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Prenatal prediction of child abuse and neglect: A prospective study
C/n/d Abwe & Neglecr, Vol. 9. pp. 225-235. Prmled in the U.S.A. All ri@~ls rewr~ed.
1985 Copyright
0145-2134185 $3.00 + .oO 0 1985 Pergamon Press Ltd
PRENATAL PREDICTION OF CHILD ABUSE AND NEGLECT: A PROSPECTIVE STUDY SOLBRITTMURPHY, M.D., M.P.H. Director, Bureau of Maternal and Child Health, State of New York, Department of Health, Office of Public Health, The Governor Nelson A. Rockefeller Empire State Plaza, Albany, NY 12237
BONNIEORKOW, M.S.W. Director. Program Operations, Bureau of Medical Services, State Department of Social Services, 1575 Sherman Street, Denver, CO 80203
RAY M. NICOLA, M.D., M.H.S.A. Director, Tacoma-Pierce County Health Department, Tacoma, WA Abstract-Five hundred eighty-seven women in a combined Maternity-Infant, Children and Youth project were interviewed at between 3 and-6 months of gestation by a skilled masters degree social worker (M.S:W.j using a Familv Stress Checklist develoned at the Universitv of Colorado Health Sciences Center. Onlv 7% of the women were scored as “high risk” for s’erious parenting problems. Neither single status nor teenage status increased the risk signiftcantly. A review of charts of 100 of the children whose mothers had been considered “at risk” was conducted 2 to 2.5 years later, and compared with 100 charts on children whose mothers had been considered at “no risk,” giving the following results: Twenty-five children had experienced failure to thrive, neglect or abuse. Twenty of these were from the original high risk mothers, giving an incidence of neglect/abuse in that group of 52%. The no risk control group of 100 mothers showed a 2% incidence of abuse/neglect; a low risk group showed a 4% incidence of abuse/neglect; and a mid-score group had an abuse/neglect rate of 5%. The scale proved a remarkably accurate predictor, with a sensitivity (percent correct negatives) of 89%. The authors suggest use of such scales prenatally or even before conception as a step toward the development of true preventive measures. R&tt&-Dans un projet de recherche concemant la mere et l’enfant, les auteurs ont enrblt 587 femmes, avec l’aide dun travailleur social diplomt et special& La grille de risque avait tte auparavant dtveloppte au Centre des Sciences de la Sante de I’Universitt du Colorado. Cette grille de risque incluait des points prtcis relatifs au comportement intra-familial et aux renseignements anamnestiques des parents. En outre, des facteurs de risque ont encore ttt extraits du dossier relatif a la naissance. Le 7% des femmes e&lees dans l’etude ont tte considtrtes comme presentant tm risque elevt par rapport au problbme de capacitt parentale. D’emblte, il est apparu que le status de mere ctlibataire ou de mere adolescente n’augmentait pas le risque. Deux a deux ans et demi apres l’tvaluation initiale. les auteurs ont examine les dossiers de 200 meres et de 200 enfants. I1 est apparu que 25 des enfants avaient ttt revus pour mauvaise prise de poids, negligence ou francs s&ices. Vingt de ces 25 enfants ttaient nb de meres qui avaient tte considtrees comme a haut risque, ce qui fait une frequence de maltraitance-negligence dans le groupe a haut risque de 52%. Par contre, parmi les meres estimtes presentant un risque bas, on n’a trouve que 2% de maltraitance-negligence. 11s’agissait la d’un groupe temoin. Dam le groupe des meres emBEes considtrkes comme ne Reprint requests should be sent to Bonnie Orkow, M.S.W., Director, Division of Program Operations, Bureau of Medical Services, State Department of Social Services, 1576 Sherman St., Denver, CO 80203 From the Tri-County Distric Health Department. Englewood, Colorado. A sequel to this study, Implementation of a Family Stress Checklist, by Bonnie Orkow, MSW, will appear in the next issue of the Journal. 225
226
Solbritt Murphy, Bonnie Orkow and Ray M. Nicola
prtsentant qu’un risque bas, on a eu une frequence de 4% de maltraitance-negligence. Enfin, une frequence de 5% a tte observee dans un groupe qui avait un score moyen en ce qui conceme le risque. En conclusion. l’evaluation a montre que la grille de risque et les facteurs de risque prenataux avaient une bonne valeur predictive. avec un pourcentage de prediction correcte de 80% et une specificite (c’est-a-dire un pourcentage des negatifs correct) de 89%. Les auteurs suggtrent tvidemment que ces grilles de risque prtnatales ou perinatales constituent un reel progres vers le dtveloppement de mesures preventives efficaces. Key Words-Child
abuse prediction, Prenatal predictions, Neglect prediction.
INTRODUCTION THE CONCERN ABOUT CHILD ABUSE AND NEGLECT has increased steadily in the last 15 years. Helfer [l] describes the stages of concern regarding any new disease as being: Step 1. The most serious form of a given disease is recognized. Step 2. Nonspecific and supportive treatment programs are developed. Step 3. Concurrent research into its cause takes place. Step 4. More specific treatment programs are initiated. Step 5. Expansion of the concepts of the problem to related areas occurs. Step 6. Research is conducted on early identification and prevention. Step 7. Screening and prevention programs are initiated. Efforts to identify and treat child abuse and neglect have followed these steps very closely. In the last few years many efforts have been made at early identification and prevention (Step 6). Such studies first focused on attempts to identify the abusive parent. Several retrospective studies performed in the last few years compared parents of abused or neglected children with “normal” controls. These parents and their controls have been compared through life-stress inventories [2, 31, M.M.P.1.s [4, 51, Michigan Screening profile of parenting [6], Rorschachs [5], socioeconomic stress reviews [2, 7, 81, current and past psychopathological scales (C.A.P.P.S) [9], child abuse potential inventories [lo], and psychiatric screens [ll, 121. Most authors agree that there are distinctive characteristics among abusive and neglecting parents. Most commonly they are described as socially isolated, suspicious, living in an almost constant state of crisis, immature, dependent, often with a history of themselves having been abused as children and with tendencies toward violent, angry behavior. Many authors state parents are more often from a lower socioeconomic group [7, 8, 12-141 and many see single parenthood [7, 8, 13, 141, poor education [7, 131 and teenage status [ 10, 151 as contributing factors. A few studies have started with the birth of the infant. Rosemary Hunter et al. [ 161reports the outcome of 255 infants discharged from an ICU, whose parents had been evaluated using a psychosocial risk inventory. This study found 10 infants (3.9%) who were officially reported for abuse-neglect in the first year of life, all 10 of whom had been identified as at high risk before discharge (constituting 24.4% of the high-risk group). No low-risk babies were abused. An English study by Lynch et al. [17], reviewed maternity and infant charts of 50 children after they had been reported for neglect-abuse but controlled their study with the next live born child following each abuse case born in the same hospital, They found neonatal chart notes, antedating the abuse, indicating staff concerns regarding families of the later abused children in 35 of 50 cases (70%), while similar concerns had been expressed about only 5 in 50 controls (10%). Gray et al. [ 181, collected perinatal data on 350 mothers, among whom they then selected 25 high-risk intervention, 25 high-risk non-intervention and 25 low-risk families. They then reviewed the course of these families when children were 17-35 months. Abnormal parenting practices were found among 22 families of the high-risk groups (22/50 = 44%) but only in 2 of 25 of the control families (8%).
Prenatal prediction of child abuse and neglect
221
The above studies indicate it should be possible to identify families at risk for neglecting or abusing their children at least from the time of the child’s birth. However, all of them have a specific, selected maternity population, and none are truly prospective. To reach Helfer’s Step 7, i.e., initiation of general screening and prevention programs, would require screening of a general parenting population preferably before the birth of their children. One must also verify the accuracy of any abuse-neglect prediction through a prospective study, showing that the high-risk parent is indeed more likely to abuse-neglect. Only after this has been done, can true prevention programs be initiated. This study screened a general maternity population using a Family Stress Checklist developed by B. Schmitt and C. Carroll [ 191at the University of Colorado Health Sciences Center. This checklist had previously been used only in evaluating parents known to have abused or neglected their children. A prospective review of the children born was made.
PRENATAL
PREDICTION
METHOD
The patient population of a large federally supported combined Maternal and Infant, Children and Youth Project was studied. This project provides care throughout pregnancy, with enrollment of infants at birth. Care is comprehensive, with physicians and physician assistants working as a team with social workers, public health nurses, nutritionists, screeners and outreach workers. Comprehensiveness of services, neighborhood location and limited outside facilities for the low-income clientele combine to make this population unusually stable as users of these clinics. Projects are located in Metro-Denver, an urban-suburban area. The maternity population consists of women 14 to 38 years of age, with a median age of 20.9. About one-third are Spanish-surname, the remainder Caucasian. The average educational level is 1Ith grade. Sixty percent of the maternity population are married; the rest are single, divorced, separated or live-in. All have well below average family incomes. Women are enrolled in the maternity project between the third and sixth month of gestation. As part of the intake procedure, all women are interviewed by a social worker. The Family Stress Checklist (Table 1) was included in this interview. Specific questions were designed to give answers to each item on the Checklist [20]. These questions were interspersed in the general intake interview. Specific informed consent was therefore not obtained. Handling of all data throughout the study was through chart numbers only, not names. Social workers received six hours specific training to elicit accurate answers to the checklist categories. Inter-rater reliability was considered acceptable when all workers’ total scores placed the patients in the same category, i.e., no risk, moderate or high risk. The checklist encompasses ten factors, each listed as no risk, risk, or high risk. Scoring O-5-10 for each factor, any one individual can score from 0 to a maximum score of 100. In 95% of cases interviews were with the prospective mother only. Scoring on prospective fathers was therefore generally done through data elicited from their partners.
PRENATAL
PREDICTION
RESULTS
Total Scores These data represent results from the first consecutive 587 completed checklists on patients seen from late 1977 to early 1979. There were 3 17 primigravidas with a mean maternal age of 19.3 years and 270 multigravidas with a mean maternal age of 22.7 years. The child’s father was the mother’s husband or boyfriend in 98% of cases.
228
Solbritt Murphy, Bonnie Orkow and Ray M. Nicola Table 1. Family Stress Checklist* No Risk, Score 0
Risk, Score 5
MF
High Risk, Score 10 MF
MF
I. Parent beaten or deprived as child
Infrequent spankings. Consistent “parenting”
Frequent spankings. some bruises: received intermittent “parenting” -
Severe beatings: repeated foster homes. No helpful parent model in childhood
2. Parent has criminal or mental illness record
Not present
Present, but demonstrates rehabilitation
Current psychosis: chronic pattern of psychiatric problems
3. Parent suspected of abuse in the past
Not present
Official report of mild abuse; child not placed in foster care _
Official report of serious abuse; children placed in foster care or died
4. Parent with low self-esteem, social isolation, or depression
Not present
Intermittent coping skills; no current lifelines or unreliable ones
Severely depressed. No lifelines in past or present
5. Multiple crises, or stresses
Not present
Moderate environmental and/or marital problems
_
Chaotic life style. severe environmental and/or marital problems
6. Violent temper outbursts
Not present
Damages property
_
Attacks people
-
7. Rigid, unrealistic expectation of child’s behavior
Not present
-
Afraid of spoiling child, unrealistic expectations
-
Intolerance of normal behavior: very strict parent
-
8. Harsh punishment of child
Not present -
Current frequent spankings or use of belt, not in head area
-
Child triggers abuse by intermittent provocative behavior
-
Risk factors present, but bonding adequate
9. Child difficult and/ or provocative or perceived to be by parents
Not present
IO. Child unwanted, or at risk of poor bonding
Not present
-
-
_
_
_
Physical punishment of baby prior to crawling; sadistic and/or dangerous punishment Child triggers abuse by constant provocative behavior (i.e., seen as having no good points)
_
Risk factors present, and bonding poor
-
* Developed by B.D. Schmitt and CA. Carroll-Child Protection Team at the University of Colorado Health Sciences Center. Abbreviations used: M = mother, F = father. Reproduced with permission of the authors and publisher from The Child Protecrion Team Handbook, B.D. Schmitt (Ed.), pp. 107-108. Garland, New York (1978).
Figure 1 shows the pattern of risk scores obtained: 150 women (25.6%) scored 0 and 355 women (60.5%) scored between 5 and 25. Scores of 30 and above were infrequent (13.9%). In the population studied, scores of 40 and over were considered as high-risk scores (a score of 40 was chosen based on the slope of the curve in Figure 1). Such scores occurred in 42 out of 587 (7%). Only 255 fathers could be scored completely. However, the fathers’ scores followed a distribution pattern almost identical to the corresponding mothers’ scores (Figure 1). Matched in pairs, 90% of the low-score mothers described their partners as low score and 90% of the high-score mothers described their partners as high score. The data were also analyzed for scoring differences between single versus married mothers, and single teenagers versus married teenagers (Figure 2). While a completely negative score (i.e., 0) was indeed more common among married women of all ages, the majority of scoresboth for all single women and for single teens-fell in the 0 to 20 category. There was a larger group of medium high scores (25 to 35) among single women, whether teens or not. High scores (40 and over) indicating possible risk for parenting problems, however, showed a remarkably similar percentage in all four groups, being only slightly higher among single teens. The differences among these groups were not statistically significant.
Prenatal
prediction
229
of child abuse and neglect
150 -r, 140
- i,
90 80 -:
*
\
6 ‘0 _:I CO-: : 50 40 30 20 _
\ t
\ i ’ t ‘\\
“,, ?
‘\
+
‘* ‘.
‘*,_*
T “i
,+--%,.-r-‘. Y ‘*--C-*__*__/*-w-_* o0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100
10 -
‘. \*__*_5?.
TOTAL SCORES FROM TABLE 1 OBTAINED BY ADDING SCORES ON EACH OF THE 10 FACTORS
Figure 1. Distribution pattern of total scores obtained by 587 mothers, 225 fathers. *. Fathers scow*-----*, Mothers score*
651 60 i 55 50 45 :: Y
40 -
G
35 -
B
30 -
G E
25 -
%
20 -
S1ng1e
Mothers
Married Teens I(r and Under
Single Teens 19 and Under
Figure 2. Percentage of married, single or teen mothers achieving total scores on the ten factors in Table 1 of 0, 5 to 20, 25 to 35, or 40 and over. Forty and over was considered high risk for serious parenting problems such as abuse, oeglect, sod failure to thrive.
230
Solbritt Murphy, Bonnie Orkow and Ray M. Nicola
Individual Factor Analysis
A factor by factor analysis of the scoring from the checklist (Table 1) showed that certain factors were common even among the parents with very low scores. The most common factor present was number 5 (crises or stresses). A moderate degree of crises or stresses was present in 73% of the population scoring 5 to 20 (329 mothers). Crises and stresses were present in the entire high score population (scoring 40 and over), but 88% (37142) scored high on this factor, indicating a chaotic lifestyle or severe crises @ = 0.01). The next most common factor present among the population with total scores of 5 to 20 was factor number 1 (parent beaten or deprived). Frequent spankings or intermittent parenting had been experienced by 42.5% of the low-score group (1401329). However, poor parenting was part of the life experience for 93% of the parents scoring 40 and over @ = 0.01) with a high score (indicating severe beatings or no real parenting) being present in 36%. Factor number 4 (social isolation or depression) was also not uncommon in this population, being present in 29.5% (97/329) of those with total scores of 5 to 20, but in 98% of those scoring 40 and over @I = 0.001). The severity of such isolation was more important than its presence or absence. Severe isolation or depression was present among 50% of the high-score group (scoring 40 and over). Ambivalence about wanting the child (factor number 10) may be anticipated in a patient group often living in marginal circumstances. Scoring indicating such feelings appeared among 29.2% (96/329) of parents with total scores of 5 to 20 and in 80% of those scoring 40 and over (p = 0.01). Almost totally absent in the low scoring population were factors number 2, 3, 6-8 (from Table 1) indicating criminal activity, serious mental illness, suspicions of past abuse, violent temper outbursts, rigid expectations of children’s behavior or a story of harsh punishment of previous children. All of these occurred increasingly as total scores increased.
CHART REVIEW
Methods
After the Family Stress Checklist was completed prenatally by the social worker, it was simply placed on the non-active side of the mother’s chart. No special care arrangements were made for mothers with high scores, since the checklist’s validity had not been tested. When the children born of the original 587 mothers had reached an age of 1 to 2 years, the charts of both mother and child were analyzed for all mothers scoring 35 and over prenatally. A control group was then chosen from mothers with total scores of 0 to 10 prenatally, but otherwise matched one to one with the high-score group in age, marital status, living arrangements, relationship with the father of the child and previous parental experience. Reviewers knew that the charts were from either high or low-score mothers and children, but not in which category each case fell. Chart review factors are shown in Table 2. A child’s chart was considered negative if all factors on the list were entirely negative, or if the events noted could not have been reasonably influenced by the parents, (for example, difficult deliveries, babies in poor medical condition, and hospitalizations for common diseases). A child was considered mildly neglected if one or more factors were present that could have been influenced by the parents, such as poor bonding noted, repeated episodes of diarrhea or cradle cap, chronic feeding problems, frequent falls, questionable shelter, but no direct evidence of abuse or neglect was present. A child was considered neglected or abused
Prenatal prediction of child abuse and neglect Table 2.
231
Chart Review Factors Used in Evahatine Child Care given
Birth Risk Factors
1. Difficult delivery (e.g., hypertension, pre-eclampsia, RH negative, diabetes, C-section) 2. Baby’s poor medical condition at delivery (e.g., LGA, SGA, premature, congenital anomalies, Apgar below 7, neonatal complications) *3. Chart observations that parents have unsuccessful experiences in caring for the baby in the hospital 4. Baby kept in hospital past 3 days *5. Observations of poor bonding noted Mild Neglect or Questionable Bonding 1. Parent says baby is:
Poor feeder Cries a lot, “difficult” Spoiled 2. Parent not coming in for health maintenance care or for sick child care as needed 3. Repeated episodes of diarrhea, cradle cap, skin infections in normal child Child Neglect
1. Failure to thrive (underweight) labeled on chart 2. Failure to provide food, clothing shelter or supervision noted 3. “Accident-prone” child, i.e., more than one incident of: Poison ingestion Falls, severe Abrasions or bruises, severe enough to cause clinic visit Hospitalization for any accident Child Abuse
Welts Bruises Bums Broken bones Either verified or strongly suspected to be inflicted injuries * All these factors were statistically analyzed, but only #3 and #5 were to influence later parenting problems and were kept in the final list of important birth risk factors.
if evidence was present indicating that failure to thrive, direct neglect or abuse had taken place.
Results A very clear division was apparent between completely negative charts, those showing mild neglect, and those showing neglect-abuse. The 38 mothers scoring 40 and over prenatally (Figure 3) had frequent problems with child care (of the original 42 mothers with high scores, there were 4 with no baby charts, 2 mothers had moved, and 2 had relinquished their infants). Only 9 (23.7%) of their children’s charts were negative; 9 showed evidence of mild neglect (23.7%); and 20, evidence of direct neglect or abuse (52.6%). Among the 5 1 charts of children whose mothers had total scores of 10 to 20 prenatally, there were 38 negative charts (74%); 11 (21%) charts showing mild neglect, and 2 (4%) showing neglect-abuse. Among the 57 charts of children whose mothers had total scores of 25 to 35 prenatally (of the original 58 mothers, one chart was not reviewed because there was no baby follow-up data available), there were 36 negative charts (63.2%); 18 (31.8%) charts showing mild neglect, and 3 (5.0%), showing neglect-abuse By contrast among the 100 charts of children of control mothers with total prenatal risk scores of 0 to 10, very few problems in child care were found. Of these, 84 children’s charts were completely negative; 14 indicated mild neglect; and two showed definite neglect-abuse.
Solbtitt Murphy, Bonnie Orkow and Ray M. Nicola
232 100 90 80 70 z z g
605040 30 20 10 oControls Total Score 0 to 10 N = 100
Low Risk Parents Total Score 10 to 20 N = 51
Medium Risk Total Score 25 to 35 N = 57
High Risk Parents Total Score 40 and over N=38
Figure 3. Results of chart review showing outcome of child care when child l-2 years of age. No child care problems Mild neglect noted Definite abuse or neglect present N=number of mother and child charts reviewed in each group.
The sensitivity of a prediction for neglect-abuse was 80% (Table 3), while the specificity (i.e., predictability of which parents will not be likely to neglect or abuse) was 89.4% The type of abuse-neglect noted showed a continuum between failure to thrive, neglect and abuse (Table 4). Table 3. Sensitivity and Specificity of Prenatal Predictions from the Checklist Total Scores Actual Neglect or Abuse Noted
No
Yes C
A Predicted
18
20
Yes
Neglect or Abuse would occur
D
B No
I52
5
A Sensitivity = % of correct yes = A+B D Specificity = % of correct no’s = C+D Predictive value of a positive $
Predictive value of a negative s
20
= X 100 = 80% 20 + 5 = - 152 = 152 + 89.4% 170 18 + 152
= 52.5%
= 96.8%
Prenatal prediction of child abuse and neglect Table 4.
233
Type of Incidence Noted in the 25 Cases of NeglectAbuse Found on Chart Review
Abuse only
4
Abuse/FTT and neglect Abuse and neglect FTT and nealect FTT only Neglect only Abuse sib, patient removed
2 4 6 2
6
I 25
Total
A comparison was made of the prenatal scoring among the 20 high-score families where abuse-neglect was known to have taken place by the time the child had reached age 1 to 2 years, and the remaining 18 of the high-scoring families, where no serious child-rearing problems had as yet been noted 1 to 2 years after the child’s birth. There were no significant differences between these two groups; both had an equal background of exposure to poor parenting, previous criminal or mental illness, past abuse suspicions, social isolation, violent tempers, multiple crises and rigid expectations of their children.
IMPLICATIONS Results in this study contradict some earlier findings. The general clinic population showed a remarkably low incidence of risk factors, even in a low-income, racially mixed, generally very young population. Neither teenage nor single status appeared to contribute significantly to abuse-neglect risks There is a general belief that these two groups are at serious risk for poor parenting. In the case of teenage parents, this belief is also supported by large federal expenditures (PL95-626) [21]. If our concern is the welfare of the children born, such money may be better directed. The data presented here indicate marked similarity in scores between fathers and mothers. Since data on fathers was primarily obtained from mothers, its accuracy must be questioned. The likelihood is that the mothers were at least close to correct, and that, in fact, couples have a tendency to seek partners with similar past experiences and lifestyle. The message for case workers and medical personnel is that a careful evaluation needs to be done on both parents or partners in abuse and neglect cases, without any assumptions that the non-abusive parent is “safe” for the child. The Family Stress Checklist turned out to be a remarkably accurate predictor, having predicted 20 out of 25 (80%) of all families so far identified as abusive or neglectful in this population. This checklist previously had only been used retrospectively, and was developed from experience with cases of confirmed abusive families. Authors Schmitt and Carroll suggest using this checklist to determine abusive potential [19]. This study found it equally helpful in predicting children with failure to thrive and neglect. In the present study, there appeared to be no clear-cut distinction between these three problems but rather a continuum (See Table 4). This checklist has been used at the University of Colorado Health Sciences Center with weighting of various factors [19]. Our experience was that such weighting confused the scoring and unfairly penalized parents with specific backgrounds-such as violent temper outbursts No single factor appeared of major importance; rather, it was the clustering of factors, both in present and past life events, that seemed associated with abuse-neglect. Since the data from the child abuse checklist can be considered nominal-level data (Stevens’ typology). it is possible to use factor analysis or a related procedure to examine the
SolbrittMurphy,Bonnie Orkow and Ray M. Nicola
234
proportion of variance accounted for by each question; however. time and budget restraints make this sophisticated analysis a project for the future. The present paper uses the standard error of the mean to test the null hypothesis between control and abuser groups. The checklist itself is remarkably simple and easier to use than a large number of other reported screening mechanisms. As physicians increasingly use counseling personnel in their offices. prenatal or even premarital interviews aimed at evaluating parenting readiness could include such a checklist. Prospective parents with an unusually high score could then be counseled regarding the problems they may encounter and specific help offered. At the time of this study, we had no proof that the scale used was indeed valid. Specific support programs were therefore not developed for high-risk mothers. They were referred to public health nurses or social services as specific problems arose, just as any other patient would be referred. However, it must be understood that once a scale such as this one has been verified to accurately identify families at serious risk for parenting problems, the issue of not providing support services becomes a serious matter. A study in cooperation with the University of Colorado Medical Center is presently underway [22] providing lay home visitors to high-score parents soon after identification prenatally. A control group with equal scores and without such assistance will be used. It is hoped that the lay visitors will be able to at least decrease the incidence of abuse-neglect among the high-score parents. There are no answers to what may happen in high-score families where no abuse or neglect has as yet been noted. It is possible that, a few years from now, a much larger percentage of these children may be involved. It is also possible that there are as yet unidentified factors restraining these high-scoring parents from neglecting or abusing their children. The present study has attempted to demonstrate that accurate predictions of parenting ability can be made before the birth of a family’s children, even the first. Verification from different population groups and different socioeconomic backgrounds is needed. Once a method of accurate prediction has been verified, preventive programs can be implemented in a selective manner.
REFERENCES I. HELFER, R. E. Early identification and prevention of unusual childrearing practices. Pediafric Annals 5:91-105 (1976). 2. JUSTICE, B. et al. Life crisis as a precursor to child abuse. Public Health Reports 91: 110-l 15 (1976). 3. GREEN, A. H. et al. Child abuse: Pathological syndrome of family interaction. American Journal of Psychiatry 131:882-886 (1974). 4. PAULSON, M. J. et al. A discriminant function procedure for identifying abusive parents. Suicide 5: 104- 114
(1975). 5. WRIGHT, L. The “sick but slick” syndrome as a personality component of parents of battered children. Journal of Clinical Psychology 32:41-45
(1976).
6. GAINES, R. et al. Etiologicai factors in child maltreatment: A multivariate study of abusing, neglecting and normal mothers. Jownnl of Abnormal Psychology 87:531-540 (1978). 7. GARBARINO, J: A preliminary study of some ecological correlates of child abuse: The impact of socioeconomic stress on mothers. Child Development 47: 178-185 (1976). 8. SHAPIRO, D. A CWLA study of factors involved in child abuse. Child Werfare 59:242-243 (1980). 9. GREEN, A. H. et al. Psychopathological assessment of child-abusing, neglecting and normal mothers. Journal of Nervous and Mental Disease 168:356-60 (1980). IO. MILNER, J. S. et al. An inventory for the identification of child abusers. Journal of Clinical Psychology 35:95- 100 (1979).
II. SMITH, S. M. et al. Parents of battered babies: A controlled study. Bntish Medical Journal 4:388-391 (1973). 12. SERRANO, A. C., SNELZER, M. B. et al. Ecology of abusive and non-abusive families: Implications for intervention. Journal of rhe American Academy of Child Psychiatry 18:67-75 (1979). 13. SMITH, S. M. et al. Social aspects of the battered baby syndrome. Bruish Journal of Psychiatry 125:568-582 (1974).
14. VESTERDAL, J. Psychological mechanisms in child abusing parents. Paediarrician 8: 145- 15 I ( 1979). 15. BAVOLEK, S. J. et al. Primary prevention of child abuse and neglect: Identification of high risk adolescents. Child Abuse & Neglect 3: 1071-1080 (1979).
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16. HUNTER, R. S. et al. Antecedents of child abuse and neglect in premature infants: A prospective study in a newborn I.C.U. Pediatrics 61:629-635 (1978). 17. LYNCH, M. A. et al. Predicting child abuse: Signs of bonding failure in the maternity hospital. British Medical Journal 60/61:624-626 (1977). 18. GRAY, J. D., CUTLER, C. A. et al. Prediction and prevention of child abuse. Seminars in PerinafologV 3:85 (1979). 19. SCHMITT, B. D. The Child Protection Team Handbook, pp. 83-108. Garland, New York and London, (1978).
20. ORROW, B. A method for predicting child abuse. Unpublished data, Tri-County District Health Department, Englewood, Co. 21. Information Bulletin, Office of Adolescent Pregnancy Program 1:l DHEW P.H.S., Washington, D.C. (1980). 22. DAWSON, P., DOORNICK, B. Use of lay home visitors in high risk families. Unpublished data, University of Colorado Medical Center, Denver.
1985 Copyright
0145-2134185 $3.00 + .oO 0 1985 Pergamon Press Ltd
PRENATAL PREDICTION OF CHILD ABUSE AND NEGLECT: A PROSPECTIVE STUDY SOLBRITTMURPHY, M.D., M.P.H. Director, Bureau of Maternal and Child Health, State of New York, Department of Health, Office of Public Health, The Governor Nelson A. Rockefeller Empire State Plaza, Albany, NY 12237
BONNIEORKOW, M.S.W. Director. Program Operations, Bureau of Medical Services, State Department of Social Services, 1575 Sherman Street, Denver, CO 80203
RAY M. NICOLA, M.D., M.H.S.A. Director, Tacoma-Pierce County Health Department, Tacoma, WA Abstract-Five hundred eighty-seven women in a combined Maternity-Infant, Children and Youth project were interviewed at between 3 and-6 months of gestation by a skilled masters degree social worker (M.S:W.j using a Familv Stress Checklist develoned at the Universitv of Colorado Health Sciences Center. Onlv 7% of the women were scored as “high risk” for s’erious parenting problems. Neither single status nor teenage status increased the risk signiftcantly. A review of charts of 100 of the children whose mothers had been considered “at risk” was conducted 2 to 2.5 years later, and compared with 100 charts on children whose mothers had been considered at “no risk,” giving the following results: Twenty-five children had experienced failure to thrive, neglect or abuse. Twenty of these were from the original high risk mothers, giving an incidence of neglect/abuse in that group of 52%. The no risk control group of 100 mothers showed a 2% incidence of abuse/neglect; a low risk group showed a 4% incidence of abuse/neglect; and a mid-score group had an abuse/neglect rate of 5%. The scale proved a remarkably accurate predictor, with a sensitivity (percent correct negatives) of 89%. The authors suggest use of such scales prenatally or even before conception as a step toward the development of true preventive measures. R&tt&-Dans un projet de recherche concemant la mere et l’enfant, les auteurs ont enrblt 587 femmes, avec l’aide dun travailleur social diplomt et special& La grille de risque avait tte auparavant dtveloppte au Centre des Sciences de la Sante de I’Universitt du Colorado. Cette grille de risque incluait des points prtcis relatifs au comportement intra-familial et aux renseignements anamnestiques des parents. En outre, des facteurs de risque ont encore ttt extraits du dossier relatif a la naissance. Le 7% des femmes e&lees dans l’etude ont tte considtrtes comme presentant tm risque elevt par rapport au problbme de capacitt parentale. D’emblte, il est apparu que le status de mere ctlibataire ou de mere adolescente n’augmentait pas le risque. Deux a deux ans et demi apres l’tvaluation initiale. les auteurs ont examine les dossiers de 200 meres et de 200 enfants. I1 est apparu que 25 des enfants avaient ttt revus pour mauvaise prise de poids, negligence ou francs s&ices. Vingt de ces 25 enfants ttaient nb de meres qui avaient tte considtrees comme a haut risque, ce qui fait une frequence de maltraitance-negligence dans le groupe a haut risque de 52%. Par contre, parmi les meres estimtes presentant un risque bas, on n’a trouve que 2% de maltraitance-negligence. 11s’agissait la d’un groupe temoin. Dam le groupe des meres emBEes considtrkes comme ne Reprint requests should be sent to Bonnie Orkow, M.S.W., Director, Division of Program Operations, Bureau of Medical Services, State Department of Social Services, 1576 Sherman St., Denver, CO 80203 From the Tri-County Distric Health Department. Englewood, Colorado. A sequel to this study, Implementation of a Family Stress Checklist, by Bonnie Orkow, MSW, will appear in the next issue of the Journal. 225
226
Solbritt Murphy, Bonnie Orkow and Ray M. Nicola
prtsentant qu’un risque bas, on a eu une frequence de 4% de maltraitance-negligence. Enfin, une frequence de 5% a tte observee dans un groupe qui avait un score moyen en ce qui conceme le risque. En conclusion. l’evaluation a montre que la grille de risque et les facteurs de risque prenataux avaient une bonne valeur predictive. avec un pourcentage de prediction correcte de 80% et une specificite (c’est-a-dire un pourcentage des negatifs correct) de 89%. Les auteurs suggtrent tvidemment que ces grilles de risque prtnatales ou perinatales constituent un reel progres vers le dtveloppement de mesures preventives efficaces. Key Words-Child
abuse prediction, Prenatal predictions, Neglect prediction.
INTRODUCTION THE CONCERN ABOUT CHILD ABUSE AND NEGLECT has increased steadily in the last 15 years. Helfer [l] describes the stages of concern regarding any new disease as being: Step 1. The most serious form of a given disease is recognized. Step 2. Nonspecific and supportive treatment programs are developed. Step 3. Concurrent research into its cause takes place. Step 4. More specific treatment programs are initiated. Step 5. Expansion of the concepts of the problem to related areas occurs. Step 6. Research is conducted on early identification and prevention. Step 7. Screening and prevention programs are initiated. Efforts to identify and treat child abuse and neglect have followed these steps very closely. In the last few years many efforts have been made at early identification and prevention (Step 6). Such studies first focused on attempts to identify the abusive parent. Several retrospective studies performed in the last few years compared parents of abused or neglected children with “normal” controls. These parents and their controls have been compared through life-stress inventories [2, 31, M.M.P.1.s [4, 51, Michigan Screening profile of parenting [6], Rorschachs [5], socioeconomic stress reviews [2, 7, 81, current and past psychopathological scales (C.A.P.P.S) [9], child abuse potential inventories [lo], and psychiatric screens [ll, 121. Most authors agree that there are distinctive characteristics among abusive and neglecting parents. Most commonly they are described as socially isolated, suspicious, living in an almost constant state of crisis, immature, dependent, often with a history of themselves having been abused as children and with tendencies toward violent, angry behavior. Many authors state parents are more often from a lower socioeconomic group [7, 8, 12-141 and many see single parenthood [7, 8, 13, 141, poor education [7, 131 and teenage status [ 10, 151 as contributing factors. A few studies have started with the birth of the infant. Rosemary Hunter et al. [ 161reports the outcome of 255 infants discharged from an ICU, whose parents had been evaluated using a psychosocial risk inventory. This study found 10 infants (3.9%) who were officially reported for abuse-neglect in the first year of life, all 10 of whom had been identified as at high risk before discharge (constituting 24.4% of the high-risk group). No low-risk babies were abused. An English study by Lynch et al. [17], reviewed maternity and infant charts of 50 children after they had been reported for neglect-abuse but controlled their study with the next live born child following each abuse case born in the same hospital, They found neonatal chart notes, antedating the abuse, indicating staff concerns regarding families of the later abused children in 35 of 50 cases (70%), while similar concerns had been expressed about only 5 in 50 controls (10%). Gray et al. [ 181, collected perinatal data on 350 mothers, among whom they then selected 25 high-risk intervention, 25 high-risk non-intervention and 25 low-risk families. They then reviewed the course of these families when children were 17-35 months. Abnormal parenting practices were found among 22 families of the high-risk groups (22/50 = 44%) but only in 2 of 25 of the control families (8%).
Prenatal prediction of child abuse and neglect
221
The above studies indicate it should be possible to identify families at risk for neglecting or abusing their children at least from the time of the child’s birth. However, all of them have a specific, selected maternity population, and none are truly prospective. To reach Helfer’s Step 7, i.e., initiation of general screening and prevention programs, would require screening of a general parenting population preferably before the birth of their children. One must also verify the accuracy of any abuse-neglect prediction through a prospective study, showing that the high-risk parent is indeed more likely to abuse-neglect. Only after this has been done, can true prevention programs be initiated. This study screened a general maternity population using a Family Stress Checklist developed by B. Schmitt and C. Carroll [ 191at the University of Colorado Health Sciences Center. This checklist had previously been used only in evaluating parents known to have abused or neglected their children. A prospective review of the children born was made.
PRENATAL
PREDICTION
METHOD
The patient population of a large federally supported combined Maternal and Infant, Children and Youth Project was studied. This project provides care throughout pregnancy, with enrollment of infants at birth. Care is comprehensive, with physicians and physician assistants working as a team with social workers, public health nurses, nutritionists, screeners and outreach workers. Comprehensiveness of services, neighborhood location and limited outside facilities for the low-income clientele combine to make this population unusually stable as users of these clinics. Projects are located in Metro-Denver, an urban-suburban area. The maternity population consists of women 14 to 38 years of age, with a median age of 20.9. About one-third are Spanish-surname, the remainder Caucasian. The average educational level is 1Ith grade. Sixty percent of the maternity population are married; the rest are single, divorced, separated or live-in. All have well below average family incomes. Women are enrolled in the maternity project between the third and sixth month of gestation. As part of the intake procedure, all women are interviewed by a social worker. The Family Stress Checklist (Table 1) was included in this interview. Specific questions were designed to give answers to each item on the Checklist [20]. These questions were interspersed in the general intake interview. Specific informed consent was therefore not obtained. Handling of all data throughout the study was through chart numbers only, not names. Social workers received six hours specific training to elicit accurate answers to the checklist categories. Inter-rater reliability was considered acceptable when all workers’ total scores placed the patients in the same category, i.e., no risk, moderate or high risk. The checklist encompasses ten factors, each listed as no risk, risk, or high risk. Scoring O-5-10 for each factor, any one individual can score from 0 to a maximum score of 100. In 95% of cases interviews were with the prospective mother only. Scoring on prospective fathers was therefore generally done through data elicited from their partners.
PRENATAL
PREDICTION
RESULTS
Total Scores These data represent results from the first consecutive 587 completed checklists on patients seen from late 1977 to early 1979. There were 3 17 primigravidas with a mean maternal age of 19.3 years and 270 multigravidas with a mean maternal age of 22.7 years. The child’s father was the mother’s husband or boyfriend in 98% of cases.
228
Solbritt Murphy, Bonnie Orkow and Ray M. Nicola Table 1. Family Stress Checklist* No Risk, Score 0
Risk, Score 5
MF
High Risk, Score 10 MF
MF
I. Parent beaten or deprived as child
Infrequent spankings. Consistent “parenting”
Frequent spankings. some bruises: received intermittent “parenting” -
Severe beatings: repeated foster homes. No helpful parent model in childhood
2. Parent has criminal or mental illness record
Not present
Present, but demonstrates rehabilitation
Current psychosis: chronic pattern of psychiatric problems
3. Parent suspected of abuse in the past
Not present
Official report of mild abuse; child not placed in foster care _
Official report of serious abuse; children placed in foster care or died
4. Parent with low self-esteem, social isolation, or depression
Not present
Intermittent coping skills; no current lifelines or unreliable ones
Severely depressed. No lifelines in past or present
5. Multiple crises, or stresses
Not present
Moderate environmental and/or marital problems
_
Chaotic life style. severe environmental and/or marital problems
6. Violent temper outbursts
Not present
Damages property
_
Attacks people
-
7. Rigid, unrealistic expectation of child’s behavior
Not present
-
Afraid of spoiling child, unrealistic expectations
-
Intolerance of normal behavior: very strict parent
-
8. Harsh punishment of child
Not present -
Current frequent spankings or use of belt, not in head area
-
Child triggers abuse by intermittent provocative behavior
-
Risk factors present, but bonding adequate
9. Child difficult and/ or provocative or perceived to be by parents
Not present
IO. Child unwanted, or at risk of poor bonding
Not present
-
-
_
_
_
Physical punishment of baby prior to crawling; sadistic and/or dangerous punishment Child triggers abuse by constant provocative behavior (i.e., seen as having no good points)
_
Risk factors present, and bonding poor
-
* Developed by B.D. Schmitt and CA. Carroll-Child Protection Team at the University of Colorado Health Sciences Center. Abbreviations used: M = mother, F = father. Reproduced with permission of the authors and publisher from The Child Protecrion Team Handbook, B.D. Schmitt (Ed.), pp. 107-108. Garland, New York (1978).
Figure 1 shows the pattern of risk scores obtained: 150 women (25.6%) scored 0 and 355 women (60.5%) scored between 5 and 25. Scores of 30 and above were infrequent (13.9%). In the population studied, scores of 40 and over were considered as high-risk scores (a score of 40 was chosen based on the slope of the curve in Figure 1). Such scores occurred in 42 out of 587 (7%). Only 255 fathers could be scored completely. However, the fathers’ scores followed a distribution pattern almost identical to the corresponding mothers’ scores (Figure 1). Matched in pairs, 90% of the low-score mothers described their partners as low score and 90% of the high-score mothers described their partners as high score. The data were also analyzed for scoring differences between single versus married mothers, and single teenagers versus married teenagers (Figure 2). While a completely negative score (i.e., 0) was indeed more common among married women of all ages, the majority of scoresboth for all single women and for single teens-fell in the 0 to 20 category. There was a larger group of medium high scores (25 to 35) among single women, whether teens or not. High scores (40 and over) indicating possible risk for parenting problems, however, showed a remarkably similar percentage in all four groups, being only slightly higher among single teens. The differences among these groups were not statistically significant.
Prenatal
prediction
229
of child abuse and neglect
150 -r, 140
- i,
90 80 -:
*
\
6 ‘0 _:I CO-: : 50 40 30 20 _
\ t
\ i ’ t ‘\\
“,, ?
‘\
+
‘* ‘.
‘*,_*
T “i
,+--%,.-r-‘. Y ‘*--C-*__*__/*-w-_* o0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100
10 -
‘. \*__*_5?.
TOTAL SCORES FROM TABLE 1 OBTAINED BY ADDING SCORES ON EACH OF THE 10 FACTORS
Figure 1. Distribution pattern of total scores obtained by 587 mothers, 225 fathers. *. Fathers scow*-----*, Mothers score*
651 60 i 55 50 45 :: Y
40 -
G
35 -
B
30 -
G E
25 -
%
20 -
S1ng1e
Mothers
Married Teens I(r and Under
Single Teens 19 and Under
Figure 2. Percentage of married, single or teen mothers achieving total scores on the ten factors in Table 1 of 0, 5 to 20, 25 to 35, or 40 and over. Forty and over was considered high risk for serious parenting problems such as abuse, oeglect, sod failure to thrive.
230
Solbritt Murphy, Bonnie Orkow and Ray M. Nicola
Individual Factor Analysis
A factor by factor analysis of the scoring from the checklist (Table 1) showed that certain factors were common even among the parents with very low scores. The most common factor present was number 5 (crises or stresses). A moderate degree of crises or stresses was present in 73% of the population scoring 5 to 20 (329 mothers). Crises and stresses were present in the entire high score population (scoring 40 and over), but 88% (37142) scored high on this factor, indicating a chaotic lifestyle or severe crises @ = 0.01). The next most common factor present among the population with total scores of 5 to 20 was factor number 1 (parent beaten or deprived). Frequent spankings or intermittent parenting had been experienced by 42.5% of the low-score group (1401329). However, poor parenting was part of the life experience for 93% of the parents scoring 40 and over @ = 0.01) with a high score (indicating severe beatings or no real parenting) being present in 36%. Factor number 4 (social isolation or depression) was also not uncommon in this population, being present in 29.5% (97/329) of those with total scores of 5 to 20, but in 98% of those scoring 40 and over @I = 0.001). The severity of such isolation was more important than its presence or absence. Severe isolation or depression was present among 50% of the high-score group (scoring 40 and over). Ambivalence about wanting the child (factor number 10) may be anticipated in a patient group often living in marginal circumstances. Scoring indicating such feelings appeared among 29.2% (96/329) of parents with total scores of 5 to 20 and in 80% of those scoring 40 and over (p = 0.01). Almost totally absent in the low scoring population were factors number 2, 3, 6-8 (from Table 1) indicating criminal activity, serious mental illness, suspicions of past abuse, violent temper outbursts, rigid expectations of children’s behavior or a story of harsh punishment of previous children. All of these occurred increasingly as total scores increased.
CHART REVIEW
Methods
After the Family Stress Checklist was completed prenatally by the social worker, it was simply placed on the non-active side of the mother’s chart. No special care arrangements were made for mothers with high scores, since the checklist’s validity had not been tested. When the children born of the original 587 mothers had reached an age of 1 to 2 years, the charts of both mother and child were analyzed for all mothers scoring 35 and over prenatally. A control group was then chosen from mothers with total scores of 0 to 10 prenatally, but otherwise matched one to one with the high-score group in age, marital status, living arrangements, relationship with the father of the child and previous parental experience. Reviewers knew that the charts were from either high or low-score mothers and children, but not in which category each case fell. Chart review factors are shown in Table 2. A child’s chart was considered negative if all factors on the list were entirely negative, or if the events noted could not have been reasonably influenced by the parents, (for example, difficult deliveries, babies in poor medical condition, and hospitalizations for common diseases). A child was considered mildly neglected if one or more factors were present that could have been influenced by the parents, such as poor bonding noted, repeated episodes of diarrhea or cradle cap, chronic feeding problems, frequent falls, questionable shelter, but no direct evidence of abuse or neglect was present. A child was considered neglected or abused
Prenatal prediction of child abuse and neglect Table 2.
231
Chart Review Factors Used in Evahatine Child Care given
Birth Risk Factors
1. Difficult delivery (e.g., hypertension, pre-eclampsia, RH negative, diabetes, C-section) 2. Baby’s poor medical condition at delivery (e.g., LGA, SGA, premature, congenital anomalies, Apgar below 7, neonatal complications) *3. Chart observations that parents have unsuccessful experiences in caring for the baby in the hospital 4. Baby kept in hospital past 3 days *5. Observations of poor bonding noted Mild Neglect or Questionable Bonding 1. Parent says baby is:
Poor feeder Cries a lot, “difficult” Spoiled 2. Parent not coming in for health maintenance care or for sick child care as needed 3. Repeated episodes of diarrhea, cradle cap, skin infections in normal child Child Neglect
1. Failure to thrive (underweight) labeled on chart 2. Failure to provide food, clothing shelter or supervision noted 3. “Accident-prone” child, i.e., more than one incident of: Poison ingestion Falls, severe Abrasions or bruises, severe enough to cause clinic visit Hospitalization for any accident Child Abuse
Welts Bruises Bums Broken bones Either verified or strongly suspected to be inflicted injuries * All these factors were statistically analyzed, but only #3 and #5 were to influence later parenting problems and were kept in the final list of important birth risk factors.
if evidence was present indicating that failure to thrive, direct neglect or abuse had taken place.
Results A very clear division was apparent between completely negative charts, those showing mild neglect, and those showing neglect-abuse. The 38 mothers scoring 40 and over prenatally (Figure 3) had frequent problems with child care (of the original 42 mothers with high scores, there were 4 with no baby charts, 2 mothers had moved, and 2 had relinquished their infants). Only 9 (23.7%) of their children’s charts were negative; 9 showed evidence of mild neglect (23.7%); and 20, evidence of direct neglect or abuse (52.6%). Among the 5 1 charts of children whose mothers had total scores of 10 to 20 prenatally, there were 38 negative charts (74%); 11 (21%) charts showing mild neglect, and 2 (4%) showing neglect-abuse. Among the 57 charts of children whose mothers had total scores of 25 to 35 prenatally (of the original 58 mothers, one chart was not reviewed because there was no baby follow-up data available), there were 36 negative charts (63.2%); 18 (31.8%) charts showing mild neglect, and 3 (5.0%), showing neglect-abuse By contrast among the 100 charts of children of control mothers with total prenatal risk scores of 0 to 10, very few problems in child care were found. Of these, 84 children’s charts were completely negative; 14 indicated mild neglect; and two showed definite neglect-abuse.
Solbtitt Murphy, Bonnie Orkow and Ray M. Nicola
232 100 90 80 70 z z g
605040 30 20 10 oControls Total Score 0 to 10 N = 100
Low Risk Parents Total Score 10 to 20 N = 51
Medium Risk Total Score 25 to 35 N = 57
High Risk Parents Total Score 40 and over N=38
Figure 3. Results of chart review showing outcome of child care when child l-2 years of age. No child care problems Mild neglect noted Definite abuse or neglect present N=number of mother and child charts reviewed in each group.
The sensitivity of a prediction for neglect-abuse was 80% (Table 3), while the specificity (i.e., predictability of which parents will not be likely to neglect or abuse) was 89.4% The type of abuse-neglect noted showed a continuum between failure to thrive, neglect and abuse (Table 4). Table 3. Sensitivity and Specificity of Prenatal Predictions from the Checklist Total Scores Actual Neglect or Abuse Noted
No
Yes C
A Predicted
18
20
Yes
Neglect or Abuse would occur
D
B No
I52
5
A Sensitivity = % of correct yes = A+B D Specificity = % of correct no’s = C+D Predictive value of a positive $
Predictive value of a negative s
20
= X 100 = 80% 20 + 5 = - 152 = 152 + 89.4% 170 18 + 152
= 52.5%
= 96.8%
Prenatal prediction of child abuse and neglect Table 4.
233
Type of Incidence Noted in the 25 Cases of NeglectAbuse Found on Chart Review
Abuse only
4
Abuse/FTT and neglect Abuse and neglect FTT and nealect FTT only Neglect only Abuse sib, patient removed
2 4 6 2
6
I 25
Total
A comparison was made of the prenatal scoring among the 20 high-score families where abuse-neglect was known to have taken place by the time the child had reached age 1 to 2 years, and the remaining 18 of the high-scoring families, where no serious child-rearing problems had as yet been noted 1 to 2 years after the child’s birth. There were no significant differences between these two groups; both had an equal background of exposure to poor parenting, previous criminal or mental illness, past abuse suspicions, social isolation, violent tempers, multiple crises and rigid expectations of their children.
IMPLICATIONS Results in this study contradict some earlier findings. The general clinic population showed a remarkably low incidence of risk factors, even in a low-income, racially mixed, generally very young population. Neither teenage nor single status appeared to contribute significantly to abuse-neglect risks There is a general belief that these two groups are at serious risk for poor parenting. In the case of teenage parents, this belief is also supported by large federal expenditures (PL95-626) [21]. If our concern is the welfare of the children born, such money may be better directed. The data presented here indicate marked similarity in scores between fathers and mothers. Since data on fathers was primarily obtained from mothers, its accuracy must be questioned. The likelihood is that the mothers were at least close to correct, and that, in fact, couples have a tendency to seek partners with similar past experiences and lifestyle. The message for case workers and medical personnel is that a careful evaluation needs to be done on both parents or partners in abuse and neglect cases, without any assumptions that the non-abusive parent is “safe” for the child. The Family Stress Checklist turned out to be a remarkably accurate predictor, having predicted 20 out of 25 (80%) of all families so far identified as abusive or neglectful in this population. This checklist previously had only been used retrospectively, and was developed from experience with cases of confirmed abusive families. Authors Schmitt and Carroll suggest using this checklist to determine abusive potential [19]. This study found it equally helpful in predicting children with failure to thrive and neglect. In the present study, there appeared to be no clear-cut distinction between these three problems but rather a continuum (See Table 4). This checklist has been used at the University of Colorado Health Sciences Center with weighting of various factors [19]. Our experience was that such weighting confused the scoring and unfairly penalized parents with specific backgrounds-such as violent temper outbursts No single factor appeared of major importance; rather, it was the clustering of factors, both in present and past life events, that seemed associated with abuse-neglect. Since the data from the child abuse checklist can be considered nominal-level data (Stevens’ typology). it is possible to use factor analysis or a related procedure to examine the
SolbrittMurphy,Bonnie Orkow and Ray M. Nicola
234
proportion of variance accounted for by each question; however. time and budget restraints make this sophisticated analysis a project for the future. The present paper uses the standard error of the mean to test the null hypothesis between control and abuser groups. The checklist itself is remarkably simple and easier to use than a large number of other reported screening mechanisms. As physicians increasingly use counseling personnel in their offices. prenatal or even premarital interviews aimed at evaluating parenting readiness could include such a checklist. Prospective parents with an unusually high score could then be counseled regarding the problems they may encounter and specific help offered. At the time of this study, we had no proof that the scale used was indeed valid. Specific support programs were therefore not developed for high-risk mothers. They were referred to public health nurses or social services as specific problems arose, just as any other patient would be referred. However, it must be understood that once a scale such as this one has been verified to accurately identify families at serious risk for parenting problems, the issue of not providing support services becomes a serious matter. A study in cooperation with the University of Colorado Medical Center is presently underway [22] providing lay home visitors to high-score parents soon after identification prenatally. A control group with equal scores and without such assistance will be used. It is hoped that the lay visitors will be able to at least decrease the incidence of abuse-neglect among the high-score parents. There are no answers to what may happen in high-score families where no abuse or neglect has as yet been noted. It is possible that, a few years from now, a much larger percentage of these children may be involved. It is also possible that there are as yet unidentified factors restraining these high-scoring parents from neglecting or abusing their children. The present study has attempted to demonstrate that accurate predictions of parenting ability can be made before the birth of a family’s children, even the first. Verification from different population groups and different socioeconomic backgrounds is needed. Once a method of accurate prediction has been verified, preventive programs can be implemented in a selective manner.
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(1975). 5. WRIGHT, L. The “sick but slick” syndrome as a personality component of parents of battered children. Journal of Clinical Psychology 32:41-45
(1976).
6. GAINES, R. et al. Etiologicai factors in child maltreatment: A multivariate study of abusing, neglecting and normal mothers. Jownnl of Abnormal Psychology 87:531-540 (1978). 7. GARBARINO, J: A preliminary study of some ecological correlates of child abuse: The impact of socioeconomic stress on mothers. Child Development 47: 178-185 (1976). 8. SHAPIRO, D. A CWLA study of factors involved in child abuse. Child Werfare 59:242-243 (1980). 9. GREEN, A. H. et al. Psychopathological assessment of child-abusing, neglecting and normal mothers. Journal of Nervous and Mental Disease 168:356-60 (1980). IO. MILNER, J. S. et al. An inventory for the identification of child abusers. Journal of Clinical Psychology 35:95- 100 (1979).
II. SMITH, S. M. et al. Parents of battered babies: A controlled study. Bntish Medical Journal 4:388-391 (1973). 12. SERRANO, A. C., SNELZER, M. B. et al. Ecology of abusive and non-abusive families: Implications for intervention. Journal of rhe American Academy of Child Psychiatry 18:67-75 (1979). 13. SMITH, S. M. et al. Social aspects of the battered baby syndrome. Bruish Journal of Psychiatry 125:568-582 (1974).
14. VESTERDAL, J. Psychological mechanisms in child abusing parents. Paediarrician 8: 145- 15 I ( 1979). 15. BAVOLEK, S. J. et al. Primary prevention of child abuse and neglect: Identification of high risk adolescents. Child Abuse & Neglect 3: 1071-1080 (1979).
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16. HUNTER, R. S. et al. Antecedents of child abuse and neglect in premature infants: A prospective study in a newborn I.C.U. Pediatrics 61:629-635 (1978). 17. LYNCH, M. A. et al. Predicting child abuse: Signs of bonding failure in the maternity hospital. British Medical Journal 60/61:624-626 (1977). 18. GRAY, J. D., CUTLER, C. A. et al. Prediction and prevention of child abuse. Seminars in PerinafologV 3:85 (1979). 19. SCHMITT, B. D. The Child Protection Team Handbook, pp. 83-108. Garland, New York and London, (1978).
20. ORROW, B. A method for predicting child abuse. Unpublished data, Tri-County District Health Department, Englewood, Co. 21. Information Bulletin, Office of Adolescent Pregnancy Program 1:l DHEW P.H.S., Washington, D.C. (1980). 22. DAWSON, P., DOORNICK, B. Use of lay home visitors in high risk families. Unpublished data, University of Colorado Medical Center, Denver.