There I was confronted by a startling finding. An examination of the Reader's Guide to Periodical Literature and the Social Science and Humanities Index showed that absolutely no articles on “child abuse” (regardless of what term one used) had been published before 1962.
Barbara Nelson, Making an Issue of Child Abuse
In 1946, a distinguished radiologist, John Caffey, exploring the use of X-rays with infants and young children, reported puzzling symptoms in children who had been admitted to the hospital for treatment of subdural hematoma (pooling of blood under the skull). Caffey's X-rays revealed that, in addition to the subdural hematoma, the children had multiple long-bone fractures in their arms and legs. Altogether in the six children studied he found twenty-three long bone fractures and four contusions (injuries to subsurface tissues where the skin is not broken). It was a puzzling phenomenon. What had caused such fractures and tissue injury? By this time, rickets and bone syphilis had become rare diseases. The most likely explanation was trauma of some sort (i.e., an externally caused injury), resulting perhaps from an accident or fall. Caffey knew that trauma did indeed produce such skeletal changes in infants and young children (Caffey and Silverman, 1945). Being a radiologist who did not have direct contact with the patient or the family, Caffey had no reason to suspect trauma from assault. Were the fractures related somehow to the subdural hematoma? Might the two be symptoms of some new children's disease? Caffey (1946) duly reported the symptoms in the American Journal of Roentgenology, the professional journal for research on the medical applications of X-ray technology.
Table 5.1 Emergence of medical evidence of Physical Child Abuse
During the decade following Caffey's report, other radiologists and physicians reported similar findings. Lis and Frauenberger (1950) in the United States, Smith (1950) in Canada, Marquezy, Bach, and Blondeau (1952), and Marie (1954) in France all reported cases similar to that reported by Caffey (see Table 5.1). In 1953, Silverman reported three cases of infants with symptoms similar to those observed by Caffey. Silverman, however, concluded that the bone changes observed with X-rays were obviously the result of traumatic injuries accumulated over time. He urged physicians to obtain reliable patient histories so that the etiology of these injuries might be better understood. However, Silverman cautioned that physicians not alarm parents with feelings of guilt by asking too many questions or appearing too suspicious about the parents’ actions and intentions.1
Such cases continued to accumulate. In 1955, Woolley and Evans published a review of reports of infants coming into medical facilities with serious physical injuries that were “unaccompanied by readily volunteered and adequate account of injury.” Woolley and Evans identified two syndromes of serious physical injury of unknown origin in infants: (1) subdural hematoma with multiple long bone fractures, and (2) traumatic periostitis (inflammation of bone tissue). No evidence existed to suggest that these syndromes were due either to a disease process or to an unusual bone fragility in the affected infants. In their search for an explanation, the researchers examined the infants’ family backgrounds. Their study of twelve infants “presenting multiple areas of bone damage which appeared to have accrued over an extended period of time and for which no easily elicited story of injury was available,” revealed that the infants “came invariably from unstable households with a high incidence of neurotic or frankly psychotic behavior on the part of at least one adult” (Woolley and Evans, 1955, 542-543).
Woolley and Evans published their work in the Journal of the American Medical Association where “it reached the radio, television, and press and electrified the public” (Radbill, 1974, 18). The study contributed to the emerging concern of the U.S. Children's Bureau with child abuse reporting legislation. It laid the foundation for the understanding of “battered children” developed by Kempe and his colleagues, six years later. Summarizing the work of the radiologists, Costin (1992, 194) wrote, “The long dormancy of child abuse as a major professional and public issue might have continued had it not been interrupted by new knowledge and the skills of radiologists.”
The Battered Child Syndrome
In 1962, C. Henry Kempe and his colleagues surveyed eighty-eight hospitals in which they identified 302 children who had been “battered.” Kempe sharpened the focus on what was clearly emerging as “child abuse” by defining the “battered child syndrome” as a child or infant less than three years old who presented the physician with unusual injuries, broken bones, or cranial injuries that were inadequately or inconsistently explained. When published, this survey, which graphically catalogued brutality to young children many of whom suffered multiple injuries, ignited a broad-based national effort to find ways to protect children (Gil, 1970; Nagi, 1977). Specifically, it led to calls for implementation of mandated child abuse reporting systems, to ensure that whenever a “battered child” was even suspected, the case would be reported and measures taken to protect the child. Reporting was viewed as the first step in providing protection to the suspected battered child.
During this period (early 1960s), the Children's Bureau, responding to physicians’ concerns, began developing a model reporting law that mandated that physicians report cases of suspected child battering. By 1963 thirteen states had adopted mandatory reporting laws. Bagley and King (1990, 33) report, that “by 1966 all fifty American states had passed new legislation regulating child abuse.” Shortly after, every state had developed much broader definitions of abuse than the “battered child syndrome,” all of which mandated reporting. In 1986, every state but one required reporting of neglect, and forty-one states made explicit reference to reporting of emotional or psychological abuse (Hutchison, 1993).
The early intent had been to limit mandated reporting to physicians only. However, the American Medical Association, which objected to being singled out, urged that mandated reporting be required of other professionals as well. As a result, no state mandatory reporting laws limit reporters solely to medical professionals, but include teachers, nurses, counselors, and the general public.
Table 5.2 Reports of Child Abuse
The Avalanche of Child Abuse Reports
The state mandated reporting laws resulted in an immediate and meteoric rise in child abuse reports across the United States. Florida, for example, saw the number of abuse reports increase in one year from 17 (1970) to 19,120 (1971).2 In 1962, when Kempe and his colleagues published their report, “The Battered Child Syndrome,” there had been about 10,000 child abuse reports (see Table 5.2). By 1976, the number of child abuse reports had risen to more than 669,000, and by 1978, to 836,000. By 1992, according to the National Committee for the Prevention of Child Abuse (McCurdy and Daro, 1993), there were almost three million reports of child abuse nationwide, including 1,261 child-abuse-related fatalities.
Historical Precedents for Protective Services
To understand the impact of child abuse reports on child welfare agencies, it is important to understand the perceived mission of child welfare agencies prior to this time. Public child welfare agencies’ responsibility to protect children from harm and cruelty began well before the turn of the century (Antler and Antler, 1979). In 1874, when eight-year-old Mary Ellen was brought before a New York court wrapped in a blanket, the judge turned his head away rather than view the child's tortured body. The judge removed the child from her guardian and placed her in the custody of the American Society for the Protection of Animals, there being no organization at the time to protect children. The case led to the founding that year of the New York Society for the Prevention of Cruelty to Children. Although child protection in North America began with a narrow focus on cases of physical cruelty, it soon broadened its focus to include physical neglect, abandonment, and child welfare in general (Antler, 1981; Lynch, 1985). Gradually child abuse became only one of many concerns of the public child welfare system.
Although cases of severe physical abuse continued to arouse public outrage and so provide substantial support for the efforts of the children's aid societies, the main focus of the societies was, in fact, the thousands of abandoned and orphaned children. By the early twentieth century, severe physical abuse had become a minor concern, because it represented such a small part of the problems that came to the agencies’ attention (Costin, 1992). As Kadushin observed, the absorption of protective services into public child welfare resulted in a “decline of interest [in protective services] between 1920 and the 1960s. Child maltreatment as a social concern dropped out of the public agenda” (Kadushin and Martin, 1988, 222-223). Thus, while child abuse was “discovered” in 1874 and the child protective movement spread rapidly, it just as quickly receded. Costin (1992, 177) observed, “By 1910, more than 200 societies [to prevent child cruelty] existed in the United States. Twenty years later, however, the anticruelty movement had lost momentum, changed in purpose, and become much less visible. The social work literature of the early 1900s through the 1950s reflects a sharply diminished discussion of child abuse as a condition requiring intervention by community agents.”
Indeed, the child welfare studies by Brace (1880), Theis (1924), and Trotzkey (1930) focused on the relative merits of foster care and institutional care. No major studies on child abuse appeared during this period. As for the calls for research in the 1950s, little mention was made of child abuse (Dybwad, 1949; Kahn, 1956; Norris and Wallace, 1965).
Part of the problem had to do with proving that children's injuries had been inflicted by the parents, who often could provide a variety of plausible explanations for an injury. The only person who could contradict them were the children, who were generally regarded as neither credible nor reliable. As well, even in the face of the most severe brutality, the child would often cling to whatever love or bond existed with the parent (Elmer, 1967). Social workers lacked the tools to determine when the bruises and severe injuries were accidental and when they were intentionally inflicted by an angry parent.
Thus, by the time the Social Security Act was passed in 1935, the child welfare system had been defined as being for the “protection and care of homeless, dependent and neglected children and children in danger of becoming delinquent.” Concern with the issue of physical child abuse had receded. For the next thirty years child welfare services went about providing foster care along with an assortment of other services (including diminishing institutional care) to needy children and families.
The decades from 1950 to 1970, which saw the rapid growth of the public child welfare system, were characterized by an effort to construct an empirical knowledge base that would guide and inform the child welfare system. Alfred Kadushin synthesized the results of the emerging research into a theoretical framework that firmly established the field. The child welfare system, according to Kadushin, was to help parents meet their child-rearing responsibilities through the provision of supportive and supplementary services or, when that was not possible, to remove the children from their parents and provide substitute care. Child abuse was not central to the perspective, but regarded as an “interaction event” that derived from problems in the parent-child relationship (Kadushin and Martin, 1988). Kadushin's definition was illustrative of how psychological theories that had been evolving steadily since the 1920s were being integrated into social welfare practice. With the emergence of mandated child abuse reporting, however, the perspective changed, and the goals of the agencies were abruptly redirected toward a whole new set of problems. The view developed by Kadushin, which may have been appropriate for an earlier time, was swept aside by the tide of child abuse reports. As Besharov reported (1983, 155), “the great bulk of reports now received by child protective agencies would not have been made but for the passage of mandatory child abuse reporting laws and the media campaigns that accompanied them.”
Impact of Child Abuse Reporting on the Child Welfare System
In 1990, Kamerman and Kahn reported on their comprehensive study of child welfare programs in a range of localities throughout the United States. Although they found major differences between the locations they studied, one over-arching theme emerged: child welfare agencies within the decade of the 80s had been changed from foster care agencies into protective service agencies whose function was to investigate the ever-increasing avalanche of child abuse reports. Kamerman and Kahn (1990) wrote:
Child Protective Services (CPS) (covering physical abuse, sexual abuse, and neglect reports, investigations, assessments, and resultant actions) have emerged as the dominant public child and family service, in effect “driving” the public agency and often taking over child welfare entirely…Child protective services today constitute the core public child and family service, the fulcrum and sometimes, in some places, the totality of the system. Depending on the terms used, public social service agency administrators state either that “Child protection is child welfare”, or that “The increased demand for child protection has driven out all other child welfare services.” (Pp. 7-8)
For the most part these protective services are child rather than family-focused. They are organized around investigation and risk assessment rather than treatment, and as a result the large proportion of cases where the allegations are not substantiated receive no help regardless of how troubled the children and families may be…Child protective staff fear errors—especially the failure to take endangered children into care—and the subsequent public response to deaths or severe abuse and neglect. (P. 8)
Child welfare resources were, as a result of mandatory reporting laws, redirected from providing services to needy children and families toward investigating and intervening in the increasing number of child abuse reports. For every report received, a child welfare agency worker was sent to investigate. The worker interviewed parents, neighbors, teachers—anyone who might have evidence to substantiate or deny the allegations brought forth in the complaint. The investigation might take a week, two weeks, a month, or longer, before sufficient data was collected that would permit a decision on what action should be taken. The process was difficult and expensive.3
Throughout the seventies and eighties, as public awareness campaigns alerted the public to the prevalence of child abuse, the number of reports escalated, which in turn increased the need for more investigators and resources in child welfare agencies. At the same time the mood in society and government was turning increasingly skeptical toward social programs. Throughout the decade of the eighties, expenditures for social services were repeatedly cut. Paradoxically, while the public continued to demand greater efforts be made to curb child abuse, it was increasingly unwilling to fund those efforts. Thus, child welfare was having to confront a steadily growing problem with steadily diminishing resources (Faller, 1985). Even for a field that from the beginning had been required to accomplish more with less, the task was impossible. The result was a continual narrowing of focus regarding who should receive child welfare services (Garbarino, Carson, and Flood, 1983; Weston, 1974).
The residual approach had always necessitated a “means test”—poverty, neglect, abandonment, being orphaned—before the child would be granted services. Child abuse now became the litmus test for conferring eligibility for services. Moreover, how severe was the abuse? Was the child being beaten, sexually molested, starved, tortured? Was the situation life-threatening? The millions of children living in destitute families, whose hopes and dreams were daily obliterated by poverty, and whom the agencies had previously attempted to aid, now, because they did not qualify, began dropping through the holes of the protective services safety net. To make matters worse, family supportive services that might have alleviated the demand for child welfare services were often cut to finance the new protective service investigations. In Virginia, for example, “increases in CPS budgets for investigation…were matched by decreases in AFDC service budgets” (Dattalo, 1991, 13).
From the outset, the approach taken by agencies in investigating child abuse reports was accusatory. That is, the caseworker's responsibility was to collect information that might eventually be used to build a case against the accused parent in order to protect the affected child. Whereas previously the welfare worker might have been viewed as coming forward to help a troubled family, the worker now was unmistakably cast in the role of inquisitor prying into and judging the affairs of the family, with predictably adverse effects on the family. Elizabeth Hutchison (1993, 60) notes:
Investigation of a report of child maltreatment is not an innocuous intrusion into family life. By the time an investigation is complete, the family has had to cope with anxieties in both their formal and informal support systems alerted to state suspicion of their parenting. Even if the report is expunged from the central registry due to lack of substantiation, it is seldom expunged from the mind of the family—or from the memories of persons in the support system.
Pelton (1989, 123) offers a perspective on the predicament of parents who are reported for alleged child abuse:
The parent-agency interaction represents a particular type of conflict, one in which—far from the two parties having more or less equal power—one party is vastly more powerful than the other. The agency has on its side the police, the law, and public opinion. The caseworker has emergency legal power to remove a child from his home on the spot. When the agency goes to court, it has an abundance of reports containing interpretations according to its own lights, the product of vast investigatory resources. The case record is embellished with reports in sophisticated language with opinion freely expressed, from school officials, psychologists, and representatives of other agencies. It contains the results of psychological tests and medical examinations, not to mention the allegations of neighbors. Confronted with this array of power, the parent may see little means at her disposal, except to “clam up,” become secretive, pull her shades down, avoid the social worker and neighbors, prevent her children from talking with anyone, lie, and “say what the caseworker wants to hear.”
While protective services seeks to protect the child, the parent, who may be innocent of the charge, is without protection.4 Pelton (1989, 123) continues:
No one is advocate for the allegedly abusive or neglectful parent. No one investigates and collects evidence on her behalf, presents her side of the story, presents results of psychological tests commissioned by her rather than the government, nor bears witness on her behalf. Pathologized by psychiatrists and victimized through her interaction with the agency, she stands isolated and alone. As cruel as her actions toward her children might appear, she deserves an advocate. Her hostility, which has often been observed within the context of her interaction with the agency, may stem at least in part from her utter powerlessness within the situation, having no advocate.
While impoverished parents may often experience the situation Pelton describes, the more affluent parents have other options. Attorney Douglas Besharov (1990b, 220) offers the following advice to accused parents having adequate financial resources:
The problem is knowing whether you need a lawyer during the investigation. Early representation by a lawyer can be crucial to preventing a court action. It is much easier to convince investigators and prosecutors not to seek an indictment than it is to have them dismiss one. Many court actions are filed because of a simple breakdown in communication. A lawyer may be able to convince investigators that you are innocent or that the case is better resolved informally. No jurisdiction, however, will provide a lawyer before the initiation of a court case against you. Hence, if you want legal representation during the investigation, you will have to pay for it yourself. Legal fees are expensive: Expect hourly charges of $75 to $200, with a required retainer of $1,000 to $5,000.
You should consider hiring a lawyer whenever you are unhappy with the direction the investigation is taking. (Italics in original)
Besharov and Pelton are not examining different phenomena. They are simply writing to different audiences. Pelton is concerned with understanding the existential condition of the many single mothers accused and investigated for child abuse (who constitute the majority of those who have their children removed) and how they come to perceive the child protection services provided. For Pelton it is not possible to separate child welfare services from an understanding of the poverty and economic despair most clients of public child welfare endure. Besharov, as a lawyer, is providing a practical word on how the system works to affluent parents who can afford legal counsel in the rare instances when they might be accused. These vastly different accounts, with one resembling an image from Kafka's Trial and the other a Better Homes and Gardens coffee table chat with an expert, point out the inherent injustice of the current system. Those who can afford counsel are less likely to be accused. In the rare instance whey they are accused, they are usually able to protect themselves against an unfair or unsubstantiated allegation. Unfortunately, the same cannot be said of the lone-mother mired in poverty who is accused of abuse or neglect. Unable to afford independent legal counsel, she is at the mercy of the court and, to an ever greater extent, the child welfare caseworker.
Has Mandated Child Abuse Reporting Reduced Child Abuse?
From the beginning, mandatory reporting was perceived as leading to a decline in child abuse, especially fatalities. Besharov (1990b, 10-11), the first director of the National Center on Child Abuse and Neglect, argues the case for increased reporting:
Child protective services still have major problems…Nevertheless, one must be impressed with the results of this twenty-year effort to upgrade them. Specialized “child protective agencies” have been established to receive reports (usually via highly publicized hotlines) and then to investigate them. And treatment services for maltreated children and their parents have been expanded substantially.
As a result, many thousands of children have been saved from death and serious injury. The best estimate is that over the past twenty years, deaths from child abuse and neglect have fallen from over 3,000 a year (and perhaps as many as 5,000) to about 1,000 a year. In New York State, for example, within five years of the passage of a comprehensive reporting law that also created specialized investigative staffs, there was a 50 percent reduction in child fatalities, from about 200 a year to under 100. Similarly, Drs. Ruth and C. Henry Kempe, well-known leaders in the field, reported that “in Denver, the number of hospitalized abused children who die from their injuries has dropped from 20 a year (between 1960 and 1975) to less than one a year.” (Italics added)
According to this assessment, increased reporting not only saved thousands of childrens’ lives but probably also spared even larger numbers of children from physical and sexual abuse that did not end in death. This view holds that child abuse fatalities are just the tip of the iceberg. Underneath the fatality counts are thousands of children who suffer severe pain and injury at the hands of their parents, yet somehow manage to cling to life.
There is considerable debate about the nature and seriousness of various forms of emotional, sexual, and even physical abuse (Giovannoni and Becerra, 1979; Ringwalt and Caye, 1989; Select Committee on Children, Youth, and Families, 1989a, 225). By selecting child abuse fatalities Besharov has selected the ultimate dependent variable. Death, unlike other forms of abuse, is difficult to cover up. It calls for an involvement of the police and the courts as well as the social worker. Most of the time an autopsy is required, especially if there are any unusual circumstances (Greenland, 1987; Schloesser, Pierpont, and Poertner, 1992).5 Although disagreements may arise over whether the fatality was due to child abuse, there is usually agreement that a nonaccidental death occurred. The death might be ruled suspicious or homicide, but the death is recorded. Consequently, if it can be demonstrated that increased reporting has led to a reduction in child abuse fatalities generally, measured as either homicide or homicide plus deaths caused by “injury undetermined whether accidentally or purposefully inflicted,” the argument that increased reporting has decreased child abuse overall is significantly strengthened. This, of course, assumes that child abuse fatalities are the most reliable and valid indicator of child abuse currently available. Unfortunately, Besharov’s assertion of a decline in child abuse fatalities “from over 3,000 a year (and perhaps as many as 5,000) to about 1,000 a year” after mandatory reporting laws were enacted is contradicted by data from several important sources (Sedlak, 1991).6
Data from the National Center for Health Statistics
According to the National Center for Health Statistics the homicide rates for both infants (zero to one) and children one to four have not declined over the last twenty years, but have increased. In 1975, approximately 720 children died as a result of homicide or “injury undetermined whether accidentally or purposefully inflicted” (Select Committee on Children, Youth, and Families, 1989b, 174-175). By 1986, this number had increased to about 770. Not all of these “undetermined injury” deaths were the result of child abuse. Yet, the number of child homicides also increased from 1970 to 1987 (see Figure 5.1). Meanwhile, between 1975 and 1986 the number of official child abuse reports increased several fold.