- Email: [email protected]
Changing approaches to treatment of child abuse and neglect
Child Abuse and Ncglrcr, Vol. 6. pp 491-493. Pnnkd m the U.S.A. All nghts mewed.
1982
l~l45-2134/82~6U1191-03~3 0010 Capyngh! E 1982 Pcr~amon Pms Ltd.
BRIEF COMMUNICATION
CHANGING APPROACHES TO TREATMENT OF CHILD ABUSE AND NEGLECT C. HENRY KEMPE, M.D. University of Colorado Health Sciences Cenrer. Denver, Colorado 80332
IT IS A fascinating question to consider why it is that during the past seventy years of active protective services work on behalf of troubled families, the focus of diagnosis and treatment has been upon the mother rather than on each member of the family, but it is not surprising. For one thing, the mother was more readily available to a social worker who was beginning to provide diagnostic and treatment services to a family while the father was at work during the time the social worker was available and he was often hostile and sometimes dangerous. Moreover. the philosophy of protective services for the past fifty years has been very much geared to the feeling that if a mother could be helped to be more competent or.more loving to her child, or able to stabilize her marriage, even though the father might be the primary abuser, that good things would of necessity happen in regards to the abused child and the other children in the family. It is not surprising. therefore, that whiie there has been an extensive literature on case work with mothers. there was much less written on work with fathers, and until recently. very little on the abused child. Pioneers in social work received little or no support from anyone, including pediatricians and psychiatrists. Historically, most studies have been retrospective, that is, starting out in juvenile detention homes. prisons and psychiatric clinics and hospitals. The very high incidence of child abuse of individuals in these institutions was often remarked upon but it is fair to say that the abused child was not dealt with either from a diagnostic or a treatment point of view until he was known to be deviant either by failing kindergarten and primary school, or requiring many foster home placements because of personality difficulties, or later on because of adolescent deviant behavior such as truancy or delinquency. On the other hand. all of us who have dealt with abused children over the past thirty years have been struck by the very massive emotional disturbance often found in these children even in the very first year of life. Our own ability to focus on the child involved in child abuse from the earliest time of our contact perhaps was delayed by our need first to know more about the psychodynamics of the adults involved in all forms of chiid abuse and neglect, and the development of numerous modalities of treatment in addition to case work in trying to help both abusive parents. We know that social workers’ care needs to be supplemented by individual psychiatric treatment, backed up by lay-therapists, crisis nurseries, parents’ groups, including self-help groups such as Parents Anonymous. family learning centers or family residentiai centers and therapeutic day schools for abused children. Thus. one provides a range of therapeutic modalities which are not only more effective but can very often speed the decision-making process in child abuse when relinquishment or termination of parental rights must be considered. We know that unless both parents receive active intervention with combinations of the above modalities, they will not easily tolerate treatment of their child. Indeed. when children are placed
Portions of this paper are reprinted with permission from The Abused Company. 491
Child. Copyright 1976. Baliinger Publishing
492
C. Henry Kempe
in therapeutic nursery schools and are moved from “frozen watchfulness” to awareness and then to personal creativity, parents view such a change almost invariabiy 3s a worsening of the child’s behavior which is often intolerable to them and results in termination of such treatment. On the other hand, if the parents themselves receive what they perceive to be useful and consistent support from lay-therapists or from other parents in self-help or parents’ groups and some professionals, they can work through these feehngs and tolerate changes in the chiid and begin to enjoy each other and their developing child. All of us have come to know that for many abusing f3miIies it is far easier to change the parents’ behavior than the basic psychopathology. but that is a big gain even so. Some therapists feel so very committed to the abusive parent, primarily the mother, that the child is seen 3s needed for her tre3tment. This burden is too heavy for any child and the outcome is generally disastrous. It happens most often when there is a separate therapist for each famify member and nobody sees the famify as 3 whole and the chiid as in need of early rescue. It is now possible to turn from the well-established approaches to the parents’ needs to the less well established approaches to the child. Prompt diagnosis of the emotional damage to the physically abused, sexually abused, or seriously neglected child is imperative if reasonable treatment 3pproaches are to be evaluated. But regardless of the amount of psychological and intellectual damage that has occurred, it is now clear that all such children, and indeed all their siblings, require some kind of outreach help from early on. Any child protective service department that fails to recognize the needs for therapeutic intervention on behalf of the child is simply failing to do an adequate job, Moreover, the erroneous notion that placing a child in foster care necessarily represents “treatment” must be overcome. Foster care can be therapeutic, but regrettably, it often is not. This is so because some of the children involved are not easy to care for, and the child may f3il foster c3re very much as he fails kindergarten and primary school later on. Further. the violent and abrupt separation from the parent is in itself traumatic to the abused child who invariably feels 3bandoned and often responsible, even at very young ages. The abused child in foster care cannot understand why he can oniy see his mother for an hour a week in 3 str3nge place and under difficult circumstances and usually c3nnot see his father at ail. Not only is visiting by biologic parents in foster homes discouraged or disallowed, but, further. foster parents often do not want to have the abused child attend a therapeutic day care center. When the child is comphant. as so many of these children are when they are first placed, the foster family may want to keep him just that way. While detailed experience with the diagnosis and treatment of abused children is a relatively recent development. it is already very clear that the needs of these children are enormous; that these needs represent a developments emergency; and their diagnosis and treatment by encouraging emotional growth and development and providing a safe and supportive curative environment must be initiated at once when the diagnosis of physical abuse has been made. Children are on a timetable of their own, and emotional growth and development of 3 child cannot tolerate 3 situation where the child is placed in an emotional deep freeze waiting for the time when the parents have been made better six or twelve months hence. Unfo~unately, often twelve months yield no greater progress. The time involved in improving parents is so enormous if considered in terms of a chiid’s emotional growth and development that it is little wonder that the child suffers grievously in the interim. The dilemma of welfare departments is clear: If they are to be totally safe in terms of prevention of reinjury or other forms of abuse, then foster care separation may seem the only approach. And yet foster care separation has been nbused by its prolonged nature; the cruel separation from the family when the child is thought to be, in time, eligible for return: and the selection of foster families who do not al!ow the parents ready 3ccess to the child in 3 safe environment. These negative results could be overcome in part by the devetopment of family learning centers where the chifdren live in small groups of five or seven with a stable and loving small staff, and the granting of ready access of the parents to their children on nights nnd weekends, and by the mother during the day. By providing an 3ccumte early diagnosis of the severity of emotional damage
Changing approaches
493
done to the child who has been abused or severely neglected, it is also frequently possible to identify those families where relinquishment or termination are the only means to ensure the child’s chances for emotional survival. All these determinations are far better made when the child and the parents are available to each other and to helping people. Most current foster home practices are not consonant with this approach. It is, indeed, heartwarming to see the great improvement made by many children who are remaining at home, but who do develop through a therapeutic nursery setting the ability to grow up emotionally and to heal the scars. They then can move into regular nursery school and into regular school, but they will probably always have to have a part of their lives supplemented by love from relative strangers since they quickly perceive that as far as their own parents are concerned. love is episodic, punishment is harsh, and understanding is minimal. The child quickly learns that there can be three lives: the sleeping life, the happy life in nursery school or school, and a more difficult but tolerable life with parents who only gradually develop their own feelings of self-esteem and appreciation of some of the unique qualities of their child. The compulsion felt by some therapists and judges to “keep the family together” may well be fatal. And in situations where a “safe family” will not exist no matter what is tried, and relinquishment or termination of parental rights is essential, all should be done to make early court action and quick adoption of the child by others a reality. In any event, we have learned in the past twenty years that we cannot wait until the parents are better. because this may take years, and they may not be all that much better when they are done. Rather, we must view intervention on behalf of the child in terms of his emergency medical care as only the very first step in assessing his other needs. It is a challenge for the already overworked departments of child protection to develop programs in collaboration with private and volunteer agencies in their communities on behalf of these very needy children. This requires a meaningful collaborative effort by social workers with child psychologists, child psychiatrists, developmentai specialists and teachers at all levels.That such effort will be rewarding in human and financial terms cannot be in doubt. The emotional cripples of today are the abused children of yesterday.
1982
l~l45-2134/82~6U1191-03~3 0010 Capyngh! E 1982 Pcr~amon Pms Ltd.
BRIEF COMMUNICATION
CHANGING APPROACHES TO TREATMENT OF CHILD ABUSE AND NEGLECT C. HENRY KEMPE, M.D. University of Colorado Health Sciences Cenrer. Denver, Colorado 80332
IT IS A fascinating question to consider why it is that during the past seventy years of active protective services work on behalf of troubled families, the focus of diagnosis and treatment has been upon the mother rather than on each member of the family, but it is not surprising. For one thing, the mother was more readily available to a social worker who was beginning to provide diagnostic and treatment services to a family while the father was at work during the time the social worker was available and he was often hostile and sometimes dangerous. Moreover. the philosophy of protective services for the past fifty years has been very much geared to the feeling that if a mother could be helped to be more competent or.more loving to her child, or able to stabilize her marriage, even though the father might be the primary abuser, that good things would of necessity happen in regards to the abused child and the other children in the family. It is not surprising. therefore, that whiie there has been an extensive literature on case work with mothers. there was much less written on work with fathers, and until recently. very little on the abused child. Pioneers in social work received little or no support from anyone, including pediatricians and psychiatrists. Historically, most studies have been retrospective, that is, starting out in juvenile detention homes. prisons and psychiatric clinics and hospitals. The very high incidence of child abuse of individuals in these institutions was often remarked upon but it is fair to say that the abused child was not dealt with either from a diagnostic or a treatment point of view until he was known to be deviant either by failing kindergarten and primary school, or requiring many foster home placements because of personality difficulties, or later on because of adolescent deviant behavior such as truancy or delinquency. On the other hand. all of us who have dealt with abused children over the past thirty years have been struck by the very massive emotional disturbance often found in these children even in the very first year of life. Our own ability to focus on the child involved in child abuse from the earliest time of our contact perhaps was delayed by our need first to know more about the psychodynamics of the adults involved in all forms of chiid abuse and neglect, and the development of numerous modalities of treatment in addition to case work in trying to help both abusive parents. We know that social workers’ care needs to be supplemented by individual psychiatric treatment, backed up by lay-therapists, crisis nurseries, parents’ groups, including self-help groups such as Parents Anonymous. family learning centers or family residentiai centers and therapeutic day schools for abused children. Thus. one provides a range of therapeutic modalities which are not only more effective but can very often speed the decision-making process in child abuse when relinquishment or termination of parental rights must be considered. We know that unless both parents receive active intervention with combinations of the above modalities, they will not easily tolerate treatment of their child. Indeed. when children are placed
Portions of this paper are reprinted with permission from The Abused Company. 491
Child. Copyright 1976. Baliinger Publishing
492
C. Henry Kempe
in therapeutic nursery schools and are moved from “frozen watchfulness” to awareness and then to personal creativity, parents view such a change almost invariabiy 3s a worsening of the child’s behavior which is often intolerable to them and results in termination of such treatment. On the other hand, if the parents themselves receive what they perceive to be useful and consistent support from lay-therapists or from other parents in self-help or parents’ groups and some professionals, they can work through these feehngs and tolerate changes in the chiid and begin to enjoy each other and their developing child. All of us have come to know that for many abusing f3miIies it is far easier to change the parents’ behavior than the basic psychopathology. but that is a big gain even so. Some therapists feel so very committed to the abusive parent, primarily the mother, that the child is seen 3s needed for her tre3tment. This burden is too heavy for any child and the outcome is generally disastrous. It happens most often when there is a separate therapist for each famify member and nobody sees the famify as 3 whole and the chiid as in need of early rescue. It is now possible to turn from the well-established approaches to the parents’ needs to the less well established approaches to the child. Prompt diagnosis of the emotional damage to the physically abused, sexually abused, or seriously neglected child is imperative if reasonable treatment 3pproaches are to be evaluated. But regardless of the amount of psychological and intellectual damage that has occurred, it is now clear that all such children, and indeed all their siblings, require some kind of outreach help from early on. Any child protective service department that fails to recognize the needs for therapeutic intervention on behalf of the child is simply failing to do an adequate job, Moreover, the erroneous notion that placing a child in foster care necessarily represents “treatment” must be overcome. Foster care can be therapeutic, but regrettably, it often is not. This is so because some of the children involved are not easy to care for, and the child may f3il foster c3re very much as he fails kindergarten and primary school later on. Further. the violent and abrupt separation from the parent is in itself traumatic to the abused child who invariably feels 3bandoned and often responsible, even at very young ages. The abused child in foster care cannot understand why he can oniy see his mother for an hour a week in 3 str3nge place and under difficult circumstances and usually c3nnot see his father at ail. Not only is visiting by biologic parents in foster homes discouraged or disallowed, but, further. foster parents often do not want to have the abused child attend a therapeutic day care center. When the child is comphant. as so many of these children are when they are first placed, the foster family may want to keep him just that way. While detailed experience with the diagnosis and treatment of abused children is a relatively recent development. it is already very clear that the needs of these children are enormous; that these needs represent a developments emergency; and their diagnosis and treatment by encouraging emotional growth and development and providing a safe and supportive curative environment must be initiated at once when the diagnosis of physical abuse has been made. Children are on a timetable of their own, and emotional growth and development of 3 child cannot tolerate 3 situation where the child is placed in an emotional deep freeze waiting for the time when the parents have been made better six or twelve months hence. Unfo~unately, often twelve months yield no greater progress. The time involved in improving parents is so enormous if considered in terms of a chiid’s emotional growth and development that it is little wonder that the child suffers grievously in the interim. The dilemma of welfare departments is clear: If they are to be totally safe in terms of prevention of reinjury or other forms of abuse, then foster care separation may seem the only approach. And yet foster care separation has been nbused by its prolonged nature; the cruel separation from the family when the child is thought to be, in time, eligible for return: and the selection of foster families who do not al!ow the parents ready 3ccess to the child in 3 safe environment. These negative results could be overcome in part by the devetopment of family learning centers where the chifdren live in small groups of five or seven with a stable and loving small staff, and the granting of ready access of the parents to their children on nights nnd weekends, and by the mother during the day. By providing an 3ccumte early diagnosis of the severity of emotional damage
Changing approaches
493
done to the child who has been abused or severely neglected, it is also frequently possible to identify those families where relinquishment or termination are the only means to ensure the child’s chances for emotional survival. All these determinations are far better made when the child and the parents are available to each other and to helping people. Most current foster home practices are not consonant with this approach. It is, indeed, heartwarming to see the great improvement made by many children who are remaining at home, but who do develop through a therapeutic nursery setting the ability to grow up emotionally and to heal the scars. They then can move into regular nursery school and into regular school, but they will probably always have to have a part of their lives supplemented by love from relative strangers since they quickly perceive that as far as their own parents are concerned. love is episodic, punishment is harsh, and understanding is minimal. The child quickly learns that there can be three lives: the sleeping life, the happy life in nursery school or school, and a more difficult but tolerable life with parents who only gradually develop their own feelings of self-esteem and appreciation of some of the unique qualities of their child. The compulsion felt by some therapists and judges to “keep the family together” may well be fatal. And in situations where a “safe family” will not exist no matter what is tried, and relinquishment or termination of parental rights is essential, all should be done to make early court action and quick adoption of the child by others a reality. In any event, we have learned in the past twenty years that we cannot wait until the parents are better. because this may take years, and they may not be all that much better when they are done. Rather, we must view intervention on behalf of the child in terms of his emergency medical care as only the very first step in assessing his other needs. It is a challenge for the already overworked departments of child protection to develop programs in collaboration with private and volunteer agencies in their communities on behalf of these very needy children. This requires a meaningful collaborative effort by social workers with child psychologists, child psychiatrists, developmentai specialists and teachers at all levels.That such effort will be rewarding in human and financial terms cannot be in doubt. The emotional cripples of today are the abused children of yesterday.