Lecture 25 Childhood Psychopathology: Child Abuse and Neglect Lecture Outline I. Introduction II. Definitions and Disbelief A. Definitions B. Disbelief III.Numbers IV. Course A. Infancy and Childhood B. Adolescence and Adulthood V. Etiology A. Child factors B. Parent factors C. Cross-Generational factors D. Societal factors VI. Conclusion ------------------------------------------- I. Introduction In today's lecture we will examine child abuse and neglect, two closely related problems that have recently gained a lot of attention from professionals and the public alike. These are not new problems, however. There is evidence of child abuse and child neglect as far back as our history goes (Oates, 1982). What is new is the realization that these behaviors are terribly serious, and that they occur with alarming frequency. Public awareness of the problem was spurred in the 1960's by the landmark work of Kempe, who identified what he termed the "battered- child syndrome". Since then, public and professional interest has grown. In 1976 the International Society for the Prevention of Child Abuse and Neglect was formed. In 1979, we saw the International Year of the Child, with its special emphasis on the rights of children. The media has taken an active role in educating the public about the problem (Cohn, 1982) (for example, see Handout 25-1). Professional journals have been formed, e.g: Child Abuse and Neglect. A new field has grown up, with many investigators actively searching for an understanding of and effective interventions for the problem. Nonetheless, most experts would agree that we have a long way to go before we adequately address the problem of child abuse and neglect. II. Definitions and Disbelief The study of child abuse and neglect is complicated by a number of related issues. We begin with perhaps the most basic problem: What is it that we mean by child abuse and child neglect? A. Definitions On the face of it, the definition of abuse and of neglect is fairly straight forward. 1. Child Abuse: Acts of commission - the active use of force aimed at hurting, injuring, or destroying the child. Includes sexual and psychological abuse, in addition to physical abuse (McRae & Longstaffe, 1982). Psychological abuse (demeaning, denigrating, ridiculing, and condemning the child, placing him/her in intolerable situations such as double binds, etc) frequently accompanies actual physical abuse (Wilbur, 1985). 2. Child Neglect: Acts of omission - non-nurturing, deprivation, understimulation (McRae & Longstaffe, 1982): neglect of the legitimate needs of the developing child, whether by intention, unavailability, or some form of deficit or incapacity in the caretaker. Eg: the child is not held, comforted, bathed, kept warm, diapered, or fed adequately (Wilbur, 1985). However, these definitions are often overly broad and vague. There are many situations where it is difficult to decide: is this abuse or not. What is abuse to one person may merely be proper although strict parenting to someone else. It's sometimes very difficult to draw the line between punishment and abuse (McRae & Longstaffe, 1982). In particular, work by historians and anthropologists have clearly demonstrated vast differences, from one period to another and from one culture to another, regarding acts considered to constitute child maltreatment (Cantwell, 1982). Thus, there is wide discretion left to the courts, professionals etc to impose their own idiosyncratic definitions. The result: frequency of abuse and neglect is difficult to determine identifying children at risk is difficult identifying victims difficult devising and assessing interventions is difficult It is sometimes very difficult to balance out the rights of parents and the protection of children. For example, how do we determine where to draw the line in terms of a parent's right to discipline a child versus the right of the child not to be abused - how do we distinguish physical punishment from abuse? The complexities involved in studying abuse and neglect are compounded by a particularly insidious problem, to which we now turn. B. Disbelief Child abuse has a long history of inspiring incredulity in mental health professionals (Goodwin, 1985). The reports made by the child are often dismissed as immature fantasies, or at least as over-exaggerations. [There are certainly many skilled professionals, devoted to the rights of children. I am not suggesting here that all professionals are turning their backs on these children. However, given the horrendous nature of the crime, disbelief can occur even in the most devoted professional]. 1. Professional Incredulity: Iwan Bloch, a contemporary of Freud, stated: Children's declarations before the law are, for the truly experienced knower of children...absolutely worthless and without significance; all the more insignificant and all the more hollow the more often the child repeats the declaration and the more determined he is to stick to his statements (quoted in Goodwin, 1985, p.4). Freud originally believed that many of his patients had suffered from abuse (esp. sexual abuse) in their early childhood, but he later reversed his belief and came to see his patients memories as actually representing early fantasies and conflicts that were still not resolved - fantasies and conflicts unconsciously disguised as sexual abuse. These are but examples of the suspicion people (including scientists such as Freud) have held regarding the existence of abuse. Such disbelief is still prevalent today. Children who die because of abuse have usually been referred for child protective services, but their cases are frequently closed because no serious problem was believed to exist (Goodwin, 1985; Scott, 1973). Why such widespread disbelief? Some have argued (Goodwin, 1985) that this disbelief is rooted in our defenses against our fear, guilt and anger that are associated with child abuse. Denial and disbelief are effective ways of distancing oneself from terrifying realities. By placing limits on what we believe, we maintain for ourselves a more sane and manageable world (Wilbur, 1985)... Incredulity protects both the physician and the family from unpleasant realities, such as investigating the physical and psychological consequences to the child, inquiring about other victims, going to Court to protect the child, or making a commitment to the hundreds of hours of treatment that may be necessary (Goodwin, 1985, p.8). The key credibility issue is this: To what extent can we believe the child who says abuse has occurred? 2. The Credibility of Children: There is much debate in the field as to whether what children say should be believed. [See the entire issue of Journal of Social Issues, 20 (2), 1984 for a look at the competence of children to testify in a Court]. The fact is, children do tend to be unreliable sources of information - concerning both themselves and what is occurring in the world around them. Children's reports are questioned on a number of grounds: (i) Developmental Issues - The child has limited cognitive abilities. In particular, the young child will often mix fantasy and accounts of actual events. S/he has limited understanding and vocabulary to express events. (ii) Traumatization - It is well known that trauma can induce distortions into any one's memory for an event. For children, this seems especially true. Example: In 1976, 23 grade school children were involved in a school bus kidnapping in California. Three masked men blocked the road, took over the bus at gunpoint, drove the children around for 11 hours and then buried the children in a truck trailer were they stayed for 16 hours before two of the older boys dug them out. Months after this event, 14 of the children had major memory distortions of the event: belief in a forth kidnapper at large, mistakes about the appearance of the kidnappers, the timing of events; three of the children even hallucinated entire scenes (Goodwin, 1985). Child abuse is also a traumatic experience for a child. The distortions seen in children's reports have been used, however, to question the child's credibility. (iii) Family Context - The credibility of children is made even more problematic when it is a family member who has traumatized the child. The child may still have feelings of love, loyalty, etc toward the abuser. As a result, there is often a "conspiracy of silence" (Goodwin, 1985) - the victim denies the abuse, both to others and to him/ herself. When s/he does admit to the abuse, guilt often follows, leading to changing ones story. In addition, children may be coerced and threatened by family members to remain silent. 3. The Child's Denial: In the face of their own confused feelings, the family coercion, the disbelief from professionals and other adults, it is not surprising that as many as 1/3 of abused children deny the abuse (Goodwin, 1985). For many children of abuse, they are not so much denying anything as they are unaware that the parent's behavior is abnormal - they have nothing to compare their parents to. Thus, victims of abuse (especially sexual abuse) may not even mention it to anyone for years. III. Numbers Each year, thousands of children are abused, and thousands more are neglected. Death is not an infrequent consequence (Schwartz & Johnson, 1985). 1 to 1.9 million children in the U.S. (3.6%) between the ages 3 and 17 are bitten, kicked, or punched by their parents each year (Oates, 1982). 3% of the parents have threatened or actually used a gun or knife on their children (Schwartz & Johnson, 1985). Overall, abuse/neglect victims are young: mean age = 7.4 years (Wolfe, 1987). Neglect is more common during infancy and toddlerhood; abuse becomes more common in older children. The highest rate of actual physical injury is with children aged 12-17 years. However, even the most violent abuse does occur with very young children (Wolfe, 1987). There is no significant sex difference for abuse and neglect, except for sexual abuse (where females comprise 85% of the victims) (Wolfe, 1987). It is generally agreed that such numbers are probably underestimates - obscured by denial, secrecy, underreporting, etc... IV. Course Let us now turn to the characteristics of the child currently being abused, as well as the effects of that abuse on the child when s/he grows up. The characteristics given here are not to imply a single profile exists for all abused children. However, there is evidence that suggests that children who face chronic abuse or neglect will suffer some problems as a result (Farber & Egeland, in press). The following characteristics have been found to significantly correlate with abuse and neglect (Martin, 1982; McRae & Longstaffe, 1982): A. Infancy and Childhood 1. Wounds/Injuries: tissue damage, burns, fractures, brain injuries, internal organ damage, intracranial bleeding (from excessive shaking) 2. Health Problems: Largely because of the under-nutrition and lack of stimulation that these children suffer, numerous physical problems arise: anemia, infections, dental problems, vision and hearing deficits, failure to thrive (ie: stunted physical growth), and in some cases, death. 3. Neuro-developmental disabilities: There is considerable data that mistreated children are at considerable risk for mental retardation, brain damage, motor & language delays, and learning disabilities. It has been found that over 4 times as many abused and neglected children are in special education classes than are found in regular classrooms (Martin, 1982). 4. Behavioral and Emotional Problems: Most reports of abused children identify them as aggressive, hyperactive, poor impulse control, lacking self-esteem or a positive self- concept, distrustful, anxious, depressed, possibly suicidal (reported even in children as young as 8). In some cases, rather than aggressive and hyperactive, the child may strive to be overcompliant and passive. In general, the child may have difficulties in his/her relationships: shy, rejected, unable to relate to others. B. Adolescence and Adulthood Few studies have attempted to follow the abused child into adulthood. What evidence we do have about the long-term effects of abuse and neglect indicate that adolescents and adults (although not all) continue to suffer from various problems (Browne & Finkelhor, 1986; Martin, 1982; Wilbur, 1985): delinquency criminal behavior drop-outs teenage pregnancy social immaturity low self-esteem substance abuse the learning disabilities, etc., of childhood do not spontaneously disappear, so there are now repeated failures in work, school, and relationships psychological disorders (eg: anxiety, depression, dissociative) V. Etiology A Problem: Many of the factors that have been identified as etiologically significant in the development of child abuse and neglect also occur in families where child abuse/neglect does not occur (Oates, 1982). The picture is far from clear. It is unlikely that there will be a simple, common-to-all-families explanation of child abuse. There will be a potentially complex interaction of child, parent, family, and community variables. In addition, variables suggested as etiologically significant are actually just correlates of abuse - there is no clear indication how these variables could actually cause abuse. A. Child factors 1. Prematurity is associated with abuse/neglect in 12 to 30% of cases (Oates, 1982; Wolfe, 1987). Why this may lead to maltreatment may be that prematurity is associated with a higher degree of birth defects and medical problems. The child stays in the hospital for extended periods of time (certainly the first months), and so bonding between the mother and her child is impaired. The warm attachment that might reduce the likelihood of abuse is never formed. 2. Physical & mental handicaps in the child are also associated with up to 70% of the cases (Oates, 1982). Again, such handicaps may interfere with bonding - the parents may feel guilty, angry, resentful, etc. Nevertheless, it is difficult to determine in many of these cases which came first - the handicaps or the abuse/ neglect. The handicaps may actually be simply the result of the abuse. 3. Temperament: No longer are infants seen as the proverbial "blank slate" - shaped solely by the environment. Infants come into the world with their own unique temperament. Some babies are simply more difficult to manage: they fuss and scream and cry more than other babies (McRae & Longstaffe, 1982). B. Parent factors 1. Behavioral factors: The parents tend to be socially isolated -few contacts with the extended family or with friends (Oates, 1982; Wolfe, 1987). There is thus, limited social supports in times of crisis - no place to get help, feedback, etc. Other factors include: less communication with the child, a high rate of negative interactions within the family in general, marital problems, and inadequate parenting skills (eg: overly intrusive, inconsistent or chaotic) (Wolfe, 1987). 2. Psychological factors: Parents tend to be unhappy, rigid, distressed; there is more expressed anger, a low frustration tolerance (ie: easily upset by the child). They have been described as immature and dependent, or apathetic and passive. In particular, the parents often have inappropriate expectations of the child's needs and abilities (Oates, 1982; Wolfe, 1987). Examples: the belief that the infant is intentionally annoying the parent. the belief that the infant burping and looking away means she doesn't love the parent. parents expect the child to meet their own unmet needs (for love, affection, companionship, friendship) Combined with the lack of outside supports and thus "reality testing", such misperceptions and misbeliefs are likely to continue. Life stress has also been associated with higher rates of abuse and neglect. Stresses such as financial problems, employment, health problems, marital dissatisfaction, etc. However, what actually seems to be the key is not the amount of stress (the majority of families who are under stress do not abuse their children), but rather the parents' perception of greater life stress (Wolfe, 1987). C. Cross-generational factors Parents who grew up in families that were abusive tend to repeat the abuse with their children - there is a cycle of violence (Davis & Leitenberg, 1987; Oates, 1982; Wolfe, 1987). A history of neglect and abuse seems to stand out as a key factor in the etiology of child abuse (McRae & Longstaffe, 1982). There is at least an increased predisposition to use abusive methods with ones own children: an increase of approximately three to five times over the typical rate of child abuse in the population (Wolfe, 1987). In particular, the parents perceive their childhood as lacking affection, having a high degree of rejection and deprivation. One explanation is that the parents learned what was appropriate behavior in a family from their own family of origin, and this includes the use of force. D. Societal factors One final factor that may play a role is society's attitudes toward violence in general. It has been argued that violence is increasingly accepted as normal in our society (as seen in the increasingly violent flavor of art, music, films, television, etc) (Deveson, 1982), and such acceptance serves to legitimize or at least desensitize us to the use of force with our children. Some telling numbers: 81% of mothers with infants become sympathetic to "baby batterers"; of mothers with children 1-4 years 57% have lost their tempers and hit their child "very hard", and 40% feared one day they would lose control and truly damage their child; and it's been estimated that 97% of children are subject to some form of physical punishment (McRae & Longstaffe, 1987). VI. Conclusion Again, it must be emphasized that the majority of parents facing stress, isolation, or what have you, do not abuse their children. Indeed, it is undoubtedly normal for a parent to become angry at their child, especially during times of stress, or if the child is particularly difficult. In one study, 76% of parents interviewed said they have stopped themselves from losing their tempers with their children (by counting to ten, deep breathing, leaving the room, etc) (Wolfe, 1987). So why do some parents go on to abuse or neglect their children? It is perhaps the case that abusive parents have no way (skills, past experiences, social support, etc) to deal with these normal feelings of frustration and anger.