- Email: [email protected]
Treating abused children
Child Abuse and Ncgkcr, Vol. 5. pp. 187Printed in the U.S.A. All rights reserved
192,
0145-2134/811020187-o6)o2.oo/0 ‘E 1981 Pergamon Rss
1981
copyrighl
Ltd.
TREATING ABUSED CHILDREN Some Clinical and Research Aspects of Work Carried Out by the National Advisory Centre of the National Society for the Prevention of Cruelty to Children in the United Kingdom JUDITH TROWELL Consultant Psychiatrist National Advisory Centre, N.S.P.C.C Denver House, London, N.W. 11
RAYMOND L. CASTLE Child Abuse Consultant Head of National Advisory and Consultancy Service, N.S.P.C.C. Abstract-A study of the initial phase of intensive work with families indicated that whilst outreach techniques had dramatically reduced physical injury there was long-term distortion in the child:s relationship with mother (parent) less amenable to change. The most recent phase of work has concentrated on direct treatment for the abused child, using a multidisciplinary team that includes a play specialist and child psychotherapist in addition to the social workers involved. Out of a total number of 66 children seen between April 1977 and December 1979 it was alarming to find that almost all were emotionally disturbed; even if the abuse did not reoccur they remained with considerable problems. The study highlights the degree of emotional disturbance suffered by these abused children and how they can be helped by focusing on their particular treatment needs. It is important to assess all children in the family situation and not to miss the quiet, depressed, withdrawn child who might not have been the subject of the initial referral. In some instances the needs of the child may outweigh those of the family and the focus of treatment must be on the child.
R&urn&En ttudiant la premiere phase du travail intensif effect& avec les familles (d’enfants battus), on a constate le phtnomene suivant: les techniques de soutien et de surveillance ont abouti en une remarquable diminution des s&ices physiques; cependant la relation de l’enfant avec la mere ou avec les parents reste perturb6e et n’est pas facilement ameliorable. Plus recemment, on a done concentm les efforts sur le traitement de l’enfant lui-m&me. Pour cela, on a adjoint aux travailleurs sociaux une equipe multidisciplinaire comprenant un specialiste du jeu et un psychotherapeute d’enfants. Entre avril 1977 et dtcembre 1979, ces equipes ont vu 66 enfants; presque tous ttaient affectivement perturb&, meme si les s&ices physiques ne s’etaient pas reproduits, ce qui est t&s preoccupant. Cette etude a mis particulibrement en evidence les troubles psychiques dont souffrent ces enfants et montre aussi qu’on peut les aider considerablement en s’occupant de leurs probltmes individuellement. De plus, il faut absolument Cvaluer la situation de tous les enfants dam ces familles si I’on veut eviter de passer a c&t de l’enfant deptime, silencieux et replie sur lui-meme, qui n’a pas fait l’objet du signalement initial. I1 est des cas ou les besoins de l’enfant sont plus pressants que ceux de la famille et ou I’individu qui necessite absolument le plus d’attention est l’enfant lui-meme.
THE NATIONAL SOCIETY for the Prevention of Cruelty to Children (N.S.P.C.C.) came into being in the latter half of the nineteenth century. It is quite unique within the field of child abuse in that as a voluntary agency it has power under a Royal Charter granted in 1895 by Queen Victoria to take action to “prevent the private and public wrongs of children,” and where necessary to bring these cases before the courts. From its earliest days it has been to the forefront in pioneering services for deprived and neglected children and pressing for legislation on their behalf. In 1968 it set up the first research unit in the United Kingdom which in the words of the then Director of the Society, the Reverend 187
I88
Judith Trowel1 and Raymond
L. Castle
Arthur Morton, “was intended to strive to create an informed body of opinion about the battered child syndrome and to devise methods of treatment” [I]. The unit quickly became established as the N.S.P.C.C. Battered Child Research Department and enlarged its function to become the National Advisory Centre in 1974. Primarily the agency has focused on two main areas, research into the problem in general and clinical research based on treatment services provided at the Centre including 24-hour availability of social worker staff. Its work over the last decade has led to a number of recommendations and has greatly influenced government thinking. Recommendations that have been implemented include the setting up of Child Abuse Registers and a number of special treatment units. Important research factors which have particular implications for treatment have been the large number of very young children involved in these cases, 36% being 1 year or under, with the greatest number falling into the 5 months or under category in previous studies [2]. Earlier studies strongly indicated “the younger the child, the more likely it is to be injured and the more serious the injury is likely to be” 131. In the initial study a reinjury rate of 60% was noted and in families where the first born had been injured there was a 13 to 1 chance that subsequent children would also suffer injury. The second phase of the department’s research entailed the provision of services to families in which child abuse occurred within a clearly defined geographical area of London. Referrals were taken at any hour of the day or night. In addition a psychiatrist and psychologist were available to provide ongoing assessments of both parents and children during the period of treatment . The project was also fortunate during the early stages of the treatment programme in having the services and assistance of Professor C. Henry Kempe, whose earlier work in this field had greatly inspired the team, together with his wife, Dr. Ruth Kempel a psychiatrist with considerable knowledge and experience of child abuse, both of whom spent a sabbatical year with the Society. In January 1970 all the cooperating agencies in the research area were notified that the department was ready to accept referrals and intake began. The following year saw the opening of the agency’s first therapeutic day nursery set up primarily to provide for the needs of both the children being referred and their siblings. From the outset regular team meetings were held each week followed at a later stage by unst~ctured meetings for the purpose of looking at emotional issues arising from team inte~ention. It was during this period of intensive and continuous interaction with the families (coupled with ongoing assessments and critical analysis of the progress achieved) that it began to emerge that whilst the outreach techniques had been of positive help in dramatically reducing physical injury, problems remained. “Our system of care helped to restore the child’s overall developmental status in most cases; however, personality tests on the children administered after a period of casework with their families, and nursery care for the children, revealed a long-term distortion in the child’s relationship with the mother that appeared to be less amenable to change” [ 11. In recommending future provision it was felt that whether the child is removed from home or remains with his family, “it is likely that specific and intensive therapeutic intervention will be required if there is to be any chance of ending this distortion.” It was also recognised that in some cases the abused child, whose needs must have priority over all other considerations, may have been better served by permanent removal and early placement in an environment more conducive to his nurturing. In this connection many factors also led to firm support for the findings of Martin who points out that: in addition to the primary goal of preventing abuse from recurring there is another important goal which shonfd have priority, and that is to prevent the continuation of the whole abusive style of parenting. The wounds of the child are not only secondary to the physical trauma per se, but stem just as importantly from the overall type of parenting to which he has been exposed [4].
189
Treating abused children
Following these considerations decisions were made by the Head of Department, in consultation with the team, to attempt to focus much more on the specific treatment needs of the children.
TREATING
ABUSED CHILDREN
AT THE CENTRE
Initially the Centre offered no treatment specifically for children, there was a massive investment in mothering, and working with the parents. This reduced the reinjury rate effectively, however, problems remained. The first was that however intense and lengthy the nurturing, families found it difficult to move on and stand on their own feet. The second was that children were found to have problems in their own right; they were unable to relate to their peers, had difficulty learning in school and there was antisocial behaviour out of school. It seemed that parenting the parents was not enough, it did not enable the parents to then function effectively as parents of emotionally disturbed children, which is not surprising. Working with the children has indirectly influenced the work with the parents. Once workers begin to see the needs of the children and begin to understand-in an experiential rather than theoretical way-emotional and social development, it altered their perspectives and attitudes when working with adults who are so often children locked in an adult body. This enhanced awareness has been of inestimable benefit to all the workers in their handling of cases. It has also made difficult decisions clearer and had broadened and deepened the understanding arrived at in case discussion. The direct treatment process began in phase two when a play specialist joined the Centre. Thinking about the work with children, the agency was used to reaching out to parents and the play specialist started by reaching out in the same way. This gave rise to several problems. Many parents in fact were unwilling to accept help for their children; they either refused to let the specialist visit or, after giving verbal consent, were out or unavailable. Another difficulty was that the mother (parents) were so deprived, depressed and egocentric that there was no emotional space for the child. The mothers dominated the specialist and demanded her attention for themselves. (This has been repeated with the next play specialist so it was not a matter of personality.) The other major difficulty was the level of disturbance of some of the children. As a group they were more disturbed than children seen in any other work setting, and it was clear that some were so damaged that a play specialist was not equipped to work at their level. A high degree of sophistication and training was required, also a greater depth of trained emotional resources within the therapist in order to be able to cope with the demands of the work (perhaps it is not surprising that the parents themselves could not help their children). One way of trying to resolve the conflict of the needs of the mother/parent-which was tried and continues now with some cases-was to arrange for the play specialist to visit at the same time as the social worker so that they could each work separately with their client and also have some joint sessions. In some cases this has been successful but there have been problems. These have mainly been due to an inability to provide consistency and reliability, problems over setting limits and the inadequate space. Because of this there was an increasing desire to develop the Centre as a place for therapy, and the play specialist has tried to pull back and encourage the families to come to the Centre bringing the child. It is clear that where this is possible the benefit for the child is greatly enhanced. However, the Centre is not central to its catchment area and the public transport is very poor so that this is not an ideal answer. Phase three began in June 1978, with the recruitment of a child psychotherapist to complement the work of the play specialist. Looking at families, one helpful way of categorizing them is into stable, unstable and chaotic. A clinic population consists of stable and unstable families. At the Centre they are either unstable or chaotic. The unstable tend to be self-referrals or referred by a member of the primary health
190
Judith Trowel1 and Raymond
L. Castle
care team, and they have some organization and some motivation. The chaotic families lack organization and lack motivation; they are usually sent rather than coming to seek help. There is then the unresolvable conflict of the dual role of caregiver and authority figures, as it is usually these chaotic families where court action has taken or may take place. Work with the unstable family can often proceed steadily. They accept an assessment phase and although ambivalent can usually accept and may even welcome help. They can respond to and use marital, family or individual work. They are not totally overwhelmed and helpless and do not completely consume and paralyse the workers, so that it is possible to cope. It appears that we have been able to improve the functioning, underst~ding and emotions well-being of these families and children. In order to work with the very disturbed, deprived families, we have had to try various methods, combinations and locations. We have learnt that time and intensive work with the parents or families is needed, usually for a minimum of a year. By this time their own needs have begun to be met and they can begin to look at the needs of their children objectively. No longer so deprived, they do not need to envy or sabotage their child’s chance of receiving help. However, this means that the Centre is left with the problem of embarking on therapy for the child when the parents are beginning to stand on their own feet. This is not meant to sound complacent, there are still many families where we fail, where we have to wonder if change and emotional growth are possible. There are also parents that can only be described as reminding one of long-stay psychiatric patients. They, like those patients, can only be helped over the crisis and sent home again. A total of 66 children between the ages of 6 months and 16 years were seen between April 1977 and December 1979. It is worth noting that there was a predominance of male children in total (38 out of 66) and more males amongst the abused group (20 out of 34). Using broad categories, it is alarming to find that almost all the abused children were emotionally disturbed and in need of some form of help, so that even if the abuse does not recur they remain with considerable problems. There was a small but impo~ant group that were so disturbed that without help one could confidently predict major psychiatric illness as they grow up. About half of the abused children’s siblings had emotional difficulties needing help and it was noted that in this group there was one profoundly disturbed child (see Table 1). In order to assist these families a variety of treatment methods were employed including psychotherapy, marital and family therapy and play therapy. Removal from the home and placement in care was part of the intervention with about a quarter of the children although very few were ultimately placed in care long-term. Is this a reflection of what is best for the children and the progress the families made; or more a reflection on the environment in which the child will grow up if it is removed from home, i.e., the quality of children’s homes and foster placements? Some of the problems encountered are illustrated in the following description of several children’s case histories: Psychotic. Freddy was a psychotic boy, mother referred herself. There were serious marital problems and major personal problems for both parents. Freddy had hallucinations and delusions. He was a highly intelligent 3%-year-old. They had to be referred to another agency for family and marital help and therapy for Freddy-at that time the Centre had no suitable resources. (He is still being seen 2 years later.)
Table 1 Emotional Category Very disturbed Disturbed Within normal limits
Number of Children 7 39 20
Number of Abused Children 6 25 3
Number of Siblings 1 14 17
Treating abused children
191
Borderline Psychotic. Ray, 4 years, was a very disturbed child with marked autistic features. He spent long periods just screaming, he had no speech, frequently vomited, had rituals and panic attacks, showed gaze aversion and was withdrawn, isolated and uncontactable. We sought a place at an autistic unit but it was geographically impossible, and then the parents refused as they felt Ray had no problems! Work with the parents meant that almost a year later Ray started having onceweekly psychotherapy at the Centre. He improved to such an extent that he was able to attend a normal primary school although still withdrawn and very anxious. Failure ofPrimary Mothering. Molly, 4% years, had experienced almost total deprivation. She had spent only 4% months with her mother in short stays throughout her life and the rest of the time had been moved from one caretaker or institution to another. Settled in a children’s home she was able to receive once-weekly psychotherapy and began to make sense of her confusion and face the anger, emptiness, hopelessness and despair she felt about her experiences. It is hoped she will be able to ultimately live with her father who has been helped to renew his involvement with her. Neurotic. The majority of children seen fall within this category. Lesley received play therapy. From the assessments and the final review the following is noted: in the presenting interview it emerged that she was the bad, impossible child in a family with an angelic, good younger boy. Her parents were. both very immature and the mother very egocentric. There were major marital problems and both parents had very traumatic backgrounds. Lesley was enuretic-at home only, never when out, and her nursery class were anxious about her behaviour. Lesley was very jealous of her younger brother, attacking him verbally and physically so that they could not safely be left alone together. During Lesley’s assessment the following account reveals her conflicts and confusion and her attempt to deal with these. “A stocky, sturdy child, she related easily and soon had me organised. She issued her orders clearly and was not easily diverted. However, she was unable to play and her activity consisted of moving from toy to toy once I had placed it where I had been told. During all this time she talked well; she was an articulate, intelligent child who used some surprisingly mature words and sentence structure. School was horrible, she wished she could be a baby like Gordon and stay home with Mummy. Gordon was horrible, he spoilt evetything. She talked quite openly about Gordon wetting his knickers’ and Mummy sorted him out, and so she did the same. When she was dry Mummy was busy with Gordon, when she was wet Mummy was with her. She became very anxious when a paper streamer was moving on its own and thought it was magic, but then she got very frightened about it. “She began talking of monsters that came in the night. When she was in bed at night she got very frightened again. In the daytime it was all right and they never went to school. It was just at home, mostly at night. When she got frightened she went to Mummy but Mummy got cross.” Lesley was reassessed at the termination of her weekly play therapy and some of the impressions and material is reported. “Her appearance had changed strikingly. She was bigger, taller, but it was more her attitude to me. She was pleasant and later quite friendly, but initially was a little wary and guarded. This was in marked contrast with the last time when she immediately interacted in a very intense, positive way with powerful, coquettish seduction. Now she was much more a 5-year-old girl meeting someone she was not quite sure about. “Wesley went on to tell me that Gordon really was not too bad now; she quite liked him at times. Sometimes he was nice, sometimes not, and that Mummy was quite nice now too. Lesley played quietly for a while and then looked at the windows. ‘Do you know,’ she said, ‘there used to be monsters trying to get in but they have gone away. I’ve almost forgotten all about them.’ I wondered if she was a little bit afraid they might come back now she was stopping coming here. She looked and then said, ‘I don’t think so.’ It was time to go. She wrote down her phone number in case 1 wanted it. As she left me she took a pencil from her bag and left it, ‘for the other children to use.“’
SUMMARY
AND CONCLUSIONS
The most striking conclusion drawn from our work with these families is the degree of disturbance shown by the children involved. However, despite this our studies indicate that we have been able to help them and the authors feel that it is most important that children with these kind of problems are not ignored because their difficulties are felt to be insurmountable. When assessing families of this nature it is important to see all the children and not to miss the quiet, withdrawn, depressed child who might not have been the subject of the initial referral. When looking at the resources needed, a number of factors are clearly indicated, for example, there is a need for play therapists to train others in the community in order to ensure better communication with children and to teach them the importance of play with children. Experience
I92
Judith Trowel1 and Raymond
L. Castle
suggests that professionals are not getting adequate training in this particular area and in any case the recent financial recession does highlight the need to use more volunteers. The authors feel that there should be neutral centres where parents experiencing difficulties with their children can go for support. Again this might well be an area in the initial stages in which adequately trained volunteers can be of help, giving support and if necessary guiding the parents in obtaining skilled professional treatment. We cannot leave the subject of treatment without noting the problems presented in these families to members of the helping professions who might have a dual role, i.e., that of protecting the child against abuse and at the same time treating the family. In some instances the needs of the child may outweigh those of the family and we must ensure that the focus of treatment is on the child. Many of these children have survived physically, but as has been shown, have suffered severe emotional damage. Essentially, if we are to break this chain of deprivation our services should be aimed at helping the children of today, who are the potential parents of tomorrow, to be able to communicate with, and understand the needs of, their own children.
REFERENCES I.
2. 3. 4.
N.S.P.C.C., BA’lTERED CHILD RESEARCH DEPARTMENT, At Risk. Routledge and Kegan Paul, London (1976). SKINNER, A.E. and CASTLE, R.L., 78 Battered Children, a Retrospective Study. N.S.P.C.C., London. CASTLE, R.L. and KERR, M.A., A Study of Suspected Child Abuse. N.S.P.C.C., London (1972). MARTIN, HAROLD, A child-oriented approach to prevention of abuse. In: Child Abuse, Prediction, Prevention and Follow-up, A.W. Franklin (Ed.) Churchill Livingstone, Edinburgh (1977) pp. 9-20.
192,
0145-2134/811020187-o6)o2.oo/0 ‘E 1981 Pergamon Rss
1981
copyrighl
Ltd.
TREATING ABUSED CHILDREN Some Clinical and Research Aspects of Work Carried Out by the National Advisory Centre of the National Society for the Prevention of Cruelty to Children in the United Kingdom JUDITH TROWELL Consultant Psychiatrist National Advisory Centre, N.S.P.C.C Denver House, London, N.W. 11
RAYMOND L. CASTLE Child Abuse Consultant Head of National Advisory and Consultancy Service, N.S.P.C.C. Abstract-A study of the initial phase of intensive work with families indicated that whilst outreach techniques had dramatically reduced physical injury there was long-term distortion in the child:s relationship with mother (parent) less amenable to change. The most recent phase of work has concentrated on direct treatment for the abused child, using a multidisciplinary team that includes a play specialist and child psychotherapist in addition to the social workers involved. Out of a total number of 66 children seen between April 1977 and December 1979 it was alarming to find that almost all were emotionally disturbed; even if the abuse did not reoccur they remained with considerable problems. The study highlights the degree of emotional disturbance suffered by these abused children and how they can be helped by focusing on their particular treatment needs. It is important to assess all children in the family situation and not to miss the quiet, depressed, withdrawn child who might not have been the subject of the initial referral. In some instances the needs of the child may outweigh those of the family and the focus of treatment must be on the child.
R&urn&En ttudiant la premiere phase du travail intensif effect& avec les familles (d’enfants battus), on a constate le phtnomene suivant: les techniques de soutien et de surveillance ont abouti en une remarquable diminution des s&ices physiques; cependant la relation de l’enfant avec la mere ou avec les parents reste perturb6e et n’est pas facilement ameliorable. Plus recemment, on a done concentm les efforts sur le traitement de l’enfant lui-m&me. Pour cela, on a adjoint aux travailleurs sociaux une equipe multidisciplinaire comprenant un specialiste du jeu et un psychotherapeute d’enfants. Entre avril 1977 et dtcembre 1979, ces equipes ont vu 66 enfants; presque tous ttaient affectivement perturb&, meme si les s&ices physiques ne s’etaient pas reproduits, ce qui est t&s preoccupant. Cette etude a mis particulibrement en evidence les troubles psychiques dont souffrent ces enfants et montre aussi qu’on peut les aider considerablement en s’occupant de leurs probltmes individuellement. De plus, il faut absolument Cvaluer la situation de tous les enfants dam ces familles si I’on veut eviter de passer a c&t de l’enfant deptime, silencieux et replie sur lui-meme, qui n’a pas fait l’objet du signalement initial. I1 est des cas ou les besoins de l’enfant sont plus pressants que ceux de la famille et ou I’individu qui necessite absolument le plus d’attention est l’enfant lui-meme.
THE NATIONAL SOCIETY for the Prevention of Cruelty to Children (N.S.P.C.C.) came into being in the latter half of the nineteenth century. It is quite unique within the field of child abuse in that as a voluntary agency it has power under a Royal Charter granted in 1895 by Queen Victoria to take action to “prevent the private and public wrongs of children,” and where necessary to bring these cases before the courts. From its earliest days it has been to the forefront in pioneering services for deprived and neglected children and pressing for legislation on their behalf. In 1968 it set up the first research unit in the United Kingdom which in the words of the then Director of the Society, the Reverend 187
I88
Judith Trowel1 and Raymond
L. Castle
Arthur Morton, “was intended to strive to create an informed body of opinion about the battered child syndrome and to devise methods of treatment” [I]. The unit quickly became established as the N.S.P.C.C. Battered Child Research Department and enlarged its function to become the National Advisory Centre in 1974. Primarily the agency has focused on two main areas, research into the problem in general and clinical research based on treatment services provided at the Centre including 24-hour availability of social worker staff. Its work over the last decade has led to a number of recommendations and has greatly influenced government thinking. Recommendations that have been implemented include the setting up of Child Abuse Registers and a number of special treatment units. Important research factors which have particular implications for treatment have been the large number of very young children involved in these cases, 36% being 1 year or under, with the greatest number falling into the 5 months or under category in previous studies [2]. Earlier studies strongly indicated “the younger the child, the more likely it is to be injured and the more serious the injury is likely to be” 131. In the initial study a reinjury rate of 60% was noted and in families where the first born had been injured there was a 13 to 1 chance that subsequent children would also suffer injury. The second phase of the department’s research entailed the provision of services to families in which child abuse occurred within a clearly defined geographical area of London. Referrals were taken at any hour of the day or night. In addition a psychiatrist and psychologist were available to provide ongoing assessments of both parents and children during the period of treatment . The project was also fortunate during the early stages of the treatment programme in having the services and assistance of Professor C. Henry Kempe, whose earlier work in this field had greatly inspired the team, together with his wife, Dr. Ruth Kempel a psychiatrist with considerable knowledge and experience of child abuse, both of whom spent a sabbatical year with the Society. In January 1970 all the cooperating agencies in the research area were notified that the department was ready to accept referrals and intake began. The following year saw the opening of the agency’s first therapeutic day nursery set up primarily to provide for the needs of both the children being referred and their siblings. From the outset regular team meetings were held each week followed at a later stage by unst~ctured meetings for the purpose of looking at emotional issues arising from team inte~ention. It was during this period of intensive and continuous interaction with the families (coupled with ongoing assessments and critical analysis of the progress achieved) that it began to emerge that whilst the outreach techniques had been of positive help in dramatically reducing physical injury, problems remained. “Our system of care helped to restore the child’s overall developmental status in most cases; however, personality tests on the children administered after a period of casework with their families, and nursery care for the children, revealed a long-term distortion in the child’s relationship with the mother that appeared to be less amenable to change” [ 11. In recommending future provision it was felt that whether the child is removed from home or remains with his family, “it is likely that specific and intensive therapeutic intervention will be required if there is to be any chance of ending this distortion.” It was also recognised that in some cases the abused child, whose needs must have priority over all other considerations, may have been better served by permanent removal and early placement in an environment more conducive to his nurturing. In this connection many factors also led to firm support for the findings of Martin who points out that: in addition to the primary goal of preventing abuse from recurring there is another important goal which shonfd have priority, and that is to prevent the continuation of the whole abusive style of parenting. The wounds of the child are not only secondary to the physical trauma per se, but stem just as importantly from the overall type of parenting to which he has been exposed [4].
189
Treating abused children
Following these considerations decisions were made by the Head of Department, in consultation with the team, to attempt to focus much more on the specific treatment needs of the children.
TREATING
ABUSED CHILDREN
AT THE CENTRE
Initially the Centre offered no treatment specifically for children, there was a massive investment in mothering, and working with the parents. This reduced the reinjury rate effectively, however, problems remained. The first was that however intense and lengthy the nurturing, families found it difficult to move on and stand on their own feet. The second was that children were found to have problems in their own right; they were unable to relate to their peers, had difficulty learning in school and there was antisocial behaviour out of school. It seemed that parenting the parents was not enough, it did not enable the parents to then function effectively as parents of emotionally disturbed children, which is not surprising. Working with the children has indirectly influenced the work with the parents. Once workers begin to see the needs of the children and begin to understand-in an experiential rather than theoretical way-emotional and social development, it altered their perspectives and attitudes when working with adults who are so often children locked in an adult body. This enhanced awareness has been of inestimable benefit to all the workers in their handling of cases. It has also made difficult decisions clearer and had broadened and deepened the understanding arrived at in case discussion. The direct treatment process began in phase two when a play specialist joined the Centre. Thinking about the work with children, the agency was used to reaching out to parents and the play specialist started by reaching out in the same way. This gave rise to several problems. Many parents in fact were unwilling to accept help for their children; they either refused to let the specialist visit or, after giving verbal consent, were out or unavailable. Another difficulty was that the mother (parents) were so deprived, depressed and egocentric that there was no emotional space for the child. The mothers dominated the specialist and demanded her attention for themselves. (This has been repeated with the next play specialist so it was not a matter of personality.) The other major difficulty was the level of disturbance of some of the children. As a group they were more disturbed than children seen in any other work setting, and it was clear that some were so damaged that a play specialist was not equipped to work at their level. A high degree of sophistication and training was required, also a greater depth of trained emotional resources within the therapist in order to be able to cope with the demands of the work (perhaps it is not surprising that the parents themselves could not help their children). One way of trying to resolve the conflict of the needs of the mother/parent-which was tried and continues now with some cases-was to arrange for the play specialist to visit at the same time as the social worker so that they could each work separately with their client and also have some joint sessions. In some cases this has been successful but there have been problems. These have mainly been due to an inability to provide consistency and reliability, problems over setting limits and the inadequate space. Because of this there was an increasing desire to develop the Centre as a place for therapy, and the play specialist has tried to pull back and encourage the families to come to the Centre bringing the child. It is clear that where this is possible the benefit for the child is greatly enhanced. However, the Centre is not central to its catchment area and the public transport is very poor so that this is not an ideal answer. Phase three began in June 1978, with the recruitment of a child psychotherapist to complement the work of the play specialist. Looking at families, one helpful way of categorizing them is into stable, unstable and chaotic. A clinic population consists of stable and unstable families. At the Centre they are either unstable or chaotic. The unstable tend to be self-referrals or referred by a member of the primary health
190
Judith Trowel1 and Raymond
L. Castle
care team, and they have some organization and some motivation. The chaotic families lack organization and lack motivation; they are usually sent rather than coming to seek help. There is then the unresolvable conflict of the dual role of caregiver and authority figures, as it is usually these chaotic families where court action has taken or may take place. Work with the unstable family can often proceed steadily. They accept an assessment phase and although ambivalent can usually accept and may even welcome help. They can respond to and use marital, family or individual work. They are not totally overwhelmed and helpless and do not completely consume and paralyse the workers, so that it is possible to cope. It appears that we have been able to improve the functioning, underst~ding and emotions well-being of these families and children. In order to work with the very disturbed, deprived families, we have had to try various methods, combinations and locations. We have learnt that time and intensive work with the parents or families is needed, usually for a minimum of a year. By this time their own needs have begun to be met and they can begin to look at the needs of their children objectively. No longer so deprived, they do not need to envy or sabotage their child’s chance of receiving help. However, this means that the Centre is left with the problem of embarking on therapy for the child when the parents are beginning to stand on their own feet. This is not meant to sound complacent, there are still many families where we fail, where we have to wonder if change and emotional growth are possible. There are also parents that can only be described as reminding one of long-stay psychiatric patients. They, like those patients, can only be helped over the crisis and sent home again. A total of 66 children between the ages of 6 months and 16 years were seen between April 1977 and December 1979. It is worth noting that there was a predominance of male children in total (38 out of 66) and more males amongst the abused group (20 out of 34). Using broad categories, it is alarming to find that almost all the abused children were emotionally disturbed and in need of some form of help, so that even if the abuse does not recur they remain with considerable problems. There was a small but impo~ant group that were so disturbed that without help one could confidently predict major psychiatric illness as they grow up. About half of the abused children’s siblings had emotional difficulties needing help and it was noted that in this group there was one profoundly disturbed child (see Table 1). In order to assist these families a variety of treatment methods were employed including psychotherapy, marital and family therapy and play therapy. Removal from the home and placement in care was part of the intervention with about a quarter of the children although very few were ultimately placed in care long-term. Is this a reflection of what is best for the children and the progress the families made; or more a reflection on the environment in which the child will grow up if it is removed from home, i.e., the quality of children’s homes and foster placements? Some of the problems encountered are illustrated in the following description of several children’s case histories: Psychotic. Freddy was a psychotic boy, mother referred herself. There were serious marital problems and major personal problems for both parents. Freddy had hallucinations and delusions. He was a highly intelligent 3%-year-old. They had to be referred to another agency for family and marital help and therapy for Freddy-at that time the Centre had no suitable resources. (He is still being seen 2 years later.)
Table 1 Emotional Category Very disturbed Disturbed Within normal limits
Number of Children 7 39 20
Number of Abused Children 6 25 3
Number of Siblings 1 14 17
Treating abused children
191
Borderline Psychotic. Ray, 4 years, was a very disturbed child with marked autistic features. He spent long periods just screaming, he had no speech, frequently vomited, had rituals and panic attacks, showed gaze aversion and was withdrawn, isolated and uncontactable. We sought a place at an autistic unit but it was geographically impossible, and then the parents refused as they felt Ray had no problems! Work with the parents meant that almost a year later Ray started having onceweekly psychotherapy at the Centre. He improved to such an extent that he was able to attend a normal primary school although still withdrawn and very anxious. Failure ofPrimary Mothering. Molly, 4% years, had experienced almost total deprivation. She had spent only 4% months with her mother in short stays throughout her life and the rest of the time had been moved from one caretaker or institution to another. Settled in a children’s home she was able to receive once-weekly psychotherapy and began to make sense of her confusion and face the anger, emptiness, hopelessness and despair she felt about her experiences. It is hoped she will be able to ultimately live with her father who has been helped to renew his involvement with her. Neurotic. The majority of children seen fall within this category. Lesley received play therapy. From the assessments and the final review the following is noted: in the presenting interview it emerged that she was the bad, impossible child in a family with an angelic, good younger boy. Her parents were. both very immature and the mother very egocentric. There were major marital problems and both parents had very traumatic backgrounds. Lesley was enuretic-at home only, never when out, and her nursery class were anxious about her behaviour. Lesley was very jealous of her younger brother, attacking him verbally and physically so that they could not safely be left alone together. During Lesley’s assessment the following account reveals her conflicts and confusion and her attempt to deal with these. “A stocky, sturdy child, she related easily and soon had me organised. She issued her orders clearly and was not easily diverted. However, she was unable to play and her activity consisted of moving from toy to toy once I had placed it where I had been told. During all this time she talked well; she was an articulate, intelligent child who used some surprisingly mature words and sentence structure. School was horrible, she wished she could be a baby like Gordon and stay home with Mummy. Gordon was horrible, he spoilt evetything. She talked quite openly about Gordon wetting his knickers’ and Mummy sorted him out, and so she did the same. When she was dry Mummy was busy with Gordon, when she was wet Mummy was with her. She became very anxious when a paper streamer was moving on its own and thought it was magic, but then she got very frightened about it. “She began talking of monsters that came in the night. When she was in bed at night she got very frightened again. In the daytime it was all right and they never went to school. It was just at home, mostly at night. When she got frightened she went to Mummy but Mummy got cross.” Lesley was reassessed at the termination of her weekly play therapy and some of the impressions and material is reported. “Her appearance had changed strikingly. She was bigger, taller, but it was more her attitude to me. She was pleasant and later quite friendly, but initially was a little wary and guarded. This was in marked contrast with the last time when she immediately interacted in a very intense, positive way with powerful, coquettish seduction. Now she was much more a 5-year-old girl meeting someone she was not quite sure about. “Wesley went on to tell me that Gordon really was not too bad now; she quite liked him at times. Sometimes he was nice, sometimes not, and that Mummy was quite nice now too. Lesley played quietly for a while and then looked at the windows. ‘Do you know,’ she said, ‘there used to be monsters trying to get in but they have gone away. I’ve almost forgotten all about them.’ I wondered if she was a little bit afraid they might come back now she was stopping coming here. She looked and then said, ‘I don’t think so.’ It was time to go. She wrote down her phone number in case 1 wanted it. As she left me she took a pencil from her bag and left it, ‘for the other children to use.“’
SUMMARY
AND CONCLUSIONS
The most striking conclusion drawn from our work with these families is the degree of disturbance shown by the children involved. However, despite this our studies indicate that we have been able to help them and the authors feel that it is most important that children with these kind of problems are not ignored because their difficulties are felt to be insurmountable. When assessing families of this nature it is important to see all the children and not to miss the quiet, withdrawn, depressed child who might not have been the subject of the initial referral. When looking at the resources needed, a number of factors are clearly indicated, for example, there is a need for play therapists to train others in the community in order to ensure better communication with children and to teach them the importance of play with children. Experience
I92
Judith Trowel1 and Raymond
L. Castle
suggests that professionals are not getting adequate training in this particular area and in any case the recent financial recession does highlight the need to use more volunteers. The authors feel that there should be neutral centres where parents experiencing difficulties with their children can go for support. Again this might well be an area in the initial stages in which adequately trained volunteers can be of help, giving support and if necessary guiding the parents in obtaining skilled professional treatment. We cannot leave the subject of treatment without noting the problems presented in these families to members of the helping professions who might have a dual role, i.e., that of protecting the child against abuse and at the same time treating the family. In some instances the needs of the child may outweigh those of the family and we must ensure that the focus of treatment is on the child. Many of these children have survived physically, but as has been shown, have suffered severe emotional damage. Essentially, if we are to break this chain of deprivation our services should be aimed at helping the children of today, who are the potential parents of tomorrow, to be able to communicate with, and understand the needs of, their own children.
REFERENCES I.
2. 3. 4.
N.S.P.C.C., BA’lTERED CHILD RESEARCH DEPARTMENT, At Risk. Routledge and Kegan Paul, London (1976). SKINNER, A.E. and CASTLE, R.L., 78 Battered Children, a Retrospective Study. N.S.P.C.C., London. CASTLE, R.L. and KERR, M.A., A Study of Suspected Child Abuse. N.S.P.C.C., London (1972). MARTIN, HAROLD, A child-oriented approach to prevention of abuse. In: Child Abuse, Prediction, Prevention and Follow-up, A.W. Franklin (Ed.) Churchill Livingstone, Edinburgh (1977) pp. 9-20.