Pediatric Annals

The Long-Term Management of the Child and Family in Child Abuse and Neglect

Barton D Schmitt, MD; Patricia Beezley, MSW

Abstract

1 . Joyner. E. N. Child abuse: The role of the physician and the hospital. Pediatrics 51 (Suppl., 1973), 799.

2. Heifer. R. E. The responsibility and role of the physician. In Heifer, R. E., and Kempe, C. H. (eds.). The Battered Child. Second Edition. Chicago: University of Chicago Press. 1974, p. 25.

3. Schmitt, B. D., and Kempe. C. H. The pediatrician's role in child abuse and neglect. Curr. Probi. Pediatr. 5:5 (1975). 3.

4. De Francis, V. The status of child protective services: A natbnal dilemma. In Kempe. C. H., and Heifer. R. E. (eds.). Helping the Battered Child and His Family. Philadelphia and Toronto: J. B. Llppincott Company, 1972.

5. Hopkins. J. The nurse and the abused child. Nurs. Clin. North Am. 5 (1970). 589.

6. Chamberlin. R. W. Authoritarian and accommodative child-rearing styles: Their relationships with the behavior patterns of 2-year-old children and with other variables. J. Pediatr. 84 (1974), 287.

7. Sumpter, E. A. Behavior problems in early childhood Pediatr. Clin. North Am. 22 (1975), 663.

8. Caffey, J. On the theory and practice of shaking infants. Am. J. Dis. Child. 124 (1972), 161.

9. Steele, B. F. Working with abusive parents from a psychiatric point of view. U.S. Department of Health, Education, and Welfare. DHEW Publication No. (OHD) 75-70, 1975.

10. Geist, J., and Gerber. N. M. Joint interviewing: A treatment technique with marital partners. Soc. Casew. 41 (1960), 76.

11. Kempe, C. H.. and Heifer, R. E. Innovative therapeutic approaches. In Kempe and Heifer, op. cit.

12. Paulson, M. J., et al. Group psychiatry: A multidisciplinary approach in the treatment of abusive parents. (Unpublished manuscript.)

13. Parents Anonymous. National Office: 2930 West Imperial Highway, Suite 332, Inglewood, Calif. 90303.

14. Group for the Advancement of Psychiatry. The Field of Family Therapy. Volume 7. Report No. 78, March, 1970.

15. Ten Broeck, E. The extended family center; A "home away from home'' for abused children and their parents. Children Today (March-April, 1974), 2.

TABLE 1

PREREQUISITES FOR OPTIMAL LONG-TERM TREATMENT

TABLE 2

THE PROBLEM-ORIENTED REPORT

TABLE 3

TREATMENT MODALITIES FOR THE PARENTS

TABLE 4

TREATMENT MODALITIES FOR THE CHILD…

The successful long-term management of child abuse and neglect cases depends on four components (Table 1). All the components are essential and will be discussed. However, this article will concentrate on the broad range of treatment modalities that should be available in a modern community. These should include acute treatment in the hospital and long-term treatment for the parent and child.

COMPREHENSIVE DIAGNOSTIC ASSESSMENT OF THE FAMILY

Child abuse and neglect are symptoms of family problems. The entire family must be evaluated before decisions are made about longterm therapy. These evaluations should look beyond the perpetrator (e.g., parent, boyfriend, baby-sitter). The patient, the siblings, the mother and father (individually and together), and any other people living in the household should be interviewed. Both physical and psychologic problems of each person should be delineated. Environmental crises (e.g., inadequate home, heat, water, food, job, medical insurance) should also be assessed. Medical data should be conclusive (e.g., radiologic bone surveys or bleeding tests). In 10 to 20 per cent of cases some family members, besides undergoing a social work evaluation, will need to see a psychiatrist or psychologist. School reports may be helpful. The data should be complete before the case is presented in conference.

Table

TABLE 1PREREQUISITES FOR OPTIMAL LONG-TERM TREATMENT

TABLE 1

PREREQUISITES FOR OPTIMAL LONG-TERM TREATMENT

MULTIDISCIPLINARY TEAM DECISION MAKING AND TREATMENT PLANNING

After all the family evaluations are completed, a multidisciplinary team should meet and attempt to assimilate all of the available data into a logical, workable whole. The team members can include a pediatrician, child protective-services caseworker, hospital social worker, psychiatrist, psychologist, police representative, public health nurse, legal consultant, and child protection team coordinator.1 If the family data available to each of these professionals are combined, the family's total problems can be listed. Combining the training and experience of all of these professionals will facilitate the making of recommendations for each of the problem areas.

An example of a problem-oriented report synthesized during a multidisciplinary meeting is given in Table 2.

The most important decision made by a multidisciplinary team is usually about the safety of the home. If the home is unsafe and at high risk for a recurrence of physical abuse, the child must be placed in a foster home through court action. This decision must be made or the basis of a thorough knowledge of the family. Indications for foster-home placement are any of the following:

1. Severe abuse (e.g., lifethreatening abuse, multiple injuries, head injuries, large burns, sadistic injuries, incest, severe malnutrition, etc.)

2. Evidence of repeated and frequent abuse from history, physical examination, or x-ray

3. Repeated abuse after initial report and intervention

4. Any physical abuse in a child less than one year old

5. Child is completely unwanted or rejected

6. Child exhibits behavior that is unduly provocative or obnoxious to the parents

7. Child, with valid cause, is extremely fearful of returning home

8. Adolescent refuses to return home and is beyond parents' control

9. Parent is dangerous (e.g., sociopathic, psychotic, suicidal, or homicidal)

10. Nonperpetrator parent is not protective

11. Parent wants child placed after appropriate counseling

12. Parents persistently refuse intervention and treatment services

13. Numerous ongoing crises

TREATMENT OF THE PARENTS BEGINS AT THE HOSPITAL

Treatment for the parents begins with social assessment and diagnostic evaluation at the time of the child's hospitalization.2 At this time of crisis, the parents are extremely fearful of criticism and attack by people they consider to be authorities - that is, doctors and social workers. Therefore, they deny that they injured the child and avoid visiting the hospital. But they are also very vulnerable at this point. They know what they have done to the child, and they are receiving very little support from friends and relatives. Their feeling is often that of "I can't believe I'm part of the human race." This is the time to show them that someone cares and that treatment will be offered. The following guidelines apply to initial treatment of the parents by the hospital staff and principally by the social worker.

Interviewing the parents is primarily a matter of knowing how to ask the right questions. 1. Initially, focus on the parent and his or her feelings.

2. Never interrogate, criticize, or express anger at these parents. 3, Be gentle but thorough. 4. Elicit the parents' own background material in a way that will show your concern for what they have been experiencing. 5. Maintain a helping approach. 6. Be honest about the child-abuse report that will be made and the referral to the child protection agency. 7. Be concerned about the realities with which the parents have to deal (e.g., money for cab fare, the need to tell relatives what is happening).

Table

TABLE 2THE PROBLEM-ORIENTED REPORT

TABLE 2

THE PROBLEM-ORIENTED REPORT

Crisis intervention with these families means that someone must be available to them on a daily basis. It is helpful to introduce them to a hospital-based social worker who is present during the daytime and give them the home phone number of a social worker whom they can reach after office hours. They often need opportunities for long talks about what is happening to themselves and their families, and the physician can rarely provide this kind of time. Second, the intervention should include several contacts with the parents by the social worker. These will usually reveal much more information than the first contact. Third, the hospital social worker should be present when the protective-services worker makes initial contact with the family. This contact will often provide access to treatment for the parents. If, instead, the parents are criticized and left alone during this period, it will be much more difficult to engage them in treatment later.

Involving the parents in the child's hospital care is usually difficult. Initially, the parents will disbelieve that they are invited to participate. They may avoid spending time on the ward with their child because they are fearful that they will be watched and criticized. A social worker or nurse should encourage frequent visits, help the parents become familiar with the ward, compliment them on their efforts, and remain as interested in the parents as in the child.3 This will also reveal very useful diagnostic information regarding the parent-child interaction.

Interpretative hour. Following the multidisciplinary dispositional conference, the social worker and/or pediatrician should meet with the parents to inform them of the child protection team's recommendations. Because these decisions will often involve child-abuse reporting, foster care, and suggestions for treatment, the parents may need to vent their anger. It is useful at this point to offer them some concrete proof that the hospital and the physician, personally, are going to continue to care about what happens to them. This could be done through offers of follow-up for their child and phone calls to them by the social worker. If this phase of management goes well, the parents will leave the hospital accepting of intervention and treatment.

TREATMENT MODALITIES FOR THE PARENTS

The main goal in working with abusive parents is to help them relinquish their abusive, neglectful pattern of child rearing and to replace it with a method of caring that is more rewarding to both the parents and the child. This necessitates focusing the treatment initially on the parents and facilitating their own growth and development. Therapy for the parent includes helping him build his selfesteem; develop better basic trust and confidence; learn how to make contacts with other people in the family, neighborhood, and community; establish responsive lifelines for help; and develop the ability to enjoy life and have rewarding, pleasurable experiences with adults and with his own children.

The only two treatment modalities that are employed in all cases are child protective-services casework and pediatric services. It is imperative that these disciplines learn to work together. The treatment options of abusive parents are numerous, and several of the following should be useful in a given family (Table 3).

Casework is the traditional treatment offered to abusive parents through a child protective-services agency.4 It is primarily one-to-one contact by a social worker with a parent, usually the mother. This is an outreach service utilizing home visits. A referral to child protective services for casework should be made whenever there is any concern about an actual or potential case of abuse and neglect. Caseworkers can often coordinate services with other agencies so that treatment for individual family members is procured. The main difficulty with casework is that, because of high case loads, it is not frequent or long-term enough. Also, the social worker may be in a very difficult position regarding her therapeutic role because of past needs to investigate the family and testify against them in court. With distrustful and suspicious parents, it is frequently necessary to engage someone besides the caseworker to provide ongoing, supportive counseling.

Table

TABLE 3TREATMENT MODALITIES FOR THE PARENTS

TABLE 3

TREATMENT MODALITIES FOR THE PARENTS

Public health nurse services are the physician's main avenue of providing outreach medical services.3·5 Public health nurses are often the most nonthreatening professionals and can gain entrance to homes where no one else is accepted. In smaller communities, they are usually the most available professionals. Also, PHN services can generally be mobilized quickly and with an initial visit on the day of referral. The PHN's skills include (1) the ability to assess the child's development (e.g., Denver Developmental Screening Test), maternal attachment and bonding, parent-child relationships, and safety of the home and (2) the ability to provide counseling regarding home stimulation programs, infant feeding and nutrition, accident prevention, parent-child physical contact, and family planning. The nurse knows that if the mother does well during the baby's first year of life, the baby also will do well. The baby's absolute dependency on the mother makes it essential that the PHN focus her attention on the mother. The PHN is careful to include inquiries about how the mother is doing and whether she is getting enough sleep and recreation. She tries to build the mother's self-esteem with compliments about child-care tasks she does well. The PHN tries to avoid criticism and overlook minor details, such as a little dirt in the home, a diaper rash, or occasional propping of the bottle.

The main indications for PHN services are children with failure to thrive, repeated accidents, developmental delays, or any associated medical problems. Any preschool child who has been physically abused and remains at home could probably benefit from PHN intervention. For infants, this is mandatory. Overall, the PHN should attempt to develop a trusting and supportive relationship with the mother. A contraindication would be to cast the PHN in the role of the investigator who comes in weekly to check on the baby's condition and is critical of the mother's performance. Unfortunately, in some communities she also has to play this role.

Child-rearing counseling. Childrearing counseling is also called "discipline counseling" or "child management counseling." It can be provided by the child protective-services worker, the pediatrician, the PHN, or a parents' group.6'7 It is best if this direct counseling is done very early in case management and by someone other than the parents' primary therapist.

The physician can discuss discipline on nearly every office visit, using the following guidelines: 1. Age-appropriate limits and discipline are important. 2. Children should not be punished for normal annoying behavior, such as crying, wetting themselves, or exploring their environment. 3. Discipline for accident prevention need not begin before the age of crawling (i.e., eight or nine months). 4. Harsh discipline should never be used. 5. Excessive discipline should be avoided. (At any age, inordinate correction can be detected by asking, "How often do you find you have to spank the child?") 6. A viable, practical alternative to physical punishment should be instituted for enforcing rules (e.g., a "time-out" room or chair). 7. Knowing that physical punishment will never be completely eliminated, the physician should encourage the parents to limit it to one slap on the wrist or buttocks. 8. Shaking is serious and carries a far greater risk, in terms of subdural hematomas and other central nervous system damage, than hitting.8 9. The use of any blunt instrument in punishment should be strongly discouraged, because it hampers the adult's ability to gauge the amount of injury he is inflicting. (Some parents believe that if spanking upsets them, it is best to interpose something impersonal, like a paddle, between them and the child.)

Indications for child-rearing counseling are any cases in which the child was physically abused while being punished for misbehavior. This is especially true if the child is over age one and the parents are frustrated by their inability to control the child. Other indications include children who are being frequently spanked in the waiting room or being punished with a blunt instrument, such as a paddle or belt. Relative contraindications are parents who are using physical punishment on young children who cannot yet crawl and parents who strongly defend their right to employ harsh physical punishment with their children. These people must show progress in psychotherapy before they will be able to grasp the fundamental differences between dangerous/harmful and safe/helpful discipline.

Psychotherapy for abusive parents is usually provided by psychiatrists, clinical psychologists, or psychiatric social workers.9 It focuses primarily on intrapsychic conflicts in the parent, not on parent-child interactions. Psychotherapy can be utilized by parents with various psychiatric diagnoses. It is especially useful for neurotics and persons with character disorders, in whom additional insight is needed for progress. However, personality changes occur only when the parent is willing and able to tolerate some exploration of his behavior and feelings. It is frequently most useful in conjunction with some less traditional treatment for the parents, such as lay therapy or Parents Anonymous.

The primary drawbacks of psychotherapy are: 1. Psychotherapy rarely focuses on parent-child interactions, and changes in the parents' behavior towards the child may therefore be too slow to protect the child's psychic development. 2. Most abusive parents are too distrustful and erratic in their behavior to come to an office on time for a 50-minute hour, and few psychiatrists will make extensive home phone calls or visits in an attempt to elicit the trust of a parent. 3. Long-term psychotherapy is expensive and not generally available in rural areas.

Marital treatment is provided primarily by clinical psychologists and psychiatric social workers.10 It is very important that both husband and wife are seen together, with the focus on marital problems. This modality is especially useful when the parents are aware that anger from their marriage is being displaced onto their child. With improved communication and increased gratification of needs within the marriage, the child is less at risk. Marital treatment is contra indica ted when the parents are so dependent and hungry for attention that they need a one-to-one relationship with a therapist; they may compete for the therapist's attention and get little work done. This mode of treatment is also contraindicated if one parent is psychotic while the other has much more ego strength. In such cases, it is more useful to work individually with the healthier parent so that he can unilaterally work out long-range plans for himself and the child. Marriage counselors listed in the "yellow pages" of the telephone book can vary greatly in quality and training, and it is best to utilize an agency of proven reputation.

Lay therapy is provided by paraprofessionals who are parents themselves and have highly satisfactory family relationships. n Lay therapists are also called "parent aides" or "mothering aides." These surrogate parents attempt to befriend the abusive parents, giving a great deal of themselves and expecting very little in return. Most of their work is done through home visits several times a week and in providing transportation and social experiences for the mother or father. The main advantage of lay therapy over any other treatment method is that it can provide a great deal in terms of hours at low cost. This modality is extremely useful with most abusive and neglectful parents, for it provides a supportive relationship that the parent may never before have experienced. Frequently, lay therapists are much less threatening to these families than a more traditional mental health person would be. Lay therapists are contraindicated when the parent is psychotic, sociopathic, extremely violent, an addict, or so disturbed in some other way that a paraprofessional might become overwhelmed or endangered.

Group therapy for abusive parents is usually provided by clinical psychologists and psychiatric social workers.12 The purposes of group therapy vary, depending on the type of people concerned and what they have chosen to deal with. The advantages of groups are numerous: they provide an opportunity to reach more people with fewer professional staff, and they provide a means of decreasing the isolation of parents and facilitating a mutual-support system. There is also increased confrontation of denial and problems among group members; this usually takes place earlier and more intensely than it would in one-to-one treatment. Moreover, parents can learn through a group experience that they can be helpful to others, and their selfesteem is enhanced. Groups also provide some socialization, and many parents pursue these social contacts beyond the group meetings. Group therapy is indicated for parents who are not extremely threatened by having themselves and their feelings exposed to others.

Some parents feel safer in joining Parents Anonymous, which is a self-help group, usually without professional leaders, similar to Alcoholics Anonymous.11,13 In this group confidentiality is respected to the utmost, and reports are not made available to agencies. Groups are contraindicated if a parent is undergoing a severe crisis; parents usually need one-to-one support during this time. The decision to use groups must also be based on individual diagnosis. Parents who are extremely disturbed will be disruptive in groups and may experience further rejection.

Family therapy is a relatively new treatment modality, rarely used with abusive families.14 It can be provided by psychiatrists, clinical psychologists, or psychiatric social workers. The whole family is seen together, with emphasis on the communication, verbal and nonverbal, that occurs among them. It can be used diagnostically if the children are very young, but it is more beneficial if the children are old enough to express their feelings. Family therapy is especially useful with young adolescents and their parents. It is contraindicated if the family members are extremely competitive for the therapist's attention. If that is the case, it may be more productive to begin by seeing the family members individually and to utilize family therapy much later.

Family residential treatment is a very new modality, offered in only a few places in the United States and Europe.15 The whole family moves into a treatment facility for several months as an alternative to having the child placed in a foster home. Treatment attempts to prevent the weakening of parent-child bonds that occurs with foster placement. Extensive evaluation is needed before it can be known whether this is a useful modality for other communities. Crisis hot lines. The parent should be taught to use lifelines in times of crisis and stress.3 Ideally, the parent should be able to turn to a spouse, relatives, friends, or neighbors. For practical reasons, the parent must also learn how to tum to professionals at this time. The primary therapist, caseworker or otherwise, should provide a home phone number. The primary physician and public health nurse can do likewise. These parents never have too many lifelines. In addition, each family should be given a telephone number for crisis counseling. Many large metropolitan areas now have such hot lines, which provide supportive counseling as well as referral services. Some Parents Anonymous groups provide this service to their communities. If no hot line exists, the parent can be given the number of the nearest hospital emergency room. When overwhelmed, these parents should not feel alone or abandoned.

TREATMENT MODALITIES FOR THE CHILD

Abused children need treatment in their own right (Table 4). Physical abuse may stop very quickly following some significant intervention with the parents. But changing the distorted and negative interactions between parent and child that have gone on for quite some time and have very deep roots requires long-term therapy. In the meantime, the child is getting older, his basic personality structure is being determined, yet his psyche goes unprotected. Therefore, the child needs help in learning to feel better about himself, to feel that it was not his fault that he was injured and that he is not "bad," to realize that he can have pleasureful and consistent relationships with adults, and to be a child rather than a pseudo-adult. Foster care is often considered as treatment for the child. Considering the current quality of foster care, however, this is not enough. Children frequently also need therapeutic play schools, crisis nurseries, individual play therapy, or infant-stimulation programs. Pediatric follow-up services are essential in all cases.

Table

TABLE 4TREATMENT MODALITIES FOR THE CHILD

TABLE 4

TREATMENT MODALITIES FOR THE CHILD

The parents must be involved in all programs provided for the children, even if the child is in foster care. Without intensive work with natural and foster parents, the child's treatment will be undermined and perhaps even sabotaged. The parents should be provided with parentgroup experiences or individual parent conferences.

Pediatric services. The abused or neglected child requires more intensive primary care than the general population.3 If he has been physically abused, he needs follow-up to detect any new unexplained bruises. Sometimes the court will instruct the physician to examine the child weekly during a probational period at home. If he has sustained head injury, he needs follow-up for mental retardation, spasticity, and subdural hematoma. If he has experienced nutritional neglect, he needs careful monitoring of weight gain. If the child is reinjured and the injury itself does not warrant hospitalization, child protective services should be called to help decide on any additional steps to be taken.

Even without recent injuries, these children of high-risk, multiproblem families need twice the usual number of well-child visits (e.g., every six months instead of yearly). During times of acute illness, close pediatric follow-up is invaluable. Although sickness in a child normally tends to make the parents more protective, battering becomes more likely at this time because of the irritant effect on the parents, especially if the child is crying. It is important that these children, when sick, be followed up on a daily basis by an office visit or telephone call. Because these parents often lead an unscheduled type of existence, they may not come in at the appointed time. This results in their seeing a different physician each time. If each primary physician can commit himself to a few of these families and temporarily tolerate unscheduled appointments, he can tighten his expectations regarding appointments once the parents have become trusting and dependent on him. In some circumstances a house call may be of great benefit. If the child is having difficulty sleeping, the physician should feel a greater freedom to give sedatives. If the mother becomes exhausted or other crises develop, hospitalization of the child should be considered for psychosocial reasons. Overall, it is the availability and concern of a primary physician for the parents as well as for the child that help them turn to the physician before reinjuring the child or after a minor injury.

Crisis nurseries for children must operate 24 hours a day, seven days a week.11 They are usually staffed by early-childhood education teachers, nurses, and paraprofessionale. They provide outlets for parents during crisis situations and safety and therapeutic experiences for children. Many hospitals with pediatric wards already have this provision, but community-based facilities are far less expensive. They are especially indicated for parents who are beginning to recognize potential crises and can use lifelines. Many abusive parents will not use baby-sitters, but with help they can learn to trust the staff of a nursery. Many parents have indicated that "just knowing it was there, and that I could use it, helped me through the crisis." If they frequently leave their children at the nursery and do not pick them up on time, it may be more appropriate for a child protective-services worker to discuss with them the possibility of voluntary foster placement. The nursery is also contraindicated for children with severe emotional and medical problems that cannot be handled by paraprofessional staff. For example, a psychotic child needs a residential treatment facility, not a nursery. A child with severe medical problems that require a trained caretaker may more appropriately be placed in a medical foster home.

Therapeutic play schools are staffed by early-childhood education teachers and paraprofessionals. Multidisciplinary consultants should be available for developmental assessments of children. The emphasis in therapeutic play schools is on positive interaction among peers and between children and adults, not so much on learning in a structured setting. The play school is especially indicated for children between the ages of two and five who have not had other types of preschool experiences and who are isolated from peers at home. The parents of these children must be able to tolerate daily separation and personality changes in their children. Play school may also be indicated for children whose parents will participate in parent conferences and parent groups. Otherwise, the child may make changes that the parent does not appreciate and there may be further injury. If a therapeutic play school is not available, a day care center, Head Start class, or summer day camp may have to suffice. If a child is not in the home during part of each day, his mother is usually more tolerant of him during the rest of the day. There are few contraindications to therapeutic play schools for abused children. Only if a child is so disturbed or retarded that he will not be able to keep up with group activities should an alternative plan be discussed.

Play therapy for abused children is usually provided by child psychiatrists, clinical psychologists, and psychiatric social workers. Through the use of play materials and a safe setting, a child can learn to express his conflicts and fears. Even children as young as three and four can greatly benefit from this intensive one-to-one contact with a skilled play therapist. It is indicated for children whose conflicts are so intense that a group experience alone, such as a play school, will not be enough to resolve their problems. Children who demonstrate low self-esteem, depression, or extreme aggressiveness towards other people, or have other severe behavior management problems, should be seen in play therapy. Most abused children could benefit from this type of experience, but of course the manpower is limited. Parents must be intensely involved in parent conferences in order to ensure that they will continue letting the child be seen and that they can accept changes in the child's personality. The one contraindication is in cases where children are fairly healthy but their parents view them in a very distorted fashion. Seeing such a child in play therapy would only reinforce the parents' belief that the child is "sick."

REASSESSMENT OF TREATMENT PLANS

Case management must be flexible. The child protective-services caseworker usually coordinates the overall treatment program. The caseworker must periodically review treatment results and revise the treatment strategy accordingly.

The most important reassessment decision concerns when it is safe to return a child from a foster home to his natural home. Ideally, this is a multidisciplinary team decision. The main pitfall in making this decision is assuming that positive changes in the parent's life mean that he or she is ready to care for the child. Finding a job, cleaning the house, keeping therapy appointments, making progress with marital problems, and forming social contacts indicate only that the parent is doing better for himself. In some cases, it may indicate that the parent can do better without the child present, and relinquishment should be considered. The return of the child must be directly related to positive changes in both parents' interactions with their child. Also, after the return of the child, continued supervision and treatment are essential. If a parent is beginning to make progress and the therapeutic supports are withdrawn, the child may be reinjured and returned to foster care within a short time.

Guidelines for returning a foster child to his natural home are the presence of all of the following:

1. Parents are utilizing therapy (e.g., keep appointments, keep contracts, talk freely, consider therapy valuable, and no longer use denial).

2. Child management is improved. The child protective-services worker or other professionals have documented many specific improvements in the parents' ability to cope with their child.

A. The parents can talk about alternative ways of dealing with their anger.

B. The parents have demonstrated impulse control.

C. The parents can tolerate the child's expression of some negative feelings towards them (e.g., "I hate you").

D. The parents use disciplinary techniques that are fair, nonpunitive, and consistent.

E. The parents have asked for advice regarding child rearing and have been able to implement some of this advice.

F. The parents have recognized and solved specific problems of child rearing.

G. The parents are beginning to recognize the child as an individual with needs, desires, and rights of his own. Their expectations of him are also realistic.

H. The parents speak in positive terms about the child.

I. The parents keep all scheduled visits with their child.

J. The parents interact positively with their child during supervised visits. The parent smiles at his child.

K. The child is no longer fearful of his parents.

L. The perpetrator has shown the most improvement in these skills.

M. The perpetrator can recognize potentially dangerous situations and knows how to remove himself from the child at these times.

N. The nonperpetrator has demonstrated an ability to intervene on behalf of the child.

3. Crisis management is improved. The child protective-services worker or other professionals have documented specific improvements in the parents' ability to cope with crises.

A. The parents no longer live in the chaos of numerous overwhelming, ongoing crises.

B. The marriage is stable. The parents are supportive of each other and can relieve each other in child care or housework.

C. The parents can talk about alternatives to dealing with crises.

D. The parents have solved specific crises.

E. The parents have asked for help during crises and have been able to utilize it.

F. The parents have recognized and solved specific stresses before they could turn into major crises.

G. Interpersonal relationships have increased; isolation has decreased. The parents have a friend or relative who is supportive and available.

RESULTS OF TREATMENT

Treatment for abusive families must be intensive and long-term. Anything less will assure that the distorted patterns of interaction will continue. With the appropriate treatment, many parents and children can be helped to live together in relatively secure, warm environments. To be sure, these people may never become model parents. But the living situations can be made more tolerable for both the parents and the children. The quality of parenting can be raised to a level that is generally accepted in this society. If the physical attacks are stopped and the positive interactions increased, the vicious cycle of child abuse can be interrupted. There are families, however, that cannot be helped. With some families, we know that it is useless from the beginning. With extremely disturbed parents, such as psychotics or aggressive sociopaths, psychiatric hospitalization or criminal prosecution may be the only recourse. With others, this is determined after treatment has been attempted for six months to a year. When we see that there is no hope for even minimal improvement, we must help the parents consider relinquishment or else ask the court for termination of parental rights. Anything less is incompatible with stable adaptation for these children. D

BIBLIOGRAPHY

1 . Joyner. E. N. Child abuse: The role of the physician and the hospital. Pediatrics 51 (Suppl., 1973), 799.

2. Heifer. R. E. The responsibility and role of the physician. In Heifer, R. E., and Kempe, C. H. (eds.). The Battered Child. Second Edition. Chicago: University of Chicago Press. 1974, p. 25.

3. Schmitt, B. D., and Kempe. C. H. The pediatrician's role in child abuse and neglect. Curr. Probi. Pediatr. 5:5 (1975). 3.

4. De Francis, V. The status of child protective services: A natbnal dilemma. In Kempe. C. H., and Heifer. R. E. (eds.). Helping the Battered Child and His Family. Philadelphia and Toronto: J. B. Llppincott Company, 1972.

5. Hopkins. J. The nurse and the abused child. Nurs. Clin. North Am. 5 (1970). 589.

6. Chamberlin. R. W. Authoritarian and accommodative child-rearing styles: Their relationships with the behavior patterns of 2-year-old children and with other variables. J. Pediatr. 84 (1974), 287.

7. Sumpter, E. A. Behavior problems in early childhood Pediatr. Clin. North Am. 22 (1975), 663.

8. Caffey, J. On the theory and practice of shaking infants. Am. J. Dis. Child. 124 (1972), 161.

9. Steele, B. F. Working with abusive parents from a psychiatric point of view. U.S. Department of Health, Education, and Welfare. DHEW Publication No. (OHD) 75-70, 1975.

10. Geist, J., and Gerber. N. M. Joint interviewing: A treatment technique with marital partners. Soc. Casew. 41 (1960), 76.

11. Kempe, C. H.. and Heifer, R. E. Innovative therapeutic approaches. In Kempe and Heifer, op. cit.

12. Paulson, M. J., et al. Group psychiatry: A multidisciplinary approach in the treatment of abusive parents. (Unpublished manuscript.)

13. Parents Anonymous. National Office: 2930 West Imperial Highway, Suite 332, Inglewood, Calif. 90303.

14. Group for the Advancement of Psychiatry. The Field of Family Therapy. Volume 7. Report No. 78, March, 1970.

15. Ten Broeck, E. The extended family center; A "home away from home'' for abused children and their parents. Children Today (March-April, 1974), 2.

TABLE 1

PREREQUISITES FOR OPTIMAL LONG-TERM TREATMENT

TABLE 2

THE PROBLEM-ORIENTED REPORT

TABLE 3

TREATMENT MODALITIES FOR THE PARENTS

TABLE 4

TREATMENT MODALITIES FOR THE CHILD

10.3928/0090-4481-19760301-08

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