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Child abuse treated in a psychiatric day hospital
Child Abuse and Neglect, Vol. 3, pp. 699 -707. © Pergamon Press Ltd., 1979. Printed in Great Britain.
0145-2134/79/0901-0699 $02.00/0.
CHILD ABUSE TREATED IN A PSYCHIATRIC DAY HOSPITAL
Joy E. West and Eric D. West Wallington Day Hospital, Walllngton, Surrey, England
INTRODUCTION E x p e r i e n c e w i t h p a r e n t s and c h i l d r e n i n a p s y c h i a t r i c day h o s p i t a l h a s shown c h i l d abuse t o be a l m o s t i n v a r i a b l y the c u l m i n a t i o n o f weeks or months o f o f t e n u n r e c o g n l s a d s t r e s s and d i f f i c u l t y i n c o p i n g . E f f o r t s have been made by w o r k e r s i n v a r i o u s d i s c l p l i n e s t o e l u c i d a t e p r e d i s p o s i n g or p r e c i p i t a t i n g f a c t o r s i n p a r e n t s , or c h i l d r e n , or b o t h ( R e f s . 1 - 1 1 ) , and t h e t h e r a p e u t i c a p p l i c a t i o n s o f s u c h knowledge i n a p a e d i a t r i c h o s p i t a l h a v e been d e s c r i b e d by O u n s t e d , Oppenheimer and L i n d s a y ( 1 2 ) ; i n g e n e r a l p r a c t i c e by Beswick, Lynch and R o b e r t s (13) and i n NSPCC community work by C a s t l e and h i s c o l l e a g u e s ( 1 4 ) . The p r e s e n t p a p e r i s a p r O S p e c t i v e c o n t r o l l e d s t u d y o f 50 c h i l d a b u s e r s r e f e r r e d p r i m a r i l y £or p s y c h i a t r i c i l l n e s s and t r e a t e d w i t h t h e i r c h i l d r e n i n a p s y c h i a t r i c day h o s p i t a l between J a n u a r y 1973 and December 1976. Cpmparison was made w i t h ( a ) 50 p s y c h i a t r i c a l l y i l l b u t no~a b u s i n g p a r e n t s u n d e r g o i n g t r e a t m e n t a t t h e same t i m e and (b) a group o f 30 m o t h e r s s e l e c t e d by h e a l t h v i s i t o r s f o r t h e i r p o s i t i v e c h i l d - r e a r l n g a b i l i t i e s . The o b j e c t o f t h e s t u d y was t o d e t e r m i n e how a b u s i v e p a r e n t s i n t h i s s e t t i n g d i f f e r e d b o t h from o t h e r p s y c h i a t r i c p a t i e n t s and from h e a l t h y m o t h e r s and, where p o s s i b l e , t o u s e t h i s i n f o r m a t i o n i n t h e t h e r a p e u t i c s e t t i n g t o p r e v e n t f u r t h e r a b u s e . T h i s work was t h e p r e l i m i n a r y t o a c u r r e n t r e s e a r c h scheme i n p r i m a r y p r e v e n t i o n i n which m o t h e r s i d e n t i f i e d as v u l n e r a b l e a r e b e i n E s e l e c t e d b e f o r e d i s c h a r g e from t h e m a t e r n i t y h o s p i t a l and o f f e r e d d c a i c i l l a r y s u p p o r t d u r i n g t h e c h i l d ' s f i r s t two y e a r s .
PATIENTS AND METHODS We a t f i r s t d i v i d e d t h e p a t i e n t s i n t o a group o f t h o s e known t o have c a u s e d n o n - a c c l d e n t a l i n j u r y and a c o n t r a s t g r o u p . However, d u r i n g t h e c o u r s e of t r e a t m e n t we found t h e r e were more a t r i s k f m n i l l e s t h a n we o r i g i n a l l y t h o u g h t (15, 16). I n d e e d , t h e r e seemod few who were n o t at least potential child-abusers. In an a t t e m p t t o e v o l v e a p r a c t i c a l t h e r e f o r e d i v i d e d them as f o l l o w s :
method of i d e n t i f i c a t i o n
and r e h a b i l i t a t i o n ,
we
Hiah R i s k F i f t y p a r e n t s (48 m o t h e r s and 2 f a t h e r s ) , known t o have i n j u r e d or n e g l e c t e d t h e i r c h i l d r e n and on t h e S o c i a l S e r v i c e s ' A t R i s k ' r e g i s t e r . R e f e r r a l s were p r i m a r i l y f o r p s y c h i a t r i c i l l n e s s , 23 (~6%) b e i n g r e f e r r e d by g e n e r a l p r a c t i t i o n e r s , 12 (24%) by o t h e r p s y c h i a t r i s t s , 10 (20%) by t h e c o ~ n u n i t y p h y s i c i a n i n c h i l d h e a l t h and 5 (10%) by p a e d l a t r l c i a n s . Low R i s k A c o n t r a s t group o f 50 p s y c h i a t r i c a l l y i l l b u t n o n - a b u s i n g p a r e n t s . Of t h e 48 m o t h e r s and 2 f a t h e r s , 36 (72%) were r e f e r r e d by g e n e r a l p r a c t i t i o n e r s , 8 (16%) by o t h e r p s y c h i a t r i s t s and 6 (12%) by paediatrlcians. With regard to child abuse, some admitted during treatment: ' I have felt like it' or ' I have sometimes felt afraid I might do it', but close observation 699
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of p a r e n t - c h i l d i n t e r a c t i o n o v e r s e v e r a l m o n t h s , c o n f i r m e d by l i a i s o n w i t h g e n e r a l p r a c t i t i o n e r s and health visitors made it seem very unlikely, and none has given cause for concern i n t h i s r e s p e c t d u r i n g t h e p e r i o d o f s t u d y end f o l l o w - u p t o d a t e . ASSESSMENT
A l l p a t i e n t s (High R i s k and Low Risk) were g i v e n a s t a n d a r d p s y c h i a t r i c i n t e r v i e w a t r e f e r r a l A d d i t i o n a l information was f r e q u e n t l y f o r t h c o ~ n g d u r i n g t h e c o u r s e of t r e a t m e n t , or from r e l a t i v e s , h e a l t h v i s i t o r s or s o ~ i e l w o r k e r s . P s y c h i a t r i c i l l n e s s wee c l a s s i f i e d a c c o r d i n g to the International C l a s s i f i c a t i o n of Disease (W.H.O. 1968). A s u b - s a m p l e of 30 m o t h e r s from t h e High Risk and 30 from t h e Low R i s k group were i n v e s t i g a t e d more i n t e n s i v e l y , c ~ p l e t i n g t h e G e n e r a l H e a l t h Q u e s t i o n n a i r e (17) to a s s e s s n o n p s y c h o t i c p s y c h i a t r i c d i s t u r b a n c e ; t h e ~ a u d s l e y P e r s o n a l i t y I n v e n t o r y (18) t o a s s e s s n e u r o t l c l s m end e x t r a v e r s l o n ; s i x s u b - t e s t s o f t h e W e c h s l e r A d u l t I n t e l l i g e n c e Scale ( 1 9 ) , o f wh6ch t h r e e were v e r b a l - c o m p r e h e n s i o n , s i ~ l a r i t l e s and v o c a b u l a r y - and t h r e e p e r f o r m a n c e p i c t u r e c o m p l e t i o n , block d e s i g n and o b j e c t a s s e m b l y ; t h e M i n n e s o t a ~ u l t l p h a s i c P e r s o n a l i t y I n v e n t o r y (20) t o a s s e s s components o f p e r s o n a l i t y ; f i n a l l y , an e l e c t r o e n c e p h a l o g r a m was r e c o r d e d on t h o s e w i l l i n g t o c o o p e r a t e . The same b a t t e r y o f t e s t s was completed by a second c o n t r a s t group of 30 p s y c h i a t r i c a l l y h e a l t h y m o t h e r s o f p r e - s c h o o l c h i l d r e n s e l e c t e d by h e a l thyvisitors for positive child-rearing abilities. TREATI~NT The day h o s p i t a l i s a t h r e e - s t o r e y h o u s e in a r e s i d e n t i a l o u t e r London suburb ( p o p . 1 6 7 , 0 0 0 ) and h a s an a v e r a g e d a i l y a t t e n d a n c e o f 35 a d u l t p a t i e n t s o f e l l a g e s . An i n t e g r a l n u r s e r y opens on t o a g a r d e n / p l a y g r o u n d , and i s s t a f f e d t o accommodate up t o 15 p r e - J c h o o ~ c h i l d r e n , w h i l e o l d e r s i b l i n g s may a t t e n d d u r i n g s c h o o l h o l i d a y s . Twice-weekly group p s y c h o t h e r a p y i s c e n t r a l t o t h e t r e a t m e n t , with b e h a v i o u r a l methods employed f o r s o c i a l end o t h e r p h o b i a s , and a l s o i n t r o d u c e d i n t o t h e f i e l d of p a r e n t / c h i l d interaction. Those on t h e ' A t R i s k ' r e g i s t e r and a l l women i n t h e c h i l d b e a r i n g y e a r s who are p r e s c r i b e d psychotropic medication are s t r o n g l y encouraged to seek fm,~ly planning advice a n u r s e accompanylng them t o t h e c l i n i c i f n e c e s s a r y . N u r s e r y h o u r s a r e from 10.30 t o 3 . 3 0 , and p a r e n t s j o i n t h e c h i l d r e n f o r an h o u r a t l u n c h t i m e . They a r e a l s o a l l o t t e d a two-hour s e s s i o n a ~ e k when t h e y a r e r e q u i r e d t o be i n t h e n u r s e r y a l o n g s i d e t h e c h i l d r e n , w h i l e r e g u l a r l a s t i n g s w i t h s t a f f g i v e p a r e n t s a chance t o t h r a s h o u t n u r s e r y p r o b l e m s . Not i n f r e q u e n t l y s t a f f c h i l d r e n m i n g l e w i t h p a t i e n t s ' c h i l d r e n and t h i s , t o g e t h e r w i t h t h e p r e s e n c e of l e s s d i s t u r b e d p a r e n t s and g r a n d p a r e n t s e m o ~ t h e p a t i e n t s , p r o v i d e s a u s e f u l model o f p a r e n t i n g h e h a v i o u r . Spouses end o t h e r r e l a t i v e s a r e welcome a t a l l t i m e s , f r e q u e n t l y t e l e p h o n e , and a r e e n c o u r aged t o a t t e n d t h e m o n t h l y m a r i t a l group or r e l a t i v e s ' m e e t i n g . H e a l t h v i s i t o r s a t t e n d f o r m o n t h l y s e m i n a r s end s o c i a l workers have an open i n v i t a t i o n t o weekly c a s e r e v i e w s . In b e t w e e n , t h e r e i s f r e q u e n t l i a i s o n , and i f an 'At r i s k ' p a t i e n t f a i l s to a t t e n d w i t h o u t a d e q u a t e r e a s o n , c a n n o t be c o n t a c t e d by t e l e p h o n e , or i f a t e l e p h o n e e n q u i r y makes i t c l e a r she i s d i s t r e s s e d , h e r s o c i a l w o r k e r , h e a l t h v i s i t o r or v e r y o f t e n a n u r s e from t h e day h o s p i t a l w i l l v i s i t t h e 8 m u d a y , g i v i n g w h a t e v e r p r a c t i c a l h e l p may be needed. A comnunity p h y s i c i a n i n c h i l d h e a l t h a t t e n d s t h r e e - m o n t h l y to c a r r y o u t d e v e l o p m e n t a l h e a l t h checks on t h e c h i l d r e n and t o d i s c u s s any m a t t e r s t h e p a r e n t s choose to r a i s e , w h i l e r e l e v a n t c a s e c o n f e r e n c e s a r e f r e q u e n t l y h e l d a t t h e day h o s p i t a l ; t i ~ l y reminders to p a t i e n t s t h a t , however p e r m i s s i v e t h e a t m o s p h e r e , t h e r e i s o v e r a l l s e r i o u s c o n c e r n f o r t h e s a f e t y and w e l l - b e l n g o f t h e c h i l d r e n . ~SULTS A c t u a r i a l and S o c i a l Data A~e. With a mean age of 26.2 y e a r s a t r e f e r r a l , t h e High Risk group were s i g n i f i c a n t l y younger than the Low Risk patients (p = 0.01), with more than three times as many subjects in the 20-24 age range (p - 0.001), the mean age of the Low Risk group being 29.6 years (Fig. I)
C h i l d Abuse Treatment i n a P s y c h i a t r i c Day H o s p i t a l
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Social class. F i g u r e 2 shows t h a t both High R i s k s u b j e c t s and t h e i r spouses span a l l s o c i a l c l a s s e s , w i t h siK'ni,ficant d i f f e r e n c e s (p = 0.001) c o n t r i b u t e d by u n d e r - r e p r e s e n t a t i o n o f s u b j e c t s i n s o c i a l c l a s s I I and o v e r - r e p r e s e n t a t i o n o f s p o u s e s / c o h a b l t e e s i n s o c i a l c l a s s V compered~r~th t h e Low ~4sk p a t i e n t s ( F i g . 3).
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Countr~ o f o r i g i n and r e l i g i o n . No s / ~ n f l l c a n t d i f f e r e n c e s emerged, a p p r o x i m a t e l y 85X o f both High and Low Risk p a c z a n t s h a v i n g been born i n t h e United Kingdom, and more than 60Z i n both groups b e i n g n o . n e l l y Church o f England. Family background. S i x t y - f o u r p e r c e n t o f the High Risk p a t i e n t s were f i r s t or second c h i l d r e n o f the f a m i l y compared w i t h 80Z o f the Low Risk. Five High Risk s u b j e c t s and two Low Risk a d m i t t e d to b e i n g i l l e g l t ~ t e ; Four High Risk and t h r e e Low Risk l o s t a p a r e n t through d e a t h b e f o r e t h e age o f 11, w h i l e p a r e n t s o f f i v e i n each group d i v b r c e d or s e p a r a t e d w h i l e t h e s u b j e c t s were under t e n . There are no s i g n i f i c a n t d i f f e r e n c e s i n t h e s e f l n d l n g s ~ Three o f t h e High Risk p a t i e n t s were adopted in i n f a n c y ; e i g h t (16Z) had been i n c a r e d u r i n g c h i l d h o o d f o r p e r i o d s r a n g i n g from t h r e e months t o 15 y e a r s , w h i l e a f u r t h e r 2 (4Z) f e l t thems e l v e s t o be r e j e c t e d by t h e i r f a d l i e s , both b e i n g brought up by a widowed grandmother. In
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the Low Risk group two (4%) had each spent a few months in care while their mothers underwent psychiatric treatment, and these differences are significant (p = 0.05), as is the finding that while 14 (28%) of the High Risk patients recalled being beaten or physically ill-treated as children, the same applied to only four of the Low Risk (p = 0.01). Housing.
Figure 4 shows highly significant differences
(p = 0.001) due to the fact that
p r o p o r t i o n a t e l y more o f the High Risk p a t i e n t s l i v e d i n c o u n c i l f l a t s , l e s s were house-owners.
and p r o p o r t i o n a t e l y
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~ . r i t a l and r e p r o d u c t i v e . Highly s i g n i f i c e n t d i f f e r e n c e s e ~ r g e d (p = 0.001) both i n t h e numbers in the High Risk group who had s e p a r a t e d o r , d l v o r c e d p r i o r to r e f e r r a l (a11" had taken on new p a r t n e r s ) , and i n the i n c i d e n c e of v i o l e n c e between p a r t n e r s as compared w i t h the Low Risk p a t i e n t s . But t h e r e were no s i g n i f i c a n t d i f f e r e n c e s i n the numbers with c r i ~ n a l r e c o r d s of v i o l e n c e ( s i x High Risk and two Low R i s k ) , n o r i n the p r o p o r t i o n s who r a t e d t h e i r s e x l i v e s as u n s a t i s f a c t o r y , which were h i g h i n both groups - 26 (52Z) o f High Risk and 20 (40X) o f Low Risk. With an average age of 20.5 y e a r s a t the b i r t h o f t h e i r f i r s t c h i l d , the High Risk p a t i e n t s were s i g n i f i c a n t l y younger (p = 0 . 0 1 ) . T h i r t y (60%) o f the s u b j e c t s were p r e g n a n t a t the time , of m a r r i a g e , compared with 9 (18%) o f the Low R i s k , h i g h l y s i g n i f i c a n t a t the 0.001 l e v e l . S i m i l a r l y w i t h the f i n d i n g t h a t 15 (30%) of the s u b j e c t s had an i l l e g i t i ~ a t e c h i l d , and two (4Z) had. two~ compared w i t h only one o f the Low Risk p a t i e n t s . Although pix (12%) o f the High Risk p a t i e n t s who s u b s e q u e n t l y i n j u r e d t h e i r c h i l d r e n had been r e f u s e d t e ~ a i n a t i o n of the r e l e v a n t pregnancy, t h e r e was no s i g n i f i c a n t d i f f e r e n c e w i t h the Low Risk, i n whom two (4%) were r e f u s e d . Diagnosis a t r e f e r r a l . There were no s i g n i f i c a n t d i f f e r e n c e s between Kigh Risk and Low Risk p a t i e n t s gs r e g a r d s d i a g n o s i s , the m a j o r i t y - 41 (82Z) High Risk and 38 (76Z) Low Risk b e i n g diagnosed as d e p r e s s i v e n e u r o s i s , which in 20 (40Z) High Risk and 17 (34%) Low Risk was o f p u e r p e r a l o r i g i n . One p a t i e n t i n the High Risk and t h r e e i n t h e Low Risk group s u f f e r e d from p u e r p e r a l p s y c h o s i s o f u n r e m i t t i n g t y p e , and t h r e e i n each group from m a n i c - d e p r e s s i v e p s y c h o s i s . While only four (8%) o f the High Risk p a t i e n t s were diagnosed as p r i m a r i l y p e r s o n a l i t y d i s o r d e r s a t the time o f r e f e r r a l , compared w i t h two Low Risk p a t i e n t s , d u r i n g t r e a t u n t i t became c l e a r t h a t i ~ t u r l t y , dependence, a t t e n t i o n - s e e k i n g and i m p u l s l v e behavlour were more a p p a r e n t Jmong High Risk than Low Risk p a t i e n t s . Previous p s y c h i a t r i c m o r b i d i t y . Twenty-four o f the High Risk p a t i e n t s (48Z) had a p a s t h i s t o r y o f p s y c h i a t r i c i l l n e s s compared w i t h f o u r t e e n (28%) Low Risk, s i g n l f i c a n t at t h e 0.05 l e v e l ; s i m i l a r l y with the p a s t h i s t o r y o f o v e r d o s e / s e l f - i n j u r y - 25 (50%) High Risk and 8(16%)
Child Abuse Treatment in a Psychiatric Day Hospital
703
Low Risk , highly significant at the 0 . 0 0 1 l e v e l . Among s p o u s e s , t h e r e were no s i g n i f i c a n t differences in morbidity from a psychiatric viewpoints I0 (20Z) of spouses of High Risk patients and 4 (8Z) Low Risk admitting to a history of psychiatric illness. Fami17 c o m p o s i t i o n . S e v e n t e e n High R i s k p a r e n t s (34~) h a d one c h i l d a t t h e t i m e of r e f e r r a l and 23 (46%) h a d tWOs compared w i t h 15 (30~) and 25 (50X) r e s p e c t i v e l y o f t h e Low R i s k g r o u p . The largest families had four children: seven High Risk families (14X) had three and three(6%) had four, a total of 96 children of High Risk families and 98 Low Risk. Thls included six High Risk families and one Low Risk containing a child fr,,- a previous marrlage/llaison. S e v e n t y - s e v e n o f t h e t o t a l number o f p r e g n a n c i e s ( 8 0 . 2 X ) were s a i d by High R i s k p a r e n t s t o h a v e b e e n u n p l a n n e d , w h i l e t h e Low R i s k p a r e n t s a d m i t t e d t h i s of 36 ( 3 6 . 7 Z ) s a h i g h l y s i g n i f i c a n t difference (p = 0.001). We found no significant differences, however, in the degree of perinatal pathology resulting in early separation of mother and child - 16 (16.7%) of the total 96 births in the High Risk f-,,ilies and |4 (14.3Z) in the Low Risk. This included four caesarian sections in the High Risk and two in the Low Risk, and two premature twin deliveries in the High Risk fmniliea. There were five physically or mentally handicapped children in the High Risk and three in t h e Low Risk group. Of t h e a b u s e d c h i l d r e n , t h e r e w e r e 21 b o y s and 29 g i r l s , w i t h t h e h i g h e s t number - 14 (28%)i n t h e one t o two y e a r a g e r a n g e . O v e r a l l 26 c h i l d r e n (52Z) were i n j u r e d i n t h e f i r s t two y e a r s , and 35 (70Z) s u c h i n c i d e n t s o c c u r r e d b e f o r e t h e t h i r d b i r t h d a y . I n 38 ( 7 6 ~ ) , t h e a b u s e d c h i l d was t h e e l d e s t or o n l y c h i l d o f t h e f a m i l y , i n c l u d i n g t h r e e c h i l d r e n f r o m previous liaisons. I n 10 f a n i l i e s (20X) more t h a n one c h i l d h a d b e e n i n j u r e d or n e g l e c t e d , i n c l u d i n g t h e two s e t s o f t w i n s . 35 N
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Test Batteries and I n v e s t i g a t i o n s Gene'ral Health questionnaire (GHq). With a s c o r e o f 12 t a k e n a s t h e d e m a r c a t i o n b e t w e e n n o r m a l i t y and n o n - p s y c h o t i c p s y c h i a t r i c d i s t u r b a n c e , b o t h High and Low R i s k p a t i e n t g r o u p s showed e v i d e n c e o f p s y c h i a t r i c d i s t u r b a n c e w i t h s c o r e s o f 2 4 . 5 and 2 2 . 2 r e s p e c t i v e l y (mean s c o r e s ) , t h e d i f f e r e n c e b e t w e e n t h e means n o t r e a c h i n g s i g n i f i c a n c e . The h e a l t h y m o t h e r groups however, had a mean score of 2.9, with a highly significant d i f f e r e n c e b e t w e e n them and b o t h t h e High a n d Low R i s k p a t i e n t g r o u p s (p - 0 . 0 0 1 ) . Wechsler Adult IntelliGence three performance sub-tests
S c a l e (WAIS). The mean s c o r e s , b a s e d on t h e t h r e e v e r b a l and showed a g r a d a t i o n f r o m t h e High R i s k t h r o u g h Low R i s k t o t h e
704
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Mean s c o r e s on the f u l l s c a l e were: High Risk
93.3; Low Risk 106.2; healthy mothers 110.6, highly significant at the 0.001 level between High Risk and Low Risk groups, and also between High risk and healthy mother groups, but wlth no significant difference between the Low risk and healthy mothers.
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Maudsley Personality InVentory.
Maudsle~ P e r s o n a l i t y I u v e n t o r ~ (MPI). All t h r e e groups s c o r e d 20 plus on the n e u r o t l c i s m s c a l e , w i t h the High l i s k p a t i e n t s showing the most n e u r o t i c i s m and • g r a d a t i o n through Low Risk t o h e a l t h y m o t h e r s , with the r e v e r s e g r a d a t i o n on t h e e x t r a v e r s i o n s c a l e w i t h the h e a l t h y mothers s c o r i n g h i g h e s t , the d i f f e r e n c e s on both s c a l e s between High Risk and h e a l t h y mothers b e i n g h i g h l y 8 i K n l f i c a n t at the 0.001 l e v e l ( F i g . 7). Minnesota.Multiphasic. . P e r s o n a l i t y I n v e n t o r7 (MMPI). High Risk and Low Risk p a t i e n t s showed e q u a l l y h~8h m o r b i d i t y on a l l s c a l e s compared with the h e • i t h y m o t h e r s , the mean s c o r e on the d e p r e s s i o n s c a l e b e i n g the h i g h e s t i n both p a t i e n t groups, the d i f f e r e n c e from the h e a l t h y mothers b e l n g h l g h l y s i g n i f i c a n t (p = 0 . 0 0 1 ) . The only s i g n i f i c a n t d i f f e r e n c e s between High and Low Risk groups were on the m a s c u l i n i t y / f e m i n l n l t y s c a l e , w i t h h i g h e r f e m i n i n i t y mean s c o r e i n High Risk p a t i e n t s (p - 0 . 0 1 ) , who a l s o had h i g h e r mean s c o r e s on the mania s c a l e (p = 0 . 0 5 ) . E l e c t r o e n c e F h a l o z r a p h y (EEG). EECs were s c o r e d ' b l i n d ' on an a r b i t r • r y s c a l e from 1 (normal • I p h a r h y t h m ) , t h r o u g h 2 (some t h e r e b u t mainly a l p h a ) , 3 (more t h e r e than 2), 4 ( t h e t a w i t h some parorysmal e l e m e n t s ) , t o 5 (more p e r s i s t e n t t h e r e with marked paroxysmal e p i s o d e s q u a s l - e p i l e p t i c - and some d e l t a f r e q u e n c i e s ) . Of the 22 High Risk p • t l e n t s , the mean s c o r e was h i g h e s t a t 2.36 (S.D. 1 . 2 0 ) ; o f the 24 Low Risk the mean s c o r e was 2.04 ( S . D . I . i 0 ) and the 29 h e a l t h y mothers had a mean s c o r e o f 1.96 (S.D. 0 . 9 0 ) . All groups had some very abnormal r e c o r d s , and w h i l e t h e r e were no s t a t l s t i c a ~ l y s i g n i f i c a n t d i f f e r e n c e s , the most abnormal r e c o r d s with e p i l e p t i c - t y p e f e a t u r e s were seen i n the High Risk group. RESULTS OF TREATMENT The mean duration of day hospital treatment in the High Risk group was 14 months, an average of 180 attendances, the length of stay ranging from a few weeks to two years, c 0 ~ a r e d with • mean of eight months, average 80 •ttendance8 in the Low Risk group. The majority have been followed up as outpatients after discharge. While there was no serious injury to • child during treatment or follow-up to date, in four families there were minor traumata, a repeat injury rate of 8Z. In two other casesj when it bec~me clear that the family had reached their limit of tolerance, children were received into c a r e of the social services for • few weeks - one was a family of three boys in which all the children had been at risk over a period of seven years, the other • f m i l y of twln boys.
Child Abuse Treatment in a Psychiatric Day Hospital
705
S e v e r a l High Risk p a t i e n t s on p s y c h o t r o p i c m e d i c a t i o n , p a r t i c u l a r l y t r i c y c l i c a n t i d e p r e s s a n t s and benzodiazepineSs c ~ e n t e d t h a t w h i l e taking drugs they f e l t a b l e to ' s t a n d a p a r t ' from t h e m s e l v e s , h i t t l n g out a t t h e i r c h i - d w i t h o u t t h e customary f e e l i n g s o f remorse. Salmasn(21) and Workman (22) and s u b s e q u e n t l y o t h e r workers i n the f i e l d o f c h i l d abuse have cmmmented on t h e p a r a d o x i c a l e f f e c t of ben © d i a s e p i n e s i n r e l e a s i n g a g g r e s s i o n , and though i n our e x p e r i ence such an e f f e c t was noted only i n the more u n s t a b l e p a t i e n t s , we were e x t r e m e l y c s u t i o u s about p ~ e s c r i b i n s f o r t h o s e thought t o be prone t o a g g r e s s i v e o u t b u r s t s or l o s s o f c o n t r o l . A n t i c o n v u l s a n t s seemed to be a u s e f u l ad~anct i n management of i m p u l s i v e l y a g g r e s s i v e p a t i e n t s with e p i l e p t i c - t y p e EEGs. For t h e i r p a r t , the s o c i a l s e r v i c e s have made e v e r y e f f o r t t o reduce the p r e s ~ r e on t h e s e a t r i s k f a m i l i e s . P a t i e n t s have n o t i n f r e q u e n t l y been t r a n s p o r t e d t o the day h o s p i t a l w i t h t h e i r c h i l d r e n , the h o u s i n g department has g i v e n s y m p a t h e t i c c o n s i d e r a t i o n t o r e h o u s i n g where a p p r o p r i a t e , w i t h p r i o r i t y f o r t h o s e i n h i g h - or m e d i , ~ - r i s e f l a t s , and on d l s c h a r s e from the day h o s p i t a l , c h i l d r e n have been g i v e n p r i o r i t y f o r n u r s e r y o r n u r s e r y school p l a c e s as a p p r o p r i a t e . DISCUSSION While i t i s g e n e r a l l y a c c e p t e d t h a t the a e t l o l o g y o f c h i l d abuse i s m u l t i f a c t o r i a l , the p a u c i t y o f c o n t r o l l e d s t u d i e s has s o n e t i m e s led t o u n c r i t i c a l a c c e p t a n c e o f a n e c d o t a l d a t a . The S e l e c t Committee on V i o l e n c e i n the Family (23) has s t r e s s e d the need f o r f u r t h e r r ~ e s e a r c h on p r e v e n t i v e s c r e e n i n g o f f a m i l i e s a t r i s k , as w e l l as on t r e a t m e n t of f ~ l i e s where abuse has o c c u r r e d . In the p r e s e n t s t u d y , l l k e C a s t l e e t e l . ( 1 4 ) , we found the index s u b j e c t s t o be s i ~ i f i c a n t l y younger t h a n the c o n t r a s t group a t the b i r t h o f t h e i r f i r s t c h i l d , and as i n h i s r e s e a r c h , as w e l l as i n t h e c o n t r o l l e d s t u d y of Smich, Hanson and Noble ( 3 ) , we found s l s n i f i c a n t l y ~ r e p r e m a r i t a l c o n c e p t i o n s , unplanned p r e s n a n c l a s and i l l e g i t i m a t e c h i l d r e n , a h i g h e r i n c i d e n c e o f d e p r i v a t i o n and f a m i l y v l o l e n c a from c h i l d h o o d onwards and lower aeerlq~e i n t e l l i g e n c e i n the High Risk p a t i e n t s . But our f i n d i n g s d i f f e r from t h o s e o f Smith and h i s c o l l e e n s in which almost h a l f o f t h e i r sample of i n d e x mothers had IQs b o r d e r i n g on t h e subnormal, nor did we f i n d the t r e n d toward lower v e r b a l lQs o f C a s t l e ' s s e r i e s . Our r e s u l t s s u g g e s t chat p s y c h i a t r i c m o r b i d i t y may be o f l e s s importance than has been p r e v i o u s l y s u g g e s t e d , i n c l u d i n S c o n t r o l l e d s t u d i e s by Smith, Hanson and Noble (14) and by Lynch and Roberts ( 9 ) . Nor do our EEG f i n d i n g s , which r e p r e s e n t the f i r s t comparative s t u d y in c h i l d a b u s e r s , s u b s t a n t i a t e t h e s u g g e s t i o n made by Smith, H o n l g s b e r g e r and Smith (4) t h a t an abnormal EEC may be u s e f u l in p r e d i c t i n g c h i l d abuse. Unlike O l i v e r and Cox (24) and Lynch ( 9 ) , we d i d n o t f i n d more p e r l n a t a l pathology i n the c h i l d r e n who were l a t e r abused: we found no s i g n i g l c a n t d i f f e r e n c e s between the High Risk and Low Risk p a t i e n t g r o u p s , and the p e r i n a t a l p a t h o l o g y i n the h e a l t h y mother group was m a r g i n a l l y h i g h e r . Moreover, we were unable t o c o r r o b o r a t e L y n c h ' s f i n d i n g t h a t where t h e r e i s an abused c h i l d d i s a d v a n t a g e d by p e r l n a t a l p a t h o l o g y , h e a l t h ~ s i b l i n g s are l e f t unharmed; o b s e r v a t i o n o f p a r e n t s i n t h i s c a t e g o r y over t h r e e y e a r s o r more has shown t h a t s e v e r a l have t r a n s f e r r e d t h e i r a g g r e s s i o n on t o the next youngest c h i l d . Compared w i t h the e x p e r i e n c e s o f S k i n n e r and C a s t l e (1) t h a t more than 60Z o f c h i l d r e n who were r e t u r n e d home were l a t e r s e e n w i t h f u r t h e r i n j u r i e s , and o f C a s t l e ' s l a t e r work (14) where, d e s p i t e i n t e n s i v e s u p p o r t i n the community 54X r e c e i v e d f u r t h e r i n j u r i e s , a l b e i t minors as w a l l as o f NSPCC r e p o r t s from t h e i r s p e c i a l c e n t r e s in Manchester and L i v e r p o o l t h a t a p p r o x i m a t e l y two out o f 10 abused c h i l d r e n are r e - l n j u r e d , our r e s u l t s seem e n c o u r a g i n g . One f a c t o r i s u n d o u b t e d l y t h e masslve s u p p o r t some o f the f l a i l i e s r e c e i l e d over a prolonged p e r i o d . More i m p o r t a n t , p e r h a p s , was the o v e r t p s y c h i a t r i c i l l n e s s i n the i n d e x group which led t o e a r l y r e f e r r a l . T h i s , t o g e t h e z with t h e f a c t t h a t a l l s o c i a l c l a s s e s are r e p r e s e n t e d i n our s t u d y , s u g g e s t s t h a t we a r e s e e i n g a d i f f e r e n t p a r t o f the s p e c t r u m o f c h i l d abuse. C e r t a i n l y we are l e a s t s u c c e s s f u l w i t h f a L ~ l i e s r e f e r r e d t o us a f t e r long involvement w i t h c a s e w o r k e r s on the a l e r t f o r c h i l d abuse; i n e v i t a b l y they then see us as t h e end o f a long l i n e of what t h e y i n t e r p r e t as a u t h o r i t y f i g u r e s , and even t h o s e who keep the i n i t i a l appointment are prone t o d e f a u l t e a r l y on i n t r e a t m e n t . On c l i n i c a l grounds, our f i n d i n g s c o n f i r m t h a t the e a r l i e r the i n t e r v e n t i o n , the g r e a t e r t h e chance o f s u c c e s s f u l r e h a b i l i t a t i o n . Nevertheless, rehabilitatic~
must s t i l l
o f t e n be d i r e c t e d t ~ a r d s
e n c o u r a g i n g an u n w i l l i n g
706
J . E . West and E. D. West
or reluctant parent to care for an unplanned or even unwanted child, often at prodigious expense. Current efforts being made in maternity units and by health visitors undoubtedly help to prevent child abuse, and Emery (25), in an investigation into cot deaths, found an u n e x p e c t e d l y lower i n c i d e n c e o f f a t a l i t i e s amongst i n f a n t s deemed t o be a t r i s k who had b e e n f o l l o w e d up by s p e c i a l l y r e c r u i t e d h e a l t h v i s i t o r s . Beswick, Lynch and Roberts (13) a l s o r e p o r t p r o m i s i n g r e s u l t s t h r o u g h o f f e r i n g p r a c t i c a l h e l p i n a g e n e r a l p r a c t i c e s e t t i n g to 22 f a m i l i e s at r i s k . H e a l t h v i s i t o r s a r e i d e a l l y p l a c e d and h a v e the a p p r o p r i a t e s k i l l and knowledge t o f i t them f o r p r e v e n t i v e work o f t h i s s o r t , though i n most a r e a s t h e i r o t h e r d u t i e s p r e c l u d e t h i s . Yet the i m p o r t a n c e o f d o m i e i l l a r y s u p p o r t emerged in our s t u d y when i t b e t - - , , c l e a r t h a t some of t h e more d i s t u r b e d High Risk p a t i e n t s were making a h a b i t o f n o n - a t t e n d a n c e or of t e l e p h o n i n g in d i s t r e s s , even threatening they might harm their child if help were not i~m~ediately forthcoming, aware that a social worker, or more probably, a nurse from the day hospital would promptly visit and stay to help sort out the difficulties; individual attention that was much sought after. As an extension of t h i s , we asked the Home Help department for a family aide for certain families at what for them were peak periods, most often early morning and late afternoon. Since then the scheme has gradually expanded. In our experience one of the most important f a c t o r s i n p r e v e n t i o n o f f u r t h e r i n c i d e n t s h a s been t h e p r o v i s i o n o f F a m i l y A i d e s , p r a c t i c a l , s u p p o r t i v e , m o t h e r l y women who go i n t o t h e home d a i l y i f n e c e s s a r y , weekends i n c l u d e d , and working a l o n g s i d e t h e m o t h e r , h e l p h e r t o o r g a n i s t h e r h o u s e h o l d , to manage h e r c h i l d or c h i l d r e n and t a k e p r i d e i n h e r a c h i e v e m e n t ; p r o f e s s i o n a l b e f r i e n d e r s who r e l a t e a l s o t o the s p o u s e and o t h e r members o f t h e f a m i l y , y e t have a c c e s s t o s o c i a l workers i f t h e r e i s any c a u s e f o r c o n c e r n about a c h i l d ' s s a f e t y or w e l l b e i n g . T h i s e x p e r i e n c e l e a d s u s t o b e l i e v e t h a t Family Aides m i g h t be used i n p r i m a r y p r e v e n t i o n , and we h a v e r e c e n t l y embarked on a r e e a r c h scheme, f i n a n c e d by j o i n t f u n d i n g from t h e h e a l t h a u t h o r i t y end s o c i a l services, i n w h i c h , u s i n g some o f t h e s i m p l e c r i t e r i a d e l i n e a t e d i n t h i s s t u d y , a p o t e n t i a l l y v u l n e r a b l e group i s b e i n E i d e n t i f i e d i n t h e a n t e - n a t a l p e r i o d . Then, a f t e r a s s e s s m e n t by a s o c i a l worker w h i l e i n t h e m a t e r n i t y ward, a Family Aide i s o f f e r e d t o t h e i n d e x group on r e t u r n home. I t i s e n v i s a g e d t h a t t h e Aide w i l l s u p p o r t t h e fmmily w i t h twice weekly v i s i t s d u r i n g t h e f i r s t two y e a r s , w h i l e a comparable group w i l l h a v e a l l t h e usual co~mnity services.
SU~qA&Y A c t u a r i a l , m e d i c a l and s o c i a l d a t a a r e r e p o r t e d on 50 p s y c h i a t r i c day h o s p i t a l p a t i e n t s known t o have abused t h e i r c h i l d r e n and 50 n o n - a b u s e r s u n d e r g o i n g t r e a t m e n t a t t h e same t i m e . A s u b - g r o u p of 30 of each c o m p l e t e d p e r s o n a l i t y and i n t e l l i g e n c e t e s t s and t h e m a j o r i t y h a d e l e c t r o e n c e p h a l o g r a m s , and t h e s e r e s u l t s were compared w i t h t h o s e of a group of 30 h e a l t h y m o t h e r s s e l e c t e d by h e a l t h v i s i t o r s f o r p o s i t i v e c h i l d - r e a r i n g a b i l i t i e s . F i n d i n g s which c o n f i r m t h o s e o f o t h e r s t u d i e s o f c h i l d abuse i n c l u d e y o u t h f u l n e s s , a h i g h e r i n c i d e n c e o f f a m i l y v i o l e n c e from c h i l d h o o d onwards, more u n p l a n n e d p r e g n a n c i e s and lower i n t e l l i g e n c e i n t h e i n d e x group. I n t h i s s a m p l e , however, a l l r.ocial c l a s s e s were r e p r e s e n t ed, t h e r e was no s i g n i f i c a n t d i f f e r e n c e i n p e r i n a t a l p a t h o l o g y between t h e g r o u p s , p e r s o n a l i t y s c o r e d showed h i g h m o r b i d i t y i n t h e p a t i e n t groups b u t few d i s t i n c t i v e f e a t u r e s , and EgGs were n o t s i g n i f i c a n t l y mere abnormal i n the i n d e x group t h a n i n t h e two c o n t r a s t g r o u p s . Moreover, t h e i n d e x group d i d n o t show t h e e x p e c t e d d i s c r e p a n c y between v e r b a l and p e r f o r m ance s u b - t e s t s on t h e W e c h s l e r Adult I n t e l l i g e n c e S c a l e . T r e a t m e n t of t h e 50 c h i l d - a b u s e r s w i t h t h e i r c h i l d r e n r e s u l t e d i n a r e - i n j u r y r a t e of 8% d u r i n g t h e f o u r y e a r p e r i o d o f s t u d y . A scheme f o r e a r l y i d e n t i f i c a t i o n and p r e v e n t i o n i s out lined.
ACKNOWLEDGEI~NTS Our t h a n k s a r e due t o the s t a f f a t W a l l i n g t o n Day H o s p i t a l f o r t h e i r s k i l l and t o l e r a n c e i n t r e a t i n g the p a t i e n t s ; to our g e n e r a l p r a c t i t i o n e r , h e a l t h v i s i t o r and s o c i a l work c o l l e a g u e s f o r t h e i r c o o p e r a t i o n ; t o Dr. Colin Blakemore and Mrs. }4. M a r t i n o v a , p s y c h o l o - i s t s and to Mrs. Olive Wickene, research assistant, for their advice and help with psychometric testing.
C h i l d Abuse Treatment i n a P s y c h i a t r i c Day H o s p i t a l
707
RE~ERENCE$ (1)
A.E. S k i n n e r & R.L. C a s t l e , Seventy e i g h t b e t t e r e d NSPCC London (1969).
children: a retrospective
reportj
(2) C. H. g~mpe & R. E. Helfer, Helpln a the Battered Child and His FIamily, Lippincott (1972) (3) S. M. Smith, R. Hanson & S. Noble, Parents of battered babies: a controlled study, Brit. Hed Jl. 4, 388 (1973).
(A) S. M. Smith, L. Honlgsberger & C. A. Smith, EgG and personality factors in baby batterers. Brit. Med. Jl. 2, 20 (1973). (5) R. J. Gelles, Child abuse as psychopathology, Amer. Jl. Orthopsychiat.43/6.
611 (1973).
(6)
M. L. Blumberg, Psychopathology of the abusing parent, Amer. Jl. Psychotherap28/l,21(1974)
(7)
A. W. Franklin (Ed.),(l~,75) Concernin~ Child Abuse. Churchill Livingstone, Edinburgh.
(8)
M. A. Lynch, lll-health and child abuse, Lancet 2, 317 (1975).
(9)
M.A.
Lynch and J. Roberts, Predicting child abuse:signs of bonding failure in the maternity hospital, Brit. Med. Jl. i, 624 (1977)
(I0)
R. R. Gordon, Predicting child abuse, Brit. Med. Jl. 1, 841 (1977).
(II)
H. P. Martin (Ed.i (1976) Which Children ~et Abused:Hiah It~sk~Fkctor8 in the Child C - - b r i d g e , Mess.Univ. P r e s s
(12)
C. Ounsted, R. Oppenheimer and J . Lindsey, Psychopatholo&7 and p s y c h o t h e r a p e u t i c t r e a t m e n t of f a m i l l e s of b a t t e r e d c h i l d r e n , Dev. Med. C h i l d . l~eurol. 16, 4~7 (1974)
(13)
K. Beswlck, M. A. Lynch & J . R o b e r t s , C h i l d abuse and g e n e r a l p r a c t i c e , 2, 800 (1976).
(14)
R. L. Castle e t e l . (1976) Kegan Paul, London.
(15)
J . West, I n a d e q u a t e m o t h e r s , Lancet 2, 1451 (1974).
(16)
M. Lynch, D. S t e i n b e r g & C. Ounsted, Family u n i t i n a c h i l d r e n ' s B r i t . Mad. J1. 2, 127 (1975).
(17)
D. P. Goldberg (1972) Univ. P r e s s .
(18)
H. J . Eyeenck (1959)
(19)
R. Wechsler (1955) The Wechsler Adult I n t e l l i a e n c e
(20)
G. Dahlstrom & G. S. Welsh (1960) An MMPI Handbook, Univ. of Minnesota Press.
(21)
C. Salzman, Chlordiazepoxide-induced 31, 401 (1974).
(22)
D.G.
(23)
Select Counittee on Violence in the Family, Violence to Children, Vol. ~,HMSO London1977
(24)
J. E. Oliver & J. Cox, A family kindred with ill-used children, Brit. Med. Jl i, 81 (1973)
(25)
J. Emery, Final results of study of infants at risk of sudden death, Nature. 268, 724 (1977).
B r i t . Mad. J1.
At Risk:NSPCC Bettered Child Research Team, Routledge &
The D e t e c t i o n of P S y c h i a t r i c
psychiatric hospital,
I l l n e s s by ~ u e e t i o n n a i r e , O x f o r d
The Maudsley P e r s o n a l i t y I n v e n t o r y ,
U n i v . of London P r e s s .
Scale
hostility in a small group setting, Arch. Gen.Psych
Workman and D. G. Cunningham, Canad. Jl. Fern. Psych. 21, 63 (1975)
0145-2134/79/0901-0699 $02.00/0.
CHILD ABUSE TREATED IN A PSYCHIATRIC DAY HOSPITAL
Joy E. West and Eric D. West Wallington Day Hospital, Walllngton, Surrey, England
INTRODUCTION E x p e r i e n c e w i t h p a r e n t s and c h i l d r e n i n a p s y c h i a t r i c day h o s p i t a l h a s shown c h i l d abuse t o be a l m o s t i n v a r i a b l y the c u l m i n a t i o n o f weeks or months o f o f t e n u n r e c o g n l s a d s t r e s s and d i f f i c u l t y i n c o p i n g . E f f o r t s have been made by w o r k e r s i n v a r i o u s d i s c l p l i n e s t o e l u c i d a t e p r e d i s p o s i n g or p r e c i p i t a t i n g f a c t o r s i n p a r e n t s , or c h i l d r e n , or b o t h ( R e f s . 1 - 1 1 ) , and t h e t h e r a p e u t i c a p p l i c a t i o n s o f s u c h knowledge i n a p a e d i a t r i c h o s p i t a l h a v e been d e s c r i b e d by O u n s t e d , Oppenheimer and L i n d s a y ( 1 2 ) ; i n g e n e r a l p r a c t i c e by Beswick, Lynch and R o b e r t s (13) and i n NSPCC community work by C a s t l e and h i s c o l l e a g u e s ( 1 4 ) . The p r e s e n t p a p e r i s a p r O S p e c t i v e c o n t r o l l e d s t u d y o f 50 c h i l d a b u s e r s r e f e r r e d p r i m a r i l y £or p s y c h i a t r i c i l l n e s s and t r e a t e d w i t h t h e i r c h i l d r e n i n a p s y c h i a t r i c day h o s p i t a l between J a n u a r y 1973 and December 1976. Cpmparison was made w i t h ( a ) 50 p s y c h i a t r i c a l l y i l l b u t no~a b u s i n g p a r e n t s u n d e r g o i n g t r e a t m e n t a t t h e same t i m e and (b) a group o f 30 m o t h e r s s e l e c t e d by h e a l t h v i s i t o r s f o r t h e i r p o s i t i v e c h i l d - r e a r l n g a b i l i t i e s . The o b j e c t o f t h e s t u d y was t o d e t e r m i n e how a b u s i v e p a r e n t s i n t h i s s e t t i n g d i f f e r e d b o t h from o t h e r p s y c h i a t r i c p a t i e n t s and from h e a l t h y m o t h e r s and, where p o s s i b l e , t o u s e t h i s i n f o r m a t i o n i n t h e t h e r a p e u t i c s e t t i n g t o p r e v e n t f u r t h e r a b u s e . T h i s work was t h e p r e l i m i n a r y t o a c u r r e n t r e s e a r c h scheme i n p r i m a r y p r e v e n t i o n i n which m o t h e r s i d e n t i f i e d as v u l n e r a b l e a r e b e i n E s e l e c t e d b e f o r e d i s c h a r g e from t h e m a t e r n i t y h o s p i t a l and o f f e r e d d c a i c i l l a r y s u p p o r t d u r i n g t h e c h i l d ' s f i r s t two y e a r s .
PATIENTS AND METHODS We a t f i r s t d i v i d e d t h e p a t i e n t s i n t o a group o f t h o s e known t o have c a u s e d n o n - a c c l d e n t a l i n j u r y and a c o n t r a s t g r o u p . However, d u r i n g t h e c o u r s e of t r e a t m e n t we found t h e r e were more a t r i s k f m n i l l e s t h a n we o r i g i n a l l y t h o u g h t (15, 16). I n d e e d , t h e r e seemod few who were n o t at least potential child-abusers. In an a t t e m p t t o e v o l v e a p r a c t i c a l t h e r e f o r e d i v i d e d them as f o l l o w s :
method of i d e n t i f i c a t i o n
and r e h a b i l i t a t i o n ,
we
Hiah R i s k F i f t y p a r e n t s (48 m o t h e r s and 2 f a t h e r s ) , known t o have i n j u r e d or n e g l e c t e d t h e i r c h i l d r e n and on t h e S o c i a l S e r v i c e s ' A t R i s k ' r e g i s t e r . R e f e r r a l s were p r i m a r i l y f o r p s y c h i a t r i c i l l n e s s , 23 (~6%) b e i n g r e f e r r e d by g e n e r a l p r a c t i t i o n e r s , 12 (24%) by o t h e r p s y c h i a t r i s t s , 10 (20%) by t h e c o ~ n u n i t y p h y s i c i a n i n c h i l d h e a l t h and 5 (10%) by p a e d l a t r l c i a n s . Low R i s k A c o n t r a s t group o f 50 p s y c h i a t r i c a l l y i l l b u t n o n - a b u s i n g p a r e n t s . Of t h e 48 m o t h e r s and 2 f a t h e r s , 36 (72%) were r e f e r r e d by g e n e r a l p r a c t i t i o n e r s , 8 (16%) by o t h e r p s y c h i a t r i s t s and 6 (12%) by paediatrlcians. With regard to child abuse, some admitted during treatment: ' I have felt like it' or ' I have sometimes felt afraid I might do it', but close observation 699
700
J.E.
West and E. D. West
of p a r e n t - c h i l d i n t e r a c t i o n o v e r s e v e r a l m o n t h s , c o n f i r m e d by l i a i s o n w i t h g e n e r a l p r a c t i t i o n e r s and health visitors made it seem very unlikely, and none has given cause for concern i n t h i s r e s p e c t d u r i n g t h e p e r i o d o f s t u d y end f o l l o w - u p t o d a t e . ASSESSMENT
A l l p a t i e n t s (High R i s k and Low Risk) were g i v e n a s t a n d a r d p s y c h i a t r i c i n t e r v i e w a t r e f e r r a l A d d i t i o n a l information was f r e q u e n t l y f o r t h c o ~ n g d u r i n g t h e c o u r s e of t r e a t m e n t , or from r e l a t i v e s , h e a l t h v i s i t o r s or s o ~ i e l w o r k e r s . P s y c h i a t r i c i l l n e s s wee c l a s s i f i e d a c c o r d i n g to the International C l a s s i f i c a t i o n of Disease (W.H.O. 1968). A s u b - s a m p l e of 30 m o t h e r s from t h e High Risk and 30 from t h e Low R i s k group were i n v e s t i g a t e d more i n t e n s i v e l y , c ~ p l e t i n g t h e G e n e r a l H e a l t h Q u e s t i o n n a i r e (17) to a s s e s s n o n p s y c h o t i c p s y c h i a t r i c d i s t u r b a n c e ; t h e ~ a u d s l e y P e r s o n a l i t y I n v e n t o r y (18) t o a s s e s s n e u r o t l c l s m end e x t r a v e r s l o n ; s i x s u b - t e s t s o f t h e W e c h s l e r A d u l t I n t e l l i g e n c e Scale ( 1 9 ) , o f wh6ch t h r e e were v e r b a l - c o m p r e h e n s i o n , s i ~ l a r i t l e s and v o c a b u l a r y - and t h r e e p e r f o r m a n c e p i c t u r e c o m p l e t i o n , block d e s i g n and o b j e c t a s s e m b l y ; t h e M i n n e s o t a ~ u l t l p h a s i c P e r s o n a l i t y I n v e n t o r y (20) t o a s s e s s components o f p e r s o n a l i t y ; f i n a l l y , an e l e c t r o e n c e p h a l o g r a m was r e c o r d e d on t h o s e w i l l i n g t o c o o p e r a t e . The same b a t t e r y o f t e s t s was completed by a second c o n t r a s t group of 30 p s y c h i a t r i c a l l y h e a l t h y m o t h e r s o f p r e - s c h o o l c h i l d r e n s e l e c t e d by h e a l thyvisitors for positive child-rearing abilities. TREATI~NT The day h o s p i t a l i s a t h r e e - s t o r e y h o u s e in a r e s i d e n t i a l o u t e r London suburb ( p o p . 1 6 7 , 0 0 0 ) and h a s an a v e r a g e d a i l y a t t e n d a n c e o f 35 a d u l t p a t i e n t s o f e l l a g e s . An i n t e g r a l n u r s e r y opens on t o a g a r d e n / p l a y g r o u n d , and i s s t a f f e d t o accommodate up t o 15 p r e - J c h o o ~ c h i l d r e n , w h i l e o l d e r s i b l i n g s may a t t e n d d u r i n g s c h o o l h o l i d a y s . Twice-weekly group p s y c h o t h e r a p y i s c e n t r a l t o t h e t r e a t m e n t , with b e h a v i o u r a l methods employed f o r s o c i a l end o t h e r p h o b i a s , and a l s o i n t r o d u c e d i n t o t h e f i e l d of p a r e n t / c h i l d interaction. Those on t h e ' A t R i s k ' r e g i s t e r and a l l women i n t h e c h i l d b e a r i n g y e a r s who are p r e s c r i b e d psychotropic medication are s t r o n g l y encouraged to seek fm,~ly planning advice a n u r s e accompanylng them t o t h e c l i n i c i f n e c e s s a r y . N u r s e r y h o u r s a r e from 10.30 t o 3 . 3 0 , and p a r e n t s j o i n t h e c h i l d r e n f o r an h o u r a t l u n c h t i m e . They a r e a l s o a l l o t t e d a two-hour s e s s i o n a ~ e k when t h e y a r e r e q u i r e d t o be i n t h e n u r s e r y a l o n g s i d e t h e c h i l d r e n , w h i l e r e g u l a r l a s t i n g s w i t h s t a f f g i v e p a r e n t s a chance t o t h r a s h o u t n u r s e r y p r o b l e m s . Not i n f r e q u e n t l y s t a f f c h i l d r e n m i n g l e w i t h p a t i e n t s ' c h i l d r e n and t h i s , t o g e t h e r w i t h t h e p r e s e n c e of l e s s d i s t u r b e d p a r e n t s and g r a n d p a r e n t s e m o ~ t h e p a t i e n t s , p r o v i d e s a u s e f u l model o f p a r e n t i n g h e h a v i o u r . Spouses end o t h e r r e l a t i v e s a r e welcome a t a l l t i m e s , f r e q u e n t l y t e l e p h o n e , and a r e e n c o u r aged t o a t t e n d t h e m o n t h l y m a r i t a l group or r e l a t i v e s ' m e e t i n g . H e a l t h v i s i t o r s a t t e n d f o r m o n t h l y s e m i n a r s end s o c i a l workers have an open i n v i t a t i o n t o weekly c a s e r e v i e w s . In b e t w e e n , t h e r e i s f r e q u e n t l i a i s o n , and i f an 'At r i s k ' p a t i e n t f a i l s to a t t e n d w i t h o u t a d e q u a t e r e a s o n , c a n n o t be c o n t a c t e d by t e l e p h o n e , or i f a t e l e p h o n e e n q u i r y makes i t c l e a r she i s d i s t r e s s e d , h e r s o c i a l w o r k e r , h e a l t h v i s i t o r or v e r y o f t e n a n u r s e from t h e day h o s p i t a l w i l l v i s i t t h e 8 m u d a y , g i v i n g w h a t e v e r p r a c t i c a l h e l p may be needed. A comnunity p h y s i c i a n i n c h i l d h e a l t h a t t e n d s t h r e e - m o n t h l y to c a r r y o u t d e v e l o p m e n t a l h e a l t h checks on t h e c h i l d r e n and t o d i s c u s s any m a t t e r s t h e p a r e n t s choose to r a i s e , w h i l e r e l e v a n t c a s e c o n f e r e n c e s a r e f r e q u e n t l y h e l d a t t h e day h o s p i t a l ; t i ~ l y reminders to p a t i e n t s t h a t , however p e r m i s s i v e t h e a t m o s p h e r e , t h e r e i s o v e r a l l s e r i o u s c o n c e r n f o r t h e s a f e t y and w e l l - b e l n g o f t h e c h i l d r e n . ~SULTS A c t u a r i a l and S o c i a l Data A~e. With a mean age of 26.2 y e a r s a t r e f e r r a l , t h e High Risk group were s i g n i f i c a n t l y younger than the Low Risk patients (p = 0.01), with more than three times as many subjects in the 20-24 age range (p - 0.001), the mean age of the Low Risk group being 29.6 years (Fig. I)
C h i l d Abuse Treatment i n a P s y c h i a t r i c Day H o s p i t a l
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Social class. F i g u r e 2 shows t h a t both High R i s k s u b j e c t s and t h e i r spouses span a l l s o c i a l c l a s s e s , w i t h siK'ni,ficant d i f f e r e n c e s (p = 0.001) c o n t r i b u t e d by u n d e r - r e p r e s e n t a t i o n o f s u b j e c t s i n s o c i a l c l a s s I I and o v e r - r e p r e s e n t a t i o n o f s p o u s e s / c o h a b l t e e s i n s o c i a l c l a s s V compered~r~th t h e Low ~4sk p a t i e n t s ( F i g . 3).
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Soc£al c l a s s o f spouse
Countr~ o f o r i g i n and r e l i g i o n . No s / ~ n f l l c a n t d i f f e r e n c e s emerged, a p p r o x i m a t e l y 85X o f both High and Low Risk p a c z a n t s h a v i n g been born i n t h e United Kingdom, and more than 60Z i n both groups b e i n g n o . n e l l y Church o f England. Family background. S i x t y - f o u r p e r c e n t o f the High Risk p a t i e n t s were f i r s t or second c h i l d r e n o f the f a m i l y compared w i t h 80Z o f the Low Risk. Five High Risk s u b j e c t s and two Low Risk a d m i t t e d to b e i n g i l l e g l t ~ t e ; Four High Risk and t h r e e Low Risk l o s t a p a r e n t through d e a t h b e f o r e t h e age o f 11, w h i l e p a r e n t s o f f i v e i n each group d i v b r c e d or s e p a r a t e d w h i l e t h e s u b j e c t s were under t e n . There are no s i g n i f i c a n t d i f f e r e n c e s i n t h e s e f l n d l n g s ~ Three o f t h e High Risk p a t i e n t s were adopted in i n f a n c y ; e i g h t (16Z) had been i n c a r e d u r i n g c h i l d h o o d f o r p e r i o d s r a n g i n g from t h r e e months t o 15 y e a r s , w h i l e a f u r t h e r 2 (4Z) f e l t thems e l v e s t o be r e j e c t e d by t h e i r f a d l i e s , both b e i n g brought up by a widowed grandmother. In
702
J.E.
West and E. D. West
the Low Risk group two (4%) had each spent a few months in care while their mothers underwent psychiatric treatment, and these differences are significant (p = 0.05), as is the finding that while 14 (28%) of the High Risk patients recalled being beaten or physically ill-treated as children, the same applied to only four of the Low Risk (p = 0.01). Housing.
Figure 4 shows highly significant differences
(p = 0.001) due to the fact that
p r o p o r t i o n a t e l y more o f the High Risk p a t i e n t s l i v e d i n c o u n c i l f l a t s , l e s s were house-owners.
and p r o p o r t i o n a t e l y
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council house
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Housing
~ . r i t a l and r e p r o d u c t i v e . Highly s i g n i f i c e n t d i f f e r e n c e s e ~ r g e d (p = 0.001) both i n t h e numbers in the High Risk group who had s e p a r a t e d o r , d l v o r c e d p r i o r to r e f e r r a l (a11" had taken on new p a r t n e r s ) , and i n the i n c i d e n c e of v i o l e n c e between p a r t n e r s as compared w i t h the Low Risk p a t i e n t s . But t h e r e were no s i g n i f i c a n t d i f f e r e n c e s i n the numbers with c r i ~ n a l r e c o r d s of v i o l e n c e ( s i x High Risk and two Low R i s k ) , n o r i n the p r o p o r t i o n s who r a t e d t h e i r s e x l i v e s as u n s a t i s f a c t o r y , which were h i g h i n both groups - 26 (52Z) o f High Risk and 20 (40X) o f Low Risk. With an average age of 20.5 y e a r s a t the b i r t h o f t h e i r f i r s t c h i l d , the High Risk p a t i e n t s were s i g n i f i c a n t l y younger (p = 0 . 0 1 ) . T h i r t y (60%) o f the s u b j e c t s were p r e g n a n t a t the time , of m a r r i a g e , compared with 9 (18%) o f the Low R i s k , h i g h l y s i g n i f i c a n t a t the 0.001 l e v e l . S i m i l a r l y w i t h the f i n d i n g t h a t 15 (30%) of the s u b j e c t s had an i l l e g i t i ~ a t e c h i l d , and two (4Z) had. two~ compared w i t h only one o f the Low Risk p a t i e n t s . Although pix (12%) o f the High Risk p a t i e n t s who s u b s e q u e n t l y i n j u r e d t h e i r c h i l d r e n had been r e f u s e d t e ~ a i n a t i o n of the r e l e v a n t pregnancy, t h e r e was no s i g n i f i c a n t d i f f e r e n c e w i t h the Low Risk, i n whom two (4%) were r e f u s e d . Diagnosis a t r e f e r r a l . There were no s i g n i f i c a n t d i f f e r e n c e s between Kigh Risk and Low Risk p a t i e n t s gs r e g a r d s d i a g n o s i s , the m a j o r i t y - 41 (82Z) High Risk and 38 (76Z) Low Risk b e i n g diagnosed as d e p r e s s i v e n e u r o s i s , which in 20 (40Z) High Risk and 17 (34%) Low Risk was o f p u e r p e r a l o r i g i n . One p a t i e n t i n the High Risk and t h r e e i n t h e Low Risk group s u f f e r e d from p u e r p e r a l p s y c h o s i s o f u n r e m i t t i n g t y p e , and t h r e e i n each group from m a n i c - d e p r e s s i v e p s y c h o s i s . While only four (8%) o f the High Risk p a t i e n t s were diagnosed as p r i m a r i l y p e r s o n a l i t y d i s o r d e r s a t the time o f r e f e r r a l , compared w i t h two Low Risk p a t i e n t s , d u r i n g t r e a t u n t i t became c l e a r t h a t i ~ t u r l t y , dependence, a t t e n t i o n - s e e k i n g and i m p u l s l v e behavlour were more a p p a r e n t Jmong High Risk than Low Risk p a t i e n t s . Previous p s y c h i a t r i c m o r b i d i t y . Twenty-four o f the High Risk p a t i e n t s (48Z) had a p a s t h i s t o r y o f p s y c h i a t r i c i l l n e s s compared w i t h f o u r t e e n (28%) Low Risk, s i g n l f i c a n t at t h e 0.05 l e v e l ; s i m i l a r l y with the p a s t h i s t o r y o f o v e r d o s e / s e l f - i n j u r y - 25 (50%) High Risk and 8(16%)
Child Abuse Treatment in a Psychiatric Day Hospital
703
Low Risk , highly significant at the 0 . 0 0 1 l e v e l . Among s p o u s e s , t h e r e were no s i g n i f i c a n t differences in morbidity from a psychiatric viewpoints I0 (20Z) of spouses of High Risk patients and 4 (8Z) Low Risk admitting to a history of psychiatric illness. Fami17 c o m p o s i t i o n . S e v e n t e e n High R i s k p a r e n t s (34~) h a d one c h i l d a t t h e t i m e of r e f e r r a l and 23 (46%) h a d tWOs compared w i t h 15 (30~) and 25 (50X) r e s p e c t i v e l y o f t h e Low R i s k g r o u p . The largest families had four children: seven High Risk families (14X) had three and three(6%) had four, a total of 96 children of High Risk families and 98 Low Risk. Thls included six High Risk families and one Low Risk containing a child fr,,- a previous marrlage/llaison. S e v e n t y - s e v e n o f t h e t o t a l number o f p r e g n a n c i e s ( 8 0 . 2 X ) were s a i d by High R i s k p a r e n t s t o h a v e b e e n u n p l a n n e d , w h i l e t h e Low R i s k p a r e n t s a d m i t t e d t h i s of 36 ( 3 6 . 7 Z ) s a h i g h l y s i g n i f i c a n t difference (p = 0.001). We found no significant differences, however, in the degree of perinatal pathology resulting in early separation of mother and child - 16 (16.7%) of the total 96 births in the High Risk f-,,ilies and |4 (14.3Z) in the Low Risk. This included four caesarian sections in the High Risk and two in the Low Risk, and two premature twin deliveries in the High Risk fmniliea. There were five physically or mentally handicapped children in the High Risk and three in t h e Low Risk group. Of t h e a b u s e d c h i l d r e n , t h e r e w e r e 21 b o y s and 29 g i r l s , w i t h t h e h i g h e s t number - 14 (28%)i n t h e one t o two y e a r a g e r a n g e . O v e r a l l 26 c h i l d r e n (52Z) were i n j u r e d i n t h e f i r s t two y e a r s , and 35 (70Z) s u c h i n c i d e n t s o c c u r r e d b e f o r e t h e t h i r d b i r t h d a y . I n 38 ( 7 6 ~ ) , t h e a b u s e d c h i l d was t h e e l d e s t or o n l y c h i l d o f t h e f a m i l y , i n c l u d i n g t h r e e c h i l d r e n f r o m previous liaisons. I n 10 f a n i l i e s (20X) more t h a n one c h i l d h a d b e e n i n j u r e d or n e g l e c t e d , i n c l u d i n g t h e two s e t s o f t w i n s . 35 N
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differences
Test Batteries and I n v e s t i g a t i o n s Gene'ral Health questionnaire (GHq). With a s c o r e o f 12 t a k e n a s t h e d e m a r c a t i o n b e t w e e n n o r m a l i t y and n o n - p s y c h o t i c p s y c h i a t r i c d i s t u r b a n c e , b o t h High and Low R i s k p a t i e n t g r o u p s showed e v i d e n c e o f p s y c h i a t r i c d i s t u r b a n c e w i t h s c o r e s o f 2 4 . 5 and 2 2 . 2 r e s p e c t i v e l y (mean s c o r e s ) , t h e d i f f e r e n c e b e t w e e n t h e means n o t r e a c h i n g s i g n i f i c a n c e . The h e a l t h y m o t h e r groups however, had a mean score of 2.9, with a highly significant d i f f e r e n c e b e t w e e n them and b o t h t h e High a n d Low R i s k p a t i e n t g r o u p s (p - 0 . 0 0 1 ) . Wechsler Adult IntelliGence three performance sub-tests
S c a l e (WAIS). The mean s c o r e s , b a s e d on t h e t h r e e v e r b a l and showed a g r a d a t i o n f r o m t h e High R i s k t h r o u g h Low R i s k t o t h e
704
J.E.
h e a l t h y m o t h e r s , as i l l u s t r a t e d
West and E. D. West
in Figure 6.
Mean s c o r e s on the f u l l s c a l e were: High Risk
93.3; Low Risk 106.2; healthy mothers 110.6, highly significant at the 0.001 level between High Risk and Low Risk groups, and also between High risk and healthy mother groups, but wlth no significant difference between the Low risk and healthy mothers.
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10 iigh Risk Fig. 7.
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Healthy mothers
Maudsley Personality InVentory.
Maudsle~ P e r s o n a l i t y I u v e n t o r ~ (MPI). All t h r e e groups s c o r e d 20 plus on the n e u r o t l c i s m s c a l e , w i t h the High l i s k p a t i e n t s showing the most n e u r o t i c i s m and • g r a d a t i o n through Low Risk t o h e a l t h y m o t h e r s , with the r e v e r s e g r a d a t i o n on t h e e x t r a v e r s i o n s c a l e w i t h the h e a l t h y mothers s c o r i n g h i g h e s t , the d i f f e r e n c e s on both s c a l e s between High Risk and h e a l t h y mothers b e i n g h i g h l y 8 i K n l f i c a n t at the 0.001 l e v e l ( F i g . 7). Minnesota.Multiphasic. . P e r s o n a l i t y I n v e n t o r7 (MMPI). High Risk and Low Risk p a t i e n t s showed e q u a l l y h~8h m o r b i d i t y on a l l s c a l e s compared with the h e • i t h y m o t h e r s , the mean s c o r e on the d e p r e s s i o n s c a l e b e i n g the h i g h e s t i n both p a t i e n t groups, the d i f f e r e n c e from the h e a l t h y mothers b e l n g h l g h l y s i g n i f i c a n t (p = 0 . 0 0 1 ) . The only s i g n i f i c a n t d i f f e r e n c e s between High and Low Risk groups were on the m a s c u l i n i t y / f e m i n l n l t y s c a l e , w i t h h i g h e r f e m i n i n i t y mean s c o r e i n High Risk p a t i e n t s (p - 0 . 0 1 ) , who a l s o had h i g h e r mean s c o r e s on the mania s c a l e (p = 0 . 0 5 ) . E l e c t r o e n c e F h a l o z r a p h y (EEG). EECs were s c o r e d ' b l i n d ' on an a r b i t r • r y s c a l e from 1 (normal • I p h a r h y t h m ) , t h r o u g h 2 (some t h e r e b u t mainly a l p h a ) , 3 (more t h e r e than 2), 4 ( t h e t a w i t h some parorysmal e l e m e n t s ) , t o 5 (more p e r s i s t e n t t h e r e with marked paroxysmal e p i s o d e s q u a s l - e p i l e p t i c - and some d e l t a f r e q u e n c i e s ) . Of the 22 High Risk p • t l e n t s , the mean s c o r e was h i g h e s t a t 2.36 (S.D. 1 . 2 0 ) ; o f the 24 Low Risk the mean s c o r e was 2.04 ( S . D . I . i 0 ) and the 29 h e a l t h y mothers had a mean s c o r e o f 1.96 (S.D. 0 . 9 0 ) . All groups had some very abnormal r e c o r d s , and w h i l e t h e r e were no s t a t l s t i c a ~ l y s i g n i f i c a n t d i f f e r e n c e s , the most abnormal r e c o r d s with e p i l e p t i c - t y p e f e a t u r e s were seen i n the High Risk group. RESULTS OF TREATMENT The mean duration of day hospital treatment in the High Risk group was 14 months, an average of 180 attendances, the length of stay ranging from a few weeks to two years, c 0 ~ a r e d with • mean of eight months, average 80 •ttendance8 in the Low Risk group. The majority have been followed up as outpatients after discharge. While there was no serious injury to • child during treatment or follow-up to date, in four families there were minor traumata, a repeat injury rate of 8Z. In two other casesj when it bec~me clear that the family had reached their limit of tolerance, children were received into c a r e of the social services for • few weeks - one was a family of three boys in which all the children had been at risk over a period of seven years, the other • f m i l y of twln boys.
Child Abuse Treatment in a Psychiatric Day Hospital
705
S e v e r a l High Risk p a t i e n t s on p s y c h o t r o p i c m e d i c a t i o n , p a r t i c u l a r l y t r i c y c l i c a n t i d e p r e s s a n t s and benzodiazepineSs c ~ e n t e d t h a t w h i l e taking drugs they f e l t a b l e to ' s t a n d a p a r t ' from t h e m s e l v e s , h i t t l n g out a t t h e i r c h i - d w i t h o u t t h e customary f e e l i n g s o f remorse. Salmasn(21) and Workman (22) and s u b s e q u e n t l y o t h e r workers i n the f i e l d o f c h i l d abuse have cmmmented on t h e p a r a d o x i c a l e f f e c t of ben © d i a s e p i n e s i n r e l e a s i n g a g g r e s s i o n , and though i n our e x p e r i ence such an e f f e c t was noted only i n the more u n s t a b l e p a t i e n t s , we were e x t r e m e l y c s u t i o u s about p ~ e s c r i b i n s f o r t h o s e thought t o be prone t o a g g r e s s i v e o u t b u r s t s or l o s s o f c o n t r o l . A n t i c o n v u l s a n t s seemed to be a u s e f u l ad~anct i n management of i m p u l s i v e l y a g g r e s s i v e p a t i e n t s with e p i l e p t i c - t y p e EEGs. For t h e i r p a r t , the s o c i a l s e r v i c e s have made e v e r y e f f o r t t o reduce the p r e s ~ r e on t h e s e a t r i s k f a m i l i e s . P a t i e n t s have n o t i n f r e q u e n t l y been t r a n s p o r t e d t o the day h o s p i t a l w i t h t h e i r c h i l d r e n , the h o u s i n g department has g i v e n s y m p a t h e t i c c o n s i d e r a t i o n t o r e h o u s i n g where a p p r o p r i a t e , w i t h p r i o r i t y f o r t h o s e i n h i g h - or m e d i , ~ - r i s e f l a t s , and on d l s c h a r s e from the day h o s p i t a l , c h i l d r e n have been g i v e n p r i o r i t y f o r n u r s e r y o r n u r s e r y school p l a c e s as a p p r o p r i a t e . DISCUSSION While i t i s g e n e r a l l y a c c e p t e d t h a t the a e t l o l o g y o f c h i l d abuse i s m u l t i f a c t o r i a l , the p a u c i t y o f c o n t r o l l e d s t u d i e s has s o n e t i m e s led t o u n c r i t i c a l a c c e p t a n c e o f a n e c d o t a l d a t a . The S e l e c t Committee on V i o l e n c e i n the Family (23) has s t r e s s e d the need f o r f u r t h e r r ~ e s e a r c h on p r e v e n t i v e s c r e e n i n g o f f a m i l i e s a t r i s k , as w e l l as on t r e a t m e n t of f ~ l i e s where abuse has o c c u r r e d . In the p r e s e n t s t u d y , l l k e C a s t l e e t e l . ( 1 4 ) , we found the index s u b j e c t s t o be s i ~ i f i c a n t l y younger t h a n the c o n t r a s t group a t the b i r t h o f t h e i r f i r s t c h i l d , and as i n h i s r e s e a r c h , as w e l l as i n t h e c o n t r o l l e d s t u d y of Smich, Hanson and Noble ( 3 ) , we found s l s n i f i c a n t l y ~ r e p r e m a r i t a l c o n c e p t i o n s , unplanned p r e s n a n c l a s and i l l e g i t i m a t e c h i l d r e n , a h i g h e r i n c i d e n c e o f d e p r i v a t i o n and f a m i l y v l o l e n c a from c h i l d h o o d onwards and lower aeerlq~e i n t e l l i g e n c e i n the High Risk p a t i e n t s . But our f i n d i n g s d i f f e r from t h o s e o f Smith and h i s c o l l e e n s in which almost h a l f o f t h e i r sample of i n d e x mothers had IQs b o r d e r i n g on t h e subnormal, nor did we f i n d the t r e n d toward lower v e r b a l lQs o f C a s t l e ' s s e r i e s . Our r e s u l t s s u g g e s t chat p s y c h i a t r i c m o r b i d i t y may be o f l e s s importance than has been p r e v i o u s l y s u g g e s t e d , i n c l u d i n S c o n t r o l l e d s t u d i e s by Smith, Hanson and Noble (14) and by Lynch and Roberts ( 9 ) . Nor do our EEG f i n d i n g s , which r e p r e s e n t the f i r s t comparative s t u d y in c h i l d a b u s e r s , s u b s t a n t i a t e t h e s u g g e s t i o n made by Smith, H o n l g s b e r g e r and Smith (4) t h a t an abnormal EEC may be u s e f u l in p r e d i c t i n g c h i l d abuse. Unlike O l i v e r and Cox (24) and Lynch ( 9 ) , we d i d n o t f i n d more p e r l n a t a l pathology i n the c h i l d r e n who were l a t e r abused: we found no s i g n i g l c a n t d i f f e r e n c e s between the High Risk and Low Risk p a t i e n t g r o u p s , and the p e r i n a t a l p a t h o l o g y i n the h e a l t h y mother group was m a r g i n a l l y h i g h e r . Moreover, we were unable t o c o r r o b o r a t e L y n c h ' s f i n d i n g t h a t where t h e r e i s an abused c h i l d d i s a d v a n t a g e d by p e r l n a t a l p a t h o l o g y , h e a l t h ~ s i b l i n g s are l e f t unharmed; o b s e r v a t i o n o f p a r e n t s i n t h i s c a t e g o r y over t h r e e y e a r s o r more has shown t h a t s e v e r a l have t r a n s f e r r e d t h e i r a g g r e s s i o n on t o the next youngest c h i l d . Compared w i t h the e x p e r i e n c e s o f S k i n n e r and C a s t l e (1) t h a t more than 60Z o f c h i l d r e n who were r e t u r n e d home were l a t e r s e e n w i t h f u r t h e r i n j u r i e s , and o f C a s t l e ' s l a t e r work (14) where, d e s p i t e i n t e n s i v e s u p p o r t i n the community 54X r e c e i v e d f u r t h e r i n j u r i e s , a l b e i t minors as w a l l as o f NSPCC r e p o r t s from t h e i r s p e c i a l c e n t r e s in Manchester and L i v e r p o o l t h a t a p p r o x i m a t e l y two out o f 10 abused c h i l d r e n are r e - l n j u r e d , our r e s u l t s seem e n c o u r a g i n g . One f a c t o r i s u n d o u b t e d l y t h e masslve s u p p o r t some o f the f l a i l i e s r e c e i l e d over a prolonged p e r i o d . More i m p o r t a n t , p e r h a p s , was the o v e r t p s y c h i a t r i c i l l n e s s i n the i n d e x group which led t o e a r l y r e f e r r a l . T h i s , t o g e t h e z with t h e f a c t t h a t a l l s o c i a l c l a s s e s are r e p r e s e n t e d i n our s t u d y , s u g g e s t s t h a t we a r e s e e i n g a d i f f e r e n t p a r t o f the s p e c t r u m o f c h i l d abuse. C e r t a i n l y we are l e a s t s u c c e s s f u l w i t h f a L ~ l i e s r e f e r r e d t o us a f t e r long involvement w i t h c a s e w o r k e r s on the a l e r t f o r c h i l d abuse; i n e v i t a b l y they then see us as t h e end o f a long l i n e of what t h e y i n t e r p r e t as a u t h o r i t y f i g u r e s , and even t h o s e who keep the i n i t i a l appointment are prone t o d e f a u l t e a r l y on i n t r e a t m e n t . On c l i n i c a l grounds, our f i n d i n g s c o n f i r m t h a t the e a r l i e r the i n t e r v e n t i o n , the g r e a t e r t h e chance o f s u c c e s s f u l r e h a b i l i t a t i o n . Nevertheless, rehabilitatic~
must s t i l l
o f t e n be d i r e c t e d t ~ a r d s
e n c o u r a g i n g an u n w i l l i n g
706
J . E . West and E. D. West
or reluctant parent to care for an unplanned or even unwanted child, often at prodigious expense. Current efforts being made in maternity units and by health visitors undoubtedly help to prevent child abuse, and Emery (25), in an investigation into cot deaths, found an u n e x p e c t e d l y lower i n c i d e n c e o f f a t a l i t i e s amongst i n f a n t s deemed t o be a t r i s k who had b e e n f o l l o w e d up by s p e c i a l l y r e c r u i t e d h e a l t h v i s i t o r s . Beswick, Lynch and Roberts (13) a l s o r e p o r t p r o m i s i n g r e s u l t s t h r o u g h o f f e r i n g p r a c t i c a l h e l p i n a g e n e r a l p r a c t i c e s e t t i n g to 22 f a m i l i e s at r i s k . H e a l t h v i s i t o r s a r e i d e a l l y p l a c e d and h a v e the a p p r o p r i a t e s k i l l and knowledge t o f i t them f o r p r e v e n t i v e work o f t h i s s o r t , though i n most a r e a s t h e i r o t h e r d u t i e s p r e c l u d e t h i s . Yet the i m p o r t a n c e o f d o m i e i l l a r y s u p p o r t emerged in our s t u d y when i t b e t - - , , c l e a r t h a t some of t h e more d i s t u r b e d High Risk p a t i e n t s were making a h a b i t o f n o n - a t t e n d a n c e or of t e l e p h o n i n g in d i s t r e s s , even threatening they might harm their child if help were not i~m~ediately forthcoming, aware that a social worker, or more probably, a nurse from the day hospital would promptly visit and stay to help sort out the difficulties; individual attention that was much sought after. As an extension of t h i s , we asked the Home Help department for a family aide for certain families at what for them were peak periods, most often early morning and late afternoon. Since then the scheme has gradually expanded. In our experience one of the most important f a c t o r s i n p r e v e n t i o n o f f u r t h e r i n c i d e n t s h a s been t h e p r o v i s i o n o f F a m i l y A i d e s , p r a c t i c a l , s u p p o r t i v e , m o t h e r l y women who go i n t o t h e home d a i l y i f n e c e s s a r y , weekends i n c l u d e d , and working a l o n g s i d e t h e m o t h e r , h e l p h e r t o o r g a n i s t h e r h o u s e h o l d , to manage h e r c h i l d or c h i l d r e n and t a k e p r i d e i n h e r a c h i e v e m e n t ; p r o f e s s i o n a l b e f r i e n d e r s who r e l a t e a l s o t o the s p o u s e and o t h e r members o f t h e f a m i l y , y e t have a c c e s s t o s o c i a l workers i f t h e r e i s any c a u s e f o r c o n c e r n about a c h i l d ' s s a f e t y or w e l l b e i n g . T h i s e x p e r i e n c e l e a d s u s t o b e l i e v e t h a t Family Aides m i g h t be used i n p r i m a r y p r e v e n t i o n , and we h a v e r e c e n t l y embarked on a r e e a r c h scheme, f i n a n c e d by j o i n t f u n d i n g from t h e h e a l t h a u t h o r i t y end s o c i a l services, i n w h i c h , u s i n g some o f t h e s i m p l e c r i t e r i a d e l i n e a t e d i n t h i s s t u d y , a p o t e n t i a l l y v u l n e r a b l e group i s b e i n E i d e n t i f i e d i n t h e a n t e - n a t a l p e r i o d . Then, a f t e r a s s e s s m e n t by a s o c i a l worker w h i l e i n t h e m a t e r n i t y ward, a Family Aide i s o f f e r e d t o t h e i n d e x group on r e t u r n home. I t i s e n v i s a g e d t h a t t h e Aide w i l l s u p p o r t t h e fmmily w i t h twice weekly v i s i t s d u r i n g t h e f i r s t two y e a r s , w h i l e a comparable group w i l l h a v e a l l t h e usual co~mnity services.
SU~qA&Y A c t u a r i a l , m e d i c a l and s o c i a l d a t a a r e r e p o r t e d on 50 p s y c h i a t r i c day h o s p i t a l p a t i e n t s known t o have abused t h e i r c h i l d r e n and 50 n o n - a b u s e r s u n d e r g o i n g t r e a t m e n t a t t h e same t i m e . A s u b - g r o u p of 30 of each c o m p l e t e d p e r s o n a l i t y and i n t e l l i g e n c e t e s t s and t h e m a j o r i t y h a d e l e c t r o e n c e p h a l o g r a m s , and t h e s e r e s u l t s were compared w i t h t h o s e of a group of 30 h e a l t h y m o t h e r s s e l e c t e d by h e a l t h v i s i t o r s f o r p o s i t i v e c h i l d - r e a r i n g a b i l i t i e s . F i n d i n g s which c o n f i r m t h o s e o f o t h e r s t u d i e s o f c h i l d abuse i n c l u d e y o u t h f u l n e s s , a h i g h e r i n c i d e n c e o f f a m i l y v i o l e n c e from c h i l d h o o d onwards, more u n p l a n n e d p r e g n a n c i e s and lower i n t e l l i g e n c e i n t h e i n d e x group. I n t h i s s a m p l e , however, a l l r.ocial c l a s s e s were r e p r e s e n t ed, t h e r e was no s i g n i f i c a n t d i f f e r e n c e i n p e r i n a t a l p a t h o l o g y between t h e g r o u p s , p e r s o n a l i t y s c o r e d showed h i g h m o r b i d i t y i n t h e p a t i e n t groups b u t few d i s t i n c t i v e f e a t u r e s , and EgGs were n o t s i g n i f i c a n t l y mere abnormal i n the i n d e x group t h a n i n t h e two c o n t r a s t g r o u p s . Moreover, t h e i n d e x group d i d n o t show t h e e x p e c t e d d i s c r e p a n c y between v e r b a l and p e r f o r m ance s u b - t e s t s on t h e W e c h s l e r Adult I n t e l l i g e n c e S c a l e . T r e a t m e n t of t h e 50 c h i l d - a b u s e r s w i t h t h e i r c h i l d r e n r e s u l t e d i n a r e - i n j u r y r a t e of 8% d u r i n g t h e f o u r y e a r p e r i o d o f s t u d y . A scheme f o r e a r l y i d e n t i f i c a t i o n and p r e v e n t i o n i s out lined.
ACKNOWLEDGEI~NTS Our t h a n k s a r e due t o the s t a f f a t W a l l i n g t o n Day H o s p i t a l f o r t h e i r s k i l l and t o l e r a n c e i n t r e a t i n g the p a t i e n t s ; to our g e n e r a l p r a c t i t i o n e r , h e a l t h v i s i t o r and s o c i a l work c o l l e a g u e s f o r t h e i r c o o p e r a t i o n ; t o Dr. Colin Blakemore and Mrs. }4. M a r t i n o v a , p s y c h o l o - i s t s and to Mrs. Olive Wickene, research assistant, for their advice and help with psychometric testing.
C h i l d Abuse Treatment i n a P s y c h i a t r i c Day H o s p i t a l
707
RE~ERENCE$ (1)
A.E. S k i n n e r & R.L. C a s t l e , Seventy e i g h t b e t t e r e d NSPCC London (1969).
children: a retrospective
reportj
(2) C. H. g~mpe & R. E. Helfer, Helpln a the Battered Child and His FIamily, Lippincott (1972) (3) S. M. Smith, R. Hanson & S. Noble, Parents of battered babies: a controlled study, Brit. Hed Jl. 4, 388 (1973).
(A) S. M. Smith, L. Honlgsberger & C. A. Smith, EgG and personality factors in baby batterers. Brit. Med. Jl. 2, 20 (1973). (5) R. J. Gelles, Child abuse as psychopathology, Amer. Jl. Orthopsychiat.43/6.
611 (1973).
(6)
M. L. Blumberg, Psychopathology of the abusing parent, Amer. Jl. Psychotherap28/l,21(1974)
(7)
A. W. Franklin (Ed.),(l~,75) Concernin~ Child Abuse. Churchill Livingstone, Edinburgh.
(8)
M. A. Lynch, lll-health and child abuse, Lancet 2, 317 (1975).
(9)
M.A.
Lynch and J. Roberts, Predicting child abuse:signs of bonding failure in the maternity hospital, Brit. Med. Jl. i, 624 (1977)
(I0)
R. R. Gordon, Predicting child abuse, Brit. Med. Jl. 1, 841 (1977).
(II)
H. P. Martin (Ed.i (1976) Which Children ~et Abused:Hiah It~sk~Fkctor8 in the Child C - - b r i d g e , Mess.Univ. P r e s s
(12)
C. Ounsted, R. Oppenheimer and J . Lindsey, Psychopatholo&7 and p s y c h o t h e r a p e u t i c t r e a t m e n t of f a m i l l e s of b a t t e r e d c h i l d r e n , Dev. Med. C h i l d . l~eurol. 16, 4~7 (1974)
(13)
K. Beswlck, M. A. Lynch & J . R o b e r t s , C h i l d abuse and g e n e r a l p r a c t i c e , 2, 800 (1976).
(14)
R. L. Castle e t e l . (1976) Kegan Paul, London.
(15)
J . West, I n a d e q u a t e m o t h e r s , Lancet 2, 1451 (1974).
(16)
M. Lynch, D. S t e i n b e r g & C. Ounsted, Family u n i t i n a c h i l d r e n ' s B r i t . Mad. J1. 2, 127 (1975).
(17)
D. P. Goldberg (1972) Univ. P r e s s .
(18)
H. J . Eyeenck (1959)
(19)
R. Wechsler (1955) The Wechsler Adult I n t e l l i a e n c e
(20)
G. Dahlstrom & G. S. Welsh (1960) An MMPI Handbook, Univ. of Minnesota Press.
(21)
C. Salzman, Chlordiazepoxide-induced 31, 401 (1974).
(22)
D.G.
(23)
Select Counittee on Violence in the Family, Violence to Children, Vol. ~,HMSO London1977
(24)
J. E. Oliver & J. Cox, A family kindred with ill-used children, Brit. Med. Jl i, 81 (1973)
(25)
J. Emery, Final results of study of infants at risk of sudden death, Nature. 268, 724 (1977).
B r i t . Mad. J1.
At Risk:NSPCC Bettered Child Research Team, Routledge &
The D e t e c t i o n of P S y c h i a t r i c
psychiatric hospital,
I l l n e s s by ~ u e e t i o n n a i r e , O x f o r d
The Maudsley P e r s o n a l i t y I n v e n t o r y ,
U n i v . of London P r e s s .
Scale
hostility in a small group setting, Arch. Gen.Psych
Workman and D. G. Cunningham, Canad. Jl. Fern. Psych. 21, 63 (1975)