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.