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Recent developments in the field of child abuse
Child Abuse and Neglect, Vol. 2, pp. 261-267. OPergamon Press Ltd., 1978. Printed in Great Britain.
014%2134/78/1101-0261$02.00/O
RECENT DEVELOPMENTS IN THE FIELD OF CHILD ABUSE C. Henry Kempe, M.D., Professor of Pediatrics and Microbiology Director, National Center for Prevention and Treatment of Child Abuse and Neglect, Department of Pediatrics, University of Colorado 4200 East Ninth Avenue, Denver, Colorado 80262 All of us concerned with the welfare of children the world over must remember that to this very day vast numbers of children, and particularly those living in portions of the third world, still face malnutrition and infectious diseases as the two major problems of survival. Nations concerned with malnutrition and the prevention of infectious diseases must first address these primary needs, but it is interesting that even in countries struggling with these basic concerns, the problem of child abuse is now being considered. In Europe and North America we see that, as birth rates drop, each child is expected to survive. Without concerns about malnutrition or infectious diseases as likely causes of death, many additional threats to the child's life and health are increasingly considered, and among them is child abuse. In a sense, therefore, the very consideration of child abuse as a problem worthy of the public's concern means that children have reached a certain plateau of basic care. A unique event in the lives of children the world over will occur in a few weeks. 1979 will mark the International Year of the Child by order of all 149 member states of the United Nations. The International Year of the Child is a worldwide effort to better the lot of children. Broadly based national committees all over the world are planning what each country wants most urgently to do for her children. Many of the national comnittees are considering plans for improved childhood nutrition, immunization, and improvement in education. There seems to be a consensus among national committees working in each member country that the rights of children should be prominently considered, and child abuse has already been named as a topic by a number of them. The International Year of the Child will see broadly ordered programs throughout the world dedicated to emphasizing the unique needs of the child and for the first time, on an international basis, address the rights of all children. The United Nations is on record as savino that it is not enouoh for a child not to be abused, not to be neglected, not to be starved, and not to be sexualrassaulted. On the contrary, the Children's Charter states that all children ‘have the right to be in a seiting that will attempt to develop each child to his or her greatest potential. To do so children need to be born well, to be valued, to enjoy optimal growth and development, to be in a nurturing family environment, to learn the skills necessary for success, to receive health assessment and health maintenance, anticipatory guidance, health education for self care, easy access to competent medical and dental treatment, and to share in the advances made possible by biomedical and biosocial research. Your program committee asked me to provide a brief overview of developments in our field since our last meeting. I do so based on information available to me from letters and visits from many workers who contacted The Internation 261
262
C. Henry Kempe
al Society for the Prevention of Child Abuse and Neglect since its formation at the Geneva meetings two years ago, and based on the material submitted to the new journal, CHILD ABUSE & NEGLECT - THE INTERNATIONAL JOURNAL, which will soon be celebrating its second birthday. In Geneva two years ago we brought together many diverse professionals who could freely exchange experiences and views. This led to collaborations and cross fertilization of ideas which have been striking. I shall briefly deal with six selected areas where significant progress has occurred. These are: 1) Change from a closed system of child protection to a more open system involving many professions and the public at large. Perhaps the greatest progress we have seen is in the general recognition that social workers have carried the entire burden of protective services alone for too long a time, and that they have lacked the needed support of physicians, nurses, police,the judiciary , and finally the population they serve. Wherever the system has remained too rigidly isolated so as to preclude an interdisciplinary approach, progress has been slow and pressure from the outside, primarily from enlightened and sometimes enraged citizens, has been required to bring about needed change. But in many thousands of communities throughout the world, broad interest shown by the public and all helping professionals have brought about reorientation toward joint concerns by involving the community as a whole with all its professional and lay talents, and this has greatly improved the lot of needy families as well as the lot of primary workers in the child protection field. It is now well understood, that because of the enormous emotional stress produced in coping with child abuse, the fatigue burnout of workers in the field is great. Primary care child protection workers are the only public servants willing to constantly stretch their case load to meet any demands. They do so because they are not a militant profession with defined duties. But in the process they do an injustice to their clients and to themselves. The answer lies in the increasinq use of lay family aides as social work extenders. We now understand what must be done to prevent this phenomenon by professional and community support. In a larger sense, there is the fact that the complex problems of child abuse, with the long treatment required for families, the difficult-to-treat parents and very needy children, are in themselves such a challenge to the social care system, that there is chance that, once progress has been made, it might later be lost in an exhaustion phenomenon of the system itself. It is not possible to say that it is too expensive, too time-consuming to try to treat treatable families by pronouncing them all to be untreatable. Having once committed ourselves to helping families to prevent and treat child abuse and neglect, we must not once again leave it to the constituted authorities to slide back to the isolationist days so recently overcome. It is not surprising that every country I have anal,yzed goes through a specific sequence of developmental stages in addressing the problem of child abuse. Stage One is denial that either physical or sexual abuse exists to a significant extent. Serious abuse that surfaces is ascribed to a psychotic, drunk
Recent Developments
263
or drugged parent or to foreign guest workers with different styles of child raising, "nothing to do with us." Stage Two is paying attention to the more lurid abuse - the battered child, and beginning to cope in more effective ways with physical abuse including early intervention when abuse is perhaps not so severe. Stage Three comes when physical abuse is better handled and attention is now beginning to be paid to the infant who fails to thrive, an example of passive abuse, and the general area of significant physical abuse. Stage Four comes in recogntion of emotional abuse and neglect. Its more severe form is seen in the child who is rejected, scapegoated, unloved, and so emotionally deprived as to significantly interfere with the normal physical, intellectual, and emotional growth and development. Stage Five is the paying attention to the serious plight of the sexually abused child, including the youngster involved in incest. I am certain you can think of these sequences of events in your own country, and, provided you have already passed through all these phases, you might ask yourself when you might come to face Stage Six, that of guaranteeing each child that he or she is truly wanted, is provided with loving care, decent shelter and food, and first class preventive and curative health care. If any country has solved the problem of child abuse, I have not discovered it. Some nations have moved forward in this field through all the above stages and they do possess the understanding and technical know-how to p'rovide proper services. But even in these so-called advanced countries there are as yet only islands of excellence among a sea of ineptitude and insufficient political and financial commitment. There may yet come a time when children are seen as such a precious national resource and so possessing of total civil rights that society at large will take a tenevolent interest in their welfare from the time of conception through prenatal care, birth, into infancy, early childhood, and through the school years. One of the paradoxes of our century is that society has, indeed, involved itself materially in the child's life at school age, but in many nations there remains an enormous hiatus between protection of the child afforded from conception until agesix. The question of the rights of parents to be left alone must be weighed against the rights of the child to be protected from parents unable to cope at a level assumed to be reasonable by the society in which they reside. 2)
Early treatment of the abused child and his siblings.
Another relatively recent development has been the acceptance of the concept that we cannot wait to begin the emotional reconstitution of the physically or sexually abused and neglected child, regardless of age. Treatment of the child is a relatively new concept for protective service workers who have hitherto, of necessity, had to focus on the mother while the father was largely unavailable. This was known as the "trickle down" theory by which giving nurturing help to the mother was thought to improve her total life and marriage, and would then permit her to be a more competent mother and wife. It was the credo of protective service work for one hundred years, and it turns out to be woefully lacking. It should come as no surprise to anyone
264
C. Henry Kempe
that it took parents twenty-five years to become what they have become, that it should be more difficult to change their child raising practices and also, even in a modest way, their character in a period of a year or two. On the other hand, it has been very encouraging to us to see how relatively quickly their children can be reconstituted emotionally, provided only that they receive appropriate emotional support of a skilled, reliable kind and at once. Individual and group treatment must be tailor-made to each child's needs. To fail to address the emotional needs of the abused child effectively and from the very first should nowadays have to be regarded as malpractice. 3) The growing recognition that sexual abuse is as numerous and, in many ways, as serious as physical abuse in considering the long term welfare of children. More and more is being done to prevent child abuse and to intervene successfully as early as possible before it is as yet a major threat to the child's life or growth and development. This has not yet been possible in a major way in the field of sexual abuse although even there we see inroads being made by early inclusion of family life education in schools and by providing effective rescue once sexual abuse and incest come to light. Let me add here that those who believe that incest had best be left a "family affair," that it is not of serious emotional import as judged by the fact that many victims have gone on to lead apparently normal lives, fail to take into account the enormous emotional costs paid by many of these children and the scars they bear for a lifetime. Recent studies do show that a disproportionate number of prostitutes have been involved in incest in early years, and that most children involved in incest do not grow up to have happy lives. The frequency of incest is very large and the reported number is now fully equal to that of physical abuse in our Center. Early treatment of these children, regardless of age, appears to be important in order to be successful in many cases, with some spectacular failure in others. But remember that incest is as yet hardly talked about in many countries; it is, indeed, the "last taboo." Discussing incest even at a professional level, often leads to hostile responses similar to those we heard twenty years ago when discussing the battered child. 4) The institutional abuse that occurs when society's intervention is more harmful than if intervention had not occurred. Our concept of prevention and, when that fails, of early intervention does assume that intervention is better than doing nothing. But there are times when we clearly intervene badly and do unintended harm. An intelligent treatment plan must be made that does full justice to the rights of the child without subjecting him to the alternative, institutional abuse of unduly prolonged and frequently changing foster care or institutional placements. Many a child, having been robbed of his family for his own good, is then subsequently robbed of each new family substitute, in turn, a truly devastating blow at any attempt of bonding for the child. The incredible inertia of child protection and judicial systems the world over requires public attention and action to ameliorate this kind of institutional abuse. Consider the plight of children who have committed no crime, but are placed in temporary shelters which are in fact juvenile correction institutions, training schools, and security detention facilities, all alternatives used by
Recent
Developments
265
society to cope with children who simply have no place to go because they are abused at home. In many instances the money spent by the public on institutional care of such children could be better spent in treatment of the family, with the child given additional safeguards because of this increased development of helping services. But above all, the child who is in limbo is really suffering the most. Where families cannot be reconstituted, the speedy making available for adoption of a child would be certainly far superior to shuttling children from pillar to post over a period of many years. Since our last meeting there has been lively debate about the relative importance of societal abuse of the parents by suggesting that child abuse is essentially a product of young families caught up in the stresses of poverty, racism, unemployment, poor housing and that these crises trigger the attack on the child and are the primary cause of physical abuse in children. This concept does not, of course, take care of the failure-to-thrive syndrome, or sexual abuse or incest, but it does take the therapist somewhat off the hook by blaming society's shortcomings for the parents' abusive behavior. Without underestimating the importance of external crises as a trigger phenomenon, let me just point out that we are so very struck with the high incidence and serious nature of child abuse among a group of individuals who do have a job, housing, cheap food, free comprehensive health care, are married, and live surrounded by potentially helpful people. I am talking here about a group of military families who enjoy all these societal advantages and still have a very significant problem of child abuse, with five child deaths occurring in a single military camp in my state in the past twelve months. Clearly internal and external stresses combine to trigger attacks. 5) The Two legal concepts of the law guardian and of the legal requirements for involuntary terminati,n of parental rights and the freeing of the abused child for adoption. Two legal advances which are rapidly coming to the foreground in the past two years have been the concept of a guardian ad litem, an adult who may not necessarily have legal training, who is as-by the court to be the advocate of the child in all situations where the child is deemed to be in need of protection by the court. All of our states have the possibility of providing guardians ad litem to abused children, but an increasing number of states now mandate it. Similarly, a number of states have now more clearly defined the situations under which involuntary termination of parental rights can be accomplished. This now usually entails either a particularly brutal or sadistic form of abuse or neglect by imprisonment or starvation or abandonment for a period of six or more months. Also considered are serious and incurable psychopathology on the part of the parent which places the child in immediate danger and is not amenable to treatment, and finally those situations where a serious effort at treatment has failed and it is felt by the court that a child cannot successfully be raised in his family. Such termination of parental rights is never undertaken lightly, but if information is well documented by a social worker, a pediatrician and a psychiatrist, we have yet to see it overturned on appeal. Early termination of parental rights to make the child available for adoption will, in years to come, be seen as a key element in the chain of progress for abused children. 6)
Prevention of child abuse.
C. Henry Kempe
266
Since our last meeting there has also been debate around the ethics of identifying, or some people say labeling, of some families as "in need of extra services" or "at risk." Pediatricians have always preferred prevention to treatment. We felt that it was far better to develop the poliomyelitis vaccine to prevent polio than to try to improve the iron lung respirator used by the victims of the disease. There are now a number of well controlled studies that show that it is possible to identify families who might be expected to have problems in bonding and to assist many of them by an extra effort of kindness and care. It is particularly important to those of US who work in the fields of obstetrics, midwifery, pediatrics, and nursing, that every effort be made by paying careful attention to families' attitudes toward their babies before, during, and after their births, and to find those to whom we will need to reach out in order to provide extra help if parenting should fail partially or completely, and before disasters occur. There are those who believe that even looking at a mother and a child after delivery is unethical and an invasion of their privacy. Not so! We health professionals are employed by our families to help bring into the world a healthy child with the least trauma both physically and emotionally to the baby and also to the parents. As part of comprehensive health care by obstetrics and pediatrics, we must pay attention to early bonding and adjustment needs of families. Failure to provide this comprehensive health care is medical and nursing malpractice. It should not be surprising to anyone that as we do a better job of providing early help to families in need of extra services and by educating families to seek such help when they encounter crises, we will be left with the residue of impossible-to-treat, abusive parents, who will appear to us to be more and more sick. Unless we license parenthood, this will be our lot in years to come, if we are successful in preventing the majority of instances of serious child abuse and neglect. CONCLUSION This Second International Congress represents a truly unique opportunity to listen and to learn: to have a totally open mind, to be humble and not dogmatic, and to assume that we all know very little. To those who for professional satisfaction insist on a high percentage of "cures," the field of child abuse and neglect has little to offer. But to those who find an immense satisfaction in bringing happiness, even for a time, to children and to their parents, to see them all grow and develop, and to go from constant misery to at least intermittent times of joy and satisfaction, it is, indeed, a most satisfying field. It is hard to measure the ultimate effect of our care. One simply has to see hundreds and hundreds of such families to be persuaded that humane and skilled efforts in their behalf have brought about changes for the better, and this is particularly so for the children who have been neglected so long in our early rush to help their parents. While international meetings serve a splendid purpose of acquainting us with the contributions made by many diverse groups in many countries, I should warn you that it is not always possible to transfer a program from one country to the next, even when they are neighboring countries. Differences in professional attitudes, the law, and society's readiness for change, all govern and all are important. On the other hand, it would be quite wrong to assume that just because a piece of work was done here that it cannot be useful some-
Recent Developments
267
where else. Science would not have progressed if people had persisted in reinventing the wheel. Allow me to close by quoting the preamble to the Declaration of the Rights of the Child adopted by the United Nations in 1959. "Mankind owes the child the best it has to give." I wish you an exciting and memorable meeting in the cause of the abused child and his needy family.
014%2134/78/1101-0261$02.00/O
RECENT DEVELOPMENTS IN THE FIELD OF CHILD ABUSE C. Henry Kempe, M.D., Professor of Pediatrics and Microbiology Director, National Center for Prevention and Treatment of Child Abuse and Neglect, Department of Pediatrics, University of Colorado 4200 East Ninth Avenue, Denver, Colorado 80262 All of us concerned with the welfare of children the world over must remember that to this very day vast numbers of children, and particularly those living in portions of the third world, still face malnutrition and infectious diseases as the two major problems of survival. Nations concerned with malnutrition and the prevention of infectious diseases must first address these primary needs, but it is interesting that even in countries struggling with these basic concerns, the problem of child abuse is now being considered. In Europe and North America we see that, as birth rates drop, each child is expected to survive. Without concerns about malnutrition or infectious diseases as likely causes of death, many additional threats to the child's life and health are increasingly considered, and among them is child abuse. In a sense, therefore, the very consideration of child abuse as a problem worthy of the public's concern means that children have reached a certain plateau of basic care. A unique event in the lives of children the world over will occur in a few weeks. 1979 will mark the International Year of the Child by order of all 149 member states of the United Nations. The International Year of the Child is a worldwide effort to better the lot of children. Broadly based national committees all over the world are planning what each country wants most urgently to do for her children. Many of the national comnittees are considering plans for improved childhood nutrition, immunization, and improvement in education. There seems to be a consensus among national committees working in each member country that the rights of children should be prominently considered, and child abuse has already been named as a topic by a number of them. The International Year of the Child will see broadly ordered programs throughout the world dedicated to emphasizing the unique needs of the child and for the first time, on an international basis, address the rights of all children. The United Nations is on record as savino that it is not enouoh for a child not to be abused, not to be neglected, not to be starved, and not to be sexualrassaulted. On the contrary, the Children's Charter states that all children ‘have the right to be in a seiting that will attempt to develop each child to his or her greatest potential. To do so children need to be born well, to be valued, to enjoy optimal growth and development, to be in a nurturing family environment, to learn the skills necessary for success, to receive health assessment and health maintenance, anticipatory guidance, health education for self care, easy access to competent medical and dental treatment, and to share in the advances made possible by biomedical and biosocial research. Your program committee asked me to provide a brief overview of developments in our field since our last meeting. I do so based on information available to me from letters and visits from many workers who contacted The Internation 261
262
C. Henry Kempe
al Society for the Prevention of Child Abuse and Neglect since its formation at the Geneva meetings two years ago, and based on the material submitted to the new journal, CHILD ABUSE & NEGLECT - THE INTERNATIONAL JOURNAL, which will soon be celebrating its second birthday. In Geneva two years ago we brought together many diverse professionals who could freely exchange experiences and views. This led to collaborations and cross fertilization of ideas which have been striking. I shall briefly deal with six selected areas where significant progress has occurred. These are: 1) Change from a closed system of child protection to a more open system involving many professions and the public at large. Perhaps the greatest progress we have seen is in the general recognition that social workers have carried the entire burden of protective services alone for too long a time, and that they have lacked the needed support of physicians, nurses, police,the judiciary , and finally the population they serve. Wherever the system has remained too rigidly isolated so as to preclude an interdisciplinary approach, progress has been slow and pressure from the outside, primarily from enlightened and sometimes enraged citizens, has been required to bring about needed change. But in many thousands of communities throughout the world, broad interest shown by the public and all helping professionals have brought about reorientation toward joint concerns by involving the community as a whole with all its professional and lay talents, and this has greatly improved the lot of needy families as well as the lot of primary workers in the child protection field. It is now well understood, that because of the enormous emotional stress produced in coping with child abuse, the fatigue burnout of workers in the field is great. Primary care child protection workers are the only public servants willing to constantly stretch their case load to meet any demands. They do so because they are not a militant profession with defined duties. But in the process they do an injustice to their clients and to themselves. The answer lies in the increasinq use of lay family aides as social work extenders. We now understand what must be done to prevent this phenomenon by professional and community support. In a larger sense, there is the fact that the complex problems of child abuse, with the long treatment required for families, the difficult-to-treat parents and very needy children, are in themselves such a challenge to the social care system, that there is chance that, once progress has been made, it might later be lost in an exhaustion phenomenon of the system itself. It is not possible to say that it is too expensive, too time-consuming to try to treat treatable families by pronouncing them all to be untreatable. Having once committed ourselves to helping families to prevent and treat child abuse and neglect, we must not once again leave it to the constituted authorities to slide back to the isolationist days so recently overcome. It is not surprising that every country I have anal,yzed goes through a specific sequence of developmental stages in addressing the problem of child abuse. Stage One is denial that either physical or sexual abuse exists to a significant extent. Serious abuse that surfaces is ascribed to a psychotic, drunk
Recent Developments
263
or drugged parent or to foreign guest workers with different styles of child raising, "nothing to do with us." Stage Two is paying attention to the more lurid abuse - the battered child, and beginning to cope in more effective ways with physical abuse including early intervention when abuse is perhaps not so severe. Stage Three comes when physical abuse is better handled and attention is now beginning to be paid to the infant who fails to thrive, an example of passive abuse, and the general area of significant physical abuse. Stage Four comes in recogntion of emotional abuse and neglect. Its more severe form is seen in the child who is rejected, scapegoated, unloved, and so emotionally deprived as to significantly interfere with the normal physical, intellectual, and emotional growth and development. Stage Five is the paying attention to the serious plight of the sexually abused child, including the youngster involved in incest. I am certain you can think of these sequences of events in your own country, and, provided you have already passed through all these phases, you might ask yourself when you might come to face Stage Six, that of guaranteeing each child that he or she is truly wanted, is provided with loving care, decent shelter and food, and first class preventive and curative health care. If any country has solved the problem of child abuse, I have not discovered it. Some nations have moved forward in this field through all the above stages and they do possess the understanding and technical know-how to p'rovide proper services. But even in these so-called advanced countries there are as yet only islands of excellence among a sea of ineptitude and insufficient political and financial commitment. There may yet come a time when children are seen as such a precious national resource and so possessing of total civil rights that society at large will take a tenevolent interest in their welfare from the time of conception through prenatal care, birth, into infancy, early childhood, and through the school years. One of the paradoxes of our century is that society has, indeed, involved itself materially in the child's life at school age, but in many nations there remains an enormous hiatus between protection of the child afforded from conception until agesix. The question of the rights of parents to be left alone must be weighed against the rights of the child to be protected from parents unable to cope at a level assumed to be reasonable by the society in which they reside. 2)
Early treatment of the abused child and his siblings.
Another relatively recent development has been the acceptance of the concept that we cannot wait to begin the emotional reconstitution of the physically or sexually abused and neglected child, regardless of age. Treatment of the child is a relatively new concept for protective service workers who have hitherto, of necessity, had to focus on the mother while the father was largely unavailable. This was known as the "trickle down" theory by which giving nurturing help to the mother was thought to improve her total life and marriage, and would then permit her to be a more competent mother and wife. It was the credo of protective service work for one hundred years, and it turns out to be woefully lacking. It should come as no surprise to anyone
264
C. Henry Kempe
that it took parents twenty-five years to become what they have become, that it should be more difficult to change their child raising practices and also, even in a modest way, their character in a period of a year or two. On the other hand, it has been very encouraging to us to see how relatively quickly their children can be reconstituted emotionally, provided only that they receive appropriate emotional support of a skilled, reliable kind and at once. Individual and group treatment must be tailor-made to each child's needs. To fail to address the emotional needs of the abused child effectively and from the very first should nowadays have to be regarded as malpractice. 3) The growing recognition that sexual abuse is as numerous and, in many ways, as serious as physical abuse in considering the long term welfare of children. More and more is being done to prevent child abuse and to intervene successfully as early as possible before it is as yet a major threat to the child's life or growth and development. This has not yet been possible in a major way in the field of sexual abuse although even there we see inroads being made by early inclusion of family life education in schools and by providing effective rescue once sexual abuse and incest come to light. Let me add here that those who believe that incest had best be left a "family affair," that it is not of serious emotional import as judged by the fact that many victims have gone on to lead apparently normal lives, fail to take into account the enormous emotional costs paid by many of these children and the scars they bear for a lifetime. Recent studies do show that a disproportionate number of prostitutes have been involved in incest in early years, and that most children involved in incest do not grow up to have happy lives. The frequency of incest is very large and the reported number is now fully equal to that of physical abuse in our Center. Early treatment of these children, regardless of age, appears to be important in order to be successful in many cases, with some spectacular failure in others. But remember that incest is as yet hardly talked about in many countries; it is, indeed, the "last taboo." Discussing incest even at a professional level, often leads to hostile responses similar to those we heard twenty years ago when discussing the battered child. 4) The institutional abuse that occurs when society's intervention is more harmful than if intervention had not occurred. Our concept of prevention and, when that fails, of early intervention does assume that intervention is better than doing nothing. But there are times when we clearly intervene badly and do unintended harm. An intelligent treatment plan must be made that does full justice to the rights of the child without subjecting him to the alternative, institutional abuse of unduly prolonged and frequently changing foster care or institutional placements. Many a child, having been robbed of his family for his own good, is then subsequently robbed of each new family substitute, in turn, a truly devastating blow at any attempt of bonding for the child. The incredible inertia of child protection and judicial systems the world over requires public attention and action to ameliorate this kind of institutional abuse. Consider the plight of children who have committed no crime, but are placed in temporary shelters which are in fact juvenile correction institutions, training schools, and security detention facilities, all alternatives used by
Recent
Developments
265
society to cope with children who simply have no place to go because they are abused at home. In many instances the money spent by the public on institutional care of such children could be better spent in treatment of the family, with the child given additional safeguards because of this increased development of helping services. But above all, the child who is in limbo is really suffering the most. Where families cannot be reconstituted, the speedy making available for adoption of a child would be certainly far superior to shuttling children from pillar to post over a period of many years. Since our last meeting there has been lively debate about the relative importance of societal abuse of the parents by suggesting that child abuse is essentially a product of young families caught up in the stresses of poverty, racism, unemployment, poor housing and that these crises trigger the attack on the child and are the primary cause of physical abuse in children. This concept does not, of course, take care of the failure-to-thrive syndrome, or sexual abuse or incest, but it does take the therapist somewhat off the hook by blaming society's shortcomings for the parents' abusive behavior. Without underestimating the importance of external crises as a trigger phenomenon, let me just point out that we are so very struck with the high incidence and serious nature of child abuse among a group of individuals who do have a job, housing, cheap food, free comprehensive health care, are married, and live surrounded by potentially helpful people. I am talking here about a group of military families who enjoy all these societal advantages and still have a very significant problem of child abuse, with five child deaths occurring in a single military camp in my state in the past twelve months. Clearly internal and external stresses combine to trigger attacks. 5) The Two legal concepts of the law guardian and of the legal requirements for involuntary terminati,n of parental rights and the freeing of the abused child for adoption. Two legal advances which are rapidly coming to the foreground in the past two years have been the concept of a guardian ad litem, an adult who may not necessarily have legal training, who is as-by the court to be the advocate of the child in all situations where the child is deemed to be in need of protection by the court. All of our states have the possibility of providing guardians ad litem to abused children, but an increasing number of states now mandate it. Similarly, a number of states have now more clearly defined the situations under which involuntary termination of parental rights can be accomplished. This now usually entails either a particularly brutal or sadistic form of abuse or neglect by imprisonment or starvation or abandonment for a period of six or more months. Also considered are serious and incurable psychopathology on the part of the parent which places the child in immediate danger and is not amenable to treatment, and finally those situations where a serious effort at treatment has failed and it is felt by the court that a child cannot successfully be raised in his family. Such termination of parental rights is never undertaken lightly, but if information is well documented by a social worker, a pediatrician and a psychiatrist, we have yet to see it overturned on appeal. Early termination of parental rights to make the child available for adoption will, in years to come, be seen as a key element in the chain of progress for abused children. 6)
Prevention of child abuse.
C. Henry Kempe
266
Since our last meeting there has also been debate around the ethics of identifying, or some people say labeling, of some families as "in need of extra services" or "at risk." Pediatricians have always preferred prevention to treatment. We felt that it was far better to develop the poliomyelitis vaccine to prevent polio than to try to improve the iron lung respirator used by the victims of the disease. There are now a number of well controlled studies that show that it is possible to identify families who might be expected to have problems in bonding and to assist many of them by an extra effort of kindness and care. It is particularly important to those of US who work in the fields of obstetrics, midwifery, pediatrics, and nursing, that every effort be made by paying careful attention to families' attitudes toward their babies before, during, and after their births, and to find those to whom we will need to reach out in order to provide extra help if parenting should fail partially or completely, and before disasters occur. There are those who believe that even looking at a mother and a child after delivery is unethical and an invasion of their privacy. Not so! We health professionals are employed by our families to help bring into the world a healthy child with the least trauma both physically and emotionally to the baby and also to the parents. As part of comprehensive health care by obstetrics and pediatrics, we must pay attention to early bonding and adjustment needs of families. Failure to provide this comprehensive health care is medical and nursing malpractice. It should not be surprising to anyone that as we do a better job of providing early help to families in need of extra services and by educating families to seek such help when they encounter crises, we will be left with the residue of impossible-to-treat, abusive parents, who will appear to us to be more and more sick. Unless we license parenthood, this will be our lot in years to come, if we are successful in preventing the majority of instances of serious child abuse and neglect. CONCLUSION This Second International Congress represents a truly unique opportunity to listen and to learn: to have a totally open mind, to be humble and not dogmatic, and to assume that we all know very little. To those who for professional satisfaction insist on a high percentage of "cures," the field of child abuse and neglect has little to offer. But to those who find an immense satisfaction in bringing happiness, even for a time, to children and to their parents, to see them all grow and develop, and to go from constant misery to at least intermittent times of joy and satisfaction, it is, indeed, a most satisfying field. It is hard to measure the ultimate effect of our care. One simply has to see hundreds and hundreds of such families to be persuaded that humane and skilled efforts in their behalf have brought about changes for the better, and this is particularly so for the children who have been neglected so long in our early rush to help their parents. While international meetings serve a splendid purpose of acquainting us with the contributions made by many diverse groups in many countries, I should warn you that it is not always possible to transfer a program from one country to the next, even when they are neighboring countries. Differences in professional attitudes, the law, and society's readiness for change, all govern and all are important. On the other hand, it would be quite wrong to assume that just because a piece of work was done here that it cannot be useful some-
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where else. Science would not have progressed if people had persisted in reinventing the wheel. Allow me to close by quoting the preamble to the Declaration of the Rights of the Child adopted by the United Nations in 1959. "Mankind owes the child the best it has to give." I wish you an exciting and memorable meeting in the cause of the abused child and his needy family.