Non-accidental injury to children—II

Behac. Res. Ther. Vol. 22, No. 4, pp. 349-366.

1984

Pnnted in Great Britain. All rights reserved

Copyright

NON-ACCIDENTAL

INJURY

0005-7967/X4 $3.00 + 0.00 Cc: 1984 Pergamon Press Ltd

TO CHILDREN-II

A CONTROLLED EVALUATION OF A BEHAVIOURAL MANAGEMENT PROGRAMME JANE Department

of Psychology,

E.

SMITH and S. J.

RACHMAN*

Institute of Psychiatry, De Crespigny London SE5 8AF, England (Received

3 August

Park,

Denmark

Hill,

1983)

Summary-A controlled treatment trial was conducted to evaluate the contribution of a psychological approach to child-abusing families. Ten families participated in the trial, and although some successes were observed in treated and control comparison families (e.g. no further confirmed injuries) the final outcome was inconclusive. A conclusive outcome was precluded by the very high rate of non-cooperation encountered in the 17 other families accepted for inclusion in the study: 11 of these withdrew prior to completion of the initial assessment procedures and 6 withdrew before completing the trial period proper. The results from the 10 participating families are of interest, and indicate that it is feasible to carry out a full, complete evaluation, given considerable resources and even more considerable endurance and patience.

INTRODUCTION Reports of the successful behavioural treatment of child-abusing families began to appear in the literature in the form of single-case studies in the mid 1970s (Polakow and Peabody, 1975; Gilbert, 1976). In their comprehensive review Parke and Collmer (1975) put forward a ‘social-situational’ model for child abuse, and discussed its implications for treatment. If the behavioural approach could be used successfully with child-abusing families, in a variety of settings, it would have important implications for the management of a serious social problem which has increasingly concerned the Western World over the last decade. Estimates of the incidence of physical abuse vary widely (depending on researchers’ definitions of child abuse and methods of data collection) but are currently reported as between 1.4 and 1.9 million children per annum in the U.S.A. (Straus, Gelles and Steinmetz, 1979), and 4500 children (15.6% of the child population) in the U.K. in 1979 (NSPCC Library, 1983). The promising case reports of successful intervention in single cases suggested the need for a controlled evaluation of behavioural treatment in a natural setting. In the U.K., where field social workers carry the statutory responsibility for monitoring reported cases of child abuse, the most usual treatment setting is the home, with work carried out by Local Authority social workers. The purpose of the present project was to develop and evaluate a psychological treatment approach to families where there had been non-accidental injury (NAI) to children. The work was carried out in a Social Services Department, taking unselected referrals as they came in to the Department. The question we hoped to be able to answer was: do behavioural techniques have anything to contribute in the treatment of.families where there has been non-accidental injury to children? Over the 3 years of the project the problems we encountered raised a further question: is it possible to carry out traditional evaluative research with these families? We believe that evaluative research is possible, altho’ugh difficult, but that it will need to be innovative rather than traditional. In Part III of this paper (Smith, Rachman and Yule, 1984, this issue, pp. 367-383) we suggest some guidelines for future research. The behavioural literature on child abuse published in the last decade has been reviewed in Part I of this paper (Smith, 1984, this issue, pp. 331-347). Briefly, when we embarked on the project in 1977, apart from the single-case studies mentioned above and Parke and Collmer’s review article, there existed a very practical chapter on behavioural treatment in one of the recognized texts on child abuse (Jeffrey, 1976) and not much else. An extensive search of the child-abuse literature *Present

address:

Department

of Psychology,

University

of British 349

Columbia,

Vancouver.

B.C.. Canada

350

JANE E. SMITH and S. J. RACHMAN

produced no references to any systematic evaluation of treatment approaches-of whatever theoretical orientation. Treatment outcome was typically discussed in terms of detailed single-case study successes (Baher, Hyman, Jones, Jones. Kerr and Mitchell, 1976; Reaveley and Gilbert. 1976: Ounsted and Lynch, 1976) but there were no systematic comparative group data for any of the various treatment approaches. Our aim was to attempt a systematic evaluation of a behavioural intervention in families where there had been physical abuse. and, as we were working in a Social Services setting. we adopted the term ‘non-accidental injury’ as used by social workers in the U.K. [Discussion of the problems inherent in defining child abuse can be found in Giovannoni and Becerra (1979) and Smith (1984).] The choice of a behavioural intervention method was prompted by the considerable successes achieved with these methods in dealing with a range of psychological problems in adults [e.g. anxiety management, Meichenbaum (1973); anger control, Novaco (1975); and marital therapy. Jacobson and Martin (1976)] as well as the success of behavioural parent-training methods in teaching parents to modify maladaptive family-interaction patterns [e.g. the work of Patterson and his colleagues in Oregon with the families of aggressive boys, Patterson, Cobb and Ray (1973)].

METHOD The research design was that of a controlled trial in three adjacent towns which cluster in an urban conglomeration round an estuary on the south-east coast of England, and form a discrete geographical entity. The area was divided into treatment and control areas according to geographical location. Where one is dealing with a phenomenon such as child abuse. which carries the risk of serious injury and/or death in identified and untreated cases, it is impossible to use the normal research methods of lack of treatment. or even postponed treatment, as a control: the risks are too great. Instead one has to compare the results of available treatment methods with the results of available methods plus an extra ingredient: e.g. in this project a behavioural treatment approach by a psychologist. The only question which could reasonably be asked with such a procedure is: does the addition of a psychological treatment approach in a social-work setting produce an effect over and above that of the existing casework treatment normally provided? This was the question we hoped to answer in this project. Clients living in the treatment area were offered treatment by the research psychologist working on the project, in addition to existing provision by the Social Services Department; clients in the control area received the usual services based on current procedures. These services usually combined monitoring, practical help and counselling by the allocated social worker on each case. The theoretical orientation of the casework reflected the preference of the individual social workers. but was not, so far as we were aware, behavioural in systematic form or approach. During the intake period of the treatment trials (August 1978-December 1979) all cases of NAI referred to the three Social Services Divisions covering the area were notified to the project for inclusion and. providing both the family and the social workers concerned were agreeable, the family was evaluated as soon as possible after referral and again after a 6- to &month treatment interval.

Evaluation of outcome

was assessed

by the following:

(1) Incidence of re-injury to the child. (2) Whether it was considered safe for the child to remain at. or to be returned home. (3) Evaluation of clinical improvement by an outside assessor, who conducted a standardized clinical interview with each family on the basis of which he then rated improvement in various areas. He was kept blind as to whether families belonged to the treatment or contol groups. The main focus of the interview was on child-management problems. The rater elicited information from the parents on how they managed feeding, toilet training, occupation, discipline, bedtime. night waking and other aspects of their child’s behaviour. The rater than decided on the presence or absence of any problems and rated their severity. There were four versions of the interview. with slight variations in the questions. appropriate to four different age groups of children. Global ratings were made of the severe marital problems, parental severity of any related problems (social isolation.

Non-accidental

injury to children--II

351

depression etc.) where, if problems did exist, change would need to take place concurrently with changes in child-management techniques. (4) At the end of the clinical interview three target problems were jointly agreed by rater and parents as the most urgent problems which needed to be tackled over the next 6 months. Improvement on these target problems was evaluated by parental ratings of their severity at the pre- and post-treatment interviews. The treatment approach was based on established behavioural procedures and suggestions drawn from published single-case studies and from Parke and Collmer’s (1975) review article. The approach is derived from social learning theory, in which psychologists have attempted to use behavioural approaches to solve child-management problems, exemplified by the work of Patterson and his colleagues (see Smith, 1984). The primary aim was to teach the parent/s more appropriate, non-violent ways of handling their children. The psychologist’s brief was to approach the problem by modelling and teaching appropriate parenting skills where these were lacking, and by re-educating the parents where maladaptive parenting behaviour had been established. In addition the psychologist was free to apply a behaviourally-oriented approach to other problems &thin the family which were judged, on the basis of the pre-treatment assessment, to be so closely implicated in the abuse of the child that a change in those areas would be a pre-requisite for change in parental behaviour. The psychologist always worked in harness with the allocated social worker. A plan was worked out for each family and treatment apportioned between the psychologist and the social worker (so, for example, the social worker might concentrate on practical problems such as electricity or rent arrears, or might take on marital counselling, while the psychologist concentrated on a particular child-related problem such as managing bed-wetting or temper tantrums). It was impossible to control for the varied theoretical orientations of the social workers, but it was hoped that these would cancel each other out across the treatment and control groups. It was made clear to the families (in writing, or by the social worker in an interview if the parents were illiterate) that the psychologist, while not employed by the DHSS, was working in close coordination with them in an evaluated attempt to improve the services offered to families, and that she would be obliged to report back to the social worker any incidents over child handling which gave her cause for concern. The behavioural treatment methods used were varied: teaching the parents a variety of child-management skills such as use of differential reinforcement, use of time out and token systems etc.; relaxation training; assertion training; anger control; behavioural treatment of depression; structured approaches to problems involving social skills such as job hunting, visiting dentists or family-planning clinics etc. Modelling was used wherever possible. The original plan was to spend 6 months setting up the project, and then to run treatment trials for 2 years. The final 6 months were to be spent in evaluation and writing up. In the event we found that it took 12 months to complete the necessary preliminaries (including work with five pilot cases, design and piloting of assessment procedures etc.) and the treatment trial ran for 22 months (with new referrals taken over a 16-month span). The final 2 months were intended for data analysis and writing up: these 2 months were largely taken up in disengaging from the treatment families and the writing of a preliminary report. Final writing up was deferred in order to allow a follow-up (albeit minimal) at 3 years. Procedure

Over 16 months (1.8.78-l. 12.79) all new cases of NAI in the three Social Services Divisions were referred to the research psychologist for inclusion in the project. NAI was defined as suspected or proven non-accidental injury to a child under the age of 10 years, and included, as far as possible, cases where the social worker was sufficiently concerned about the risk of physical injury to place the child’s name on the Central Child Abuse ‘At Risk’ Register. Cases of neglect. failure to thrive, emotional abuse where there was no physical injury, or sexual abuse, were not included. Each case was assessed as soon as possible after referral: mothers (whether natural or step) were interviewed in all cases; fathers were also interviewed where possible. Section I of the standardized interview (covering background epidemiological information) was administered by the psychologist

352

JANE E. SMITH and S.J.RACHMAN

alone; Section II was administered by the outside assessor, who then made pre-treatment clinical ratings of the severity of problems in various areas. The psychologist sat in on this pre-treatment interview and filled in a duplicate form as a reliability check. (Inter-rater reliability for global clinical ratings of problem severity at pre-assessment, calculated by the traditional percentageagreement method, was 70%.) The social worker (or key worker) filled in a shortened form of global ratings on the family. There was then a ‘treatment span’ which was planned as 6-8 months for all cases (but in two control group cases ran longer than this). The post-assessment version of Section II was then administered by the outside assessor alone, who was kept blind as to groups The social worker repeated the global ratings for post-treatment. Records were kept of time spent by the psychologist and social worker in face-to-face contact with the family; where a child was in care a record of visits by the natural parents to the foster home was kept. Subjects

Referrals to the project during the 16 months of the treatment trials totalled 30 families. Three were rejected as not fulfilling our criteria (one case was neglect rather than injury; in two cases available evidence refuted the original suspicion of NAI). Of the 27 accepted referrals, 10 went through the full trial (pre-assessment, treatment period and post-assessment) and make up our two comparison groups: six treatment and four control cases. The other 17 families dropped out of the trial for various reasons: 11 before pre-assessment and 6 after pre-assessment. This group was almost equally divided geographically: eight from the treatment area and nine from the control group area. These families are discussed separately (Smith et al., 1984). Data Basic background

information

Collection

was collected on the accepted referrals (N = 27). (See Smith et ul..

1984.) Detailed information was collected on 16 families who went through the pre-assessment procedure: 10 came from the treatment group area and 6 from the control group area. Four treatment families and two control families did not complete the full trial. (See Smith et al. 1984, for a discussion of those families who did not stay the whole course). Pre- and post-treatment data were collected on the 10 comparison group families, and are presented below. 3- Year follow-up: some information was obtained from the social-work files on those families who were still living in the area. Follow-up data available on the 10 comparison group families are presented later in Tables 9 and 10.

RESULTS Sample

Characteristics

Basic background information on the 10 comparison group families is given in Tables 1 and 2. Inspection of the sample characteristics shows that the two groups (six treatment, four control) do not differ markedly on variables such as parental ages, socio-economic status and family composition. However. they do differ on one crucial variable: severity of injury, and also--linked with this-on the ages of the target children. Measures Incidence

of Change

of re -injury

In no case was there any known incidence of re-injury to the child during the treatment period. Child remaining

ut, or returned,

home

In the treatment group one child was in care at pre-assessment because of psychiatric disturbance in the mother and remained in care at post-assessment. Another, although still at home at post-assessment, was about to make a planned move to live with paternal grandparents.

Non-accidental

353

injury to children--II

Table I. Sample characteristics: treatment WJUD(IV= 6) Subject No. Age of index child Injury: Degree Perpetrator NAI Register (Category) Legal proceedings Child in care Mother’s age (years) Father’s age (years) Parental status Ordinal position (index child) Number of’ sibs Social class Criminal records (parents)

23

22

2

2f years Threatened Father Index: injury to sib NO NO 25 28 Mother & father

3 months Threatened Mother Unconfirmed

5 years Threatened Mother No

Care Order Yes 21 27 Mother & father I

NO NO 23 28 Mother & father 2

None III NO

2 (twins) III No

Mother: current puerperal psychosis

NO

1; Petty Theft

Psychiatric history (parents)

NO

Table 2. Sample characteristics: Subiect No. Age of index child Injury: Degree Perpetrator NAI Register (Category) Legal proceedings Child in care Mother’s age (years) Father’s age (years) Parental status Ordinal position (index child) Number of sibs Social class Crimmal records (parents)

Psychiatric history (parents)

21

I5

3 years Minor Mother Confirmed No

22 25 Mother & father

I

2 years Threatened Mother NO

Threatened Stepmother NO

No NO 22 Not known Mother & cohabitee

NO NO 22 28 Stepmother & father

8

1 IV NO

Mother:

previous -- anxiety, OP treatment

None

I

III Cohabitee:

III NO

ior GBH Mother: previous depression, hospitahzed

NO

control group (N = 4)

16

3

18

17

2 years Severe ?Cohabttee Confirmed Care Order Yes

3 years Moderate Stepfather Confirmed No Living with MGM 19 30 Mother & stepfather 1

2 years Moderate ?Father Confirmed NO NO

7 months Severe ?Father Unconfirmed No: voluntary R.1.C Yes

21 23 Mother & father I None III No

31 34 Mother & father 3

I$ Single mother I None V Shoplifting

years

V Shoplifting

Stepfather: schizophrenia

If I

Father: suspended prison sentence for burglary Mother: previous depression, OP treatment

In the control group three children (out of the four) were away from home at pre-assessment: one returned home from care by the (delayed) post-assessment: one was returning home for weekends and living with maternal grandmother during the week, and the third remained in care. Clinical evaluation of change (i) Goal achievement: change in target problems. Inspection of the data in Table 3 shows that only two out of the four control group families could (or would) name target problems at pre-assessment but both rated considerable improvements at post-assessment. All six treatment group families named one or more target problems and all rated improvements on one or more targets. (ii) Clinical ratings of change in child management. Tables 4 and 5 show the clinical ratings of change in treatment and control groups. In the treatment group three families (S2, S15, S21) showed considerable improvement; two families (~523 and Sl) were variable; and for one (S22), ratings could not be made post-assessment as the child was in care. * In the control group one family

*Comparisons of child-management ratings at pre- and post-assessment were impossible where the child had remained in care with limited parental contact throughout the treatment period. The exception was S16, where the mother had made regular visits to the foster home and had also had the child home on a planned series of visits-see p. 362.

354

JANE E. SHUH and S. J. Table

3. Parental

Treatment

ratmg

of m~provement

NO.

No I

7

0

23

2

5

0

3 I

NS IO

,

N.S

NA

;

NS

NA

15

?I

Pre-

N/S

rating

= not

NO.

NO.

I

N.S

XA

16

2

NS

VA

N,‘A

3

N.S

?-*A

0

I

IO

IO

,

Y

3

;

7

6 0

dsSess”le”t

3

IO 7

4

3

7

6

IO

I

9

0

2 3

5 N’S

0 NA

I

IO

3

2

5

6

3

IO

0

IO

I7

Post-

assessme”L

dSSeSS”E”t

I

4

2

7

3

3

4

1

I

N’S

N A

7 ;

WS

NA

N’S

NA

IO

6

5

of problem:

N,A

18

Pre-

3

8

spectfied:

group

GOd

I

of seventy

problems

SubJecl

2

3 Parental

Post-

dssessment

I 1

I

target

Control

GOA

2

on

group

Subject

22

RACHMAN

= not

IO = severe

problem,

0 = no problem

applicable.

Table 4. Clinical ratings

of change

s23

in child-management

s22

problems.

s2

treatment

group

s15

(N

= 6)

S2I

Sl

Chdd-management problems

Pre-

Prc-

Post-

Pre-

P05t-

Pre-

Bedtimes

0

I

I

0

I

0

I

I

0

0

Night-waking

0

0

3

0

I

0

2

0

0

2

Todet-training

2

3

2

I

3

2

2

2

I

0

Meals

I

2

I

I

0

0

2

I

I

0

Occupatlo”

0

0

I

0

I

0

2

0

0

0

Discipline

2

I

3

3

2

I

2

I

2

3

Severity

of problem,

Post-

4 = severe

Table

5 Climcal

NiA:

Prc-

child

in care

problem.

ratmgs

Post-

0 = no

of change

Post-

Prc-

Post-

problem

in child-management

Sl6”

problems:

s3

control

group

Sl8

(N

= 4)

Sl7

Chdd-management problems

Prc-

Post-

Prc-

Post-

Pre-

Post-

BedtImes

0

2

0

0

2

7

Night-wakulg

I 0

0 0

0

0

?

i

Todet-training

3

3

N:A

0

Meals

0

0

0

0

0

0

Occupation

I1

0

0

0

2

0

I

I

I

I

I

I

DlSlXDh”c Severity “Sl6.

of problem: although

4 = severe

III care

throughout

problem,

Pre-

Post

N:A:

chdd

I” care

0 = no problem.

the treatment

period.

had

had

regular

wstts

home.

(S3) showed no changes, two were variable (S 16 and S 18) and again for one (S 17) post-assessment ratings could not be made as the child was in care. (iii) Marriages. Ratings* were made on a 6-point scale, using an abbreviated version of the Interview Assessment of Marriage developed by Quinton, Rutter and Rowlands (1976). This rates marriages judged as less than ‘very good’ along two dimensions of discord or apathy. There was variable change in both groups. as shown in Table 6. (iv) Maternal depression. Where it existed, little change was seen (see Table 7). One treatment group mother (S22) was rated as depressed at both pre- and post-assessment (but she was, in fact. suffering from post-puerperal manic-depressive psychosis). Three treatment group mothers (S2, S15 and S21) and one control (S 16) were rated as slightly depressed at both pre- and post-assessment. and one control had become slightly depressed by post-assessment (S17).

were rated for the ‘target father’ living with mother and index child at the time of referral children m the sample had a target father at this stage. but in some cases (e.g. S16) father had pre-assessment.

*‘Marriages’

for injury-all moved out by

Non-accidental Table Treatment Subject NO.

6.

I

relationships

Controlgroup Subject No.

Post3D 3D 2D 1 2D 2D

Average Average Good Very good Good Good

1 = very good. 2D-6D

of marital

group

Pre-

23 22 2 15 21

Quality

= increasing

355

injury to children-11

Very good Average Average Very good Average Good

discord,

2A-6A

I

16 3 18 17

3D 3D

1

Pre-

Post-

Poor Average Very good Average

4D 3D

I 3D

N/A Very good Very good Very poor

I I 5A

3D 2D = increasing

apathy.

(v) Social isolation. Table 8 shows the global ratings of social isolation made after questioning parents about leisure activities and contact with friends and relatives. At pre-assessment 50% of both the treatment and control group families were rated as socially isolated (i.e. a rating of 2 on the scale). By post-asssessment 50% of the treatment group and 75% of the controjs were rated as socially isolated. One treatment (Sl) and one control (S18) had achieved a normal social life; one treatment family had maintained the previous level of contact (S2) and one previously isolated treatment family had improved (S 15)

3- Year Follow -up In February/March 1983 we went back to the three Social Services Divisional Offices to find out from the social-work files what had happened to the families in the 3 years since we had last heard of them. One case (Sl) had been closed in 1979, when the child moved out of the family, and another (S 18) had been closed in late 1981 when the family moved to Germany. Reasonably up-to-date information was available on the remaining eight families although not on all the variables of interest for all eight families. Follow-up data is presented in Tables 9 and 10. Case Examples

Brief accounts of three cases are given below: one improved control case (S18); one improved treatment case (S15); and one failed treatment case (Sl). Subject No. 18: control group case-improved

Bob was a 2-year-old boy referred after an incident where he sustained moderately severe bruising to his face, for which the parents could provide no explanation. He was entered on the Register as a confirmed case of NAI. The father was a regular soldier based at one of the local army barracks. The mother was German-the family had lived in Germany, while father was based there, for the first 14 months of Bob’s life. They had moved to their present army accommodation 6 months previously. When interviewed at pre-assessment the mother was very homesick: her English was good, but she had no friends on the camp and missed her family. She reported feeling depressed and isolated, but the marriage was rated as good. She found Bob a handful: he was very active and demanding

Table Treatment

Table 7 Depression Treatment SubJect No. 23 22 2 15 21

I

group

Pre-

Post-

0 2

0 2

I I I n

I I I n

0 = No depression. s,on.

I = slight

in mother

Control group _.._~______ Subject No PrePost16 3 18 17

depression,

I

I

0 0 0

0 0

I

2 = clinical depres-

8. Social isolation

group

Control

group

Subject No.

Pm-

Post-

Pre-

Post-

23 22 2

2 2 3

2 2 3

16 3 18

3 2 2

I5 21

2 3 3

3 2 5. normal social life

17

3

2 2 5, normal social life 2

I

Subject No.

Very isolated (contact with professionals only) = I; isolated (contact with professionals and l-3 relatives and/or friends) = 2: fairly isolated (contact with relatives and/or friends but no group activities) = 3; group activities but little contact with friends or relatives = 4; normal social life = 5.

New children in hmily Family moved

Criminal involvement (parents) Developmental progress (child)

Psychiatric treatment (parents)

Current Social Services involvement Parental status

~.____

22

Satisfactory

None Mother hving with MGPs Father-no information

None Mother and children recently moved out of distrtct

Mother and father separated Mother continuing OP lithium treatment None

Name still on (unconfirmed) In care: still livtng with same foster-parents Child made Ward of Court: legal wranghng continues Case open -acttve

-..

15 21

None No

Assessed as normal IQ but needing remedial teaching

None

One No

No intkmati

n

Mother OP treatment for overdose

None NO

No info~~tion

No information

Mother and cohabitee separated No information

None

Unchanged

Case open-unallocated

Case closed (2; years after post-assessment) Unc~nged

N/A

Case open-active

Never on Living with mother and new partner N/A

Name removed Living with mother and Tather

Living with mother and father N/A

Never on

2

Table 9. 3.Year follow-up: treatment group

No information

None

Case closed (3 years after post-assessment) Mother and father divorced None

Living with mother and new partner N/A

Whereabouts of child

Legal proceedings

Name removed

23

NAI Register

Subject No.

I

Reported as doing well in school If years after post-assessment None Parents moved within dtstrtct soon after postassessment

No information

No information

Case closed (soon after post-assessment) No information

Living with paternal grandparents N/A

Never on

of child

Mother and father divorced: mother remarried None

Father Satisfactory

Two Mother and children moved within district

No information No information

No information No information

One Family moved to Germany I8 months after post-assessment

Unchanged

Assessed as ESN(M) 18 months after post-assessment One Family moved within district

None

Satisfactory

in prison

Case closed (2; years after post-assessment)

R.1.C

Case closed (I 8 months after post-assessment)

Criminal involvement (parents) Developmental progress (child)

None NO

I7 Name removed: legal custody given to Social Services In care: still living with same foster-parents

Case open-active

N/A

Stepfather-several hospital admissions (one on section) for acute psychotic episodes None

New children in family Family moved

I8 Name removed

group

N/A, voluntary

control

Living with mother and father I8 months after post-assessment. No further information N/A

Name still on (unconfirmed) Living with mother and stepfather

3

IO. 3-Year follow-up:

None

status

Table

Care Order revoked 2 years after post-assessment Formal supervision ceased. Case still open-voluntary supervision Unchanged

Name still on (unconfirmed) Returned home from care: living with single mother

16

Psychiatric treatment (parents)

Parental

Current Social Services involvement

Legal proceedings

Whereabouts

NAI Register

Subject No.

358

JANE E. SMITH and S. J. RACHHAN

and she was always tired. He used few words-some English and some German-and she worried that his speech was delayed. Her named target problems (rated on the scale of 10 = severe problem. 0 = no problem) were: (i) calming Bob’s over-activity (ii) Bob’s screaming fits = 7 (iii) Bob’s getting into parents’

= 4 bed at night = 4.

During the treatment span of 7 months the mother was visited by a motherly social worker (who had a family of her own) and also received supportive counseiling from the Army Welfare Officer. (No comprehensive record of the visits was kept.) At post-assessment the mother reported marked improvement. Bob taow attended a play group in the mornings. and she had made several friends on the camp, most of whom also had small children. Bob’s speech was improving. She was pregnant, and delighted about it. Our outside assessor’s ratings on child-management problems showed some improvement (see Table 5) and on target problems she rated Bob’s over-activity as no longer a problem and his screaming fits and coming into their bed as having improved (see Table 3). Most noticeable-as the outside assessor commented-was her subjective assessment of the child as being much less of a problem. At follow-up we were unable to obtain up to date information-the family had been posted to Germany some 18 months after the post-assessment. At that time no further problems had been reported. The mother was successfully managing the new baby as well as Bob. and it had been formally decided to remove Bob’s name from the NAI Register. Subject

No.

15: treatment

group case-improved

Johnny was a 3-year-old boy referred after an incident where his mother had admitted to grabbing him by the collar and throwing him across the room. causing bruising to his throat. He was entered on the Register as a confirmed case of NAI. The father was unemployed, having given up his studies at art college because they couldn’t manage on a student grant. Johnny had an 18-month-old sister. and the mother was a full-time housewife. The family had recently moved to a council house on a large estate. For the first 18 months of Johnny’s life they had lived with paternal grandparents. who had indulged Johnny. Since moving to the council estate the family had become very isolated, and mother was dominated by the middle-aged next-door neighbour who alternately mothered her. interfered with her management of the children, and bought her friendship with presents of clothes for the children. At pre-assessment the parents’ main complaints were of Johnny’s over-activity and problems over disciplining him. The mother could ‘name only two target problems: (i) Johnny’s (ii) Johnny’s

behaviour to the baby, over-activity = 5.

e.g. pushing

and biting

her = 9

Toilet training and general discipline seemed to the rater to be the main management problems (See Table 4). During the 8-month treatment span the psychologist visited at least once a week. as well as accompanying the mother on visits to the family-planning clinic and the G.P. Total treatment time (including visits and phone calls) was 47 hr. The mother had a general tendency to hypochondriasis-as a child she had been thought to be a coeliac and had spent some time in hospital. She worried about her own health and the children’s health. Her own parents were chronic invalids and her husband’s father was prematurely senile. Treatment by the psychologist focussed on three areas: (i) teaching the parents consistent differential reinforcement of the children’s behaviour, and how to structure day-time activities for small children. (ii) encouraging a realistic attitude in the mother to health problems (which included accompanying her on visits to her G.P.. as well as keeping menstrual record charts and records of mood changes, and correlating these with changed prescriptions of oral contraceptives). (iii) encouraging the mother to be independent of the neighbour.

Non-accidental

359

injury to children-II

The social worker concentrated on financial problems, and on the practical implementation of getting a place for Johnny in a nursery school. By post-assessment there was considerable improvement. The husband had got a job, and they were managing to get up in time for him to get there. Johnny had started play-school and the mother had made friends with other mothers there. She was earning pin-money by making children’s clothes for friends, and was also having driving lessons. The family had had a major row with the neighbour and refused any further offers of help. The assessor rated considerable improvement in child-management problems (see Table 4) and the mother’s own rating of target problems was that both had totally disappeared (see Table 3). The mother perceived a considerable improvement in her own health. At follow-up 3 years later there had been no further incidents. Johnny’s name had been removed from the Register. After the psychologist’s involvement ended the mother had made two hysterical demands for helpone an overdose. which she described as a cry for help-from the’ Social Services. The level of social-work involvement had been gradually reduced, but the neighbour had been reinstated in her dominant role with the family. The husband had held down his job until the birth of a new baby some 2; years after post-assessment. The case had been closed 6 months before follow-up, as the Social Services felt there was no further cause for concern. Subject

No. i: treatment

group

case--failed

Sharon was an 8-year-old girl referred because of stepmother’s threats that she had tried to strangle the child. She was not entered on the NAI Register, as there was no evidence of any injury. (Retrospectively, in discussion with the stepmother, it became clear that the child had been regularly beaten with a slipper until she became too big for stepmother to lay across her knee.) Sharon’s natural mother had left Sharon’s father when the baby was a few weeks old, and up to the age of 2 Sharon had been brought up by her paternal grandparents. The stepmother had started to cohabit with the father when Sharon was aged 3 (and the stepmother herself only 17) and had given up her job in order to look after Sharon. At the time of referral Sharon lived with her 22-year-old stepmother, now married to her 28-year-old natural father, and their 3-year-old son. There was a long and chequered history on the social-work files of involvement with various agencies, a recommendation for maladjusted boarding school for Sharon and a period of her voluntary reception into care. At pre-assessment the stepmother was complaining of Sharon’s occasional enuresis, of her greed at mealtimes and of her general disobedience. Her named target problems were: (i) to get Sharon to be appropriately assertive over areas (ii) Sharon’s lying = 8 (iii) to be able herself to show affection for Sharon = 6.

of disagreement

= 10

The psychologist’s intervention (over 8 months) involved 55 visits and 70 hr of treatment/ discussion. Initially visits were two to three per week, over the first 4 months, then once a week for the next 3 months. There were two main aspects of treatment: (i) to help the stepmother to be less punitive to Sharon and to develop a warmer relationship with her; (ii) to smooth the path of the natural mother’s resumption of access visits to Sharon. The social worker

and psychologist

The first task was tackled

(4 The stepmother

(b)

worked

jointly

on the second

task.

in two stages.

was taught to control her temper. Anger-control techniques and relaxation training were used. and a complete ban was put on corporal punishment. With intensive support this programme worked well for the first 2 months and both stepmother and father were pleased. The second stage was to increase positive interaction with Sharon. Three different programmes were set up-one after the other-where the stepmother was to reward

360

JANE E. SMITH and

S. J. RACHMAN

Sharon for desirable behaviour (e.g. cleaning her teeth, not staring at stepmother, going downstairs quietly to the toilet at night). Each programme failed because the stepmother witheld rewards on minor pretexts: she seemed unable to allow Sharon to succeed. The second task, the reintroduction of natural mother, was undertaken in a graded series of meetings (to avoid the doorstep rows with the stepmother which had occurred in the past). The stepmother first took Sharon to meet her mother in town for coffee. On the next occasion the mother took her out for a couple of hours, then later for a whole day, and finally for a weekend. This went quite smoothly. After the first four months, when the positive interaction programme began to fail. the stepmother became much less cooperative. She reverted to being verbally extremely punitive towards Sharon, and maintained that neither she nor the father wanted to keep the child. An interview with the father about his feelings for Sharon finally elicited the information that he had doubts about her paternity, and simply regarded her as an obligation on him until she reached 16. At this point it was decided that Sharon’s best interests would be secured by removing her from the family. Neither parent would accept what they saw as the stigma of fostering, so it was finally arranged through the mediations of the social worker that Sharon would go to live with paternal grandparents in a planned move at the end of the summer term. At post-assessment this move had been set up but not yet carried through, and the whole family found the waiting period extremely difficult. Sharon was stealing from the stepmother, and the ratings of increased severity of child-management problems reflect this (see Table 4). The only target problem rated as significantly decreased was Sharon’s appropriate assertiveness (which had reduced from 10 to 3): lying had increased from 8 to 10, and the stepmother’s inability to feel warmth was rated as 5 instead of 6 (see Table 3). At 3-year follow-up we had no up-to-date information, as the case had been closed after Sharon moved out of the family. However, a spontaneous letter of thanks to the treatment psychologist from the natural mother a year after Sharon’s move reported her as being very happily settled and doing well in her new school. DISCUSSION Discrepancies

We are unable to make any firm comparisons of various discrepancies.

Between

Groups

between the treatment and control groups because

(a) The two groups differ on the crucial variable of severity of injury. We classified injuries by degree of severity as minor, moderate or severe, using the criteria taken by Baher et al. (1976) in the sample of families referred to the NSPCC. In addition we included cases where there was threat of injury by parents but no evidence of its actual occurrence: these cases are categorized as ‘threatened injury’. Of the 10 families who participated in the treatment trial more, severe injuries were reported in the control group, and this was correlated with the younger ages of the control group children (see Tables 1 and 2). These differences reflect the unanticipated differences between treatment and control group areas over the whole sample [see Smith et al. (1984) for a more detailed discussion]. (b) The ‘blind’ was lost at post-assessment for three of the treatment group families (S 1, S2 and S22) in spite of detailed instructions to the family to preserve anonymity during the interview. (c) Missing data: two of our control group families (S 16 and S 17) could not, or would not, specify target problems at the pre-assessment interview. In addition it was impossible to rate any improvement in child management for those two families (S22 and S17) where the children remained in care for the whole of the treatment span. Measures

of Change

Two of the three measures of change-incidence of re-injury and whether or not the child remains at, or returns, home-turned out to be too gross to be useful over a 6- to &month treatment span. We had no recorded incidents of re-injury, but it should be noted that 4 out of

Non-accidental

injury to children-II

361

the 10 index children were not living at home for most or all of the treatment period, so that opportunities for re-injury were reduced. Whether or not the child remains at home is not a useful measure of successful outcome (see the discussion of the diagnostic value of behavioural intervention below). Our third and major measure of change, clinical evaluation, based on the standardized interview carried out by a ‘blind’ assessor, produced some interesting results. The key finding is that the two (out of the four) control group families who specified target problems rated considerable improvement on those target problems-i.e. the ones which they most wanted to see change (see Table 3). We can make a guess at the reasons for this: one mother (S 18) who at pre-assessment had been very isolated (see Table 8 and case history on p. 355) had, by post-assessment, made several new friends among other mothers on the army camp where she lived, and thus was exposed to ‘normal’ models of child-rearing (her own mother lived abroad). The other (S3) had been living with the maternal grandmother, with the index child, while her husband was a psychiatric in-patient and had similarly been exposed to ‘normal’ child-rearing techniques. All six treatment group families had been receiving direct teaching in child-management skills from the research psychologist, and all rated improvement on their target problems. Three subjects rated all their named target problems (six problems over 3 Ss-see Table 3) as totally eradicated by post-assessment. The remaining 3 Ss each rated improvement on two out of three problems. This improvement in the treatment group would appear to be directly related to the teaching of child-management skills to the parents. However, the fact that the control group also showed improvement on target problems, without planned intervention, underlines the importance of not making claims for the efficacy of any treatment intervention without a control group comparison. Similar changes may be occurring in other families for other reasons. Clinical evaluation of change in child management (rated by the ‘blind’ assessor) shows, as can be seen in Tables 4 and 5, that three of the treatment families were rated as having made considerable improvements. We were unable to rate one family (S22) as the child was still living with foster-parents and there was no way of assessing whether the natural parents would be better able to cope with problems such as night-waking. The one family where the situation had deteriorated at post-assessment (S 1) was described earlier; it was decided that the child should leave home and live with paternal grandparents. Of our other changes measures, maternal depression (Table 7) did not show up as very useful, except in so far as it aided the diagnosis of puerperal manic-depressive psychosis in one mother (S22-see p. 363). The finding of a high level of social isolation across the 10 families is interesting in the light of claims by various authors (e.g. Elmer, 1967; Garbarino, 1977) that social isolation is a common factor in child-abusing families. Wahler and his colleagues have recently shown (Wahler, 1980; Wahler, Leske and Rogers, 1979) that treatment effects with their sample of low-income ‘insular’ (i.e. socially isolated) families had washed out by follow-up at 1 year. Long-term prognosis for those of our families who remained socially isolated may therefore be poor. Clinical ratings of the quality of marriages in our sample are notable in that those marriages rated as less than very good were (with one exception at post-assessment) all rated as discordant rather than apathetic. The two marriages rated as ‘very good’ at both pre- and post-assessment (S 1S and S 18) are both cases which we rated as having been successfully treated-although S 18 was a control group case. Marital discord in the other families may again be a poor prognostic indicator for the children. Quinton et al. (1976) point out that in one of their samples 37% of children rated as 3D/4D on the discord dimension showed deviance in school on teacher’s ratings. 3- Year Follow -up In a recent review of behavioural interventions in the treatment of child abuse (Isaacs, 1982) the author comments on the fact that, out of 20 studies reviewed, only 11 included outcome data, and of those 11 only 8 included a follow-up. The follow-up period ranged in length from a few weeks to 12 months post-treatment, with only two studies reporting a 1Zmonth follow-up. We did not have the resources to revisit or re-assess our families after 3 years, but the collection of information from social-work files does provide some assessment of outcome in terms of what has happened to the child. There is anxiety among social workers in the U.K. lest they are found

362

JANE E. SMITH and S. J. RACHMAN

to fall short of their statutory duties on child-abuse cases and are pilloried by the media (see, for example, Parton, 1979). We therefore feel reasonably satisfied that the reports in the social-work files were up to date and that any further incidents of NAI would have been carefully recorded. In fact, there was no record of further incidents for any of the families. The Social Services were still involved with six of the cases. Two children (S22 and S17) had remained in care with the same foster-parents and were making satisfactory developmental progress. The control group child (S16) who had returned home just prior to the (delayed-after a 16-month treatment span) post-assessment had remained at home. Discussion of this case with the social workers concerned revealed an unexpected contamination effect. Owing to a reorganization of management responsibility in one of the Divisional Offices, the control group social worker responsible for S16 had, since midway through the treatment trial. been receiving supervision from a principal social worker in charge of one of the teams covering the treatment area. This principal social worker had been involved with one of our pilot group behavioural treatment cases. He had then supervised a carefully planned graded return home for the little boy in case S16. The single mother had been taught child-rearing skills by a very able foster-mother, and a neatly planned and carefully executed behavioural treatment approach had culminated in the child’s return home on a trial basis, planned revocation of the Care Order after 2 years, and formal cessation of Social Services supervision. The single mother was still voluntarily being supported by the social worker: there had been no further incidents and the child’s development was satisfactory. It was planned to formally remove the child’s name from the NAI Register in 2 years time. In fact, a highly successful use of a behavioural treatment approach-with a control group case. However, we are left with the open question of what ure satisfactory outcome measures at follow-up? As discussed in Part III of this paper (Smith et al., 1984) incidence of re-injury and agency closure of cases are inadequate as measures of global quality of life for the child. The information that one control group child (S3) (who had returned from grandparental care to live with mother and schizophrenic stepfather at home) had recently been assessed as ESN(M) is disquieting. The two children who had remained with the same foster-parents throughout (S22-treatment group, and S17-control group) were both reported to be doing well in foster-care. The parents of both children had split up by post-assessment-as had the parents of two other treatment group children (S23 and S21) for whom we have no up-to-date developmental information. The child-development literature is increasingly suggesting that most children are upset by a parental marital separation, at least in the short-term (Richards and Dyson, 1982). Without resources for developmental assessment of children and detailed assessment of parental functioning, both individually and within the family, we cannot satisfactorily assess the long-term outcome of any intervention. GENERAL

CONCLUSIONS

To return to the question that we set out to try to answer: do behavioural techniques have anything to contribute in a Social Services setting in the treatment of families where there has been non-accidental injury to children? We believe that the answer to this is yes, although we cannot yet support the argument with conclusive evidence. The changes in child-handling techniques in our treatment group look encouraging in isolation, but the improvement on self-reported achievement in two of the control group emphasizes the importance of having a comparable control group before one can draw conclusions. However, we have also had the experience of 3 years of clinical work with child-abusing families in a Social Services setting. On the basis of this we feel that the behavioural approach can make two definite contributions: as a treatment technique and for diagnostic purposes.

Use

of

home-based

behavioural

treatment

techniques

with families

referred

to the Social

Services

We believe that the behavioural treatment approach has a definite contribution to make if provided on the basis of a supportive relationship over an extended period of time. The research psychologist worked closely with 13 families (six treatment group, five pilot group and two who dropped out of treatment) over the 3 years. In each case it was found necessary to

Non-accidental

injury

363

to children-II

take time to build up a good relationship with these (often extremely difficult and highly suspicious) families before a treatment programme could begin. When such a relationship was established it was then often necessary to tackle problems other than child management first-maternal depression, anxieties about health, social isolation, job-hunting strategies-before the family were ready and willing to tackle the specific child-handling problems, which to them often seemed enormously difficult. The research psychologist adopted a problem-solving approach: teaching a mother how to overcome her own depression by structuring her day and getting through some of her housework (thereby restoring her self-esteem) or giving an unemployed father the necessary confidence to present well at interviews by teaching him specific strategies to use in looking for, and applying for, jobs. [The need for a treatment approach which is wider and more flexible than simple training in child-management skills is also being advocated by other behavioural clinicians: Reaveley and Gilbert (1979), McAuley and McAuley (1977) and McAuley (1980).] Once a family had begun to experience some small successes, and to see themselves as becoming more ‘normal’, i.e. having jobs, friends etc., it was then possible to get them to try different ways of handling children, and to lower their excessive expectations about children’s behaviour. The case study on p. 358 (515) describes the treatment of a family with a reasonably successful outcome after 8 months, but where the 3-year follow-up suggested that the mother had not been ready to function independently at the point where the research psychologist had to terminate treatment. We feel that the 6- to 8-month treatment span was too short to consolidate changed patterns of behaviour. One of our most successful cases was a pilot group family where close involvement was possible for more than a year; the control group case (S16) successfully (and inadvertently) treated by behavioural methods had a treatment span of 13 months before the child was returned home. There is as yet no evidence in the literature of long-term maintenance of treatment effects after brief successful behavioural interventions with child-abusing families (e.g. Denicola and Sandler, 1980; Wolfe, Sandler and Kaufman, 1981) and we would emphasize the importance in future research both of long-term follow-up with related outcome measures and of the controlled comparison of brief and longer interventions for the maintenance of treatment effects. The diagnostic function

of Sehavioural

treatment

approaches

in a Social Services

setting

A further contribution of the behavioural approach, which had not been foreseen when the project was set up, was a diagnostic function. The research psychologist was often the first professional of many who had been involved in a case to have: (a) the time to collate and structure a mass of information from several agencies over several years; and (b) an approach to treatment which involved observing and recording behaviour before embarking on treatment. A detailed functional analysis (see Kanfer and Saslow, 1965) involves identifying all the systems within the family which will affect changes: e.g. if you get one parent to handle the child differently will the other parent sabotage the progress? Is there a grandmother in the background whose criticism is more potent than the immediate support and encouragement of the therapist? This may involve not only spending a lot of time in the house observing what goes on, but arranging to be there when grandmother visits. This approach produced in three cases (two pilot group and one treatment group-41) sufficient hard information for a considered judgement to be made by the Social Services Department that the child concerned would be better out of the home rather than in it. (See above for a description of what happened with S 1.) In two other cases the careful observation and recording of behaviour allowed a firm diagnosis of psychiatric disturbance to be made [the mother in S22, thought to be an hysteric, was shown to be a rapid-cycling manicdepressive; another (pilot group) mother, who refused to admit any professional to the house except for 1 hr on Wednesday afternoons, proved to have an obsessional cleaning compulsion]. With the cooperation of the consultant psychiatrists involved, both were put on appropriate medication as a direct result of the research project’s involvement. In addition. the failure of the attempts to teach the manic-depressive mother more appropriate child management. in spite of concentrated work, provided evidence that the child could not safely be returned home. It is important to recognize the enormous variation both in the severity of injuries to children which are classified as NAI and in the families of such children (Smith ef a/., 1984). It is often impossible to decide at the point of referral either what the treatment goals should be for any particular family or how strong is their motivation to change. Some authors (e.g. McAuley and

364

JANE

E. SMITHand S. J.

RACHMAN

McAuley 1977; McAuley, 1980) have suggested that where successful treatment is reported it ‘appears to have occurred in families in which the overail problems were of relatively short duration and where parental mismanagement could be explained as a result of interactions of relatively recent onset”- in contrast to failures where “there were long standing histories of multiple family problems” (McAuley, 1980, p. 16). This fits in with our experience over the 3 years. However, in order to establish whether or not a family is able to change, and whether the child should remain in, or be returned to, the family it seems to us that a behavioural treatment approach, used simultaneously both as a treatment intervention and a diagnostic tool, has enormous potential. For those with statutory responsibility for making decisions about a child‘s future, the evidence from a carefully monitored~u~~e~ treatment programme that some parents are unable, or unwilling, to change their maladaptive parenting behaviour is just as usefut as the evidence that other parents are able to change. This diagnostic aspect of a behavioural intervention involves a broadening of treatment goals: successful outcome of treatment should be seen in terms of quality of life for the child, not simply in terms of changes in the parents. There may be cases where a satisfactory quality of life for the child (involving an emotionally secure home atmosphere as well as the use of non-violent disciplinary measures) can only be achieved by removing the child to a foster home (Dubanoski, Evans and Higuchi, 1978; Smith, 1984). Such a move should not be regarded as a treatment failure, but as the successful outcome of an appropriate diagnostic use of behavioural techniques. Non-cooperation

of an unselected sample of famiiies referred for NAI to children

In this study we were limited by the ethical considerations of coltecting data in a community setting from families where statuto~ly-responsible professionals were experiencing a high level of anxiety. An additional problem was the attitude of the families themsetves: they had ali either admitted to, or been accused of, injuring a child. They were often suspicious both of the Social Service agency and of the research psychologist as a professional working with that agency. Our contact with the pilot group families during the first year made it clear that we would not be able to use any recording equipment which the families would see as collecting evidence against them. The standardized interview was deliberately constructed so that the social worker introduced the research psychologist to each family for the initial interview, which simply collected background information and did not deal with the emotionally-loaded subject of child management. Getting into the house at all was often a major undertaking. Although initial appointments had been arranged through the social worker there was often no reply: curtains were sometimes still tightly closed at mid-day. Smith et al. (1984) discuss the sample as a whole, and the similarity of some of the families to Tonge, James and Hillam’s (1975) sample of problem families. Tonge and his colleagues comment on the pertinacity necessary, the number of abortive visits, the difficulty of interviewing garrulous parents and the filthy state of some of the houses they visited. These comments applied to some of our families. It was not so much the problem of getting them to turn the TV down-the TV had often been repossessed by the hire company for non-payment-but the problem of trying to get the parents to concentrate on a structured interview for an hour, when the state of the house, and of the children, made it clear that routines and planning ahead were non-existent. SUMMARY

OF CONCLUSIONS

Although the small number of families that finally participated in the study preciudes any firm conclusions, we believe that behavioural techniques do have a contribution to make to the treatment of child-abusing families in a Social Service context. (1) They need to be provided over an extended period of time by the same psychologist or other behaviourally-trained professional. (2) Specific child-handling techniques should be incorporated as part of a behavioural problem-solving approach: teaching families to manage life more like ‘normal’ families.

Non-accidental

injury to children-11

365

(3) The initial behavioural functional analysis can also serve a valuable diagnostic function, and in all cases where the family is prepared to accept treatment it provides the time and non-threatening contact necessary to build up trust. A carefully monitored ‘failed’ behavioural treatment programme may also serve (4) a diagnostic function by providing evidence of parental inability to change for professionals with statutory responsibility to make decisions about a child’s future. Treatment goals should be conceptualized in terms of global quality of life for (5) the child, rather than changes in parental child-management skills. Acknowledgements-The research project was supported by a grant from the DHSS. The authors would like to thank the Director and staff of Kent Social Services, and particularly the social workers and clerical staff of the three Social Services Divisions who participated in the treatment and data collection. Thanks are also due to Dr Roger Morgan for helping to incubate the idea and assisting during the first stage of the research, to Dr R. S. Hallam for acting as outside assessor, and to the members of the Project Advisory Committee: Mr R. Castle, Miss V. Clarke, Mrs K. Cutler, Dr J. D. W. Fisher, Mr D. Gregory, Mr M. Lauerman, Dr S. Little, Dr M. Lynch, Miss M. McLaughlin, Mr V. Slythe, Mr C. Weaver and Mr A. Young. We are grateful to Dr G. Dunn, Mr D. Quinton and Mrs B. Yule for their assistance.

REFERENCES Baher E.. Hyman C., Jones C., Jones R., Kerr A. and Mitchell R. (1976) At Risk: An Account ofthe Work of the Bartered Child Research Department, N.S.P.C.C. Routledge & Kegan Paul, London. Denicola J. and Sandler J. (1980) Training abusive parents in child management and self-control skills. Eehuv. Ther. 11, 263-270. Dubanoski R. A., Evans I. M. and Higuchi A. A. (1978) Analysis and treatment of child abuse: a set of behavioural propositions. Child Abuse Neglect 2, 153-172. Elmer E. (1967) Children in Jeopardy:A Sfudy of Abused Minors and their Families. Univ. of Pittsburgh Press, Pittsburgh, Penn. Garbarino J. A. (1977) The price of privacy in the social dynamics of child abuse. Child Welfare 56, 565-575. Gilbert M. T. (1976) Behavioural approach to the treatment of child abuse. Nurs. Times 72 140-143. Giovannoni J. M. and Becerra R. M. (1979) Defining Child Abuse. Free Press/Macmillan, New York. Isaacs C. D. (1982)Treatment of child abuse: a review of behavioural interventions. J. appl. Behao. Analysis 15, 273-294: Jacobson N. S. and Martin B. (1976) Behavioural marriage therapy: current status. PsychoI. Bull. 33, 540-556. Jeffrey M. (1976) Practical ways to change parent-child interaction in families of children at risk. In Child Abuse and Neglect (Edited by Heifer R. E. and Kempe C. H.). Ballinger, Cambridge, Mass. Kanfer F. H. and Saslow G. (1965) Behavioural analysis: an alternative to diagnostic classification. Archs gen. Psychiuf. 12. 529-538.

McAuley R. and McAuley P. (1977) Child Behaviour Problems: An Empirical Guide IO Management. Macmillan, London. McAuley R. (1980) Success and failure in applying behavioural analvsis. Sot. Wk Today 11. 15-17. Meichenbaum D. H. (1973) A self-instructional approach to stress management: a proposal for stress inoculation training. In Srress and Anxiefy (Edited by Spielberger C. D. and Sarason I. G.). Wiley, New York. NSPCC Library (1983) Personal communication. Estimate of national incidence of non-accidental injury, based on cases reported as suspected NAI to registers maintained by NSPCC Special Units. NSPCC Library, London. Novaco R. (1975) Anger Control: The Development and Evaluation of an Experimental Treatment. Heath, Lexington, Mass. Ounsted C. and Lynch M. A. (1976) Family pathology as seen in England. In Child Abuse and Neglect: The Family and the Community, Chap. 4 (Edited by Heifer R. E. and Kempe C. H.). Ballinger, Cambridge, Mass. Parke R. D. and Collmer C. W. (1975) Child abuse: an interdisciplinary analysis. In Review of Child Developmenr Research, Vol. 5, Chap. 9 (Edited by Hetherington E. M.). Univ. of Chicago Press, Chicago, Ill. Parton N. (1975) The natural history of child abuse: a study in social problem definition. Br. J. sot. Wk 9, 431-451. Patterson G. R., Cobb J. A. and Ray R. S. (1973) A social engineering technology for retraining the families of aggressive boys. In Issues and Trends in Behauiour Therapy (Edited by Adams H. E. and Unikel I. P.). Thomas, Springfield, Ill. Polakow R. L. and Peabody D. L. (1975) Behavioural treatment of child abuse. Inf. J. offender Ther. camp. Crimin. 19, 100-103. Quinton D., Rutter M. and Rowlands 0. (1976) An evaluation of an interview assessment of marriage. Psychol. Med. 6, 577-586.

Reaveley W, and Gilbert M. T. (1976) The behavioural treatment approach to potential child abuse: two illustrative cases, Sot. Wk Today 7, 166168. Reaveley W. and Gilbert M. T. (1979) The analysis and treatment of child abuse by behavioural psychotherapy. Child Abuse Neglecr 3, 509-5 14.

Richards M. P. M. and Dyson M. (1982) Separation, divorce and the development of children: a review. Unpublished report prepared for the DHSS, London. Smith J. E. (1984) Non-accidental injury to chiklren-I. A review of behavioural interventions. Be/mu. Res. Ther. 22, 331-347.

Smith J. E., Rachman S. J. and Yule B. A. (1984) Non-accidental injury to children-III. Methodological problems of evaluative treatment research. Behac. Res. Ther. 22, 367-383. Straus M. A., Gelles R. J. and Steinmetz S. K. (1979) Behind Closed Doors: Violence in the American Family. Doubleday/Anchor. Garden City, New York. Tonge W. L., James D. S. and Hillam S. M. (1975) Families without hope: a controlled study of 33 problem families. Br. J. Psvchiaf., Spec. Publ., No. 11. Headley Bros, Ashford, Kent, England.

JANE E. SMITH and S. J.

366

RACHMA~

Wahler R. G., Leske G. and Rogers E. S. (1979) The insular family: a deviance support system for oppositional children. In Behavioural Systems for the Developmentally Disabled--l. School and Family Enrironments (Edited by Hamerlynck L. A.). Brunner/Mazel. New York. Wahler R. G. (1980) The insular mother: her problems in parent-child treatment. J appl. Behac. Analysis 13, 207T219. Wolfe D. A., Sandier J. and Kaufman K. (198 I) A competency based parent-training program for child abusers. .I. consult. clin.

Psvchol.

49, 633-640.