Abuse, Interpersonal: I. Child Abuse
I. CHILD ABUSE
Current pediatrics and social-work textbooks generally include chapters on child abuse that describe the epidemiology, clinical manifestations, differential diagnosis, and treatment of abused children. They usually discuss the legal requirement to notify state child-protection agencies of suspected abuse, and may describe the investigations such reports trigger. It is accepted by most pediatricians, social workers, and laymen that investigations may result in legal actions against parents and other responsible adults. Children may be removed from their homes. Parents may have their custodial rights terminated, and may face criminal charges. The entire process of diagnosis and intervention for child abuse is presented as both necessary and morally compelling.
Changing Attitudes on Child Abuse
However, within this seeming consensus of moral sentiment lies a mystery. Until the twentieth century, much of what we now consider to be child abuse was regarded as morally acceptable and legally permissible. In fact, people generally argued not only that it was permissible to oppress and punish children to the point of physical abuse, but also that such abuse was necessary for the children's moral edification (Radbill). Thus, "Spare the rod and spoil the child." Parents and teachers had absolute authority over children's lives. They could, and did, physically and sexually abuse children with an impunity so complete that such acts were seldom recognized or acknowledged.
Our current approaches to child abuse reflect a radical change in our moral view of the family. Until the twentieth century, families were usually seen as small, autocratic moral universes. Parents (in most cases, fathers) could use children (and wives) as they saw fit. Children had no independent moral rights. The movement to recognize and prevent child abuse, and to punish abusers, reflects a partial empowerment of the child. Such a sea change in moral sentiment raises important questions about the timelessness of moral principles affecting the care of children. Either child abuse was always wrong but not recognized as wrong, suggesting that our moral sensitivities are improving over time, or child abuse became wrong only recently, suggesting that moral values are not timeless and immutable but transient and constantly evolving.
Whether moral principles, such as those designed to guide the care of children, have changed over time or whether people have gradually become more or less virtuous in the treatment of children will be debated elsewhere in this work. Currently, attempts to formulate standards for appropriate ethical and legal responses to child abuse can be seen as efforts to craft social and legal policies that reflect our views of how children should be cared for and reared. But parents and other caregivers receive conflicting messages from current social policies; whereas our society restricts child abuse, its institutions and laws condone other activities—such as sexual activity during early teenage years and exposure to violence in television, films, and daily life—that would have been regarded as morally problematic in societies of previous eras and are so regarded in non–U.S. societies in the early twenty-first century. From one perspective, these conflicting efforts can be seen as experiments in social policy; from another perspective, selective legal interventions in the area of child abuse are viewed as justified by the legal doctrine of parens patriae. In this doctrine the state claims an interest in protecting the lives and well-being of children, even if this means limiting parental autonomy and infringing on family privacy.
Nevertheless, physical and sexual abuse of children is still common; in most instances, abuse is never reported or discovered.
Defining Child Abuse
Definitions of abuse are notoriously variable, circular, or designed to leave room for interpretation on a case-by-case basis. In the United States, the Child Abuse Prevention and Treatment Act of 1974 (PL93–247) defines abuse and neglect as:
the physical and mental injury, sexual abuse, negligent treatment or maltreatment of a child under the age of 18 by a person who is responsible for the child's welfare under circumstances which indicate that the child's health and welfare is harmed or threatened thereby.…
State definitions based on this law vary. Arguments about whether a particular act constitutes abuse under such a definition may focus on the nature of the act itself, whether the act caused harm, whether there was or should have been prior recognition that the act would cause harm, and whether the caretaker might have prevented the harm.
In both physical and sexual abuse, different individuals or communities distinguish acceptable from unacceptable behaviors using different criteria. In physical abuse, a distinction must be made between acceptable forms of discipline or punishment and abuse. As Kim Oates (1982) points out, definitions must specify whether abuse should be defined in terms of particular actions or particular effects. He describes two children who are pushed roughly to the ground by their fathers. One falls against a carpeted floor, the other hits a protruding cupboard door. The second sustains a skull fracture, the first is uninjured. If an act must cause harm to be abuse, then the second child was clearly abused, while the first may not have been. Acts that leave no physical marks are harder to classify as abuse, and it is generally harder to sustain criminal convictions or obtain civil sanctions in such cases, even though an unmarked child may sustain as much or more psychological harm as from actions that cause physical signs of abuse.
In sexual abuse, definitional problems also arise. Child sexual abuse is generally intrafamilial, and falls under the rubric of incest. While prohibitions against incest are universal, different cultures define incest to include, or exclude, different activities. "Parent-child nudity, communal sleeping arrangements, and tolerance for masturbation and peer sex play in children coexist with stringent incest taboos.…(M)others in many cultures use genital manipulation to soothe and pleasure infants. Some cultures prescribe the deflowering of pubertal girls by an adult male or by the father" (Goodwin, p. 33). Exotic cultural differences may be mirrored by different beliefs in our own culture. Some parents may sleep with their children, bathe with them, or take pictures of the children naked on the beach. In some jurisdictions, these activities may be defined as illegal or morally inappropriate.
Cultural or religious differences may also play a role in evaluating what constitutes medical neglect. Christian Scientists, for example, may claim that it is appropriate not to take their sick children to a doctor, while courts may determine that such behavior constitutes neglect. Some Native Americans believe that organ transplantation is prohibited, and so may refuse lifesustaining treatment for their children in liver failure. Similarly, Jehovah's Witnesses may, on the basis of their belief, seek to refuse consent for blood transfusions for their children, even if transfusions would preserve life. In situations like these, judgments must be made about the relative importance of respecting religious and cultural diversity, on the one hand, and protecting the interests of vulnerable children, on the other.
In addition to cultural differences in defining what behaviors are or are not permissible, serious moral problems arise when we attempt to determine whether, in any particular case, a behavior that is clearly not permissible in fact occurred. Court cases may turn on the rules governing the collecting and presentation of evidence. Even in adult rape cases, victims have difficulty convincing juries that they have been raped. Such difficulties are compounded in child-abuse cases, where young children often cannot testify convincingly on their own behalf.
In summary, both physical abuse and sexual abuse of children exist along a spectrum, from obvious cruelty and exploitation to grayer areas of corporal punishment or sexual game playing. The strong moral arguments against egregious abuse of children often lose strength as the definition of abuse expands along a spectrum including activities that may be considered morally praiseworthy, morally acceptable, morally forgivable, or immoral but noncriminal.
Reporting Child Abuse
Most laws are vague in defining the reporting requirements for child abuse. Generally, they require reporting if someone "has reasons to believe that a child has been subjected to abuse." Such laws do not attempt to quantify the degree of suspicion, the quality of the evidence, or the likelihood of abuse that must be present to compel a report. In the crafting of such laws, it seems that the goal was to protect people who report abuse by allowing broad latitude to individuals in defining what they mean by a "suspicion" of abuse. A utilitarian calculus seems to be at work—that it would be better to have reports made that prove to be groundless than to allow subtle cases of abuse to go unreported. Even with such vague and permissive requirements, evidence suggests that abuse is underreported rather than overreported.
There are a number of reasons why people might not report child abuse even though they believe it to be wrong. Child abuse may be ignored because people have difficulty defining and recognizing it (Besharov; Zellman, 1992). It may go undiscovered because adults who are aware that a child is being abused are reticent to get involved and do not report it (Dhooper et al.). Or professionals may feel reticent to threaten what they perceive as a therapeutic relationship with the adult or adults involved. When abuse is reported, health professionals and legal agencies need to weigh the relative risks and benefits of preserving the family against those of removing the child from it (Zellman, 1990).
Reticence to report suspected child abuse may be based on the sociology of healthcare delivery, on respect for confidentiality in the doctor-parent relationship, on unwillingness to stigmatize parents when there is doubt about the actual occurrence of abuse, or on a desire to preserve a therapeutic relationship or avoid the perception that professionals are enemies.
Pediatricians in private practice are paid by the parents or other adults responsible for the children to whom they provide care, and often develop long-term relationships with these adults and the children. In such situations, relationships must be based on mutual trust. Pediatricians may give adults the benefit of the doubt regarding injuries that may be associated with abuse. They may also be fearful that child-abuse reports will be bad for business. These factors may partially explain why reports of abuse are more likely to come from hospital emergency rooms than from private doctors' offices (Badger).
In addition to economic considerations, moral aspects of the doctor–parent (or other adult) relationship may impede reporting. Generally, doctors promise confidentiality, and the moral reasons for confidentiality are compelling. Adults must confide in doctors, and may need to tell them information that would be embarrassing or damaging were it known by others. However, this promise of confidentiality may conflict with a pediatrician's concern about the child's best interest. Although the law requires doctors to report suspected child abuse, reporting is quite sporadic and inconsistent (Dhooper et al.; Zellman, 1990; Oates). Studies of pediatricians reveal that older doctors are less likely to report child abuse than are younger doctors, and males are less likely to report it than females (Kean and Dukes). None of the studies that document inconsistent reporting disentangle the economic, moral, and legal considerations that lead doctors and other child-welfare professionals to report or not to report abuse.
Reticence to report may also result from a lack of faith in the efficacy of interventions. Many child-protection agencies are underfunded and understaffed. In times of tight budgets, they may not receive the highest legislative priority. As a result, they may be unable to provide counseling and supervision services to every child or family reported to them. In some states, child-protection agencies operate under court supervision because they have been found to neglect the children in their custody. While such agencies clearly provide excellent services to most children, highly publicized cases in which they have failed to provide adequate protection may lead to skepticism about the efficacy of reporting.
Risks and Benefits of Intervention
Because society only recently recognized the problem of child abuse, there has been little time to evaluate the effects of different responses to abuse. Three types of responses have been attempted: (1) those designed to prevent abuse; (2) those designed to deal with the psychological consequences of abuse; and (3) those designed to punish offenders.
Preventive programs are difficult to evaluate because of almost insurmountable ethical and methodological problems (Conte). Abuse is a hidden problem. Assessing whether heightened awareness of the problem leads to increased reporting or decreased occurrence would require intrusive evaluation and follow-up for enormous numbers of people (Reppucci and Haugaard; Fink and McCloskey). Generally, studies focus on surrogate outcome measures, such as "ability to discriminate safe from unsafe situations," rather than on actual decreases in the incidence of sexual abuse (Hazzard et al., p. 134).
Intervention for children who have suffered abuse requires a delicate balance between trying to protect the child, trying to help the parents, and trying to preserve the family. Parents who abuse children often have been abused themselves, and may have a higher incidence of psychiatric problems (Steele and Pollack). Many parents regret their actions, desire psychiatric help, and comply with treatment programs. However, 5 to 30 percent of abused children who stay in their family are subject to further episodes of abuse (Jellinek et al.). At present, there are no reliable indicators of which parents will continue to abuse their children and which are likely to respond to therapy. Furthermore, any data that might address this issue will necessarily be probabilistic. Thus, decisions about the value of such data in an individual case will incorporate normative values about the degree of risk appropriate for a particular child facing a particular custody decision.
Programs designed to punish child abusers are driven less by considerations of the risks and benefits of interventions and more by the dictates of the legal system. Evidence against alleged abusers seldom establishes guilt beyond a reasonable doubt. As a result, criminal prosecution is rare, and conviction even rarer (Peters). Furthermore, it is unclear whether stricter laws or harsher punishments decrease the incidence of child abuse. As in other areas of criminal law, the justification for criminal prosecution seems to derive more from a notion of punitive justice than from a calculation of the degree to which punishment of offenders deters potential future offenders. Debate about this issue must take place in the context of more general debates about the morality of incarceration or the potential for rehabilitation in any criminal situation.
An apparent consensus about child abuse masks profound disagreements about the proper boundaries of family privacy, the obligations of parents and health professionals, and governmental responsibility to oversee the care and nurturing of children. These disagreements are reflected in difficulties in defining child abuse, difficulties in enforcing compliance with mandatory reporting requirements, and difficulties in evaluating the effects of interventions. Thus, while the law requires that child abuse be reported if it is suspected, health professionals can create their own index of suspicion. Some providers may report ambiguous cases, while others rarely report suspected abuse at all.
Individuals who work with children must balance their legal and ethical obligations to children, to their parents or caretakers, and to society. Professionals who have a higher regard for familial privacy and parental authority may develop a stricter standard or a higher threshold for suspecting abuse, and thus may be less likely to report it. Professionals who believe more strongly in the independent rights of children may develop a lower threshold for suspecting abuse, and may thus be more likely to report it. Current legal and moral approaches, while theoretically compelling, are quite recent, and have not been thoroughly evaluated. The principle that children deserve protection and nurturance is generally accepted, but the means by which the principle is to be brought to fruition remain uncertain.
john d. lantos (1995)
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