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Cross-cultural and historical perspectives on child abuse and neglect
Chiiif Abnw and Ne#kct, Vol. 5, pp. 299-m. Printed in tbt U.S.A. All t’i&ItOmsmcd.
1981
CROSS-CULTURAL AND HISTORICAL PERSPECTIVES ON CHILD ABUSE AND NEGLECT LEON EISENBERG,M.D. Maude and Lillian Presley professor of Social Medicine and Professor of Psychiatry Harvard Medical School, Boston, Massachusetts 02115
BECAUSE THIS IS an International Congress, convened to better the condition of children the
world over, our charge-the mobilization of knowledge about child abuse and neglect as a basis for programs of prevention and treatment-must be placed in the broadest possible context. Cultures differ markedly from one another (a) in modal patterns of child rearing, (b) in the extent to which they recognize childhood to be a developmental stage meriting special consideration, (c) in the conditions which they consider to be necessary for healthy development and (d) in the “rights” they accord to children, if such rights are indeed recognized at all. Not only do these conceptions differ from country to country but, within each country, they differ from one epoch to another. Let me emphasize that these observations do not justify a position of complete relativism with respect to children’s needs. To the contrary, clinical experience as well as the historical record make it abundantly clear that some modes of child rearing interfere with the realization of individual potential and, ulti~tely, with national achievement [I]. Nor is it true that history is simply a record of beliefs which swing back and forth like a pendulum between extremes. Cumulative knowledge, greater productivity and the growing power of democratic ideals have made possible important advances in the physical and mental health of children. Nonetheless, cross-cultural and historical perspectives are essential, whether we work in a Third World country or a Western “post-industrial” state, if we are to respect the diversity which enhances individual differences and if we are to identify the basic needs which all cultures, no matter how diverse, must meet if children are to ffower. It is my assignment to open this session on the topic of emotional violence. In my view, emotional abuse is no less severe in its consequences for suffering and for impaired function than is physical maltreatment. All too often, the sequellae of emotional violence are overlooked in the press of medical concern for repair of physical trauma or they may be regarded as “merely” the concomitants of organic pathology. Yet, emotional abuse can occur without physical abuse. Moreover, methods of physical coercion which carry a high risk of producing injury may be commonplace in a culture which regards such methods as “necessary” for proper child rearing. In such a context, the circumstances of the victimized child will not be recognizably different from those of his peers. I begin by hig~ighting the importance of culture as the prime determinant of attitudes and behaviors toward children by using deliberate infauticide as an extreme instance of violence. It can occur in the context of a culture which is in all other respects highly supportive of children or as part of a continuum of punitive and neglectful child-rearing practices. I will cite two examples This paperwas presented at: The Third International Congress on Child Abuse and Neglect, Amsterdam, Netherlands, 23 April 1981. Supported in part by funds from the Jane Hitder Harris Trust. 299
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from preliterate peoples and then briefly review the history of its occurrence in Western countries. Among the !Kung San, Kalahari hunter-gatherers, pregnant women give birth to their children in the bush at a site from which men are excluded. After the child has been born, the mother examines it carefully for evidence of defect; if such is found, the infant is buried with the afterbirth and reported back to the community as a stillborn [2]. Howell [3] estimates that infanticide occurs no more frequently than in l-2% of live births, though others have computed a somewhat higher rate [4]. Infanticide plays little role in fertility regulation, which is controlled by postpartum sexual taboos [2] and by frequent and prolonged nursing [5]. From the evolutionary standpoint, the killing of a defective newborn conserves maternal investment among a nomadic people where childcarrying, necessary over long distances, places a high demand for energy expenditure on women. Although the romantic characterization of the !Kung as “the harmless people” [6] is not literally correct even within their traditional society [2] and hardly true at all in the contemporary South African context [7], we face the challenge of understanding the toleration of infanticide among a people who are gentle and indulgent toward their children. Infanticide, highly selective for females, occurs among the Netsilik Eskimo, whose habitat is northwest of Hudson Bay in Canada 181. If a female child is born at a time when there is no suitable male of appropriate age (2-5 years old) for betrothal, the infant is put out in the cold to die before it is named; for, without a name, it is, by definition, not human. Although there is no direct documentation, the frequency of infanticide can be inferred from the 1.4 to 1 male-to-female ratio among the Netsilik, which indicates extensive resort to the practice. Other central Arctic Eskimo tribes, who occupy less unstable ecosystems, are characterized by more nearly equal sex ratios; extreme environmental pressure appears to be the force leading to female infanticide, in an environment in which it is only the men who can obtain food by hunting. Yet, the Netsilik, like the !Kung San, are “extremely devoted to their children. Children at all ages [are] an endless source of joy to their parents, despite the sacrifices that their rearing entails. . Relations between grandparents and grandchildren are marked by ceaseless fondling and joking” [9]. Again, we have an instance of a people tightly bound by a close kinship network, warm and indulgent toward their children and yet able to accept infanticide. Sex preference in infanticide is not consistent in the ethnographic literature. In a review of the data in the Human Relations Area Files from 99 societies, Whiting and his colleagues [lo] report records of infanticide among 84 of the 99 for such reasons as: illegitimacy, family spacing and planning, and defective offspring. More than half the societies who depended primarily on hunting, gathering and/or fishing practiced infanticide whereas such was true for less than 10% of the pastoral and agricultural societies. Thus, it is likely that an unpredictable subsistence base is a precondition for the custom. Although the examples of the !Kung and the Netsilik indicate that the practice can occur among groups which emphasize peaceful conflict resolution and warm and indulgent child rearing, where its presence is discordant with other values, its occurrence in a culture of violence is less surprising. The aggressive and war-like Yanomamo Indians [ 1 l] resort to female infanticide at so high a rate that the juvenile sex ratio is 1.5 males to 1 female and overall effective fertility is strikingly low [12]. In Yanomamo society, the survival of each tribe is dependent on males for success in hunting and in war. In most of the world today, infanticide is regarded with such horror as to lead to condemnation of those who practice it. Yet, before we rush to judgement, it is instructive to review Western history. For millenia, infanticide has “been the accepted procedure for disposing not only of deformed or sickly infants, but of all such newborns as might strain the resources of the individual family or the larger community” [ 131. It was an extremely common practice in ancient Greece and Rome and was rationalized by philosophers. Plato, in the Republic (Chapter V), argued for maintaining the quality of the citizenry of the state by assuring that “the best of either sex should be united with the best as often, and the inferior with the inferior, as seldom as possible.” He recommended that the “offspring of the inferior, or of the better when they chance to be deformed, will be put away in some mysterious unknown place” by “the proper officers” of the state. Aristotle,
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like Plato, recognized the need to limit population because “the neglect of the subject. . . is a never failing cause of poverty among the citizens and poverty is the parent of revolution and crime” (Politics 11:6). Aristotle differed from Plato, however, in preferring abortion to exposure except for deformed children (VII:16) whose birth could not be anticipated. Rabbinical law held infanticide to be murder. The Bible had long declared that having many children was a virtue (Genesis 1:28; 9:7; 35:ll; Psalms 128:31). The Hebrews were at pains to dissociate themselves from the Canaanite god Moloch who was worshipped by child sacrifice (Leviticus 18:21). With the triumph of Christianity in the Roman Empire, the decrees of Emperors from Constantine through Gratian had made infanticide a major crime by the end of the 4th century A.D. However, the demographic context in which these decisions were taken was one of “progressive depopulation due to devastating epidemics, recurrent famines and general disorder. Under the circumstances. . . increased fertility was desired” [ 131. Nonetheless, despite official condemnation by the major Western religions, infanticide by exposure was practiced widely throughout Europe well into the 19th century. In response to the common practice of abandoning infants, foundling homes were established by religious orders. In France in 1833, the number of infants left at the foundling hospitals exceeded 160,000! The mortality rate among such foundlings was enormous. For example, in Dublin, in the last quarter of the 18th century, only 45 of the more than 10,000 infants admitted to the foundling home survived [ 141. Although they were established under the rationale of upholding the sanctity of life, foundling homes were little more than a convenient social invention. They served to obscure the complicity of the class structure of society in differential infant mortality by allowing infants, whom parents were unable to care for, to die from “natural” causes with no need to acknowledge responsibility for the deaths. Indeed, the fate of home reared children was little better. It was not until 1800 that children born in London had a 50% chance of living until their 5th birthday. In the 19th century, families of the underclass had no choice but to put their children out for cheap labor in factories and mines. We can judge how onerous the conditions of work must have been from the terms of the Reform Law in 1833; regarded as a forward step, it provided that “children from 9 to 13 were not to work more than 48 hours in the week and those from 13 to 18 nor more than 68” [ 141. Effective laws against child labor had to await the present century. This century has seen enormous gains in child health; infant mortality in the United States, for example, has fallen to less than one-eighth of what it is estimated to have been at the turn of this century [ 151. Yet, marked inequity in life chances for newborns continues to persist between and within Western countries. Infant mortality is twice as high in Italy, Ireland and Australia as it is in Denmark, Sweden and The Netherlands [ 16, p. 1351. Within the U.K., neonatal mortality is twofold greater and postneonatal mortality threefold greater when infants born into social class V are compared with those born into social class I [ 171. Within the U.S., a black newborn is still twice as likely to die as a white newborn [ 16, p. 291. For the U.S.S.R., extrapolation from available statistics indicates a rise in infant mortality since 1960 [18]. Thus, what is anathema today in societies which consider themselves enlightened was commonplace among the very same societies not many years ago; what offends us among the peoples we call “primitive” has been deleted from the archives of our past and is ignored in the record of our present. Culturally sanctioned infanticide evolved as an adaptation to the imbalance between population and environment resources. What made it possible to apply the concepts we now adhere to was, on the one hand, marked improvement in living conditions and, on the other, the availability of effective contraception and safe abortion. Mark well that I am not sanctioning infanticide; rather, I caution against crediting ourselves with moral superiority without examining the social conditions which make possible, though they do not assure, a regard for the sanctity of life. We have only to recall Nazi Germany to remind ourselves that high technology is no guarantor of the moral structure of society. We have no systematic information on the attitudes of ordinary families toward their children
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in earlier centuries. Certainly, the death of children was so common an occurrence as to have made it a part of every parent’s expectations. Yet, the ethnographies of the !Kung San and the Netsilik make it evident that infanticide sanctioned under defined conditions is in no way incompatible with loving and caring for children, once they have been included as members of the group. The contention advanced by opponents of abortion that abortion on demand-or even contraception -necessarily results in the brutalization of children is palpably false. indeed, prohibition of abortion can lead to a caricature of life for the severely handicapped victim [ 191. It is the quality of life for children with which we must be concerned. That quality is determined by social context as well as cultural values, context and values which have evolved over time [20]. The French historian, Phillippe Aries [21] has presented evidence that the concept of childhood itself as a developmental stage, requiring special institutions for its cultivation, is an invention of relatively modern times: In medieval society, the idea of childhood did not exist; this is not to suggest that children were neglected, fore&en or despised. The idea of childhood is not to be confused with affection for children; it corresponds to an awareness of the particular natnre of childhood. . . . Language did not give the word child tbe restricted meaning we give it today.
With the writing of Locke [22] and Rousseau [23], childhood was conceptualized as a developmental epoch important in itself. Rousseau’s “‘Emile or On Education” proposed revolutionary ideas: successive stages of development, the necessity for the exercise of mental functions, adaptation to age-appropriate circumstances, and individuality in development. It is instructive to recall the words of Helvetius, a philosopher of the Enlightenment, who wrote: The inequality of minds is the effect of a known cause, and this cause is the difference of education. . . If I could demonstrate that man is indeed but the product of his education, I should have undoubt~iy revealed a great truth to the nations. They would then know that they hold within their hands the instrument of their greatness and their happiness, and that to be happy and powerful is only a matter of perfecting the science of education 1241.
The theory of evolution provided a me~h~ism for the doctrines of human ~~e~tibility heralded by the Encyclopedists. As homologies were sought between the phylogenetic progression of species and the development of human individuals in society, comparative psychology was founded; human beings were to be understood not by an analysis of their adult functions but by a study of their origins- in the scale of nature and in the child. In the Origin ofSpecies, Darwin [25] wrote: I should premise that I use this term (struggIe for existence] in a large and metaphorical sense, including dependence of one being on another and including (which is more irn~~:) not only tbe Iife of the ind~vidu~, but success in leaving progeny.
Success in leaving progeny means, of course, progeny able to reach the age of fertility and to produce offspring of their own. Thus, effective fertility is dependent upon a matrix of parenting behaviors essential for the survival of the young. In our species, postnatal maturation is extraordinarily prolonged. The limited behavioral repertoire with which the newborn is equipped permits behavior to be fitted to ecological demands. The human brain quadruples its weight postnatally while its development is being shaped by env~o~en~l contingencies which modulate connectivity patterns [26]. The price our species pays for this malleability is the total dependence of infant and child upon adequate parenting behaviors. All primates live in groups with a complex social order and a division of labor based on sex and age. The critical role of group behavior for survival points to genetic antecedents for the social learning which ties the individual to the group. The genes concerned do not determine the behavior; rather, they determine the readiness with which it is learned. The social bond is fashioned initially out of the dependence of the infant on its adult caretaker and then from interactions with peers and other adults. Harlow 1271demons~t~ that even though infant monkeys can be successfully
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reared as isolates in the laboratory, they are subsequently unable to adjust to colony existence and have great difficulty in learning to mate. If two such non-mothered infant monkeys are permitted to share a cage, peer interactions lead to a considerable reduction in deviant behavior. When impregnated at maturity, isolation-reared female rhesus macaques exhibit few of the expected patterns of primate maternal behavior. However, the strength of proximity-seeking behavior in the newborn macaque is evident from the fact that the infants of such mothers persist in attempts to cling to them despite abuse; they learn to approach them from the side or the rear to avoid injury. It is the infant who initiates the interplay which determines such adaptation to the presence of the infant as the mother is able to tolerate [28]. There is a striking parallel between the behavior of these young monkeys and that of the abused toddlers (age 1 to 3) George and Main [29] studied in day care. In response to friendly overtures from caregivers, the abused children “were more likely to approach to the side, to the rear or by turning about and backstepping. . . [They] combined movements of approach with movements of avoidance” in contrast to the unambivalent approach behavior of matched controls. Moreover, they were more aggressive to peers and to adult caregivers; in the environment of abuse and neglect, they learn patterns of behavior which serve further to isolate them from the growth-promoting interactions which might mitigate their distress. The social behaviors of the earliest humans can only be inferred from the nature of the artifacts associated with fossil bones. Some tentative surmises can be made from these data and the observation of human groups still living with Stone Age technologies. They exhibit the following characteristics: relatively open groups of 20 to 50 members; a division of labor by sex and by family unit; common language; social rules which regulate mating and competition; a kinship ethic which prescribes mutual food sharing; and a craving by each member for a response from his or her peers, a craving as fundamental to man as that for food. Although patterns of interpersonal exchange differ in different groups, all include reciprocal giving and receiving which create a confident expectation of help from others as well as a firm obligation to give to others [30]. The imperative need for recognition and acceptance by one’s reference group is everywhere preeminent. Social connectedness is a biological necessity, not only for survival itself, but for the development of human characteristics. Man is man only in a social context [ 11. Moreover, the potency of social ties is no less evident for adults than it is for children. Both morbidity and mortality are higher among those who are relatively isolated. Brown and Harris [31] have demonstrated that having an intimate male confidant has a powerful protective effect against depression among women under stress. Henderson et al. [32] have shown, in an epidemiologic study in Canberra, Australia, that, at the same level of life stress, morbidity is less among those who report having stronger social supports. Most striking of all is the study by Be&man and Symes [33] of a community sample of 5,000 persons; mortality rates proved to be more than two-fold higher during a 9-year follow-up among the individuals who were the most isolated in comparison with those who were the most connected. These few examples from an extensive literature [34] document the proposition that social ties are essential for the maintenance of health, biological as well as psychological. I have thus far argued that the interplay between ecological pressures and cultural beliefs is a major determinant of morbidity and mortality in childhood; that the awareness of childhood as a developmental stage in itself has evolved historically from the interaction between social and political forces; that the anlugen of social ties are established in childhood; but that the need for affiliation is no less compelling throughout the life cycle than the need for food. If we are to develop a public health program to prevent-or at least to diminish-child abuse and neglect, our first task is to identify (a) the sociocultural factors which contribute to their prevalence and (b) the populations at special risk. That list of contributory forces begins with economic privation and social isolation. Although child abuse does occur in all classes of society, “child abuse and neglect are strongly related to poverty, in terms of prevalence and of severity of consequences” [35]. Indeed the conditions of
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slum are hardly less deleterious for the child not known to have been deliberately abused. In an 8-year follow-up of 17 abused children matched for age, race, sex and socioeconomic status with 17 who had been in accidents and an equal group with no kno+v#history of abuse or accident, the most striking finding was the prevalence of problems in all groups, with the clinical differences between them small [36]. Among these lower class urban children, it was almost as if happenstance determined whether an episode of abuse came to official attention. Urban enclaves with a high frequency of child abuse are characterized by an aggregation of needy families competing for scarce resources in a “neighborhood” notably lacking in help and support from others 1371. Although I believe clinical in~~ention can make a difference for the outcome of children once they are recognized to have been abused, the public health effects of care after the fact will remain marginal unless we act simultaneously to improve the life environment of disadvantaged children 1381. Inaddition to the general risk associated with social disadvantage, there are infants at particular risk because of the infant’s inability to elicit appropriate behaviors from its mother and to respond to her so as to provide the grati~cation necessary to sustain mothering. Such infants include those who are premature [39], congenitally impaired [40] and those who have experienced fetal malnutrition (411. Zeskind and Ramey [41] have compared the development over a 3-year period of a group of fetally malnourished infants reared in adequate and inadequate caretaking environments compared with the outcome of infants with a normal ponderal index. The combination of retarded fetal growth and a nonsupportive environment resulted in delayed development, an outcome avoided for infants with equal fetal malnut~tion who had been provided adequate home care. What merits emphasis is that the transactions between biological and environmental contributions to development are bidirectional and that they begin prenatally [42] and continue postnatally [43, 441. The development of undernourished infants reflects (a) the earlier biological history of their mothers, themselves frequently malnourished and chronically ill, (b) the increased obstetrical risk during pregnancy and (c) the transactions between an impaired infant and an impaired mother, both adversely affected by continuing social disadvan~ge 1451. I stress this transactional approach to contrast it with the increasingly common view that the neglect and abuse experienced by premature and low birth weight infants is ascribable to a failure of bonding between infant and mother because of prolonged postnatal hospitalization [46, 47). In a careful prospective study of 267 primiparous women, Egeland and Vaughn [48] found no evidence that limited contact after birth distinguished the mothers exhibiting neglect and abuse from those providing excellent care. Indeed, a critical review of the relevant literature on human and other primate infant-mother pairs [49] makes clear the salience of species differences, of social context, of interactions over time, and-of therapeutic interventions to the developing relationship between infant and mother. Furthermore, the study by Gaensbauer and Sands [50] emphasizes that the very personality traits, which evolve in abused and neglected children in the abusive envi#nment, in turn interfere with mutual engagement and elicit negative responses in caretakers, thus perpetuating m~development. However one weighs the various ~ont~butions of mother, infant, biological insult and social context to the pattern of neglect and abuse, the public health implications are clear; namely, prenatal nutritional, obstetrical and social services targeted toward pregnant women at risk and post-natal pediatric and home visitor follow-up for low-birth weight and otherwise handicapped infants [51, 521. A third social influence which increases the risks for child abuse is a culture of violence in the family [53]. In the United States and Europe, “the family is the preeminent social setting for all types of aggression and violence”-from murder to verbal assault 1541. Conjugal violence, which is strongly associated across cultures with male dominance [55], is so widespread in the West as to make the marriage license the equivalent of “a hitting license” [54]. Violence in one family role is associated with violence in others; couples who use physical force on each other use physical punishment for their children more frequently and their children attack their siblings more often. Observations of aggressive behavior on children’s playgrounds in Germany, Italy and Denmark the urban
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reveal that German adults “are significantly more often aggressive toward German children, and German children toward other children, than are either the Italians or the Danes” [561. Contrary to the hypothesis that expressing aggression leads to catharsis, the evidence is clear that the display of aggression breeds further aggression by social modelling [57]. It is easy enough to agree that a culture which tolerates violence in the family, let alone one which makes it normative, increases the probability of child abuse; it is far more difficult to prescribe effective and realistic remedies. In a world armed to the teeth, in which the major powers have means to destroy each other and themselves many times over, and in which expenditures euphemistically labelled “for defense” far exceed those for human welfare, readiness for violence at governmental command becomes “patriotism.” Psychiatrists have no expertise in international affairs; they do have a duty as citizens to point out the consequences of preparing for war even before war occurs and to work with others for the renunciation of nuclear armaments [58, 591. At a domestic level, we must work toward social norms which regard the use of force in marriage as totally unacceptable and which celebrate child rearing without resort to physical punishment. Simultaneously, we must help to expose the destructive effects of sex stereotyping on men as well as women and strive toward the end that women have a full range of choices in social role [60]. With due regard for free expression, we must advocate the elimination of the gratuitous display of violence in the mass media [61]. If isolated nuclear families, particularly those characterized by limited education, inadequate social resources and parental immaturity, are at greatest risk for child abuse, then it follows that communal child rearing practices, which are still modal in much of the developing world and in such social innovations as the kibbutzim in Israel [62], have much to teach us about potential remedy. Collective child rearing buffers idiosyncratic and pathological interactions particular to a given family through positive caretaking experiences with other adults and through growthpromoting play and work with peers. Inadequate parents need no longer be solely responsible for around-the-clock care for the children who seem to them so great a burden. Competent parents are a valuable source for instructing failed parents in the appropriate management of child behavior. At the simplest level, child care facilities provide a much needed vacation for troubled parents and difficult children from each ‘other. We cannot, of course, return to a way of life long since abandoned-and wouldn’t want to if we could. What we can do is adapt the best of the past to the conditions of the present. In particular, I emphasize the importance of a universally accessible network of day care centers in public schools, a proposal all the more feasible in view of the declining school population in most industrialized societies. The attachment to public schools provides a double opportunity. It makes use of an existing social institution and permits the incorporation of older children and adolescents into caring for toddlers. With the erosion of the extended family and a declining birth rate, our children grow up without the opportunity to learn child care in the family. An active role for older children in caring for younger ones and a public school curriculum in human development could enable us to prepare a generation of young adults more adequate in, and more comfortable with, parenting roles. If I stress prevention, I do so in large part because the magnitude of present and likely future problems of child abuse far exceeds the efficacy and availability of resources for remedy. Nonetheless, I fully recognize the urgency of action by the best means we now have to rehabilitate the victims of abuse and to keep them from additional harm; they must not be abandoned while we await utopia. It is to the everlasting credit of the President of the International Society, C. Henry Kempe, that he has succeeded in alerting the medical community to the “battered child syndrome” 1631 and has been so effective in spearheading an organized response to its magnitude [64]. Because others at this Congress have discussed methods of detection and treatment extensively, I will not comment further on these questions except to note the paucity of clinical resources even in so wealthy a country as my own. The limited services which have been available are threatened by cutbacks proposed by the current administration.
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The U.S. National Conference on Child Abuse and Neglect, which met in Milwaukee the week of April 5th, has protested against these budget cuts; the federal official in charge of Human Development Services responded that the critics were voicing a “parochial” viewpoint [65]. Of course, professionals engaged in child abuse work respond to the loss of income; but it is a sad commentary on morality in government when advocacy for the needs of children can be dismissed as only “parochial.” If further evidence is needed for the thesis that enlisting public support for programs for children is primarily a political matter rather than a scientific one, budget discussions in every country provide it. When resources are constrained, choices must be among the claims upon those resources [661. Those choices, in the final resort, are not determined by economics but by a scale of values. How much do we value child welfare as opposed to a reduction in taxes, the building of missiles, increase in profits and so on through the list of national priorities? Let me conclude by stating my position OR this question with the hope that it is also yours. Children matter-in and of themselves-for what they tell us about ourselves-and for the future. The last of these-the future-is commonly invoked to support programs for children. The value of a new pediatric service is often justified on the ground that the investment will yield healthier adults; or a more productive work force; or savings in ultimate medical costs. Of course, it is important what kinds of adults children will become. But arguing for services for children solely on the basis of the future is a risky strategy. More than that, it is morally unacceptable. It takes a generation to know whether the prediction of adult benefit will be borne out. Its inevitable uncertainty provides grounds for denying children what they need now. Measurement by distant outcome places a terrible burden of proof on childhood interventions; they must be powerful indeed to be able to show a clear effect despite the vicissitudes of subsequent life experience. Consider: we have overwhelming evidence of the importance of infant nutrition; yet the best fed baby will not grow to become a healthy adolescent if it is starved in later childhood. Is that an argument against feeding babies? Judging by the future implies that things are not worth doing for children unless they have a long run payoff. Do any of us really believe that? Do we have to prove that starvation produces mental retardation before we can justify feeding infants? That is why I begin with the proposition that children matter in and of themselves. It should be justification enough for a program to show that it improves the quality of life for the children who participate in it, whether or not it has enduring after-effects. Otherwise, we shall impoverish our common humanity by reducing the environment of our children to the minimal conditions that permit survival without gross impairment. Children matter for what they tell us about ourselves. They cannot defend their rights; such rights as they enjoy must be freely given to them. Thus, the care children receive in a society is a sensitive index of its morality. I leave it to each of us to judge for ourselves how well our nations measure up to this standard. Of course, children do matter for the future. They are the future of our species. Their survival has an urgent quality about it. Children do not keep. They are exquisitely sensitive to time. The food they need, the love they require, the stimulation their development depends upon cannot be put off without harm to their growth. In the words of the Chilean poet, Gabriela Mistral: “The child cannot wait. Many things we need can wait, but he cannot. . . . To him, we cannot say ‘tomorrow,’ his name is ‘today.“’ Providing the best care we know how to give is no guarantee of a trouble-free future. Nothing is. But it does make it more likely that our children will be better equipped than we have been to manage the problems inherent in the human condition. REFERENCES I. EISENBERG, L., The human nature of human nature. Science 176:123-128 (1972). 2. LEE, R. B., The !Kung San: Men, Women and Work in a Foraging Society. Cambridge University Press (1979).
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3. HOWELL, N., The population of the Dobe area !Kung. In: R. 3. Lee and 1. DeVore (Ms.), Kaiukari &utterGatherers. Harvard University Press, Cambridge, MA, pp. 137- 151 (1976). 4. BIRDSELL, I. B., Some predictions for the pleistocene based on equilibrium systems among recent hunter-gatherers. In: R. B. Lee and I. Devote (Eds.), Mun the Hunter. Aldine, Chicago, pp. 229-249 (1968). 5. KONNER, M. and WORTHMAN, C., Nursing frequency, gonadal function and birth spacing among !Kung huntergatherers. Scientx #M:788-791 (1980). 6. THOMAS, E. M., The Harmless People. Knopf, New York (1959). 7. KOLATA, G. B., !Kung bushmen join South African Army. Science 211:562-564 (1981). 8. RICHES, D., The Netsilik Eskimo: A special case of selective female infanticide. Ethnof. 13:351-361 (1974). 9. BALIKSCI, A., The Netsilik Eskimo. The Natural History Press, Garden City, N.Y. (1970). 10. WHITING, J., BOGUCKI, P,, KWONG, W. Y. and NIGRO, J., Infanticide. Paper presented at the Society for Cross-Cultural Research. East Lansing, MI (February 1977). 11. HARRIS. M.. Cows. Pias. Wurs and Witches: The Riddles of Culture. Random House, New York (1974). 12. NEEL, J.’ V. and CHAGNGN, N. A., The demography of two tribes of primitive, relatively unacculturated American Indians. Proc. Nat. Acad. Sciences (U.S.) 59:680-689 (1968). 13. LANGER, W., Infanticide: A historical survey. Hist. Cki~~ood Quart. 1:353-365 (1974). 14. KESSEN, W., The Child. John Wiley and Sons, New York (1965). 15. National Office of Vital Statistics, Historical Statistics of the U.S.: Colonial Times to 1970, Part 1. Vital Statistics Series B-120, U.S. Government Printing Office, Washington, D.C. (1975). 16. U.S. Depattment of Health and Human Services, Health UnitedStates 1980. DHHS Publication No. (PHS) 81-1232. U.S. Government Printing Of&e, Wa~in8~n, D.C. (1980). 17. MORRIS, J. N., Social inequalities undiminished. Lancer i:87-90 (1979). 18. DAVIS, C. and FESHBACH, M., Rising Infant Mortality in the U.S.S.R. in the 1970’s. United States Bureau of the Census, Series P-95, No. 74 (1980). 19. EISENBERG, L., The etbics of intervention: Acting amidst ambiguity. J. Childf’sychot. Psychiut. 16:93-104 (1975). 20. EISENBERG, L. The so&l context of health: effects of time, place and person. ln: S. H. Fine, R. Krell and T. Y. Lin (Ms.). Toa+s Priorities in Mental Health. Dordrecht, Holland, D. Reidei Publishing Company, pp. 35-48 (1981). 21. ARIES, P., Centuries of Childhood. Knopf, New York (1962). 22. LOCKE, J., Some Thoughts Concerning Education. Churchill, London. (1699). 23. ROUSSEAU, J. J., Em& or On Educatian. Translated by B. Foxiey. Dent, London 191t (1762). 24. RANDALL, I. H., The Making of the Modern Mind. Riverside Press, Cambridge, MA (1940). 25. DARWIN, C., The Origin of Species by Means of Naturul Seiection, or the Preservation of Favored Races in the Struggle for Life. A. L. Burt Company, London (1859). 26. EISENBERG, L., Development as a unifying concept in psychiatry. Brit. J. Psycbiat. 131:225-237 (1977). 27. HARLOW, H. F. and HARLOW, M. K., The affectional systems in behavior of non-human primates. In: Behavior ofNon-Humun Primates, Vol. II, pp. 287-334. A. M. Schrier, H. F. Harlow and F. Stollnitz (Eds.). Academic Press, New York (1965). 28. SEAY, B. et al., Maternal behavior of socially deprived rhesus monkeys. J. Abnarm. Sot. Psycho/. 69:345-354 (1964). 29. GEORGE, C. and MAIN, M., Social interactions of young abused children: Approach, avoidance and aggression. Child Develop. 50~306-318 (1979). 30. JENSEN, B., Human interaction: An arctic exemplification. Amer. J. Orthopsychiut. 43:447-458 (1973). 31. BROWN, G. W. and HARRIS, T., Social Origins of Depression: A Study of Psychiatric Disorder in Women. The
Free Press, New York (1978). 32. HENDERSON, S. et al., Social bonds, adversity and neurosis. In: L. N. Robins, P. J. Clayton, J. K. Wing (Eds.). The Social Consequences qffpsychiatric Disorder. BmnnedMazel, New York (1980). 33. BERKMAN, L. F. and SYMES, S. L., Social networks, host resistance and mortality: A nine-year follow-uo study of Alameda County residents. Amer. J. Epidemiol. 109:186-204 (1979). 34. EISENBERG, L.. what makes Demons “natients” and uatients “well.” Amer. J. Med. 69~277-286 (1980). 35. PELTON, L. H. Child abuse a&l neglect: The myth of‘classlessness. Amer. J. D~~p~c~iat. 48~608-617 (1978). 36. ELMER, E., A follow-up study on tmumatized children. Pediat. 59~273-279 (1977). 37. GARBARINO, J. and SHERMAN, D., High-risk neighborhood and high-risk families: The human ecology of child maltreatment. Child Developm. 51:188-198 (1980). 38. National Academy of Sciences. Toward a National Policy for Children and Families. U.S. Government Printing Office, Washington, DC. (1976). 39. HUNTER, R. S. et al., Antecedents of child abuse and neglect in premamre infants. Pediat. 61:629-635 (1978). 40. EPPLER, M. and BROWN, G., Child abuse and neglect: Preventable causes of mental retardation. Chi%fAbuse and Neglect 1:309-313 (1977). 41. ZESKIND, P. S. and RAMEY, C. T. Preventing intellectual and interactional sequellae of fetal malnutrition. Child Developm. 52~213-218 (1981). 42. GOTTLElB, G., Conceptions of prenatal development: Behavioral embryology. Psychol. Rev. 83~215-234 (1976). 43. SAMEROFF, A. and CHANDLER, M. J., Reproductive risk and the continuum of caretaking casualty. In: F. D. Horowitz (Ed.). Review of Child Development Research, Vol. 4. University of Chicago Press, Chicago, pp. 187-244
(1975). 44. WERNER, E. E. et al. The Children of Kauai: A LangitudinaL Studyfrom the Prenatal Period to Age IO. University of Hawaii Press. Honolulu (1971).
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45. BIRCH, H. G. and GUSSOW, J. D., Disadvantaged Children: Health, Nutrition and School Failure. Harcourt, Brace and World, New York (1970). 46. LYNCH, M. and ROBERTS, J., Predicting child abuse: Signs of bonding failure in the maternity hospital. Brit. Med. J. 1:624-626 (1977). 47. FANAROFF, A. et al., Follow-up of low birth-weight infants: The predictive value of maternal visiting patterns. Pediat. 48. 49.
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SCHLEGEL, A., Male Dominance and Female Autonomy: Domestic Authority in Matrilineal Societies. Hraf Press, New Haven, CT (1972). BELLAK, L. and ANTELL, M., An intercultural study of aggressive behavior on children’s playgrounds. Amer. J. Orthopsychiat. 44:503-511 (1974). BANDURA, A., Aggression: A Social Learning Analysis. Prentice-Hall, Englewood Cliffs, New Jersey (1973). HIATT, H. H., Preventing the last epidemic. J. Amer. Med. Assoc. 244:2314-2315 (1980). Editorial, The threat of nuclear war. Lancer i:1225-1226 (1980). EISENBERG, L., Psychiatry and society: A sociobiologic synthesis. New Eng. J. Med. 296:903-910 (1977). BERKOWITZ, L., Control of aggression. In: B. M. Caldwell and H. N. Ricciuti (Eds.). Review ofChild Development Research, Vol. 3. University of Chicago Press, Chicago, pp. 95- 140 (1973). EISENBERG, L. and NEUBAUER, P. B., Mental health issues in Israeli collectives: Kibbutzim. J. Amer. Acad. Child Psychiat.
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EGELAND, B. and VAUGHN, B., Failure of “bond formation” as a cause of abuse, neglect, and maltreatment. Amer. J. Orrhopsychiar. 51:78-84 (1981). EISENBERG, L., The social context of child development. Pediat. In Press (1981). GAENSBAUER, T. J. and SANDS, K., Distorted affective communications in abused/neglected infants and their potential impact on caretakers. J. Amer. Acad. Child Psychiar. 18:236-250. Select Panel for the Promotion of Child Health. Better Health for our Children: A National Strategy. A Report to the United States Congress and the Secretary of Health and Human Services. Washington, D.C. DHHS (PHS) Publication No. 79-55071 (1981). GRAY, J., CUTLER, C., DEAN, J. and KEMPE, C. H., Prediction and prevention of child abuse and neglect. Presented to the Society for Research in Child Development. New Orleans, La. (1977). LYSTAD, M. H., Violence at home: A review of the literature. Amer. J. Orthopsychiar. 45:328-345 (1975). STRAUS, M. A., Societal morphogenesis and intrafamily violence in cross-cultural perspective. Annals N.Y. Acad.
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KEMPE, C. H. et al, The battered-child syndrome. J. Amer. Med. Assoc. 181:17-24 (1962). 64. SILVER, H. K., Presentation of the Howland Award: Some observations introducing C. Henry Kempc, M.D. Pediar. Res. 14:1151-1154 (1980). 65. The New York Times, April 8, 1981. 66. EISENBERG, L., Equity, quality and constraints. Hosp. Commun. Psychiat. 29:781-787 (1978).
1981
CROSS-CULTURAL AND HISTORICAL PERSPECTIVES ON CHILD ABUSE AND NEGLECT LEON EISENBERG,M.D. Maude and Lillian Presley professor of Social Medicine and Professor of Psychiatry Harvard Medical School, Boston, Massachusetts 02115
BECAUSE THIS IS an International Congress, convened to better the condition of children the
world over, our charge-the mobilization of knowledge about child abuse and neglect as a basis for programs of prevention and treatment-must be placed in the broadest possible context. Cultures differ markedly from one another (a) in modal patterns of child rearing, (b) in the extent to which they recognize childhood to be a developmental stage meriting special consideration, (c) in the conditions which they consider to be necessary for healthy development and (d) in the “rights” they accord to children, if such rights are indeed recognized at all. Not only do these conceptions differ from country to country but, within each country, they differ from one epoch to another. Let me emphasize that these observations do not justify a position of complete relativism with respect to children’s needs. To the contrary, clinical experience as well as the historical record make it abundantly clear that some modes of child rearing interfere with the realization of individual potential and, ulti~tely, with national achievement [I]. Nor is it true that history is simply a record of beliefs which swing back and forth like a pendulum between extremes. Cumulative knowledge, greater productivity and the growing power of democratic ideals have made possible important advances in the physical and mental health of children. Nonetheless, cross-cultural and historical perspectives are essential, whether we work in a Third World country or a Western “post-industrial” state, if we are to respect the diversity which enhances individual differences and if we are to identify the basic needs which all cultures, no matter how diverse, must meet if children are to ffower. It is my assignment to open this session on the topic of emotional violence. In my view, emotional abuse is no less severe in its consequences for suffering and for impaired function than is physical maltreatment. All too often, the sequellae of emotional violence are overlooked in the press of medical concern for repair of physical trauma or they may be regarded as “merely” the concomitants of organic pathology. Yet, emotional abuse can occur without physical abuse. Moreover, methods of physical coercion which carry a high risk of producing injury may be commonplace in a culture which regards such methods as “necessary” for proper child rearing. In such a context, the circumstances of the victimized child will not be recognizably different from those of his peers. I begin by hig~ighting the importance of culture as the prime determinant of attitudes and behaviors toward children by using deliberate infauticide as an extreme instance of violence. It can occur in the context of a culture which is in all other respects highly supportive of children or as part of a continuum of punitive and neglectful child-rearing practices. I will cite two examples This paperwas presented at: The Third International Congress on Child Abuse and Neglect, Amsterdam, Netherlands, 23 April 1981. Supported in part by funds from the Jane Hitder Harris Trust. 299
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from preliterate peoples and then briefly review the history of its occurrence in Western countries. Among the !Kung San, Kalahari hunter-gatherers, pregnant women give birth to their children in the bush at a site from which men are excluded. After the child has been born, the mother examines it carefully for evidence of defect; if such is found, the infant is buried with the afterbirth and reported back to the community as a stillborn [2]. Howell [3] estimates that infanticide occurs no more frequently than in l-2% of live births, though others have computed a somewhat higher rate [4]. Infanticide plays little role in fertility regulation, which is controlled by postpartum sexual taboos [2] and by frequent and prolonged nursing [5]. From the evolutionary standpoint, the killing of a defective newborn conserves maternal investment among a nomadic people where childcarrying, necessary over long distances, places a high demand for energy expenditure on women. Although the romantic characterization of the !Kung as “the harmless people” [6] is not literally correct even within their traditional society [2] and hardly true at all in the contemporary South African context [7], we face the challenge of understanding the toleration of infanticide among a people who are gentle and indulgent toward their children. Infanticide, highly selective for females, occurs among the Netsilik Eskimo, whose habitat is northwest of Hudson Bay in Canada 181. If a female child is born at a time when there is no suitable male of appropriate age (2-5 years old) for betrothal, the infant is put out in the cold to die before it is named; for, without a name, it is, by definition, not human. Although there is no direct documentation, the frequency of infanticide can be inferred from the 1.4 to 1 male-to-female ratio among the Netsilik, which indicates extensive resort to the practice. Other central Arctic Eskimo tribes, who occupy less unstable ecosystems, are characterized by more nearly equal sex ratios; extreme environmental pressure appears to be the force leading to female infanticide, in an environment in which it is only the men who can obtain food by hunting. Yet, the Netsilik, like the !Kung San, are “extremely devoted to their children. Children at all ages [are] an endless source of joy to their parents, despite the sacrifices that their rearing entails. . Relations between grandparents and grandchildren are marked by ceaseless fondling and joking” [9]. Again, we have an instance of a people tightly bound by a close kinship network, warm and indulgent toward their children and yet able to accept infanticide. Sex preference in infanticide is not consistent in the ethnographic literature. In a review of the data in the Human Relations Area Files from 99 societies, Whiting and his colleagues [lo] report records of infanticide among 84 of the 99 for such reasons as: illegitimacy, family spacing and planning, and defective offspring. More than half the societies who depended primarily on hunting, gathering and/or fishing practiced infanticide whereas such was true for less than 10% of the pastoral and agricultural societies. Thus, it is likely that an unpredictable subsistence base is a precondition for the custom. Although the examples of the !Kung and the Netsilik indicate that the practice can occur among groups which emphasize peaceful conflict resolution and warm and indulgent child rearing, where its presence is discordant with other values, its occurrence in a culture of violence is less surprising. The aggressive and war-like Yanomamo Indians [ 1 l] resort to female infanticide at so high a rate that the juvenile sex ratio is 1.5 males to 1 female and overall effective fertility is strikingly low [12]. In Yanomamo society, the survival of each tribe is dependent on males for success in hunting and in war. In most of the world today, infanticide is regarded with such horror as to lead to condemnation of those who practice it. Yet, before we rush to judgement, it is instructive to review Western history. For millenia, infanticide has “been the accepted procedure for disposing not only of deformed or sickly infants, but of all such newborns as might strain the resources of the individual family or the larger community” [ 131. It was an extremely common practice in ancient Greece and Rome and was rationalized by philosophers. Plato, in the Republic (Chapter V), argued for maintaining the quality of the citizenry of the state by assuring that “the best of either sex should be united with the best as often, and the inferior with the inferior, as seldom as possible.” He recommended that the “offspring of the inferior, or of the better when they chance to be deformed, will be put away in some mysterious unknown place” by “the proper officers” of the state. Aristotle,
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like Plato, recognized the need to limit population because “the neglect of the subject. . . is a never failing cause of poverty among the citizens and poverty is the parent of revolution and crime” (Politics 11:6). Aristotle differed from Plato, however, in preferring abortion to exposure except for deformed children (VII:16) whose birth could not be anticipated. Rabbinical law held infanticide to be murder. The Bible had long declared that having many children was a virtue (Genesis 1:28; 9:7; 35:ll; Psalms 128:31). The Hebrews were at pains to dissociate themselves from the Canaanite god Moloch who was worshipped by child sacrifice (Leviticus 18:21). With the triumph of Christianity in the Roman Empire, the decrees of Emperors from Constantine through Gratian had made infanticide a major crime by the end of the 4th century A.D. However, the demographic context in which these decisions were taken was one of “progressive depopulation due to devastating epidemics, recurrent famines and general disorder. Under the circumstances. . . increased fertility was desired” [ 131. Nonetheless, despite official condemnation by the major Western religions, infanticide by exposure was practiced widely throughout Europe well into the 19th century. In response to the common practice of abandoning infants, foundling homes were established by religious orders. In France in 1833, the number of infants left at the foundling hospitals exceeded 160,000! The mortality rate among such foundlings was enormous. For example, in Dublin, in the last quarter of the 18th century, only 45 of the more than 10,000 infants admitted to the foundling home survived [ 141. Although they were established under the rationale of upholding the sanctity of life, foundling homes were little more than a convenient social invention. They served to obscure the complicity of the class structure of society in differential infant mortality by allowing infants, whom parents were unable to care for, to die from “natural” causes with no need to acknowledge responsibility for the deaths. Indeed, the fate of home reared children was little better. It was not until 1800 that children born in London had a 50% chance of living until their 5th birthday. In the 19th century, families of the underclass had no choice but to put their children out for cheap labor in factories and mines. We can judge how onerous the conditions of work must have been from the terms of the Reform Law in 1833; regarded as a forward step, it provided that “children from 9 to 13 were not to work more than 48 hours in the week and those from 13 to 18 nor more than 68” [ 141. Effective laws against child labor had to await the present century. This century has seen enormous gains in child health; infant mortality in the United States, for example, has fallen to less than one-eighth of what it is estimated to have been at the turn of this century [ 151. Yet, marked inequity in life chances for newborns continues to persist between and within Western countries. Infant mortality is twice as high in Italy, Ireland and Australia as it is in Denmark, Sweden and The Netherlands [ 16, p. 1351. Within the U.K., neonatal mortality is twofold greater and postneonatal mortality threefold greater when infants born into social class V are compared with those born into social class I [ 171. Within the U.S., a black newborn is still twice as likely to die as a white newborn [ 16, p. 291. For the U.S.S.R., extrapolation from available statistics indicates a rise in infant mortality since 1960 [18]. Thus, what is anathema today in societies which consider themselves enlightened was commonplace among the very same societies not many years ago; what offends us among the peoples we call “primitive” has been deleted from the archives of our past and is ignored in the record of our present. Culturally sanctioned infanticide evolved as an adaptation to the imbalance between population and environment resources. What made it possible to apply the concepts we now adhere to was, on the one hand, marked improvement in living conditions and, on the other, the availability of effective contraception and safe abortion. Mark well that I am not sanctioning infanticide; rather, I caution against crediting ourselves with moral superiority without examining the social conditions which make possible, though they do not assure, a regard for the sanctity of life. We have only to recall Nazi Germany to remind ourselves that high technology is no guarantor of the moral structure of society. We have no systematic information on the attitudes of ordinary families toward their children
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in earlier centuries. Certainly, the death of children was so common an occurrence as to have made it a part of every parent’s expectations. Yet, the ethnographies of the !Kung San and the Netsilik make it evident that infanticide sanctioned under defined conditions is in no way incompatible with loving and caring for children, once they have been included as members of the group. The contention advanced by opponents of abortion that abortion on demand-or even contraception -necessarily results in the brutalization of children is palpably false. indeed, prohibition of abortion can lead to a caricature of life for the severely handicapped victim [ 191. It is the quality of life for children with which we must be concerned. That quality is determined by social context as well as cultural values, context and values which have evolved over time [20]. The French historian, Phillippe Aries [21] has presented evidence that the concept of childhood itself as a developmental stage, requiring special institutions for its cultivation, is an invention of relatively modern times: In medieval society, the idea of childhood did not exist; this is not to suggest that children were neglected, fore&en or despised. The idea of childhood is not to be confused with affection for children; it corresponds to an awareness of the particular natnre of childhood. . . . Language did not give the word child tbe restricted meaning we give it today.
With the writing of Locke [22] and Rousseau [23], childhood was conceptualized as a developmental epoch important in itself. Rousseau’s “‘Emile or On Education” proposed revolutionary ideas: successive stages of development, the necessity for the exercise of mental functions, adaptation to age-appropriate circumstances, and individuality in development. It is instructive to recall the words of Helvetius, a philosopher of the Enlightenment, who wrote: The inequality of minds is the effect of a known cause, and this cause is the difference of education. . . If I could demonstrate that man is indeed but the product of his education, I should have undoubt~iy revealed a great truth to the nations. They would then know that they hold within their hands the instrument of their greatness and their happiness, and that to be happy and powerful is only a matter of perfecting the science of education 1241.
The theory of evolution provided a me~h~ism for the doctrines of human ~~e~tibility heralded by the Encyclopedists. As homologies were sought between the phylogenetic progression of species and the development of human individuals in society, comparative psychology was founded; human beings were to be understood not by an analysis of their adult functions but by a study of their origins- in the scale of nature and in the child. In the Origin ofSpecies, Darwin [25] wrote: I should premise that I use this term (struggIe for existence] in a large and metaphorical sense, including dependence of one being on another and including (which is more irn~~:) not only tbe Iife of the ind~vidu~, but success in leaving progeny.
Success in leaving progeny means, of course, progeny able to reach the age of fertility and to produce offspring of their own. Thus, effective fertility is dependent upon a matrix of parenting behaviors essential for the survival of the young. In our species, postnatal maturation is extraordinarily prolonged. The limited behavioral repertoire with which the newborn is equipped permits behavior to be fitted to ecological demands. The human brain quadruples its weight postnatally while its development is being shaped by env~o~en~l contingencies which modulate connectivity patterns [26]. The price our species pays for this malleability is the total dependence of infant and child upon adequate parenting behaviors. All primates live in groups with a complex social order and a division of labor based on sex and age. The critical role of group behavior for survival points to genetic antecedents for the social learning which ties the individual to the group. The genes concerned do not determine the behavior; rather, they determine the readiness with which it is learned. The social bond is fashioned initially out of the dependence of the infant on its adult caretaker and then from interactions with peers and other adults. Harlow 1271demons~t~ that even though infant monkeys can be successfully
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reared as isolates in the laboratory, they are subsequently unable to adjust to colony existence and have great difficulty in learning to mate. If two such non-mothered infant monkeys are permitted to share a cage, peer interactions lead to a considerable reduction in deviant behavior. When impregnated at maturity, isolation-reared female rhesus macaques exhibit few of the expected patterns of primate maternal behavior. However, the strength of proximity-seeking behavior in the newborn macaque is evident from the fact that the infants of such mothers persist in attempts to cling to them despite abuse; they learn to approach them from the side or the rear to avoid injury. It is the infant who initiates the interplay which determines such adaptation to the presence of the infant as the mother is able to tolerate [28]. There is a striking parallel between the behavior of these young monkeys and that of the abused toddlers (age 1 to 3) George and Main [29] studied in day care. In response to friendly overtures from caregivers, the abused children “were more likely to approach to the side, to the rear or by turning about and backstepping. . . [They] combined movements of approach with movements of avoidance” in contrast to the unambivalent approach behavior of matched controls. Moreover, they were more aggressive to peers and to adult caregivers; in the environment of abuse and neglect, they learn patterns of behavior which serve further to isolate them from the growth-promoting interactions which might mitigate their distress. The social behaviors of the earliest humans can only be inferred from the nature of the artifacts associated with fossil bones. Some tentative surmises can be made from these data and the observation of human groups still living with Stone Age technologies. They exhibit the following characteristics: relatively open groups of 20 to 50 members; a division of labor by sex and by family unit; common language; social rules which regulate mating and competition; a kinship ethic which prescribes mutual food sharing; and a craving by each member for a response from his or her peers, a craving as fundamental to man as that for food. Although patterns of interpersonal exchange differ in different groups, all include reciprocal giving and receiving which create a confident expectation of help from others as well as a firm obligation to give to others [30]. The imperative need for recognition and acceptance by one’s reference group is everywhere preeminent. Social connectedness is a biological necessity, not only for survival itself, but for the development of human characteristics. Man is man only in a social context [ 11. Moreover, the potency of social ties is no less evident for adults than it is for children. Both morbidity and mortality are higher among those who are relatively isolated. Brown and Harris [31] have demonstrated that having an intimate male confidant has a powerful protective effect against depression among women under stress. Henderson et al. [32] have shown, in an epidemiologic study in Canberra, Australia, that, at the same level of life stress, morbidity is less among those who report having stronger social supports. Most striking of all is the study by Be&man and Symes [33] of a community sample of 5,000 persons; mortality rates proved to be more than two-fold higher during a 9-year follow-up among the individuals who were the most isolated in comparison with those who were the most connected. These few examples from an extensive literature [34] document the proposition that social ties are essential for the maintenance of health, biological as well as psychological. I have thus far argued that the interplay between ecological pressures and cultural beliefs is a major determinant of morbidity and mortality in childhood; that the awareness of childhood as a developmental stage in itself has evolved historically from the interaction between social and political forces; that the anlugen of social ties are established in childhood; but that the need for affiliation is no less compelling throughout the life cycle than the need for food. If we are to develop a public health program to prevent-or at least to diminish-child abuse and neglect, our first task is to identify (a) the sociocultural factors which contribute to their prevalence and (b) the populations at special risk. That list of contributory forces begins with economic privation and social isolation. Although child abuse does occur in all classes of society, “child abuse and neglect are strongly related to poverty, in terms of prevalence and of severity of consequences” [35]. Indeed the conditions of
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slum are hardly less deleterious for the child not known to have been deliberately abused. In an 8-year follow-up of 17 abused children matched for age, race, sex and socioeconomic status with 17 who had been in accidents and an equal group with no kno+v#history of abuse or accident, the most striking finding was the prevalence of problems in all groups, with the clinical differences between them small [36]. Among these lower class urban children, it was almost as if happenstance determined whether an episode of abuse came to official attention. Urban enclaves with a high frequency of child abuse are characterized by an aggregation of needy families competing for scarce resources in a “neighborhood” notably lacking in help and support from others 1371. Although I believe clinical in~~ention can make a difference for the outcome of children once they are recognized to have been abused, the public health effects of care after the fact will remain marginal unless we act simultaneously to improve the life environment of disadvantaged children 1381. Inaddition to the general risk associated with social disadvantage, there are infants at particular risk because of the infant’s inability to elicit appropriate behaviors from its mother and to respond to her so as to provide the grati~cation necessary to sustain mothering. Such infants include those who are premature [39], congenitally impaired [40] and those who have experienced fetal malnutrition (411. Zeskind and Ramey [41] have compared the development over a 3-year period of a group of fetally malnourished infants reared in adequate and inadequate caretaking environments compared with the outcome of infants with a normal ponderal index. The combination of retarded fetal growth and a nonsupportive environment resulted in delayed development, an outcome avoided for infants with equal fetal malnut~tion who had been provided adequate home care. What merits emphasis is that the transactions between biological and environmental contributions to development are bidirectional and that they begin prenatally [42] and continue postnatally [43, 441. The development of undernourished infants reflects (a) the earlier biological history of their mothers, themselves frequently malnourished and chronically ill, (b) the increased obstetrical risk during pregnancy and (c) the transactions between an impaired infant and an impaired mother, both adversely affected by continuing social disadvan~ge 1451. I stress this transactional approach to contrast it with the increasingly common view that the neglect and abuse experienced by premature and low birth weight infants is ascribable to a failure of bonding between infant and mother because of prolonged postnatal hospitalization [46, 47). In a careful prospective study of 267 primiparous women, Egeland and Vaughn [48] found no evidence that limited contact after birth distinguished the mothers exhibiting neglect and abuse from those providing excellent care. Indeed, a critical review of the relevant literature on human and other primate infant-mother pairs [49] makes clear the salience of species differences, of social context, of interactions over time, and-of therapeutic interventions to the developing relationship between infant and mother. Furthermore, the study by Gaensbauer and Sands [50] emphasizes that the very personality traits, which evolve in abused and neglected children in the abusive envi#nment, in turn interfere with mutual engagement and elicit negative responses in caretakers, thus perpetuating m~development. However one weighs the various ~ont~butions of mother, infant, biological insult and social context to the pattern of neglect and abuse, the public health implications are clear; namely, prenatal nutritional, obstetrical and social services targeted toward pregnant women at risk and post-natal pediatric and home visitor follow-up for low-birth weight and otherwise handicapped infants [51, 521. A third social influence which increases the risks for child abuse is a culture of violence in the family [53]. In the United States and Europe, “the family is the preeminent social setting for all types of aggression and violence”-from murder to verbal assault 1541. Conjugal violence, which is strongly associated across cultures with male dominance [55], is so widespread in the West as to make the marriage license the equivalent of “a hitting license” [54]. Violence in one family role is associated with violence in others; couples who use physical force on each other use physical punishment for their children more frequently and their children attack their siblings more often. Observations of aggressive behavior on children’s playgrounds in Germany, Italy and Denmark the urban
Cross-culturaland historical perspectives
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reveal that German adults “are significantly more often aggressive toward German children, and German children toward other children, than are either the Italians or the Danes” [561. Contrary to the hypothesis that expressing aggression leads to catharsis, the evidence is clear that the display of aggression breeds further aggression by social modelling [57]. It is easy enough to agree that a culture which tolerates violence in the family, let alone one which makes it normative, increases the probability of child abuse; it is far more difficult to prescribe effective and realistic remedies. In a world armed to the teeth, in which the major powers have means to destroy each other and themselves many times over, and in which expenditures euphemistically labelled “for defense” far exceed those for human welfare, readiness for violence at governmental command becomes “patriotism.” Psychiatrists have no expertise in international affairs; they do have a duty as citizens to point out the consequences of preparing for war even before war occurs and to work with others for the renunciation of nuclear armaments [58, 591. At a domestic level, we must work toward social norms which regard the use of force in marriage as totally unacceptable and which celebrate child rearing without resort to physical punishment. Simultaneously, we must help to expose the destructive effects of sex stereotyping on men as well as women and strive toward the end that women have a full range of choices in social role [60]. With due regard for free expression, we must advocate the elimination of the gratuitous display of violence in the mass media [61]. If isolated nuclear families, particularly those characterized by limited education, inadequate social resources and parental immaturity, are at greatest risk for child abuse, then it follows that communal child rearing practices, which are still modal in much of the developing world and in such social innovations as the kibbutzim in Israel [62], have much to teach us about potential remedy. Collective child rearing buffers idiosyncratic and pathological interactions particular to a given family through positive caretaking experiences with other adults and through growthpromoting play and work with peers. Inadequate parents need no longer be solely responsible for around-the-clock care for the children who seem to them so great a burden. Competent parents are a valuable source for instructing failed parents in the appropriate management of child behavior. At the simplest level, child care facilities provide a much needed vacation for troubled parents and difficult children from each ‘other. We cannot, of course, return to a way of life long since abandoned-and wouldn’t want to if we could. What we can do is adapt the best of the past to the conditions of the present. In particular, I emphasize the importance of a universally accessible network of day care centers in public schools, a proposal all the more feasible in view of the declining school population in most industrialized societies. The attachment to public schools provides a double opportunity. It makes use of an existing social institution and permits the incorporation of older children and adolescents into caring for toddlers. With the erosion of the extended family and a declining birth rate, our children grow up without the opportunity to learn child care in the family. An active role for older children in caring for younger ones and a public school curriculum in human development could enable us to prepare a generation of young adults more adequate in, and more comfortable with, parenting roles. If I stress prevention, I do so in large part because the magnitude of present and likely future problems of child abuse far exceeds the efficacy and availability of resources for remedy. Nonetheless, I fully recognize the urgency of action by the best means we now have to rehabilitate the victims of abuse and to keep them from additional harm; they must not be abandoned while we await utopia. It is to the everlasting credit of the President of the International Society, C. Henry Kempe, that he has succeeded in alerting the medical community to the “battered child syndrome” 1631 and has been so effective in spearheading an organized response to its magnitude [64]. Because others at this Congress have discussed methods of detection and treatment extensively, I will not comment further on these questions except to note the paucity of clinical resources even in so wealthy a country as my own. The limited services which have been available are threatened by cutbacks proposed by the current administration.
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The U.S. National Conference on Child Abuse and Neglect, which met in Milwaukee the week of April 5th, has protested against these budget cuts; the federal official in charge of Human Development Services responded that the critics were voicing a “parochial” viewpoint [65]. Of course, professionals engaged in child abuse work respond to the loss of income; but it is a sad commentary on morality in government when advocacy for the needs of children can be dismissed as only “parochial.” If further evidence is needed for the thesis that enlisting public support for programs for children is primarily a political matter rather than a scientific one, budget discussions in every country provide it. When resources are constrained, choices must be among the claims upon those resources [661. Those choices, in the final resort, are not determined by economics but by a scale of values. How much do we value child welfare as opposed to a reduction in taxes, the building of missiles, increase in profits and so on through the list of national priorities? Let me conclude by stating my position OR this question with the hope that it is also yours. Children matter-in and of themselves-for what they tell us about ourselves-and for the future. The last of these-the future-is commonly invoked to support programs for children. The value of a new pediatric service is often justified on the ground that the investment will yield healthier adults; or a more productive work force; or savings in ultimate medical costs. Of course, it is important what kinds of adults children will become. But arguing for services for children solely on the basis of the future is a risky strategy. More than that, it is morally unacceptable. It takes a generation to know whether the prediction of adult benefit will be borne out. Its inevitable uncertainty provides grounds for denying children what they need now. Measurement by distant outcome places a terrible burden of proof on childhood interventions; they must be powerful indeed to be able to show a clear effect despite the vicissitudes of subsequent life experience. Consider: we have overwhelming evidence of the importance of infant nutrition; yet the best fed baby will not grow to become a healthy adolescent if it is starved in later childhood. Is that an argument against feeding babies? Judging by the future implies that things are not worth doing for children unless they have a long run payoff. Do any of us really believe that? Do we have to prove that starvation produces mental retardation before we can justify feeding infants? That is why I begin with the proposition that children matter in and of themselves. It should be justification enough for a program to show that it improves the quality of life for the children who participate in it, whether or not it has enduring after-effects. Otherwise, we shall impoverish our common humanity by reducing the environment of our children to the minimal conditions that permit survival without gross impairment. Children matter for what they tell us about ourselves. They cannot defend their rights; such rights as they enjoy must be freely given to them. Thus, the care children receive in a society is a sensitive index of its morality. I leave it to each of us to judge for ourselves how well our nations measure up to this standard. Of course, children do matter for the future. They are the future of our species. Their survival has an urgent quality about it. Children do not keep. They are exquisitely sensitive to time. The food they need, the love they require, the stimulation their development depends upon cannot be put off without harm to their growth. In the words of the Chilean poet, Gabriela Mistral: “The child cannot wait. Many things we need can wait, but he cannot. . . . To him, we cannot say ‘tomorrow,’ his name is ‘today.“’ Providing the best care we know how to give is no guarantee of a trouble-free future. Nothing is. But it does make it more likely that our children will be better equipped than we have been to manage the problems inherent in the human condition. REFERENCES I. EISENBERG, L., The human nature of human nature. Science 176:123-128 (1972). 2. LEE, R. B., The !Kung San: Men, Women and Work in a Foraging Society. Cambridge University Press (1979).
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3. HOWELL, N., The population of the Dobe area !Kung. In: R. 3. Lee and 1. DeVore (Ms.), Kaiukari &utterGatherers. Harvard University Press, Cambridge, MA, pp. 137- 151 (1976). 4. BIRDSELL, I. B., Some predictions for the pleistocene based on equilibrium systems among recent hunter-gatherers. In: R. B. Lee and I. Devote (Eds.), Mun the Hunter. Aldine, Chicago, pp. 229-249 (1968). 5. KONNER, M. and WORTHMAN, C., Nursing frequency, gonadal function and birth spacing among !Kung huntergatherers. Scientx #M:788-791 (1980). 6. THOMAS, E. M., The Harmless People. Knopf, New York (1959). 7. KOLATA, G. B., !Kung bushmen join South African Army. Science 211:562-564 (1981). 8. RICHES, D., The Netsilik Eskimo: A special case of selective female infanticide. Ethnof. 13:351-361 (1974). 9. BALIKSCI, A., The Netsilik Eskimo. The Natural History Press, Garden City, N.Y. (1970). 10. WHITING, J., BOGUCKI, P,, KWONG, W. Y. and NIGRO, J., Infanticide. Paper presented at the Society for Cross-Cultural Research. East Lansing, MI (February 1977). 11. HARRIS. M.. Cows. Pias. Wurs and Witches: The Riddles of Culture. Random House, New York (1974). 12. NEEL, J.’ V. and CHAGNGN, N. A., The demography of two tribes of primitive, relatively unacculturated American Indians. Proc. Nat. Acad. Sciences (U.S.) 59:680-689 (1968). 13. LANGER, W., Infanticide: A historical survey. Hist. Cki~~ood Quart. 1:353-365 (1974). 14. KESSEN, W., The Child. John Wiley and Sons, New York (1965). 15. National Office of Vital Statistics, Historical Statistics of the U.S.: Colonial Times to 1970, Part 1. Vital Statistics Series B-120, U.S. Government Printing Office, Washington, D.C. (1975). 16. U.S. Depattment of Health and Human Services, Health UnitedStates 1980. DHHS Publication No. (PHS) 81-1232. U.S. Government Printing Of&e, Wa~in8~n, D.C. (1980). 17. MORRIS, J. N., Social inequalities undiminished. Lancer i:87-90 (1979). 18. DAVIS, C. and FESHBACH, M., Rising Infant Mortality in the U.S.S.R. in the 1970’s. United States Bureau of the Census, Series P-95, No. 74 (1980). 19. EISENBERG, L., The etbics of intervention: Acting amidst ambiguity. J. Childf’sychot. Psychiut. 16:93-104 (1975). 20. EISENBERG, L. The so&l context of health: effects of time, place and person. ln: S. H. Fine, R. Krell and T. Y. Lin (Ms.). Toa+s Priorities in Mental Health. Dordrecht, Holland, D. Reidei Publishing Company, pp. 35-48 (1981). 21. ARIES, P., Centuries of Childhood. Knopf, New York (1962). 22. LOCKE, J., Some Thoughts Concerning Education. Churchill, London. (1699). 23. ROUSSEAU, J. J., Em& or On Educatian. Translated by B. Foxiey. Dent, London 191t (1762). 24. RANDALL, I. H., The Making of the Modern Mind. Riverside Press, Cambridge, MA (1940). 25. DARWIN, C., The Origin of Species by Means of Naturul Seiection, or the Preservation of Favored Races in the Struggle for Life. A. L. Burt Company, London (1859). 26. EISENBERG, L., Development as a unifying concept in psychiatry. Brit. J. Psycbiat. 131:225-237 (1977). 27. HARLOW, H. F. and HARLOW, M. K., The affectional systems in behavior of non-human primates. In: Behavior ofNon-Humun Primates, Vol. II, pp. 287-334. A. M. Schrier, H. F. Harlow and F. Stollnitz (Eds.). Academic Press, New York (1965). 28. SEAY, B. et al., Maternal behavior of socially deprived rhesus monkeys. J. Abnarm. Sot. Psycho/. 69:345-354 (1964). 29. GEORGE, C. and MAIN, M., Social interactions of young abused children: Approach, avoidance and aggression. Child Develop. 50~306-318 (1979). 30. JENSEN, B., Human interaction: An arctic exemplification. Amer. J. Orthopsychiut. 43:447-458 (1973). 31. BROWN, G. W. and HARRIS, T., Social Origins of Depression: A Study of Psychiatric Disorder in Women. The
Free Press, New York (1978). 32. HENDERSON, S. et al., Social bonds, adversity and neurosis. In: L. N. Robins, P. J. Clayton, J. K. Wing (Eds.). The Social Consequences qffpsychiatric Disorder. BmnnedMazel, New York (1980). 33. BERKMAN, L. F. and SYMES, S. L., Social networks, host resistance and mortality: A nine-year follow-uo study of Alameda County residents. Amer. J. Epidemiol. 109:186-204 (1979). 34. EISENBERG, L.. what makes Demons “natients” and uatients “well.” Amer. J. Med. 69~277-286 (1980). 35. PELTON, L. H. Child abuse a&l neglect: The myth of‘classlessness. Amer. J. D~~p~c~iat. 48~608-617 (1978). 36. ELMER, E., A follow-up study on tmumatized children. Pediat. 59~273-279 (1977). 37. GARBARINO, J. and SHERMAN, D., High-risk neighborhood and high-risk families: The human ecology of child maltreatment. Child Developm. 51:188-198 (1980). 38. National Academy of Sciences. Toward a National Policy for Children and Families. U.S. Government Printing Office, Washington, DC. (1976). 39. HUNTER, R. S. et al., Antecedents of child abuse and neglect in premamre infants. Pediat. 61:629-635 (1978). 40. EPPLER, M. and BROWN, G., Child abuse and neglect: Preventable causes of mental retardation. Chi%fAbuse and Neglect 1:309-313 (1977). 41. ZESKIND, P. S. and RAMEY, C. T. Preventing intellectual and interactional sequellae of fetal malnutrition. Child Developm. 52~213-218 (1981). 42. GOTTLElB, G., Conceptions of prenatal development: Behavioral embryology. Psychol. Rev. 83~215-234 (1976). 43. SAMEROFF, A. and CHANDLER, M. J., Reproductive risk and the continuum of caretaking casualty. In: F. D. Horowitz (Ed.). Review of Child Development Research, Vol. 4. University of Chicago Press, Chicago, pp. 187-244
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