Concerned About Unconventional Mental Health Interventions?

Concerned About Unconventional Mental Health Interventions?
Alternative Psychotherapies: Evaluating Unconventional Mental Health Treatments

Sunday, October 30, 2011

What Is Child Abuse? Not Such an Easy Question

Most parents and teachers feel that, although they can’t necessarily define child abuse, they know it when they see it. Given anecdotes about several children’s experiences, they can readily identify each one as having been “abuse” or “not abuse”. Nevertheless, the term “child abuse” can be confusing. At times it’s used simply to mean that the speaker doesn’t like something, as in Richard Dawkins’ famous statement that religious instruction is child abuse. In addition, what is or is not abusive changes historically. I’ve been reminded of that recently by a communication from a distant relative of about my own age, to the effect that the person’s father used to punish his children by imprisoning them in a rabbit hutch. People now past middle age may remember that kind of punishment, or having their mouths washed out with laundry soap, or being sent to bed without supper-- not methods practiced by every family, but frequent enough to be known and recognized, and not widely perceived as abusive.

Even psychotherapists and other professionals may be unsure about whether a parent’s action constitute abuse or neglect, and they want to be sure because they are required to report to child protective services when they have knowledge of such actions. The other day, I was present at a discussion in which a therapist who works with parents was expressing her concern over a patient who had moved away. but had called to tell some things about her toddler’s life that had caught the therapist’s attention. Nothing had really happened, but the therapist was worried not only about the child but about her own obligations and the effect on her licensure if she made a mistake.

If we want a nice clear definition, can’t we just consider child abuse to be a matter of breaking laws about how children should or should not be treated? No, unfortunately that does not work very well. Statutes prohibiting abusive treatment are written as generally as possible for fear of omitting some unusual but undesirable action. There may be no very bright line between a permitted punishment and one that is regarded as abusive. If a child may legally be sent to her room as a punishment, does it matter how small the room is? Is being confined to a bathroom, or to a closet with a light in it, equivalent to being sent to her room? When does a structure become a large cage rather than a small room?

In day-to-day legal decisions, these matters are treated on a case-by-case basis, and considered within the context of factors like past history, the child’s age, and so on. But it would be impossible to do reliable research on child abuse if two cases that were counted in the same way actually had very different characteristics. Over a number of years, the four National Incidence Studies of Child Abuse and Neglect have worked out categories and definitions of child abuse events that are used for the purpose of describing samples of cases and extrapolating the frequencies of events in the United States. The most recent of these studies, NIS-4, is described at https://www.nis4.org/DOCS/ProjectSummary.pdf. The description discusses “sentinel agencies” which are asked to report to NIS-4, and notes that “the kinds of abusive and neglectful situations included in the NIS do not necessarily correspond to those covered by their state’s child abuse and neglect reporting statutes. The study guidelines should not be interpreted as indicating whether an official report is required or appropriate” (important points for professionals who are mandatory reporters of abusive treatment).

Other documents, such as http://www.nis4.org/NIS_History.pdf show the development over time of categories of child abuse. For example, failing to seek necessary medical care is one category of abuse and neglect, but the category was fine-tuned to exclude failure to provide even legally-mandated immunizations, unless the parent had received specific advice that this ought to be done. This decision is obviously arguable, but it involves recognition that failure to immunize, out of ignorance or because of religious objections, is a different matter from failing to have a child professionally treated for a broken leg. The History document shows steps in the development of current definitions, from the original telephone and in-person interviews with parents to more recent interviews with child protective services supervisors.

Does child abuse consist of actions that cause harm to a child? Generally speaking, behavior is likely to come to the attention of authorities only if some demonstrable harm has resulted. However, by NIS standards, there are actions that are so egregious that they are considered to be abusive even if no harm to the child can be demonstrated. These are shown in Table 6.2 of the History document and are described as having “assumed” harm. They include sexual penetration, abandonment, and failure to permit a runaway to return home. Also included are tying or binding of a child, but not confinement to close quarters (for which harm must be demonstrated).

The NIS definitions do not specifically mention (except as “other”) some forms of maltreatment that have been discussed on this blog. “Hot-saucing” (by putting stinging condiments on the child’s tongue) and restraining the child physically in the prone position are not discussed, possibly because they are quite rare or because they were little known at the time the NIS definitions were being developed.

Neither do the NIS definitions address the problem of the therapeutic use of actions that would ordinarily be defined as abusive or neglectful. If there were evidence that methods like prone restraint or food withholding are effective treatments for emotional disturbance, their use under appropriate circumstances could not be defined as abusive-- but of course there is no such evidence. And although there is evidence that aversive treatment like electric shock can be an effective way to stop severely disturbed children from mutilating themselves, there is no evidence that broad-scale, noncontingent use of such methods (as in the Judge Rotenberg Center cases) is a generally-effective disciplinary approach. Quasi-professionals or misguided professionals may advise parents to use such methods and may persuade child protective services or the courts that they are not abusive in spite of all evidence to the contrary. It would be wise if NIS efforts to come followed the thinking of reports like that of the American Professional Society on the Abuse of Children (APSAC; http://depts.washington.edu/hcsats/PDF/Attachment TaskForceAPSAC.pdf) and gave serious consideration to the problem of abuse in the guise of intervention.

7 comments:

  1. That's the trouble, isn't it? There's a huge overlap between punishment and abuse. often rendering them indistinguishable. We should be a little more honest with ourselves and re-brand them as 'acceptable' or 'unacceptable' abuse.

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  2. Do you really mean to re-frame all forms of punishment as abuse? This seems to me as confusing as if you called all abuse "punishment". I see what you're getting at, but isn't there some other term that would include both acceptable and unacceptable actions?

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  3. Wow, you are good. Gotta agree, also confusing. I'm trying to find a way for people to acknowledge that's all a continuum, that the difference is only quantitative, and that the downside of acceptable abuse is the same as that of what everyone deems abuse, except in degree - well, sort of. The acceptable aspect of "legitimate" punishment is what I'm fighting, and I think that acceptableness makes it the more powerful negative force in the world by far.
    OK, dramatic.
    I once coined a term, GVBV - Good violence/Bad Violence - but I gave it away, told someone they could have it. Stupid, I guess. Should I ask for it back?

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  4. and to your first question, yes, I have carried it that far. Call me crazy.

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  5. KAH RAZY! as my grandson says. But Jeff, do you mean only physical punishment when you say "punishment"? Do you mean to include scolding, isolation, "grounding", withholding dessert or allowance, etc.? I'm guessing that you might be limiting your definition of punishment, because you use the word "violence" as well, and although there can be emotional violence, people don't necessarily mean yelling or sarcasm when they talk about punishment.

    Have you thought about the possibility that punishment (however defined) is acceptable if it's followed by positive changes, and not if it's followed by negative changes? The specific action that has each effect could be different for different kids, and certainly would be different at different ages.

    Better get your GVBV back and have it monogrammed!

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  6. No, not only physical abuse. Punishment means, uh, unpleasantness, right? The punisher does something the miscreant finds unpleasant. It all counts. It's all someone trying to do good in the world by doing something bad to someone. Seems a crude tool for creatures that like to think they're smart. My main objection is the "cycle of violence" aspect. I think there will always be negative changes in the long run. Punishment is an expedient shortcut at best, and an unchallenged part of the cycle of violence at worst.
    I think you're right. I should contact that editor and see if she minds I reclaim that acronym. It might make a catchy title for my book!
    I've finally added another bit to my blog about it, if you've got a minute.
    http://punishmentmadeobsoletebypsychology.blogspot.com/
    Thanks, Jean. You are the best critic I've found.

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  7. Not just unpleasantness, but unpleasantness created for a specific purpose. How do you differentiate it from negative reinforcement, for example?

    I did look at your blog and would like to comment on some things, like the Alice Miller ideology and the disturbing background of the "consequences" idea-- this is a very busy week-- hope to come over there in a few days, though.

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