The case of "Mary Ellen," a child who was beaten and starved by her adoptive parents in New York City in 1874, led to the founding of the first Society for the Prevention of Cruelty to Children in the United States. It was only because the child was called a member of the animal kingdom that an agency, the Society for the Prevention of Cruelty to Animals, could intervene on her behalf. There were laws against the beating and starving of animals, not of children.
This incident is often called the first reported case of child abuse. But child abuse and maltreatment, not excluding mutilation and infanticide, have been around for as long as historical records have been kept. Radbill,1 in a scholarly review of their history, goes back 5,000 years to "the man with the whip" in the Sumerian schools of Babylonia.
There are three underlying themes that account for much of the violence toward children throughout history. First, severe physical punishment is required for discipline and learning, regardless of the child's age. "Spare the rod and spoil the child" translates into spankings, which become beatings, which spill over into torture, by parents or by teachers. Second, religious or superstitious beliefs or cultural practices demand it. Infanticide as a ritual sacrifice, whipping of children on Innocents' Day as a ritual in memory of the massacre of the innocents by Herod, beatings to exorcise devils causing such diseases as epilepsy, and binding the feet of Chinese girls are examples. Third, economic reasons provoke it. In this category is a range from infanticide and abandonment as birth control measures, through mutilations that create "attractive" - i.e., pitiable - beggars, to ordinary exploitation in prolonged, forced, hazardous labor. In addition to these, which may be said to have some rationale, are the irrational instances in which children are brutalized in fits of anger, sadistically, or, as in about 5 per cent of the cases in the United States today, by psychopaths or psychotics.
Practices with such a long history in so many different civilizations must have deep-seated foundations. Steele2 has discussed the psychoanalytic concept that "our moral convictions, our superegos, not only give us permission to be violent, but give us great approval for violence expressed in certain directions." Society's apparent sanction of this direction against children is also rooted in legal doctrine. Originally, children were considered the father's chattel - literally his property, in that he could deal with or dispose of them in any manner that he saw fit. Gradually, the laws governing homicide became applicable in the case of children. Yet the principle that a parent may inflict punishment to discipline a child is still grounded in the heritage of common law. Here, too, change has occurred and is continuing - at first outlawing only punishment that resulted in permanent injury or was inflicted with malice and now beginning to limit punishment to "what is reasonable under the circumstances" by some external standard.
Why the change? Why all the current interest in child abuse and neglect? Why federal legislation for the first time - PL 93-247, the Child Abuse Prevention and Treatment Act? Why this issue on the subject?
Radbill1 pointed out that there were what he called "periodic waves of sympathy [for abused children] which curiously subsided. . . ." There has been a child welfare movement in the United States for well over 200 years. At the outset its concern was primarily for the care of homeless children; an orphanage was organized by the Ursuline Sisters in New Orleans as early as 1729 to provide religious training and education for girls orphaned by Indian massacres. Foster care also came to be used. As the importance to children of their parents and family life became evident, services to children in their own homes were emphasized.
One of the waves of sympathy for abused children seems to have surged about the time of the "Mary Ellen" case in New York. The New York Foundling Hospital had been opened a few years before. The New York Society for the Prevention of Cruelty to Children was founded immediately after. Two years later the American Humane Association was organized. During the late 1800s and early 1900s, its membership included societies for the prevention of cruelty to children in almost every state of the Union. Most of them disappeared during the Great Depression of the 1930s. Then the original Social Security Act, in its Title V, provided for grants to state public welfare agencies for "the protection and care of homeless, dependent and neglected children" so that child protective services became a responsibility of public welfare.
The current wave of attention had its beginning in medical developments, as pediatricians and pediatric radiologists came to realize the significance and implications of some of their unexplained findings. In 1946, Caffey3 reported an association between subdural hematoma and fractures of the long bones in infants. The fractures appeared to be traumatic, but their cause was obscure.
. . . Unexplained fresh fractures appeared shortly after the patient had arrived home after discharge from the hospital. In one of these cases the infant was clearly unwanted by both parents and this raised the question of intentional ill-treatment of the infant; the evidence was inadequate to prove or disprove this point.
Nothing much happened for a while. In 1953, Silverman4 reported what he termed "unrecognized skeletal trauma" in infants, confirming that the fractures were indeed traumatic. But then, in 1955, Woolley and Evans5 reached the conclusion that not only were they traumatic, but often they were inflicted, not accidental. This was followed in the next few years by a spate of similar reports from various parts of the country.
The crescendo really began to build after 1961, when Kempe6 coined the term "battered child syndrome" in presenting to a symposium at the American Academy of Pediatrics meeting his experience and the findings of his survey of 77 district attorneys and 71 hospitals. There were 749 children identified; 78 of them had died, and 114 of the survivors had permanent brain damage.
Here was a problem of major importance. The Children's Bureau held a conference early in 1962 to see what could be done about it. One of the recommendations was the development of a model law for the reporting of child abuse to state authorities. By the next year both the Children's Bureau and the American Humane Association had published model state laws. The concept was lobbied so intensively that within five years all 50 states had reporting laws. They varied considerably from one state to another. What is reportable - only physical injury, neglect as differentiated from physical abuse, mental or emotional injury? Who is to report - physicians only, all health professionals, all people whose occupation brings them into contact with children, anyone? Should reporting be mandatory or discretionary? And so on. There were many issues.7
Along with the laws came epidemiologic studies, investigations into etiology, into psychodynamics, into methods of management, recommendations about communitywide programs, and, of course, controversy. The medical, social work, and law journals published so many articles that an exhaustive bibliography for the last 10 years runs to hundreds of citations. A common theme running through much of the literature is that there is more abuse and neglect of children in the United States than we had realized, and that even though there is no consensus on what to do about it, the existing agencies and mechanisms need help. They are unable to keep up with the work even when they know what to do.
While some states and cities augmented their programs, it was not surprising that there were appeals to Washington for help. Bills were introduced into Congress from time to time. In the spring of 1973, Senator Mondale, chairman of the Senate Subcommittee on Children and Youth, conducted hearings in Washington, Denver, and New York. In the fall, Congressman Brademas conducted similar hearings in Washington and New York for the House Select Subcommittee on Education. Both received wide publicity. A bill was passed by both houses before the end of 1973 and was signed into law by President Nixon just two years ago, at the end of January, 1974. It established a National Center on Child Abuse and Neglect, which is a training, research, and coordinating body; it provided for support of demonstration programs and projects to prevent, identify, and treat child abuse and neglect; it provided for grants to the states to assist them in developing, strengthening, and carrying out child abuse and neglect programs; and it authorized an amount climbing from $15 million to $25 million over three years for these purposes. If the appropriation matches the authorization, it should help begin to fill some of the gaps both in knowledge and in services.
Finally, why this issue on child abuse? Academic pediatricians and pediatric radiologists were largely responsible for starting the current wave of interest in the subject. The developments of the past 15 years have demonstrated the pervasiveness of child abuse and neglect. This is not a problem that belongs in or can be left to the ivory tower. All pediatricians need to be made aware of it. They need not be experts in its management, but they should not miss an occasional case any more than they should miss the occasional child with Wilms's tumor. In both situations, prompt recognition and appropriate treatment may avert an early death or a life filled with complications. While all pediatricians learned about Wilms's tumor in medical school, few now in practice learned about child abuse there. This symposium is one effort to fill that void, so that the current wave of sympathy for abused children does not also curiously subside.
1 . Radbill. S. X. A history of child abuse and infanticide. In Heifer, R. E., and Kempe, C. H. (eds.). The Battered Child. Chicago: University of Chicago Press, 1968.
2. Steele. B. F. Violence in our society. The Pharos of A.O.A. 33 (1970), 42-48.
3. Caffey. J. Multiple fractures of the long bones of infants suffering from chronic subdural hematoma. Am. J. Roentgenol. Radium Ther. Nucl. Med. 56 (1946). 163-173.
4. Silverman, F. N. The Roentgen manifestations of unrecognized skeletal trauma in infants. Am. J. Roentgenol. Radium Ther. Nucl. Med. 69 (1953), 413-427.
5. Woolley, P. V.. Jr., and Evans, W. A., Jr. Significance of skeletal lesions in infants resembling those of traumatic origin. J. A.M. A. 158 (1955). 539543.
6. Kempe, C. H.. et al. The battered child syndrome. JAMA 181 (1962), 17-24.
7. Paulsen, M. G. The legal framework of child protection. Columbia Law Review 66 (1966), 679-717.