de cet enfant. II y existe une reelle demande afin d'ameliorer la competence de plusieurs professionels qui se trouvent en contact avec ces enfants et leurs parents, afin d'arriver plutot a les identifier et offrir les directives necessaires pour resoudre ce probleme. Apres avoir identifie ces parents et leurs enfants, la qualite des services requis doit etre amelioree.
Cruelty andfear shake hands together. Honore de Balzac 1799-1850
SIMON KREINDLER,
Physically abusive behaviour towards children appears to represent only one extreme of a continuum of aggressive behaviour, for which we all have a certain potential. Therefore, it is not surprising that abusing parents may manifest virtually any type of psychopathology. Notwithstanding this fact, they do show certain psychological characteristics in common. Morris and Gould (8) have described the phenomenon of role reversal seen in these parents where they tum to the child for nurturance and protection. Steele and Pollock (14) have noted how there are two basic elements involved in this kind of behaviour, , ,... a high expectation and demand by the parents for the infant's performance and a corresponding parental disregard of the infant's own needs, limited abilities and helplessness." They also note that" ... the difference between the non-abusing and the abusing parent is that the latter implements such standards with exaggerated intensity, and most importantly, at an inappropriate early age." These authors (14) have pointed out that abusing parents have a history of having been raised in much the same way which they then recreate in the rearing of their own children. * A modified version of a contribution to a Position Paper on
"Service Delivery in Child Abuse" presented at an InterProfessional Seminar on Child Abuse. sponsored by the Ontario Ministry of Community and Social Services, Toronto, February 1976. Manuscript received April 1976. 'Department of Psychiatry, University of Toronto and Hospital for Sick Children, Toronto, Ontario. Can. Psychiatr. Assoc. J. Vol. 21 (1976)
M.D.!
Apart from other diagnostic considerations abusing parents demonstrate pathological deviations in personality development which are manifested in: • failure of the adult to develop a capacity for motherliness - an essential parental attribute which includes" ... the more subtle ingredients of tenderness, of awareness and consideration of the needs and desires of the infant, and of appropriate emotional interaction with it"; • failure to develop what Benedek has called a "sense of confidence" or what Erikson has called ."basic trust" - an essential prerequisite for the development of satisfying relationships with others; • failure to develop what Erikson describes as a sense of personal identity - a sense of him or herself as a "unique, separate individual with a continuity of personal character and ability to maintain solidarity with social groups" (14). Instead, these parents develop an identity based on a loose collection of unintegrated, disparate concepts of the self. They can " ... feel like a confident parent and quickly change to being nothing but a helpless, ineffectual, inadequate child. They can be a kindly adult and shift suddenly to being a punitive adult. They know they are men and women but are not really sure of it. They have one firm concept of what they should be and another of what they actually are. Any sense of being reasonably good can be easily displaced by a conviction of badness. They
275
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are usually quite uncertain about allying with whom no amount of help seems to prevent a group even if they join it."( 14) recurrent abuse (9) it would appear that there These deviations in personality develop- is a far larger percentage of families who are ment culminate in adults who neither believe amenable to help but who are not receiving that others can help them nor that they are it. Just as is the case of the abusing parent, worth helping. Consequently, abusing parents usually expect relationships with other the abused child may manifest any type of adults to be disappointing, if not frankly psychopathology, depending on his age, rejecting. While these parents may speak of constitutional and genetic factors, his unique having many friends, they usually turn out to life experiences, and the nature and severity of the abuse to which he has been subjected. be friends in name only. The psychotherapeutic treatment of abus- Some of the more common forms of ing parents presents a number of challenges, presenting psychopathology, especially some of which are technical, others logisti- among young children, include developmencal. In the first place, abusing parents are not tal delays which may have an organic basis but quite frequently are functional; behaviour 'good patients' in the classical sense many refuse to be involved in treatment or . disorders of an aggressive, pseudoshow only a superficial motivation to get hyperkinetic type, often associated with help. Others are unreliable in keeping learning difficulties; and frightened, anxiappointments or they abruptly discontinue ous, chronically depressed children. Although it is now fairly well accepted treatment. Changes occur slowly in these that abuse occurs within all socioeconomic patients especially the core problems of their classes of society the majority of cases are severely damaged self-esteem and their punitive superego. For the therapist, a major among the lower socioeconomic groups. obstacle is the feeling of anger these parents These children have often faced such addiprovoke, and which he must learn to handle tional stresses as being raised by a single parent; the presence of one or more effectively if treatment is to proceed. common-law partner for their single parent; Although some investigators have expres- foster placement(s); parental abandonment; sed extreme pessimism about the prospects frequent geographic moves, and so on. for rehabilitating abusing parents (11), others Martin (7) has suggested that the delay in have indicated more favourable results (12). language development seen in so many of What types of treatment have these parents these children may well be multifactorial in been receiving? Unfortunately only a very etiology but it is probably related to the small percentage receive individual child's recognition that it is potentially psychotherapy, primarily because few dangerous to express himself verbally in an therapists are interested in working with abusive environment. these people. A further small percentage As Martin (7) has pointed out, if the receive help from groups such as Parents abused child is recognized early enough, Anonymous or community agencies provid- functional retardation can be reversed by ing marital counselling, family therapy, and providing him with a loving environment, so on. A significant percentage receive help where he receives previously missing stimuof variable duration and quality from the lation, but the longer he goes unrecognized Children's Aid Society (C.A.S.) or its the harder it is to alleviate this problem. equivalent, but there is reason to suspect that Even where the child has been recognized a significant number of these parents receive early, it is important to remember that it either no help or grossly inadequate help, sometimes takes several months before either because they are never recognized or, improvement is seen. For instance, it has once diagnosed, cannot be provided with the been noted that over a three-month to necessary helping services. six-month period a previously abused child, Although it is known that there are certain with what appears to be a normal intellectual seriously disturbed abusing families for potential, will start to demonstrate increas-
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ing attention span; increasing interest in problem solving; a more positive response to praise; more creative play; and a greater interest in the people and things around him. Once these new behaviours start to appear the child seems capable of an accelerated development, although a further three-month to six-month period may be needed to demonstrate changes on the basis of psychological test scores. The author has noted a similar improvement in those neglected and abused children who presented as behaviour disorders or as withdrawn and depressed. This is particularly so if the home situation can be made more stable, or where a consistent,loving, foster placement can be arranged. Stephenson (13) has recently reported encouraging results with a group of very young (one-and-a-half years to two-and-ahalf years old), high-risk children who were seen over a two-year period for a daily four-hour enrichment program, and whose parents were simultaneously seen at least weekly by the child's nursery teacher. It would appear that the abused child does not develop a normal sense of basic trust because the environment in which he lives is so unpredictable. Prolonged exposure to this type of environment paves the way for the damaged self-esteem these children later develop as adults. The lack of a sense of basic trust seriously impairs the child's ability to develop adequate peer relationships and, later on, precludes the development of truly intimate relationships with other adults. Regardless of whether -the abused child remains in his home or is placed in a foster home, the provision of psychological treatment needs to be considered both for the child and for his parents or caretakers. Parents need help in understanding the child's behaviour and feelings and in knowing how to react to him. If the child is in foster placement it is important to recognize that this, by itself, is not sufficient for many abused children. Foster parents also need to be helped to understand the abused child's behaviour and reactions: his lack of trust; his withdrawal; his tendency to test, and so on. Without adequate support many foster parents react with disappointment when an
277
abused child does not demonstrate rapid progress. They often feel that the child's slow progress implies some deficiency in their own parenting abilities. If they are not helped to understand the reasons for this the placement frequently breaks down and the child is moved to another placement, with his already impaired self-esteem further eroded by what he perceives as yet another rejection. Another type of problem occurs when a foster parent finds it difficult to permit the child to become more independent, sensing in this a rejection of him/her personally. These parents also need understanding and assistance if they are to help the child appropriately. For the abused child in foster care it is eventually necessary to face the question of the child's possible return home, and generally, it is not safe to return him to his natural parents until there is strong evidence that they have found sufficient sources of satisfaction and pleasure in life that they no longer have to turn to the child to meet their own emotional needs. If the parents are able to help each other and can find support from others in their environment, especially in times of crisis, it is a good indication of the safety of the home, but if they continue to misperceive the child and to have unrealistic expectations of him, return home is contraindicated. Parents who pressure the C.A.S. and/or Court to return their child because of fears of public or family disapproval should alert us to the likelihood that the home environment has probably not changed significantly. Helfer and Kempe (3) have developed a useful set of guidelines which can be used to assess the safety of the home when return of the child is contemplated. However, they note that when all has gone well, when the parents have improved and when the child has returned home, there is often a tendency for either parent(s) or worker to consider terminating treatment. This should not be done since this is the time to consolidate gains and to see that whatever improvement has taken place in both parents and child is maintained. It must be remembered that the purpose of treatment is not just to return the
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child home, but to influence the basic quality of the relationship between the parents and between them and their child(ren). The prognosis for the child depends on many variables. Gil (2) has suggested that probably more than 50 percent of the children have been physically abused prior to the incident which brings them to attention. In fact, it has been suggested that physical abuse of children is often an indication of a prevailing pattern of caretaker-child interaction in a given home rather than being an isolated incident. Helfer( 4) has estimated that there is a 25 percent to a 50 percent risk of permanent injury or death if an abused child is returned home without there being any intervention. Where there is intervention, the prognosis depends not only on the type and severity of the injury sustained by the child but also on the prognosis for rehabilitating the parents. Those parents who actively and repeatedly resist all manner of therapeutic involvement have the poorest prognosis. These are generally the least stable families in terms of marital relationship; abuse of drugs and/or alchohol; unemployment; frequent moves, and so on. The prognosis becomes more and more guarded as the number of these adverse variables increases, and is probably poorest in the very small percentage of cases where the abusing parent is either sociopathic or frankly psychotic. For those parents who can be involved in a therapeutic relationship and can learn to reach out to 'helping individuals' in times of crisis the prognosis is probably good. It is even better if they can come to have a more realistic view of the child and be able to accept him or her as an individual with certain capabilities and needs of his own. The prognosis is best if, in addition to the aforesaid, the individual parent can develop a more worthwhile self-concept and can be helped to be less severely critical of his/her shortcomings. The following are some of the major problems encountered in providing treatment for abusing parents and their children: • The need for all individuals involved
Vol.21,No.5
in working with these parents and their children to recognize that changes in patterns of behaviour generally take a long time (often years). • Intensive, individual psychotherapy is realistically available to only a very small percentage of these parents and their children because of manpower problems, especially in rural areas, and a disinterest on the part of many therapists in working with these patients . • Self-help groups such as Parents Anonymous can play an important role in helping some abusing parents, but these groups are currently located only in larger population centres and attract a type of parent who already has the strength to recognize that he/she has a problem and also is willing to discuss it with others. • Adequate case-work treatment for abusing parents (as provided by C.A.S.) is repeatedly hampered by: an agency philosophy that strongly discourages development of a dependent relationship between client and worker; workers who are unable to see designated families frequently enough because of too large case-loads; inexperienced workers being given the most difficult cases to handle; worker's inadequate technical understanding of the problem of abuse; the understandable wish on a worker's part to believe that even the most superficial changes which he/she sees in these parents represent something lasting, rather than just an accommodation on the part of the parent to what he knows the worker wants to see; the far too frequent transferring of cases (often because of worker burn-out) without adequate appreciation of the detrimental effects of a poorly handled transfer; the far too frequent premature closing of cases; poor supervision of workers by senior colleagues who ought to be more knowledgeable about the problem but who are often not. • The lack of a sufficient number of adequately staffed treatment centres to deal with the very large numbers of young, abused and neglected children who are in need of psychotherapeutic help. • The unavailability of a .sufficient number of good foster homes and the lack
August, 1976
ABUSING PARENT AND ABUSED CHILD
of adequate supportive services to help foster parents to understand the pathology of the abused child. The following are some possible approaches to remedying these problems: • Educational programs for professionals both in practice and in training (especially social workers, physicians, psychologists, teachers, early childhood education specialists, and child-care workers) to help improve skills in identifying, understanding, and managing the problems of the abusing parent and the abused child. • The organization and coordination of programs which could integrate diagnostic and acute-care hospital services with a variety of long-term, community-based treatment services (5) such as: Intensive Individual or Family Case Work; Lay Therapists (6) or Parent Aid's Programs; Parents Anonymous Groups; specialized Parent-Child Centres (1,10) which, in addition to providing therapeutic help for the abused child, would offer parent education courses, individual and group counselling for parents, and so on. • Greater emphasis on the recruitment and training of specialized volunteers, homemakers, and others, whose services may be particularly appropriate in smaller communities. • Greater emphasis on the recruitment and training of a larger, more highly skilled pool of foster parents capable of providing both short-term and long-term care for abused children. References I. Galdston, R.: Violence begins at home. The parents' centre project for the study and prevention of child abuse. J. Am. Acad. Psychiatry, /0: 336-350, 1971. 2. Gil, D.G.: Violence Against Children Physical Child Abuse in the United States. Cambridge, Mass., Harvard University Press, 1970. 3. Helfer, R.E .. Kempe, C.H.: "The child's need for early recognition, immediate care and protection." In: Helping the Battered Child and His Family, Philadelphia and Toronto: LB. Lippincott, 1972. 4. Helfer, R.E.: Personal Communication. 5. Helfer, R.E., Schmidt, Rc.Unpublished Manuscripts.
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6. Kreindler, S.: "The Toronto Lay Therapist Project - The Role of the Para-professional in the Rehabil itation of the Abusing Parent." Paper presented at a Workshop on Child Abuse sponsored by the Laidlaw Foundation. Toronto, April 1975. 7. Martin, H.: "The child and his development" In: Helping the Battered Child and his Family. Eds. Kempe, C.H. and Helfer, R.C., Philadelphia and Toronto: 1.B. Lippincott, 1972. . 8. Morris, M.G., Gould, R.W.: "Role reversal: A concept in dealing with the neglected/battered child syndrome." In: The NeglectedBattered Child Syndrome. New York, Child Welfare League of America, 1963. 9. Oliver, 1.E., Cox 1.: A family kindred with ill-used children: The burden on the community,Br. J. Psychiatry, 123: 81-90,1973. 10. Ounsted, C.; Oppenheimer, R., Lindsay, J.: Aspects of bonding failure: the psychopathology and psychotherapeutic treatment. Del'. Med. Child Neurol., /6: 447-456, 1974. II. Polansky, N., Polansky, N.: "The current status on child abuse and child neglect in this country." Report to the Joint Commission on Mental Health for Children, Washington, D.C., University of Georgia typescript, 1968. 12. Pollock, Carl, Steele, Brandt: In: Helping the Battered Child and his Family. Eds. Kempe, C.H. and Helfer, R.E., Philadelphia and Toronto: 1.B. Lippincott, 1972. 13. Stephenson, P. Susan: "Project Toddler: Early Intervention with High Risk Families and Their Children." Paper presented at the Canadian Psychiatric Association Annual Meeting, Banff, Alberta, 1975. 14. Steele, B.F., Pollock, C.B.: "A psychiatric study of parents who abuse infants and small children." In: The Battered Child, Eds. Helfer, R.E. and Kempe, C.H., Chicago, University of Chicago Press, 1968
Resume Offrir des soins psychiatriques aux parents qui maltraitent physiquement leurs enfants et Ii ces enfants, demeure un probleme tres complexe. Toute therapie devrait etre centree vers le parent implique, dont le problerne initial est un manque de confiance fondamental en lui-rneme et un surmoi punitif. Toutefois, il est difficile d'inciter ces parents a suivre un traitement therapeutique de relations parent-enfant. DO a cette difficulte,
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peu de psychotherapeutes sont interesses a travailler avec ces patients. II en resulte alors, que cette responsabilite premiere de rehabilitation, retombe sur les epaules d'un travailleur social de la Societe de protection de I'enfant, qui, tres sou vent manque d'experience ou de formation pour aider ce genre de client. Les enfants maltraites physiquement, parviennent difficilernent a avoir confiance aux autres et la mauvaise projection qu'ils font de leur image, empechent Ie developpement normal des relations avec ses pairs et contribuent asa vie isolee et pseudo-mature. II importe peu que l' enfant demeure au
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foyer ou soit separe de sa famille, car on devrait egalement traite l'enfant et les parents ou les gardiens, car ils ont pareillement besoin d'aide pour comprendre et pour savoir reagir, face au comportement de cet enfant. II y existe une reelle demande afin d'ameliorer la competence de plusieurs professionels qui se trouvent en contact avec ces enfants et leurs parents, afin d'arriver plutot a les identifier et offrir les directives necessaires pour resoudre ce probleme. Apres avoir identifie ces parents et leurs enfants, la qualite des services requis doit etre amelioree.
Cruelty andfear shake hands together. Honore de Balzac 1799-1850
