Competency as a parent is usually accepted as being quite common, built into the structure of all human beings, particularly women, and invulnerable to all stress. "Women know the way to rear up children (to be just)" wrote Elizabeth Barrett Browning.1 William Cullen Bryant said, "We thank Thee for the ties that bind the mother to the child she bears."2 And, of course, the Third Commandment is "Honor thy father and thy mother."
But pediatricians, as they gain experience, become aware of the vagaries and variability of life and of the fact that not all children or parents are alike. It also becomes apparent that the maxim that natural parents are always the best parents must be recognized as a myth rather than a reality. "Blood is thicker than water" may be a physiologic truth, but it is sometimes a psychologic error.
This article is directed towards an examination of the clinical problems that result from deficiencies in the ability to parent and their diagnosis and treatment. For normal growth and development of a child, emotional attachments (bonding) must occur between the infant and the mother or other primary caretaker. These emotional ties begin with the first thoughts parents have about their roles, harking back to early experiences with their own parents. Though usually thought of as God given, the ability to parent is in great measure a learned experience. Erikson3 has written about the basic trust developed during the continuous interaction of the infant with those who care for him. Distress is relieved, comfort is given, and the infant learns that the world is a friendly, caring one.
Infants who are neglected or are cared for in fragmented, episodic, hot-one-minutecold-the-next ways do not develop the same sense of trust or confidence in their ability or in the world around them to relieve their discomfort. This group of infants suffer from such ills as failure to thrive, accidents and poisonings, and neglect or even abuse.*
Even in the most difficult of environments, some children manage to survive. A psychologist at the University of Minnesota, Dr. Norman Garmezy,4 calls such children "invulnerable." But we shall consider the clinical syndromes the average child, or even the vulnerable one, may present to the pediatrician. These syndromes are the result of less than adequate concern for the developing child. Infants and young children who are, of necessity, more dependent on their caretakers will be the focus of our discussion.
Child-care practices range from the unsafe (for instance, putting an active 15 -month-old child in an unstable high chair) to the neglectful, abusive, or, on occasion, murderous. We shall also consider the intent of these acts, whether premeditated or unconscious lapses of control, on the part of parents. (The former are a matter of concern more to lawyers, police, and the courts than to the pediatrician.
There may be a blending of one syndrome with another; one may find in a single family a history of unsafe practices, frequent accidents, child neglect, and abuse of one or several children. Families may do excellent jobs of caring for children, but moments of carelessness do occur, for parents are human and not perfect. The case of Danny is an example.
Danny, age 13 months, was seen in the emergency room with third-degree burns of his buttocks, allegedly due to scalding water. Abuse was suspected initially because the burns were confined to the buttocks and upper legs on the dorsal aspect and were believed to be older than in the history given. The parents said that they were in their bedroom at 11:30 on a Saturday morning when they heard screams from the bathroom. There the father found the child with the burns, claimed to have been caused by hot water in the basin next to the toilet. The baby was in shock when first seen and was critically ill.
After the emergency was over, a more detailed history was obtained. Danny was the last of four children, with a brother 10 and sisters six and three years old. On Saturday mornings the children usually watched television; on this particular Saturday, Danny's father did not work as he had for several weeks previously. The parents had "slept in" and expected the older children to baby-sit for their little brother, as they often did. Danny was described as "very active" and "a climber." His mother cried as she related how she had told her children of the dangers of fire, poison, and the like - but "I never warned them about hot water!" The hotwater boiler had recently been repaired; the temperature could not be regulated, so the water was very hot. Without being noticed by his brother and sisters, Danny had climbed up the stairs, gone to the bathroom, climbed on the toilet seat and then to the bowl, and turned on the scalding water. The accident, causing serious burns that required three and one-half months' hospitalization, was due to a lapse in the parents' caretaking. The family physician had always considered the parents healthy and responsible, and he had had no concerns about abuse.
There may be mild degrees of failure in bonding that may go unnoticed unless viewed by keen observers. In one case, an eightweek-old boy gained only 9 ounces in a three-week period after his mother had weaned him in order to care for a four-yearold sibling in the hospital. The baby was described as extremely pale and listless, with a depressed fontanel, inelastic skin, and lethargic expression. His conjunctival color was better than his general appearance would have suggested. He looked cold.
A nurse described the treatment, which was for the mother to give the infont intense stimulation, to which he promptly responded. It is speculated that had the child been placed in the hospital for observation and tests at the critical stage, his condition would have deteriorated. This would seem to be a description of a child in the very earliest stages of the failure-to-thrive syndrome.5
Parenting may be considered a vitamin necessary for adequate growth of a child. Sometimes there are unpredicted and temporary deficiencies, as in the case just discussed. But there may be more severe and long-lasting deficiencies that respond slowly and sometimes not at all to treatment. The case of Alice is an example.
Alice brought her daughter Sally, age two years and two months at that time, to the psychiatric clinic and thrust her angrily at the social worker, saying that the girl was "a little witch who hated everyone." She requested that Sally be hospitalized immediately and put into a foster home, for she refused to care for her anymore. This dramatic incident was the outcome of a two-year struggle to help this mother and her child. Before this incident Sally had been hospitalized twice, once at three months and again at five months, with complaints of vomiting and diarrhea. At both admissions she measured below the third percentile in height and weight, but no organic reasons could be found for her growth failure. During the hospitalization Alice refused to have any conta« with hospital personnel and requested that she be phoned when Sally's "bad behavior has been corrected," for then she would take her home.
Alice, in her mid-20s, was a small woman, always fashionably dressed, with highly teased hair and heavy makeup. She alluded to a very chaotic and deprived background, with an alcoholic and abusive father who had abandoned her mother when Alice was only 10 years old. After leaving high school in the 10th grade, she lived with a series of men, each of whom abandoned her. Eventually, at age 20, Alice became involved with a married man and began a common-law relationship with him. Her first child, Betsy, was born approximately a year later. Alice was pleased with the birth of this child, as she felt that this would cement her somewhat tenuous relationship with the child's father. He, in turn, repeatedly warned Alice not to get pregnant again, as he felt he could not support two families. However, she shortly became pregnant with Sally, and from that point on the relationship between mother and father gradually deteriorated. Alice hoped that her second child would be a boy and was disappointed to have a second girl. From the beginning, Sally was an unwanted and emotionally neglected child. Alice refused to accept the fact that Sally was a girl and immediately nicknamed her "Butch" and dressed her in boys' clothes when she was an infant. Sally was an irritable baby who cried frequently and had a problem with feeding. When she was two months old, her mother was abandoned by her father; shortly thereafter, Sally was admitted to the hospital for the first time. It was not until the birth of another child, who began having similar symptoms of failure to thrive, that Alice became involved with hospital personnel. Even then her "involvement" was characterized by demands; she was verbally abusive, threatened to sue, and would phone 15 times a day requesting help and then hang up when efforts were made to contact her. Over a period of six months, her unlisted phone number was changed five times. In spite of this, contact was maintained with her, and she eventually requested that Sally be placed. She accepted the aid of public-health nursing, homemaker sources, and weekly visits by a "student" child-welfare worker.
At the time of placement, Sally was 26 months old, weighed 17 pounds, measured 41 cm. in height, and was retarded in all areas of development. She had never talked and withdrew from contact with her mother and two sisters. She consumed large amounts of food daily. After 22 months in the foster home, she made remarkable gains. During this period, weight gain put her in the 50th percentile for weight and 10th percentile for height. She became completely toilet trained, gained good speech abilities, and slowly and tentatively began to give affection. On the Stanford-Binet she scored at an age level of three years and nine months at a chronologic age of four years and one month, putting her in the lowaverage range of intelligence.
After Sally had been in the foster home for only a few months, her mother made repeated attempts to have her returned home, but the court always upheld the continuation of foster-home care recommended by the hospital and the child-welfare agency. The foster parents with whom Sally was placed were a young couple in their mid-20s with two other children, aged three years and nine months. From the beginning, this couple expressed a wish to adopt Sally but were not able to do so because of the mother's repeated attempts to have Sally returned to her home and her requests for monthly visits.
After Sally had been in the foster home for approximately three and one-half years, Alice became pregnant for the fourth time; this time she obtained her much wanted boy. It was only after the birth of this boy that Sally's mother was able to think seriously about placing her for adoption. She made one last attempt to petition the court for Sally's return and, when this was refused, immediately signed relinquishment papers. Soon afterward Alice moved from the city, and all contact has been lost with her. After five years in the foster home, now her adoptive home, Sally is within the 50th percentile for height and weight. She is described as having good peer relationships, but she can still only tentatively give and accept affection. She is now in second grade but has many learning and behavioral problems.
As was stated previously, these children sometimes have mixed clinical problems. Billy, the fourth of five children, had such a problem. Even before his birth, Billy's family was known to the local child-protection agency, and social workers had visited the home several times over the previous four years. Shortly after Billy's birth, his father deserted the family and his mother became increasingly overwhelmed by her responsibilities.
At the age of 18 months, Billy was taken to the emergency room of a local hospital after ingesting liquid lye. Because of the seriousness of his esophageal burns, he was transferred to the children's hospital. There comprehensive evaluation was done, not only in the physical but also in the psychologic and social sense. Billy's disorder was initially diagnosed as failure to thrive, and he was found to be withdrawn and had significantly below-average intelligence. Later evaluations showed that he was able to develop rapidly in the hospital's warm and protective environment.
Billy's mother told the hospital social worker that he was "a bad child" and that he had opened and drunk the bottle of lye himself. A report of suspected abuse was filed with the local child-welfare agency, and although the caseworker who went to the home encouraged Billy's mother to visit the child during the following four months of hospitalization, she did not visit him once. When Billy was ready to be discharged from the hospital, his mother refused to take him home, saying that she already had more than she could manage. The agency received custody of Billy from the juvenile court and placed him with foster parents. He adjusted well, and after two years his injuries had healed, he had reached normal height and weight, and his IQ test scores had jumped from the 72 recorded on hospital admission to 130.
In the meantime, Billy's mother had another pregnancy and lost her other four children because of neglect. Billy's foster parents pursued and won his adoption. Billy's progress continued to be good.
Some parents may do a reasonable job of feeding and clothing their children but seem to have inordinate standards for behavior, discipline in a harsh manner, are impulsive and quick to anger, and lose control of themselves too easily. This loss of control of parental behavior can lead to traumatic injuries of children, ranging from bruises and lacerations to fractures of long bones and subdural hematomas.
Molly was hospitalized at the age of three months for failure to thrive and bilateral parietal skull fractures; results of all other studies were within normal limits. The initial history obtained from her parents was cause for much concern. Her father was young and immature, and her mother had a background of severe deprivation and actual physical abuse during her own childhood. They had married young and impulsively after a 17-day courtship. For the first two years of their marriage, they had lived with paternal grandparents; during this time their first child, a boy, was born. The grandparents were viewed as intrusive and manipulative, and the couple eventually moved to their own apartment, where Molly was conceived. This pregnancy was difficult, and Molly's mother had much nausea and was tired and depressed throughout. Molly was born prematurely and from the beginning was seen as sensitive and difficult. She vomited a great deal, and her mother described her as difficult to hold and cuddle. When Molly was six weeks old, her mother told her local pediatrician that she felt the baby "hated her" and that she was fearful that she would "go crazy" if she continued to take care of Molly.
Though exhibiting adolescent behavior, the parents expressed an eagerness for help and a desire to change. Molly was returned to her family, and arrangements were made for a nurse to make frequent home visits. The parents agreed to be seen in psychotherapy on a weekly basis. Over the next six months, however, appointments were frequently canceled and it became obvious that the mother cared more for her son than she did for her daughter, to whom she was cruel and demanding. Foster placement was suggested at the end of three months, but the parents refused. After six months Molly's mother phoned, saying that she had bruised the girl's face and was afraid she was going to kill her. The next day both children were placed with the maternal grandparents, and shortly thereafter the parents moved out of state.
We next learned about this family when a pediatrician in another state who saw Molly with multiple bruises wrote to the original attending pediatrician for records. We then learned that Molly had returned to her parents but had been removed from them following a court hearing because of suspected abuse. Subsequently the child was placed with a foster family, and three years later she was adopted by this family.
It is evident that treatment of syndromes of parental deficiency will depend on the type of deficit. Parents who are generally and usually good parents but who have had single lapses of ability are in need of no active therapy. Should these lapses be repeated, however, further inquiry is necessary.
Families that bring children to pediatric attention for accidental poisonings, failure to thrive, or multiple fractures and other manifestations of abusive care need intensive psychosocial examination. One must look into the parents' own upbringing. Patterns of behavior, control of aggression, and ability to relate are learned in childhood and tend to repeat themselves in adult life. Often such parents tend to isolate themselves from others; have less than ordinary support from their families; have few friends; and relate distantly to neighbors, their church, and those with whom they work. They tend to be lonely people with poor self-esteem and wish from their children more than can be expected. They have little ability to accept the help of others or to trust, and they are often suspicious of health professionals.
When the stress of life becomes too great, they may abandon their children physically or emotionally, neglect them, or even lash out against them and others in their frustration. There is no treatment for these clinical syndromes that is easy, quickly effective, and long-lasting. They are the most difficult management problems in pediatric practice.
Treatment of families who have great difficulty in parenting is complicated. It is not something a physician can do alone. A pediatrician must not only be skilled in the usual medical sense but also be knowledgeable in regard to community resources and be able to collaborate with welfare and other social agencies, court and other neighborhood legal services, and the local mental health system and schools. Here the pediatrician may be a facilitator, a link between agencies engaged in child care, in an attempt to organize a system of support for parents and their families. And sometimes, in the best interests of the child, parents and children must be separated temporarily and sometimes permanently, depending on the parents' ability to respond to intervention efforts.
After Kempe in 1961 coined the term "battered child syndrome,"6 many programs were developed in an effort to help parents who abuse their children. But even before that, programs were established for helping parents who neglected their children. One such experiment, conducted by Dr. Mary Sheridan in Great Britain and reported in 1959, described how neglected (though not abused) children and their mothers were required by the court to reside in "recuperative centers" for at least four months. There mothers were instructed in child care, helped with personal problems, and "mothered" themselves. After leaving the center, each family was put on probation for two or three years; during this time they met regularly with social workers. Results of this medical-school experiment, after seven and a half years, revealed that 75 per cent of the families had improved and 25 per cent of these showed excellent results. However, the other 25 per cent failed to be rehabilitated.
Initially there was some enthusiasm from reports that as many as 80 to 90 per cent of parents who abuse children could be rehabilitated so that the children could be returned to their care. Our own experience has not been that successful, but the numbers are small and the time of follow-up is short. Also, one must define one's goals for rehabilitation -whether to prevent recidivism or to gain optimum development for the child.
As in all human conditions, there is probably a bell-curve distribution, with some families that need very little treatment and some that need more than is possible. The problem for the young child is that he is in a period of growth, and while his family is in treatment - no matter what kind of treatment one considers - the child must be well cared for and protected from neglect, abuse, or other pathologic parenting. Often this requires that the child and parents be separated. Advocates for parental rights see this as an injustice to parents, but advocates for children's rights argue just as fiercely that the danger to the child outweighs the detriment to the parents. It is obvious that there is no simple answer for this complex problem.
It does seem that there must be some changes in our attitude about deficiencies in parenting, no matter which type we consider. Such deficiencies should be considered "congenital" and not the fault of anyone. A child born without arms should not be expected to become a parent who would hold a child. There must be changes in the attitude that all men and women must become parents and that those who choose not to do so are "selfish" or "not well adjusted" or "queer." There is a need to see deficiencies in parenting just as we see infectious diseases - events that happen and that may be predicted, with some accuracy as to risk. They must be seen to be as much of a medical condition as appendicitis, even though their diagnosis and treatment are much more complex. These syndromes are the result of deficiencies that some adults have that do not permit them to be adequate parents. These parents must be recognized, tolerated if not condoned, and helped to do the best possible job that they can. This may include loving their child enough to permit relinquishment to other adults who can give the child more than they can. Such changes may be slow in coming, but they are a need for the future.
Management of the syndrome of parental deficit requires truly comprehensive care. There is not only a need to be alert to the possibility that poor weight gain in an infant, a parent's complaints about a child's performance, the accident without adequate history, or the accidental poisoning is the "tip of the iceberg." There is a need for critical care, investigation and planning for long-term care, and provision for monitoring the growth and development of the child. There is a need for collaboration with others outside medicine and the hospital in order to create an effective system of child care. And there is a need for the pediatrician to continue to be a force in child advocacy while being not punitive but helpful to the unfortunate parent.
1. Browning, E. B Aurora Leigh. Book I, Line 47
2. Bryant. W C. The Mother's Hymn," Stanza 1
3. Erikson. E. R. Theory of infantile sexuakty. In Childhood and Society, Second Edition New York: W W Norton & Company, 1963. pp 48-108.
4 Garmezy. N. Vulnerability research and the issue of primary prevention. Am. J. Orthopsychiatry 41 (1971). 101-116
5 Taylor. R W Depresson and recovery at nine weeks of age. J Am. Acad. ChHd Psychtatry 12 (1973). 506-509.
6 Kempe. C. H. et al. The battered child syndrome JAMA. 181 (1962). 17-24.