DOCUMENT RESUME

ED 115 031 EC 080 477

AUTHOR Polansky, Norma; A.; And OthersTITLE Profile of Neglect: A Survey of the State of

Knowledge of Child Neglect.INSTITUTION Community Services Administration (DHEW), Washington,

D.C.PUB DATE 75NOTE 61p.

EDRS PRICE MF-$0.76 HC-$3.32 Plus PostageDESCRIPTORS Childhood; *Definitions; Disadvantaged Youth; Early

Childhood; *Etiology; Exceptional Child Research;Identification; Incidence; Infancy; *Intervention;*Literature Reviews; Prevention; Research Reviews(Publications)

IDENTIFIERS *Neglected Children

ABSTRACTReviewed is recent literature and research on child

neglect. Covered are the following topics (and ,sub-topics inparentheses) : (1) definition of neglect (distinguishing neglect fromabuse, legal vs. professional definitions, operational definition);(2) prevalence of neglect; etiology (economics, cultural values andchild caring, breakdown of the nuclear family, parental pathology,cycles of neglect); (3) identification, casefinding, early warningsignals; consequences,Aneurological and other physical sequelae,emotional sequelae, cognitive deficit, antisocial behavior); (4)

prevention (child advocacy, rights of children, help for families atrisk); and (5) (social casework, group techniques, parent-childcommunity programs, mental heal centers, day care, engineeredcommunities) . (LS) -

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PROFILE OF NEGLECT

A Survey of the State of Knowledgeof Child Neglect

Norman A. Polansky

Carolyn Hally

Nancy F. Polansky

U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARESOCIAL and REHABILITATION SERVICE

Community Services Administration1975

FOREWORD

In 1973, Norman Polansky said, "An off brown,fetid, psychological smog has descended on theAmerica of our generation." In strong language,one of the country's leading authorities on childneglect was describing our Nation today where, hesays, he would not be surprised to find a millionneglected children at any one time.

The deep concern of Congress for abused andneglected children was made evident with thepassage of the. Child Abuse Prevention and Treat-ment Act (P.L. 93-247) which President Nixonsigned on January 31, 1974.

The Department of Health, Education, andWe:fare, which in 1973 had placed the problem ofabused and neglected children among its toppriorities, was aware that most research in this areawas focused on abuse. Obviously, if Federal, State,and local agencies and organizationspublic, pri-vate, and voluntarywere to more effectivelyfulfill their responsibility for serving neglectedchildren and their families, they needed a readyresource on the state of knowledge of child neglect.

Thus, in November 1973, a child welfare researchgrant (No. 09-P-56015/5) was funded by theDepartment's Community Services Administra-tion (CSA) of the Social and Rehabilitation Ser-vice for the purpose of developing a survey of thestate of the art of child neglectthe first to ourknowledge.

Dr. Norman A. Polansky, Professor of SocialWork and Sociology, University of Georgia, wasuniquely qualified for the job of Senior Investiga-tor of-the research project. Asa psychologist, social

worker, sociologist, and researcherincluding re-cent extensive research on child neglect in Ap-palachiahe has studied neglectful parents andtheir children for many years. Dr. Polansky's col-leagues in the massive effort of compiling andanalyzing research and practice knowledge onchild neglect were Carolyn Hally, a socialcaseworker, and Nancy F. Polansky, a psychiatricnurse. Assisting them from the Federal ievel wereCSA's Mildred Arnold and Virginia White.

"Profile of Neglect" brings together an abundanceof facts and figures about child neglect: its defini-tions; its prevalence; many of its causes and results;some steps for prevention and some ways to treat.In addition, the authors impart fresh insights intounderstanding many of the forces that contributeto the neglect of children. And, so important, theytell us what we still don't know about childneglect. As they indicate in their introduction,research in this area leaves much to be desired. Itshould be noted here that the opinions expressedin "Profile of Neglect" are those of the authors andof other researchers in the field of child neglect;they are not necessarily those of the Department.

CSA hopes this publication will prove valuable toall the concerned men and women who serve, whocome in contact with, or who are in some way in aposition to help neglected children and theirparents. We also anticipate that this document willstimulate the kind of productive research that isstill needed.

Through as many avenues as possible, all of usmust seek new and better ways to protect our Na-tion's children.

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John C. YoungCommissionerCommunity Services Administration

CONTENTS

INTRODUCTION 1

DEFINITION OF NEGLECT 3

Distinguishing Neglect From Abuse 3

Legal vs. Professional Definitions 4

Operational Definition of Neglect 5

PREVALENCE OF NEGLECT 8

ETIOLOGY 11

Economics 11

Cultural Values and Child Caring 12

Breakdown of the Nuclear Family 14

Parental Pathology 15

Cycles of Neglect 17

IDENTIFICATION - CASEFINDING - EARLY WARNINGSIGNALS 19

Identification 19

Casefinding 20

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<."

Early Warning Signals 21

Policy Issues 26

SEQUELAE 27

Neurological and Other Physical Sequelae 27

Emotional Sequelae 29

Cognitive Deficit 30

Antisocial Behavior 31

PREVENTION 33

Child Advocacy 33

Fghts of Children 34

Help for Families-At-Risk 34

TREATMENT 39

Social Casework

Group Techniques

Parent-Child Community Programs

Mental Health Centers

Day Care

Engineered Communities

Some Further Questions

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REFERENCES 51

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INTRODUCTION

THE AIM OF THIS PROJECT was to assess thestate of knowledge of child neglect in this country.We undertook to survey what is knownor at

what is commonly accepted among expertsregarding the definition, prevalence, etiologies,and possible preventions and remedies for thissocial problem.

This document represents 6 months of effort inwhich staff were assembled and informationgathered and integrated. It is hoped that subse-quent published versions of our work will showthe increments which time for reflection andfurther digestion will permit.

Integration was difficult because the body of infor-mation relevant to child neglect remains diffuseand rudimentary. The Library of Congress, for ex-ample, has a subcategory for child abuse; none forneglect. We found only one substantial review arti-cle published on this topic in recent yearsthe ex-cellent but limited paper by Meier (1964) to whichrecurrent references will be made. The texts byKadushin (1974) and Costain (1972) have chap-ters deal.ng generally with protective services.

Consequently, it was necessary for us to decide theboundaries of relevance to this topic. We chosethem so as to include a number of matters whichvery much impinged on child neglect, even if theywere not previously subsumed under this heading,especially in discussion of the etiologies and se-quelae of neglect. Others may or may not acceptthese boundaries. There literally is no tradition.

In addition to the life experiences and otherprofessional qualifications of the authors, the mainsource of data for the study was the publishedliterature, including some unpublished documen-tation. We attempted to stay current and to includeimportant articles emerging in print as writing wasunder way. Colleagues around the country were

also contacted. The correspondence .was helpfulprimarily in verifying how little, really, is underway in the form of innovative projects.

Finally, we made personal contact with a numberof experts directly engaged in the work. A con-ference was held in Atlanta on May 22 and 23,1974, at which time a preliminary version of thisreport was held up for critical review. Present wereLeontine Young (Child Service Association,Newark, N.J.), Alfred J. Kahn (Columbia Univer-sity School of Social Work), G. Lewis Penner(Juvenile Protective Association, Chicago), andWalter Leefman (Massachusetts Society for thePrevention of Cruelty to Children) as invited con-sultants. Other experts were Katherine Boling andJerry White (Georgia Department of HumanResources), James Vaughn (CSA Regional Office,Atlanta), and Mildred Arnold and Virginia White(CSA Central Office, Washington, D.C.). We aregrateful to them for their critiques and addenda,and we trust this revision shows that their remarksdid not fall on deaf ears. Other individual contactstoo numerous to list also proved rewarding.

A further methodological caveat is very much inorder. In our opinion, little is known with any con-fidence about child neglect if ordinary, scientificstandards for credibility are applied. The same canbe said, evidently, of the several areas adjacent tothis topic.

Many of the papers we reviewed were "thinkpieces," advancing ideas that were supplementedwith illustrative case material. Often the "studies"cited were based on samples trivial in size and/ordubious as to representativeness. "All the casesseen at our hospital between Time 1 and Time 2"is, of course, a convenience sample. Issues of thereliability and validity of instruments weretypically not even confronted. Findings of poten-tially great imp-.ct have seldom been picked up for

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serious replication. Without singling out particularstudies for special criticism, we might add that ourdubiousness extended to fields in which we haveno expertise; e.g., nutrition and neurology.

Hardly a study in the area of child neglect can beconsidered more than a "pilot". A few achieve thestatus of being "diagnostic," meaning quantitativemethods of data collection were used in a

systematic search for promising hypotheses.

One could say, "Nothing is known about childneglect." But this is not literally true. Practiceknowledge does exist, and it is better than no infor-mation at all. Although there is no intention hereto support overconfidence in the face of ignorance,

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if policy decisions are to be made, it is better thatthey be founded on what we do have.

How then to present the data we had accumu-lated? Certainly, it would have been tortuous toqualify every assertion quoted, every summationoffered. As a matter of convenience andreadability, therefore, we wrote from the stance,"If we tentatively accept most of what we are beingtold, what then do we seem to know?" But, ac-tually, nearly every "finding" presented must beregarded as, at most, a hypothesis warrantingfurther investigation. Therefore, it is to beemphasized that child neglect is not one of thefields of which it can truthfully be said, "Wealready know all we need to; let's get on with theaction!"

DEFINITION OF NEGLECT

Distinguishing Neglect from Abuse

CHILD ABUSE AND CHILD NEGLECT areclosely linked in public thinking and in legislation.In the professional literature, they are also oftentreated as one. As if speaking of the neglectfulparent were not oversimplification enough,reference is made to the "abusive and neglectful"parent.

When we recently wrote colleagues to inquire intostimulating new programs of work on child neglect,a surprising proportion offered descriptions ofprograms dealing with abuse. So the failure to dis-criminate between the two is not limited toamateurs; a number of experts have treated thedistinction loosely (Bleiberg, 1965; Isaacs, 1972;Mulford, Cohen, and Philbrick, 1967).

Some who group the conditions together have aconscious rationale for doing so. Vincent Fontana(1973) writes:

Although we realized that it was useful,from the point of view of diagnosis andtreatment, to be able to categorize thephysical abuse as one thing and neglect asanother, we felt that such a distinctionwas really of little value to the child inneed of help .... Any treatment by whicha child's potential development isretarded or completely suppressed, bymental, emotional or physical suffering ismaltreatment, whether it is negative (asin deprivation of emotional or materialneeds) or positive (as in verbal abuse orbattering). (p. 24)

A tenet of this report is that neglect and abuse areprobably related but by no means identical. Unlesswe approach them as separate entities, there willbe no way to determine whether they represent "a

difference that makes a difference" for identifica-tion, treatment, and programmatic policy. Com-monalities between the two should be empiricallydemonstrated rather than presumed.

Abuse is by no means a univocal phenomenon,but it permits a more concise definition than doesneglect. The traditional preference of investigatorsfor readily manageable problems may well be amajor reason why abuse has been the more popu-lar object of study. Zalba (1966) labels as abusecases where physical injury has been inflicted on achild by his or her parents or parent substitutes tothe degree that life or health has been eudangered.Gil (1970) states:

Physical abuse of children is the inten-tional non-accidental use of physicalforce, or intentional, non-accidental actsof omission on the part of a parent orother caretaker interacting with a child inhis care, aimed at hurting, injuring ordestroying that child. (p. 6)

As its author remarks, this definition is fairlysatisfying conceptually but, operationally, it pre-sents difficulties. How to verify that an "act ofomission" was intentional? No wonder someoneas sophisticated as Court (1970), writing on childbattering, treats the term as self-evident.

A distinction of neglect from abuse, linking theconditions differentially to trends in the parents'personalities, was given by Chesser in 1952 andcited by Zalba,(1966):

There is a radical difference in characterbetween cases of neglect and cases ofcruelty to children .... while neglect maybe a form of cruelty, it is more oftencaused by or exaggerated by extremepoverty or ignorance. Cruelty on theother hand is more likely to be related to

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deep-seated characterological or psy-chological causes rooted in the childhoodexperiences of the abusing parent orparents, such as physical or mentalcruelty inflicted on them by their parents.(P. 5)

The same somewhat uncritical differentiation hasbeen carried forward by others, including so ex-pert a student as Kadushin (1974): "Neglect ap-pears to be a response to social stress . . . . Abuseappears to be a response to psychological stress."(p. 283) In her seminal study, Wednesday's Children,Young (1964) continued the search for differentialdiagnosis, separating the two phenomena. Agenerally accepted descriptive difference was wellexpressed by Giovannoni (1971) who associatedabuse with acts of commission; neglect, with omis-sion. Hence, neglect represents failure to performparental duties, including those of supervision,nurture and protection. The form of nurture thatis expectable or deemed essential, however,becomes a complicated question. The environ-ment's impact, after all, is experienced as"stressful" only as it impinges on individual feel-ings. We shall discuss some of the complexities inassessing "inner" versus "outer" sources ofneglectful behavior in the section on Etiology.

Legal vs. Professional Definitions

The two professional groups thus far most con-cerned with neglect have been the legalauthoritiesthat is, the courts and other relatedofficialsand social workers. Meier (1964) hasoffered a provocative review of the two sorts ofdefinitions used explicitly and implicitly by the twoprofessions. She observes (as have others) that thelegal definitions of neglect vary markedly fromState to State.

Neglect laws vary, but any neglect law must em-body these elements:

(1) the definition of a child;(2) identification of the persons qualifiedto petition to the court who allege that achild is being neglected; (3) specificationof the meaning of neglect; (4) descriptionof the nature of the legal procedures to befollowed and identification of the court ofjurisdiction; and (5) a statement of the

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ways in which the court may dispose ofthe neglect petition before it. .. .(p. 156)

Meier goes on to describe elements coveringneglect that are commonly found in statutes of in-dividual States:

Similarly, the conditions that constituteneglect are variously defined, but rathercharacteristically the laws cite these cir-cumstances: (1) inadequate physical care;(2) absence of or inadequate medicalcare; (3) cruel or abusive treatment;(4) improper supervision;(5) exploitation of the child's earningcapacity; (6) unlawfully keeping thechild out of school; (7) exposing the childto criminal or immoral influence that en-dangers his morals.... (p. 157)

Since both legislators and social workers arestrongly influenced by community norms, Meiernotes it is not surprising to find that their defini-tions of neglect have much in common. Thechild's physical, emotional, and intellectualgrowth and welfare are presumed to be jeopar-dized by a wide range of conditions: ". . .When,for example, the child is: (1) malnourished, illclad, dirty, without proper shelter or sleeping ar-rangements. . .." ranging to "(8). . .exposed to un-wholesome and demoralizing circumstances." (p.25)

However, Meier also cites the somewhat differentview of neglect which social workers hold. One isthe degree of inference involved in making a judg-ment concerning neglect. According to her, "Lawcannot be concerned with causative factors or with'predictions of future behavior." (p. 161) There aredangers involved if the law removes children onthe basis of uncertain predictions of things tocome. Hence, judges generally confine themselvesto matters of clear and present danger, whereassocial workers become concerned about what thechild's future will bring if nothing is done aboutthe child's current circumstances.

Certainly, the state of knowledge does affect whatis regarded as neglectful. For example, beforethere were rabies shots, nothing could be done fora youngster bitten by a rabid dog. Today, thefailure to get prompt medical attention for a bitten

child would, no doubt, be deemed neglectful. Thesame might be said about ensuring adequate pro-tein in an infant's diet. Hence, a professional state-ment of what constitutes child neglect depends onour knowledge of child development in all itsfacets.

Continuing, Meier notes that social workers aremore sensitized by training to concern about"emotional neglect." She, herself, questionswhether legislators should enter that particularthicket, with its wide openness to interpretation byindividual courts. Finally, she observes that,whereas the law is concerned with neglect as anentity, social work thinks of child care along a con-tinuum that ranges from excellent, through ade-quate, to cause for grave concern, and, finally, toneglect.

Although weliterally had not come across Meier'swriting at the time we did our work, it is of interestthat our own scale (described below) for measur-ing child caring follows the idea of the continuum.But, not only is child caring a continuum, it is amultiplex dimension. On the one hand, childrenprove amazingly resilient; on the other, the nur-ture of a child to his or her full potential requiresthe simultaneous meeting of needs in anastonishingly wide variety of areas. These areasrange from ensuring sheer survival to developingcognitive abilities and the capacity to love.Moreover, neglect is inevitably relative: children ofdisorganized, multiproblem American families arenearly all better off than those now starving inAfrica's drought countries.

For all these reasons, we have ourselves regardedattempts to define neglect, conceptually, as pre-mature and scientifically presumptuous (Polansky,Borgman, and DeSaix, 1972). However, the pres-ent assignment demands establishing boundaries.We offer, therefore, the following working defini-tion of child neglect:

Child neglect may be defined as a condi-tion in which a caretaker responsible forthe child either deliberately or by ex-traordinary inattentiveness permits thechild to experience avoidable presentsuffering and/or fails to provide one ormore of the ingredients generally deemedessential for developing a person's physi-cal, intellectual and emotional capacities.

Implicit in this definition are that: (a) thecaretaker may be a nonparental figure, such as asocial agency or even a community; (b) theneglect need not be limited to consciously moti-vated behavior; (c) as a matter of values, failure toalleviate avoidable suffering is deemed neglectfuleven if it leaves no certain, long-term damage;(d) we believe that the state of knowledge will(hopefully) change, so that the best we can do nowis to offer our definition in terms of what isdefinitely known in each areahence, the conceptis necessarily somewhat ambiguous; and(e) neglect, like abuse, may prove lethal (Giovan-noni, 1971; Bullard, et al., 1967, Kromrower,1964) and often does.

Our definition, then, represents a stand on avariety of related issues. It is in line with currentsocial work thinking (Kadushin, 1974). Emphasismust be given to the fact that neglect is not definedin terms of intentional parental misfeasance. Con-scious intention will often be hard to determine,especially among people living, themselves, indreadful circumstances. The key issue (accordingto parens patriae) is the probable impact on thechild, a point stressed by Goldstein, Freud, andSolnit (1973). A similar stand with respect to thelegal definition of child abuse has been taken byNewberger (1973) and by Newberger et al.,(1973).

Legal definitions usually reflect the norms andopinions most prevalent in a cultureas they pro-bably should. Nevertheless, we would urge that thedefinitions used not be held only to matters univer-sally accepted, but that advantage be taken of newscientific findings at the time such findings areadopted by responsible, expert professionals.

Operational Definition of Neglect

The working definition of neglect offered is argua-bleas definitions -always areon semantic andconceptual grounds. Thus, it might be reasonedthat an operational definition would be totally un-satisfactory. But this is not the way sciencetypically moves forward. Very often, a concept issimultaneously clarified, both conceptually andoperationally, by a process of successive approx-imations to desired criteria. Legal adjudication isone way to achieve an operational definition of

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neglect, but it is scientifically unsatisfactory forreasons already given (and to be elaborated onfurther in Prevalence of Neglect below).

Basically, two approaches are used for securingdata regarding the care a child is receiving:(1) examine what a family is providing its child or(2) examine the child and draw conclusions fromthat. All methods of inferring adequacy of care arevariations on these themes, including observationof sequelae in the child; hearing the child's Ownreport; reading parental reports of care given; ob-serving parental character and available amenitiesin the home (Polansky, Borgman, and DeSaix,1972, p. 31ff).

An instrument, long in use, that relies on many ofthe above sources is the Family Functioning Scalesof Geismar and his colleagues (1973). Developedoriginally for work on the multiproblem family,the scales depend heavily on interviews for basicdata from which ratings are then made. Satisfacto-ry levels of reliability have been achieved, as wellas evidence of construct validity. However, thescales give rather global ratings; they are notspecific to the measurement of neglect, as such.

The most relevant instrument yet in the literatureappears to be our own Childhood Level of LivingScale (Polansky, Borgman, and DeSaix, 1972),probably because it was developed out of a con-cern for children receiving care thought to bemarginal or outright neglectful. The idea for sucha scale was adopted from work by the ruralsociologists (e.g., Belcher, 1972) who were pushedto find ways of scaling families whose life styleswere at a levelWhich ordinary measures ofsocioeconomic status ceased to discriminate.

Our scale (the CLL) is multiplex. It includesnumerous facets of basic physical care along withmeasures of "cognitive/emotional" nurture. TheCLL was designed to be used with families exist-ing at or very near the poverty line. With incomethus held constant, a number of meaningful rela-tionships have been established, for example, be-tween the CLL score and facets of personality ofthe motherthe parent on whom we chose tofocus our study of poor Appalachian families.

Other* by the way, have found that, in research inrural areas, the family's level of living is by nomeans solely dependent on income. Belcher,

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Crader, and Vazquez-Calcederrada (1973) haveassessed the variance in level of living associatedwith other factors among a large group of familiesin Puerto Rico. "The greatest amount of variationis 'correlatively' explained by style of life, 40 percent .... Of particular significance is the relativelysmall amount of variation accounted for by theeconomic set alone . . . 22 per cent." (p. 191) Bylife style they mean, in this instance, somethingthey call the "middle class syndrome," charac-terized by reading habits, numbers of persons ableto drive in the family, and the like.

The internal consistency of the Childhood Levelof Living scale is very substantial, not only amongitems involving judgment and, therefore, suscepti-ble to halo-effect, but also among many items thatappear highly objective. Thus, it is meaningful torefer to the CLL as a singlt:, if complex, dimen-sion. For example, in the rural population ob-served, children in the most dilapidated housingtended to have the least amount of attention givento their needs for affection and stimulation. Theother advantage of the CLL is that it has provenuseable by other personnel (e.g., workers in theAid to Families with Dependent Childrenprogram) after very short periods of on-site train-ing by our research personnel.

Hence, there is evidently no question that a scalecan be developed for assessing child care on a con-tinuum, with many of the characteristics deemeddesirable in any research instrument. One puzzle,however, still remains: Where should the cuttingpoint be set? Below what score is a child to be con-sidered "neglected"? In practice, the criterion forthe scaling used in courts is set by cultural values.How might we supplement present procedures?

One way would be to uw the. CLL on a largepopulation. (A limitation in the scale, it should benoted, is that it was designed for children aged 4 or5, but much of it is relatively independent of thechild's age.) Norms would then be establishedfrom this greater populationsuch as we do withany other instrumentincluding scores at variouspercentile levels. The percentile rank on the CLLmight then be used as at least, one importantdatum in appraising a child's environment,although even here we would still be reluctant tofix an automatic cut-off point without further ex-perience.

A scientifically more desirable method would be adiscriminant-function analysis, using the CLLscore as the predictor variable. If research with asubstantial sample of children enabled us to set theodds that, say, a child with a CLL score below"X" would become mentally ill, delinquent,retarded, or withdrawn, the field would then be ina position to use the instrument with much greaterconfidence and impact. When the probability is 20to 1 the child will eventually be severely damaged,then the child's fate is no longer a scientificcuriosity but a moral and legal question.

There are other methods of assessing the level ofcare, including psychological testing of the child.

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The degrees of trustworthiness of all of these tech-niques are implied in the correlations reported inRoots of Futility (1972) where our research appearsmost completely. However, in all modesty (and wehave much to be modest about), the CLL is themost promising instrument, involving minimal in-ferences, available at this time.

From experience, we have learned that any suchscale must be age-graded in format. Actions thatseem part of essential mothering at one age maybecome in fantilization when the child is somewhatolder (Sharlin and Polansky, 1973).

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PREVALENCE OF NEGLECT

HOW MUCH OF A PROBLEM is child neglect?Part of the answer to this question must be quan-titative. But what statistics do we require? For mostsocial ills with an acute, denotable onset, the con-cern is with incidence. Neglect, however, does notoften fit the incidence model. More typically, it is achronic state, woefully private and undetected un-til it becomes glaring or leads to some dramaticdenouement. The more appropriate index,therefore, would be its prevalence.

The prevalence of neglect remains a mystery, withno reliable figures for the Nation as a whole.Several of us have formalized our belief in writingthat official figures available lead to serious under-estimates. The standard Method we use is to countthe number of complaino received and then todetermine the number of different families in-volved and/or the number of children (sincedifferent complaints about the same family mayinvolve differen` children). Next, we ask whethereach complaint, or investigation, proved justified.These are reasonable steps toward counting the"number of justified complaints," but even theyare not yet standardized. Will these proceduresyield incidence or prevalence? Probably, the latter.

Figures on legally adjudicated neglect have to begross underestimates of the problem. Nearly everyagency, public or private, tries to help the familywithout court action. Those seen by a judge are afraction of all families against whom justifiablecomplaints have been made (Kadushin, 1974, p.264). Judges are appropriately cautious aboutaffirming petitions to remove children for neglectfor legal reasons (Melson, 1956; Mulford, 1956;Rosenheirn, 1966; Wylegala, 1956; Rodham,1973). Occasionally, political considerations alsoenter the picture. "Parents Vote but minor childrendo not, and an unpopular decision on a neglectpetition might cost a judge more votes than

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responsible removal of such youngsters would evergain for him." (Polansky, Borgman, and DeSaix,1972, p. 30).

In surveying legislation and programs in theSoutheast related to child abuse, Johnson (1973)documented the pitfallsin definition, in man-power, and in easy access by the publicthat liebetween official agencies and reliable estimates ofthe extent of abuse. The same would apply toneglect. We have only recently begun to have lawsrequiring the reporting of abuse ta a central regis-tryor indeed to anyone. Neglect lags.behind.Lewis (1969) has also remarked that the occur-Y4'rence of neglect is substantially ,underreported.

Using fragmentary data we have, in the past, esti-mated the ratio of neglect to abuse at least as greatas 10:1 (Polansky, Borgman, and DeSaix, 1972, p.25). Kadushin (1974) and others also underscorethe probable numerical preponderance of neglectover abuse. Of over 4,700 cases referred to a pri-vate child protective agency in Massachusetts in1972, only 14 percent involved abuse(Massachusetts Society for the Prevention ofCruelty to Children, 1973).

For several years, the State of Florida has hadperhaps the most advanced system in the countryfor the central reporting of abuse and neglect (Fell,1974). The system, which resulted from a 1971change in the laws regarding child abuse,broadened the'definition of-abuse to include muchthat we know as neglect. Also, responsibility wastaken from the local juvenile courts and lodgedwith the State's Department of Health andRehabilitation. The child abuse registry was set upin October 1971. A WATS line was installed forreceiving reports from anywhere in the State; it hasbeen manned around the clock, 7 days a week.Also, an advertising firm did a tasteful and veryeffective job of placing radio and television spot

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announcements, newspaper' advertisements, andbillboards. In addition, several dramatic cases in-volving neglect were reported in the news at aboutthat time, and the media mentioned the centralreporting service with its WATS lines.

Prior to October 1971, there had been a centralregistry of sorts for doctors to report cases of grossabuse to local juvenile courts. In the year preced-ing the new system, 19 such reports were submit-ted to the central office. In the first 18 months ofthe new program (i.e., through March 1973),31,828 children were reported "abused."However, when these figures were broken downaccording to specific "type of abuse," we found6,783 children "unattended;" 8,362 with "dis-organized family life;" and so forth. Aftereliminating about 3,500 cases, the nature of whichwe could not clarify from the table available, wedivided the total into abused vs. neglected. On thisbasis, we arrived at 21,635 neglected to 6,702abused childrena bit more than a 3:1 ratio, buta smaller disproportion than all previous esti-mates. The number from this one State is verylarge when we consider that, a few years earlier,Gil (1970) tabulated about 6,500 affirmed abusecomplaints for 1 year in the whole United States.In Florida, by April 8, 1974, a gross total of 63,315complaints had been received (in a little more than30 months).

Each call received in Jacksonville is immediatelyrelayed to a social worker on call in the local coun-ty. The worker begins immediately to investigatethe complaint. Between 60 and 63 percent of allcalls prove justified, according to those in chargeof the program.

Spite calls, false alarms, or nuisance calls areseldom received; the vast bulk of calls have a basisfor being made. A heavy proportion of the callscome from the citizenry, from neighbors and rela-tives, as well as from schools and others. Themedical profession continues to be low in report-ing. But the message from Florida, with its formercount of 19 cases of child abuse, is plain. A bit oforganized casefinding enormously magnifies thevision of the number of youngsters in trouble inthese United States.

Because we were curious also about current ex-periences in other parts of the country, we securedother figures from a rural and an urban county in

South Centr; 1 New York (Couch, 1974). NewYork now requires central reporting, includingsubmitting forms at fixed intervals to demonstratethat complaints have been followed up at the locallevel. New York also has a statewide WATS linewhich receives complaints 24 hours per day as aresult of a law enacted in September 1973. Fromthen through December, in Broome County(which includes Binghamton), 416 complaints on188 different families were received by the publicchild protective service. From experience, it wasestimated that 90 percent of the complaints wouldbe justified and that about 20 percent of thosewould be taken to court.

Broome County has a staff of 20 supervisors and50 caseworkers in protective services. Even a near-by rural county (Tioga) had 31 different familieswith justified complaints in a 6-month period afterpassage of the new law. It will take a few years toclarify how great the volume will eventually proveto be in all of New York State alone.

Partly because of the nature of its reporting law,statistics from our own State of Georgia are under-stood to be incomplete, even with respect to childabuse which was, until 1974, mandated under thelaw for central registry reporting. A new bill waspassed in 1974.

According to Mr. Jerry White, the State's consul-tant on protective services, 340 cases of abuse werereported in Georgia in the fiscal year ending June20, 1973. Of these, 70to 75 percent will probablyhave been confirmed after investigation. Mr.White's data show that 88 cases (26 percent) re-quired court action to protect the child. No reliable.estimate could be made of the comparative preV-alence of neglect; Mr. White would not besurprised it if ran "as high as 20,000 cases"aratio to abuse of over 50:1.

Light (1973) recently published a paper on abusedand neglected children. Using methods familiar t'economists, he arrives at a number of conclusions.At one point, for example, he develops a pro-bability model from which to estimate the inci-dence of child abuse. Substituting constants forunknowns in his modelconstants which "ap-Peared reasonable after an informal survey," (p.565)he arrives at the estimate that "0.004 of allAmerican families physically abuse a child." (p.565) Introducing another set of constants in his

9

model yields the figure "0.01 of all Americanfamilies" (p. 566) as a maximum. The upper boundestimate, in other words, is 25 times the "reasona-ble estimate."

From such reasoning and from data from NewYork State in which "neglect" means "severenlect or sexual abuse," Light arrives at an esti-mate, nationally, of 465,000 "neglect and othermaltreatment incidents" other than abuse (p. 567).

Meanwhile, Light's observation that the "inci-dence" of abuse and neglect depends heavily onhow concerted an effort is made by State agenciesto enforce reporting certainly warrants attention.There are variations in the calculated rate as wildas 9.6 cases of abuse per 100,000 population inNew York, as contrasted to 1.5 in New Jersey,although the two States are adjacent and, in manyrespects, very comparable (p. 562).

Fontana (1973), who is impatient with the distinc-tion between abuse and neglect, speaks of"maltreatment." He cites figures from Vincent DeFrancis of the American Humane Association that"10,000 children are severely battered every year,at least 50,000 to 75,000 are sexually abused,100,000 are emotionally neglected, and another100,000 are physically, morally, and educationallyneglected." (p. 38) Fontana estimates that at least150 children die each year in New York City aloneas a result of maltreatment (p. 39). In New YorkCity, figures on maltreated children rose from1,800 cases in 1969, to 3,000 in 1970, to 6,000 in1971, and to more than 10,000 in 1972.

While recognizing that these soaring figures arepartly due to the later inclusion of neglect as wellas abuse in the statistics, Fontana believes the riserepresents more than improved reportage. "Ibelieve we are seeing an actual increase, and thatthe reported figures have not yet caught up withthe facts." (p. 159) "I cannot help but feel that thesoaring statistics. . .are symptomatic of our violent,

10

unhappy times...of the increased stresses that areconfronting all society and the crest of violencethat seems to be engulfing the world." (p. 40)

Social workers have had similar, morbid observa-tions about the state of our Nation. "An off brown,fetid, psychological smog has descended on theAmerica of our generation." (Polansky, 1973, p.57) We should not be surprised to find a millionchildren neglected in this country at any one time.

Summing up, we see that the prevalence of childneglect is still really unknown. As with childabuse, the statistics on neglect will be influencedby such factors as how it is defined, professionallyand legally; the laws passed by the various Statesrequiring central reporting to facilitate collectionof data; the success of State social service depart-ments in encouraging officials, teachers, doctors,nurses, and other interested citizens to initiate the"complaints" which eventuate in reporting. Eventhe convenience of the reporting form probablyaffects a State's final figures. It seems likely that in-sofar as prevalence statistics err, the error will beon the side of conservatism. Official figures areprobably still a fraction of all the neglect that is oc-curring.

A minor additional question has been pursued:How does neglect compare numerically withabuse. As mentioned, estimates of the ratio varymarkedly, but even Florida shows a proportion ofat least 3:1. Other estimates of the ratio put thepreponderance of neglect higher in most places inthe country. Should the figures available ever ap-pear sufficiently valid to be regarded as useablesocial indices, we shall have an interesting furtherpossibility; that is, the ratio of neglect to abuse mayactually vary fro,r, State to State, and not simplybecause of the States' systems of data collection.With valid data, it would make sense to askwhether such factors as per capita income, on theone hand, or crimes of violence against adult per-sons, on the other, have systematic relationshipswith the rates and ratios of neglect and abuse.

1)

"ETIOLOGY

THE ETIOLOGY of each case of child neglect isto be sought in the forces that result in parents whogive less than adequate care to their children. Con-troversy abounds over the nature and loci of theseforces. Some workers are so case-oriented that theybelieve as many etiologies exist as do neglect situa-tions; so they offer no generalizations at all. Othersobject to the term "etiology," since it is redolent ofthe "medical model" and implies individual weak:"ness or dysfunction; this they interpret as "fixingblame."

With respect to child neglect, as to child abuse,argument is heard over whether neglectful parentsshould be seen as victims or as culprits. Such de-bates make good rhetoric, but they are inevitablysimplistic; they have little place in the serioussearch for ways to help the children and theirfamilies.

Actually, not a great deal is known about the"causes" of child neglect. This, is,not surprising inview of-the other aspects of our ignorance thatwere documented above. What we have is a num-ber of approaches to locating the causesmetatheories rather than theorieswith specificconnections established in only a few instances.To us, it is likely that, rather than locating auniversal pattern underlying all instances ofneglect, we shall eventually come up with a seriesof types, or syndromes, involving neglect. Ratherthan discussing etiology, we shall then be discuss-ing etiologies. Meanwhile, the approaches ad-vanced are to be taken seriously but not as univer-sal answers. Rather they should be seen as repre-senting particular forces thus far identified in atleast some cases, under some circumstances.

This compact review begins with explanations thatare more or less sociological in emphasis; then ex-planations are offered of the causes of neglect,couched in terms of intrapsychic differences anddynamics.

Economics

Kadushin (1974) writes: "Neglect appears to be aresponse to social stress. More often than not, theneglectful mother has no husband, is living on amarginal income and in substandard housing, andis responsible for the care of an atypically largefamily of children." (p. 283) This is a fair state-ment of the point of view that neglectful parentsare, themselves, victims of misfortune. Poverty is,of course, a predominant form of stress, and thefailure to provide adequate economic underpin-nings for each family rests, in large measure, on anincreasingly inadequate system.

Piven and Cloward (1971) doubt that our publicwelfare system is geared to reducing either povertyor its stressfulness. Several of us have demon-strated that the standard of living of childrenreceiving assistance under the Aid to Families withDependent Children program is more barren thanamong others of the rural poor (Bonem and Reno,1968; Polansky, DeSaix, and Sharlin, 1971).Jeffers (1967) documented what life is like forwomen and their children in a poverty-level hous-ing project in Washington, D.C. As the late SophieTucker used to say, "I've lived poor and I've livedrich. Rich is better." Child neglect is seen, then, asone result of the pervading stress that poverty im-poses.

Closer to our immediate concern are the fewpapers dealing with the effects of abject familypoverty on children. In a study of women commit-ted for child neglect to the New Jersey Reforma-tory for Women, Schorr (1968) reported that atleast half had been living in housing that wasdangerous; really unfit for human occupancy.

Noting how children of migratory workers may beeither illegally at work in the fields or else leftlocked in shacks all day, Bennett (1968) has caJled

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them "the most neglected children of America."(p. 308) Reul (1974) has also dealt with the dread-ful living circumstances to which many children ofmigrant workers have been exposed, and with theextent of their hunger (1973). Hers is one of thefew writings dealing with the plight of many In-dian children residing on reservations. From ourown unsystematic observations, Indian childrenare other candidates for Bennett's unlovely title.

The study by Giovannoni and Billingsley (1970) iswell known. Assuming the effect of economicstress, as such, the study goes beyond it to examineother factors often associated with poverty. On thebasis of past histories, 186 low income womenwere grouped into three categories of child caring:adequate, potentially neglectful, and, neglectful.They were then iL, erviewed, once, in depth to tryto learn more about why some mothers were moreprone to neglect than others.

The interviews, which dealt with past and presentlife circumstances, revealed that neglectfulmothers were likely to have more children, to bewithout husbands, to have had recent maritalproblems, and to have even worse financial andother resources (e.g., no telephone) for child care.Isolated within their neighborhoods, they alsoreceived less emotional support from their kin. Onthe other hand, social and familial backgroundsdid not seem to differentiate the neglectful mothersfrom the other groups. Hence, the authors con-cluded that neglect is more typically the product ofcurrently experienced stress than of traits whichhave become part of the mother's personalitybecause of her past life;

The conclusions of Giovannoni and Billingsleyare in contrast with those of several others whobelieve they have discerned a generation-to-generation cycle of neglect. The obvious, logicalquestion to be raised is whether failure to locateeffects of the mother's earlier life in one study is tobe viewed as evidence that such effects are irrele-vant to understanding her present state.

Can reliable reporting about past life and familialbackground be obtained in a single interview?Why do neglectful women find themselves withmore children and no husbands? How did theymake their way into these hard lives? The samesort of questions must, of course, be raised with

12

respect to Schorr's conclusions from the relation-ship between housing and neglect. And furthercomplicating the logic are reports, thus far anec-dotal and impressionistic, that the rate of neglect isrising now in our affluent suburbs.

To paraphrase one of our consultants, it wouldseem conservative to assume that neglect becomesmost likely when a person who is internally dis-organized is confronted by circumstances whicheven rather competent adults would find hard tomanage; i.e., when inner chaos is joined by exter-nal stress. The -neglectful mother, for various per-sonality reasons, is more prone to get into difficultsituations. Once immersed in troubles, they ex-acerbate her sense of being overwhelmed.

Rather than a linear relationship from poverty, tostress, to neglect, we visualize a "funnel ofcausality," as in systems theory, in which past andpresent, internal and external forces play theirparts (Polansky, Borgman, and DeSaix, 1972, p.212). Among the forces, those customarily labeledeconomic and the deprivations associated withpoverty-'certainly play a role. But the role is notsimple and direct. If it were, all poor ipa'rentswould also be neglectfula proposition which iscertainly not correct.

Cultural Values and Child Caring

The impact of cultural values on the treatment ofchildren is, of course, very striking when we lookbeyond our own society to those very differentfrom ours. In the Hawaiian royal family, in whichbrother-sister marriages were the rule, the problemof defective issue from inbreeding was solved byrelegating such infants to death by exposure, acustom followed also in ancient Greece. The Brit-ish discovered a somewhat related practice in cer-tain parts of rural India. Because daughters re-quired dowries, they were considered economic

liabilities; so, female infanticide was common.Even today in some villages, male children out-number female by 50 percent, a disproportionreinforced, in part, by neglecting adequate medicalcanp for infant girls (Minturn and Hitchcock,1966).

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There are two reasons for mentioning cultural in-fluences as possibly operative in child neglect.First, one opinionlay and informal rather thanscientific, to be sureholds that what some of usregard as neglect is, among the poor or the lowersocioeconomic classes, "the way we live" and,therefore, socially accepted. The second occasionfor examining culture comes from the observationthat, whether or not whole social groups have verylow standards for child caring, there definitely ap-pear to be extended families in which the childrearing values border on neglectful.

Theories regarding the impact of the culture ofpoverty take the following general form. Actingthrough the family, culture molds the personality;the modal personality, in turn, determines theculture's institutions and values; significant in-stitutions affect child rearing practices, and these,in turn, help to establish the "average-expectable"personality in the next generation.

A few writers have focused on a "culture,"seemingly stable across successive generations,that characterizes life among the poor in theUnited States. To Walter Miller (1965), the focalconcerns of lower class culture are trouble, tough-ness, smartness, excitement, fate, and autonomy.o

"Many lower-class individuals feel that their livesare subject to a set of forces over which they haverelatively little control." (p. 155) Battle and Rotter(1963) have shown "external control of reinforce-ments" to be more commonly experienced amonglower class children than middle class. Polansky(1969) reported a similar difference on "feltpowerlessness." (See also Hollingshead, 1964, andBesner, 1968.) Komarovsky (1969) held that in thelower-lower class, there is no plan or rationale forchild rearing other than an inconsistent attempt tokeep the children under minimal control.

Hence, it might be argued that, in addition to itsobvious privations, growing up in poverty leavesyoungsters with valuesindeed with characterstructuresless useful for competing in our socialorder. When they, in turn, become parents, theyare ill equipped to provide materially for theirchildren; they are also ill equipped to help theirchildren to internalize controls.

This is an attractively complex explanation, but ithas a serious flaw: by most standards, only a small

proportion of the poor really neglect their children.We know of no culture in which one earns amedal for child neglect, for abandoning one'schildren, or for other like behavior. Since this is so,it seems appropriate to regard the "culture ofpoverty" as a condition which lays a trap for awhole class of people, but which ensnares only asmall minority. This has been true until now. It isbecoming harder to predict what will happen inthe "behavior sinks" of our cities.

There do appear to be subgroupspockets of peo-ple, isolated extended familiesabout whom wehave the strong impression that something like acultural explanation is applicable. That is, thereare couples who seem to lack meaningful stan-dards for how their children should be treated.And their histories, when known, often reveal thatthey, themselves, were reared in similarly child-anomie families.

Interestingly enough, a literature does exist onclass related differences in child rearing practicesand beliefs, but it does not really tap issues ap-proaching neglect. Studies of the age of toilet train-ing or weaning do not raise the kinds of questionsthat concern us. For example, does the motherstrongly believe children should be fed meals with-out fail? In one study of women identified asneglectful, we found that they gave socially ac-ceptable answers to such questions, but their ob-served practices were wildly out of line with whatthey professed (Polansky, Borgman, and DeSaix,1972).

No adequate methodology has as yet beendeveloped for the systematic study of culturalvalues about child caring at the basic level thatconcerns us. Practically all the data are based onself-reports, or are anecdotal, or fragmentary. Theresearch technology appears to be well withinbehavioral science capability, but it simply has notbeen developed.

We may soon be badly in need of such studies.Values about essential ingredients of child car-ingtaken for granted by the bulk of our societyfol at least the past two or three generationsareturning up missing. Nor are the poor the only ele-ments of the population for whom this is true.Some experts have the impression that there isnow more neglect in middle class families from the

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affluent suburbs than heretofore. Children are leftalone at relatively young ages while their parentsgo out of town; many are left unsupervised for longperiods; others turn up at school unkempt or inap-propriately dressed for the weather. Often, suchinstances are associated with parental alcoholism,but sometimes they reflect a more pervasive trendto abdicate parental responsibility in favor of per-sonal gratification.

Breakdown of the Nuclear Family

At what point in history have the married coupleand their children, standing relatively aloneagainst the world, been asked to undergo the levelsof stress that some of our families face? Even fron-tier families travelled and settled in groups,emphasized neighborliness, clung to the extendedfamily for protection.

One line of explanation for the possible rise in theprevalence of neglect (if there is one) is that thenuclear family is collapsing under a load it was notdesigned to carry. In this theory, the modern ver-sion of the nuclear family is a unique and ratherdysfunctional emergent from the industrial revolu-tion. Slater (1970), drawing on the traditions ofSorokin, Louis Wirth and Thomas, andZnaniecki, argues thlt basic human desires for"community, for engagement, and for depen-dence" are frustrated by the American life style."One can no longer as in the past take refuge ininstitutions such as the extended family and stablelocal neighborhood." (p. 5)

Other writers, such as Parsons-and Bales (1955),have called attention to the increased vulnerabilityof the family in times of rapid social change.Effects are thought to fall most heavily on the ur-ban poor (Raab and Selznick, 1959). Hence, theapparent similarities of neglectful families, as weobserved them in rural Appalachia, to those foundin cities have theoretical as well as practice im-plications.

The degree of role differentiation between thesexes was becoming even greater (at least whenthese statements were composed) according toRainwater (1969); also, conjugal pairs werethought to be increasingly thrown on each other in

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their joint isolation. Roach and Gurrslin (1969)went so far as to suggest that the poor are too iso-lated even to transmit group values much less a"culture of poverty;" but this is an extreme posi-tion applying perhaps only to the most dis-organized segments of the lower class. We alsohave evidence that low socioeconomic couplescommunicate less with each other than do middleclass couples. Thus, the pressure on the woman inher maternal role in a very poor family is exacer-bated (Morris, 1968).

If one is looking for universal trends, the literatureis filled with contradictory statements and analysesat cross purposes. For example, one body of opin-ion holds that, with such conveniences astelephones and automobiles, families are more incommunication than they have ever been. Hence,the statement that nuclear families are overloadedwith functions and more isolated than ever beforeand, therefore, neglectful is controversial:It is alsocontroversial if we presume that the neglect reflectsa universal trend.

It is less controversial, however, if we confine ourattention to the neglectful family, as such. Manyhave noted that neglectful families are often iso-lated, either lacking an extended family, or rejectedby it, or withdrawn from it. Evans, Reinhart, andSuccop (1972) studied 40 children with The"failure-to-thrive" syndrome. They noted that,among the features widespread in the group ofcases, both parents seemed lonely, with few socialcontacts or recreational outlets; none had supportfrom families of origin. Fathers in these familieswere also seen as offering the mothers little emo-tional sustenance in times of need.

Several features thus recur in reports on neglectfulfamilies: they are said to be out of communicationwith other comparable families in their locales;they are said to be isolated, also, with respect toreceiving emotional and practical support fromtheir extended families; and they are described asbreaking down, meaning that lines of communica-tion, assurances of security, and practical compe-tences are all scarce commodities.

In a general way, there are two popular lines of ex-planation for what has been observed or, at least,presumed. One is the sociological explanation towhich we have alluded, and the other is psy-

19

chological, in the sense that the familial collapse isseen as secondary to the personality problems ofthe parents. That the two modes of thinking are in-sufficiently on the same plane to be placed in jux-taposition has not deterred their use as vehicles ofargument.

Parental Pathology

The most immediately visible cause of theproblems of those who work directly withneglectful families lies in the personalitydifficulties and lacks in the parents. Yet, in the at-tempt to generalize about these difficulties, one islikely to be overwhelmed, especially if grounded inclinical work. Calling all these diverse people"neglectful"as if that provided a diagnosisissimply incredible. Therefore, one looks for a list-ing of diagnostic types, hopefully with some atten-tion as to which are most prevalent among parentslabelled "neglectful." The literature on neglect,such as it is today, offers very little help.

Indeed, we have found only one reference inwhich an attempt was made to identify the per-sonality types most prevalent in neglect situations,and it was our own (Polansky, DeSaix, andSharlin, 1972). And our listing is unsatisfactory ontwo grounds: first, it is based on an examinationonly of the mothers' personalities; second, it is in-complete, even in listing maternal problems.

It hardly seems worthwhile to recount theetiologies of all the clinical types we, ourselves,were able to identify. Some mothers are neglectfulbecause of their own severe mental retardation(Pavenstedt, 1973). We have been told that themain reason they do not constitute even more ofasocial problem is that severe retardation is so oftenassociated with other anomalies that cause infer-tility and/or make mating unlikely. Yet,moderately retarded people often become parents(Henshel, 1972). There is, naturally, an enormousliterature on the etiologies of retardation in whichits connection to child neglect would seem rathercoincidental.

Some mothers are schizophrenic, and the neglectof their children comes from massively distortedvisions of the world or from persuasive with-

drawal. Larger in numbers than the ambulatoryschizophrenics are the women who exist in bor-derline states, only occasionally obviously psy-chotic. Since they are often able to pull themselvestogether under the structure imposed by externalpressure, the psychiatric reasons for their odd,even weird styles of child rearing may escape theunsophisticated observer, especially if the observerplaces a higher value on "new" freedoms than ontrying to imagine how.life must be like for thechild involved.

Many women, for completely understandablereasons, live in a chronic state of depression. In aproportion of such casesas one of our col-leagues, John Patton, commentedchild neglectis secondary to the self-neglect which so often ac-companies depression. The depression may begenetic in originwhich is to recognize the bodyof opinion that endogenous depressions arebiochemical and hereditary. Or it may be chronicbecause of events in the mother's own childhood(e.g., neglect by her own mother). In other in-stances, the depression is thought to be exogenousand with a definable onset, such as desertion by ahusband or lover, or death of a parent. Theliteratures on the etiologies of depression and ofdepressive characters do not require insertion here,even if we were competent to abstract them. Theimportant thing to note is that such conditions ex-ist among mothers (and fathers) who neglect theirchildren, but the "state of the art" is such that wehave no idea in what proportion of cases well-defined depressions are present.

Our comments have been about pathological con-ditions in mothers because our own research wason maternal personality as a determinant of levelof child care. Similar listings can and should bemade as well of paternal pathologies leading toneglect. Although the role of fathers in direct childcare in the lower socioeconomic group, certainly,is less than that of mothers, the problems theycreate for their families and their failures to sup-port the _child caring processes also operatecausally inneglect situations. Fathers who areretarded, alcoholic, psychotic, sociopathic, severelyphobic, senile, or generally inadequate are amongthe types frequently mentioned in connection withneglect. Once again, however, no delineation hasbeen made of types of psychological disability.Without such listings, programs for individual

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treatment and the setting of social policy stand onshaky ground.

Is there a large group of people who are "essen-tially normal" in most respects, but who are par-ticularly crippled in their parenting? To ourknowledge, we are the only group to have raisedthis particular question, crucial as it is for plan-ning treatment. From our study of poor families inrural Appalachia, we concluded that we could nothave found some of the relationships existingamong structural personality variables unlessneglect usually tendslo be part of a more pervasivepattern, a character neurosis or disorder(Polansky, Borgrnan, and DeSaix, 1972). Thisquestion warrants further study, however, becauseeach of us in clinical practice has encounteredclients who were competent, likeable, and substan-tial people but who were, nevertheless, soengrossed in conflict with their own parents thatthey would have been poor risks for parenthood.

Just as there still is no professional typology ofneglecting parents, or even of neglecting mothers,there has been no systematic synthesis of thedynamics accompanying neglect and marginal childcare. Such listings are of interest for purposes oftheoretical integration, of course; they are f.lso oftremendous help to practitioners because they say,"Here are some constellations of motivation andemotion, mostly.unconscious, with which you maybe dealing. One or more may fit the person withwhom you are working." What are some specula-tions to date?

In their study of 15 failure-to-thrive infants, Bar-bero, Morris, and Redford (1963) comment on thematernal response to the infant. New mothers whoalready have deprecatory self-images perceive theirbabies as critical judges of their motheringcapabilities. Feeling thus threatened, such mothersare unable to meet their babies' physical and emo-tional needs. As a result, the neonates show infan-tile depressions resembling the mirasmus reportedby Spitz (1945). They also report a tendency onthe part of the mother to identify in the baby traitsin the father which she dislikes.

Incidentally, it must be mentioned that a numberof investigators have noted a relationship betweenthe failure-to-thrive maternal syndrome and thatfound in child battering (Koel, 1969; Bullard, et

16

al., 1967; Barbero and Shaheen, 1967). In a morerecent paper, Smith and Hanson (972) hypothe-size the two are on some sort of characterologicalcontinuum.

Some typical components associated with the per-sonality of the abusive parente.g., coldness andfailure to empathize with the child's needsarealso exhibited by mothers implicated in failure-to-thrive. We can advance shrewd guesses aboutwhat must have gone on in the early life of such aperson to produce the symptomatology shown inrelation to her child, but to our knowledge onlyMorris and Gould (1963) have dealt with the lifehistories of failure-to-thrive mothers. Many morecomments have been made about the psy-chogenesis of the battering parent. Obviously, itwould be fascinating, now, to know to what extentthe two surface manifestations rest on similarbases, for both are potentially aimed at infanticide.

Alcoholism in one or both parents has been recur-rently associated with reports on child neglect.Both the dynamics of alcoholism and itsbiochemical aspects have been studied, of course.How these dynamics also relate to neglect has notbeen specified, although, once again, some shrewdguesses can be made.

The New York Odyssey House, a drug rehabilita-tion center , has become alarmed about the num-bers of drug addicted young women who seek tobecome pregnant, then insist on carrying the babyto term, despite refusal to give up drugs duringpregnancy. These women also exhibit other kindsof prenatal care which endanger the fetus. Follow-ing birth, they often give the baby limited attentionor effectively abandon it. A syndrome of "poorsexual identity" has been cited as prevalent in thegroup (Densen-Gerber, Weiner, and Hochstedler,1972). Pregnancy is invited by the addict as a nar-cissistic effort to reassure herself that she is allright, a competent female being. The child, havingserved its symbolic function, has scant meaning asa person. The fact is that the neglected child wasoften unwanted as a person, and this is so not onlyamong addicted parents (Evans, Reinhart, andSuccop, 1972).

Among many infantile women (and men!), thehelpless babe-in-arms serves as a buffer againstunresolved separation anxiety and loneliness.

21

Hence, the threat which is not uncommon, "If youremove my children, we'll just make some more."Polansky, Borgman, and DeSaix (1972) have pro-posed we find adult pacifiers less vulnerable thanhuman infants.

Children are also used symbolically in marriagesthat are coming apart. Some are unconsciously re-jected according to the formulation, "If I did nothav you, I would not be so trapped in this awfulmarriage." Refusal to care for the child may serveas a means of infuriating the marital partner; thus,we find child neglect in the service of spite. Bothpartners to a bitterly engrossing bad marriage maybe depressed. Relevant examples are to be foundin the detailed case materials of Sullivan, Spasser,and Penner (1975).

These are just a few of the genotypical emotionalsituations associated with and/or underlyingneglect. It should not be hard to make a far moreextended taxonomy in the terms of ego psychologyand family dynamics. After all, the number ofwidely prevalent, dynamic constellations cannot beinfinite, and such a listing would alert profes-sionals to possible insights which are nowobscured by the surface chaos which first con-fronts them. The message of Sullivan, Spasser,and Penner is this: "These, too, are people!"

We are led finally to a residual groupthose withmarked character problems. Concerning suchparents, order is finally emerging. Several in-vestigators, operating relatively independently ofeach other, have confirmed each other's main con-clusions.

Most serious students agree that we are dealingwith a problem of severe immaturity in a substan-tial proportion of all neglectful parents. In herstudy of 180 neglectful and abusive parents,Young (1964) notes that most of the neglectful are,themselves, childlike. They are dependent, unableto carry continuing responsibility, lack adequateinner controls, have poor or distorted judgmentcharacteristics we associate with failure to mature."If the behavior of neglecting pirents toward theirchildren could be summed up in one word, thatword would be indifference. Children themselves,they reacted as children to the demands andobligations of parenthood and adult life." (p. 31)

Reports similar to Young's came from a group inBoston under the leadership of Pavenstedt. Thus,Bandler (1967) wrote, "The most striking charac-teristic of these families is that they are families ofchildren and the parents have grown up without anyclear normative system . . . . Within the familyunit the needs of the parents take precedence over theneeds of the children." (p. 231) Because of theirchildishness, the parents relate to their children asolder siblings, if, in fact, they assume that muchresponsibility (Minuchin, et al., 1967). Often, theycompete with their children as to whose dependen-cy needs will be met. We have recorded the ten-dency to push older children into the role ofmother's helper, or even of mother (Polansky,Borgman, and DeSaix, 1972).

Cycles of Neglect

The life histories of a majority of neglectfulparents are said to be alarmingly similar to thosethey are offering their own children. Allresearchers who had continuing contacts withfamilies studiedso that life histories could beknown with reasonable certaintyhave been im-pressed with the degree to which current familydisorganization and neglect seem rooted in thefamilies of origin (Young, 1964; Pavenstedt, 1967;Minuchin, et al., 1967; Polansky, Borgman, andDeSaix, 1972; Geismar, 1973). All of these in-vestigators were working contemporaneously, andour own conclusions, at least, were arrived at with-out knowledge of most of the others'. What wehave elsewhere termed the "intergenerational cy-cle of neglect" was agreed to by all our consultantsas well. One of them, G. Lewis Penner, also com-mented on the absence of routine and even ritualin the lives of these parents and of their parents.

The pointing up of intergenerational cycles doesnot discount the impact of current life stress, asemphasized by Giovannoni and Billingsley (seeabove). But it does imply that earlier deprivationsleave marks on one's personality which make theperson less capable of adequate parenting. Sincethese marks are old and go deep, they will not bereversed by superficial measures; nor will they res-pond reliably to environmental manipulations.From their own hard lives, many neglectingparents have emerged isolated and cold, nar-cissistic and basically depressed.

22 .17

The intergenerational cycle is fairly readily ex-plainable by psychoanalytic personality theory.Yet, other possibilities cannot be overlooked. Doesinadequate nutrition cause the high rate of retar-dation and lethargy found among these parents?Ar,e we confronting obscure constitutional factors?We see two parents from'equally.barren environ-ments; yet one is more amenable to help than theother. Why? Lack of expertise in genetics does notaward the privilege of discounting them. Is some-thing like infantilism inheritable?

Mention must be made of the varying forms whichmaternal and/or paternal infantilism takes. For ex-ample, we have distinguished the pattern of apa-thy-futility (i.e., withdrawal and immobilization)from impulsivity (i.e., "acting out" and irrespon-sibility) (Polansky, et al., 1970). The'"acting out"parentoften implicated in temporary abandon-ments of childrenis seen as actually lesspathological, only recurrently neglectful, moretreatable.

aThe origins of this syndromeits func-

tions as defense against inner depressivenessare rather well understood. The more severeproblemthe apathy-futility reactionis thoughtto be rooted in the first months of life, and its

18 23

etiology will be explicated in the section on Sequelaebelow, where it can be seen graphically how han-dicapped parenthood may be transmitted from onegeneration to the next.

Multiple-item behavioral scales in presence-ab-sence format have been developed by Polansky etal., (1972) to rate degrees of apathy-futility and im-pulsivity. DeSaix has used these scales with countychild welfare personnel. Factor analyses presentlyunder way demonstrate extremely high internalconsistency among scale items (Polansky andPollane, 1975, in press).

A major gap in formulations of etiology is the lackof truly relevant theory at the level of the family, assuch. Most observations cited above deal with per-sonal pathology. Yet, neglect is something thathappens in the family system. Except in gross terms,which really amount to differentiating the"organized" from the "disorganized" family, wedo not have concepts for discriminating types ofneglectful families in ways that are relevant toestimating prognosis and prescribing treatment. Even ananalytical mapping of the field of discourse mightbe a contribution at this stage.

Ati

IDENTIFICATION-CASEFINDINGEARLY WARNING SIGNALS

FEW WILL ARGUE the urgency of prompt inter -.vention when child neglect occurs. Yet almostnever, because of the very nature of the condition,will neglectful parents voluntarily present them-selves for help. Therefore, such parents have to belocated, and "casefinding" is the method for doingso.

Casefinding in child neglect requires, first, that theterm "child neglect" be defined; second, that somemeans be developed for identifying the condition;and, third, that processes be established for deter-mining whether or not neglect has occurred. Herewe will concentrate on the step that must be takenfrom the concept of child neglect to its definition.

Specifically this section deals with the operationaldefinition of child neglect, with large-scaleorganization for casefinding in local communities,and with early warning signals.

Identification

Operational definition

?artier, we proposed the following definition ofchild neglect:

Child neglect may be defined as a condi-tion in which a caretaker responsible forthe child either deliberately or by ex-traordinary inattentiveness permits thechild to experience avoidable presentsuffering and/or fails to provide one ormore of the ingredients generally deemedessential for developing a person's physi-cal, intellectual and emotional capacities.

As Gil remarked about his own definition ofabuse, our definition is reasonably satisfying at theconceptual level. The crunch comes when it mustbe applied in the field and when cases of childneglect must be identified. At the present state ofthe art in this country, only a few kinds of condi-tions can be taken as sufficiently convincing primafacie evidence to lead to immediate action by legalofficials. That is to say, we have little that is com-parable to X-ray in detecting abuse. What evi-dences are used?

Outright abandonment is an obvious form ofneglect and is so treated by both police and welfareauthorities. But what is "abandonment"? Themother who goes out, gets drunk, and leaves herinfant alone for 24 hours will be regarded as hav-ing abandoned her childthat is, if the child'ssituation is detected, then reported. The. -motherwho leaves four small children under the care oftheir 8-year-old sister while she goes "down thestreet" for an evening at a tavern is not necessarilyseen as abandoning. Age of the child and theperiod of time the mother is away both affect theappraisal of whether the child was abandoned.

Some children are killed in home fires each yearbecause no adult was at home. It has beenreported that in our own State of Georgia, after atornado has struck, it is not uncommon to findchildren wandering about whose parents are notonly not in the wreckage, they are not in thevicinity; the parents left their children unsuper-vised. So, a fair amount of "abandonment" goesby unidentified, either because it is not gross orbecause parents have played Russian roulette withchildren's lives and won.

Another evidence of neglect seems to be calculatedfrom the obvious inability of parents to fulfill their

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responsibilities because of their own conditions.Included here would be alcoholic parents foundstuporous, with their children unfed for severaldays. Drug addicts also present a problem.Children living in "immoral surroundings" maybe summarily removed, but one does not oftenhear of such action.

The failure-to-thrive syndrome can be quite relia-bly diagnosed when a child comes to medical at-tention and the parents will cooperate. If the infant'is hospitalized and given routine, good nursingcare and gains weight and height on this alonewithout positive medical findings, failure-to-thrivebecomes the residual but rather convincing diag-nosis. The evidence is even stronger when such achild, returned to the mother, loses ground, butagain improves when rehospitalized. Thedifficulties with this diagnosis, howevde,'a're,t'first,that welose many infants because they are notbrought in for checkups and, second, that themothers involved, for neurotic reasons, often"hospital shop" or otherwise elude the staff whodiagnosed the difficulty (Bullard, et al., 1967).

A very great need in identifying chronic, insidiousneglect is for some measuring stick for determin-ing adequacy of parental, especially maternal,care. This implies a scale. The items on the scalemust be likely to be known, or able to be observedand otherwise discovered, by persons doing thefrontline jobs in social service agencies, privateand particularly public (since the bulk of protec-tive services are under public auspices in this coun-try).

It was hoped that important contributions wouldcome out of the well-publicized English study ofall children born during a particular week. That is,from following the whole cohort, one might havebeen able to locate which child care ingredientspredict later difficulties. Unfortunately, the datathus far published make it unlikely these leads willbe forthcoming. Wedge and Prosser's Born toFail (1973) reveals that the predictor variables col-lected were gross, indeed, "Disadvantaged"children are compared with "ordinary." The "dis-advantaged" child was from a one-parent and/orlarge family, of low income, and 'poorly housed;"ordinary" meant none of these was true. And the"disadvantaged," as even so loosely defined, sufferdeficits that show only in relative rates (e.g., bed-

20

wetters are 1:20 among the "disadvantaged" vs.1:250 for the "ordinary").

The pursuit of specific predictor variables to be in-cluded in scales of child neglect, grAo be employedas early warning signals, will require a far moreambitious effort even than that in England. Thesaa truth is that from their gross though 'massiveanalyses, we know little more that is specific nowthan we did before they began. Specifics and ob-servables are needed in construction of predictiveindices and scales.

Casefinding

The major movement across the country for bettercasefinding has resulted from legislation thatemphasizes two provisions. First, personnel andinstitutions specified in the Child Abuse Preven-tion and Treatment Act (P.L. 93-247) are requiredto report cases involving suspected abuse, and suchpersonnel and institutions are free from criminaland civil liability. Second, responsibility is fixedusually in the public social service agencyto im-mediately investigate any such report and to takeappropriate action. Dramatic increases in num-bers of cases reported were noted in the earlier sec-tion on Prevalence of Neglect.

Another part of the movementwhich Floridaseems to have typified best of allhas been to tryto alert the citizenry to the extent of the problemand to gain their coope-ation. Securing public in-volvement seems to require four steps. It is necess-ary (1) to propagandize to get the citizenry excitedabout the need to help victimized children; (2) toinform the public of what conditions to report; (3)to organize facilities so that reporting is convenient;and (4) to provide the needed services so that in-dividuals have reason to believe their efforts andpossible risks are worthwhile.

Such efforts seem to be major facets in the Floridaoperation. Complaints come to a centralclearinghouse that is open 24 hours a day, 7 days aweek. Since each county social service agency isrequired to assign a person "on call" at all times, arequest for investigation can immediately go outlong distance from the central office. Indeed, forthose doing the work, it has some of the excitement

25

of an Army message center or of any emergencycommunity service. This "on call" requirement,however, can be a heavy burden for small countieswhere a two-man staff might have to alternateevenings and weekends in order to maintaincoverage.

The Florida pattern is spreading across the coun-try, but, how quickly, we do not yet know. By now,neglect is mentioned in the laws of most States,along with abuse. But only a few places have at-tempted the advertisement-education effort madeby Florida.

An interesting project is run by the TennesseeDepartment of Public Welfare in Nashville. Theirsetup followed an earlier survey which concludedthat better coordination among the legal and socialagencies in Nashville was essential, if not suffi-cient, to improve the care of dependent-neglectedchildren in Metropolitan Nashville (Bowman,1973).

Since July 1, 1971, with funds from the Office ofChild Development (HEW), the public welfaredepartment has been operating its "Comprehen-sive Emergency Services to Neglected-DependentChildren." In addition to better coordination ofexisting services, it had been found that "The ex-isting system failed to provide quality care for thosechildren during evenings and weekends. Thus achild reported as neglected or dependent outside ofregular office hours was usually subjected to thedrastic experience of abrupt removal from hishome and temporary institutionalization... ." (p.1)

The Nashville plan includes the following:

1. 24-hour emergency intake.

2. Emergency caretaker service. Personnel (ona small weekly retainer) are "on call" tostep into homes where parents haveabandoned their children or are other-wise missing, so that children can remainin their own homes.

3. Emergency homemaker service. For crisissituations, a homemaker is made availa-ble for 24 hours (rather than the usual 8).If necessary, the service is provided for anextended time.

4. Emergency foster homes. These homes (alsokept available on a retainer basis) areready to accept children for placementday or night. -

The Emergency Service Program is geared to po-tential child abuse or neglect, of course, but theservices have also been called into play because amother was hospitalized. These arrangementsreportedly have reduced the number of neglectand dependent petitions filed; they are keeping thechild in his or her own familiar environmentwhenever possible until a study can be made and areasonable decision reached about the child; andthey are making it possible to place the child in astable environment where adjustment can best bemadeand where neglect will not occur again (anot infrequent result when, under pressure, place-ments are made with neighbors or relatives). Now,children do not have to be taken to the police sta-tion while arrangements are made for them.

The Nashville program demonstrates an interfacebetween the processes of casefinding and treat-ment. The program can be seen as treatment, butthe fact is that, unless needed services are availa-ble, many cases will not be referred out of poorneighborhoods. Only if social agencies have ser-vices to bring to a problem do they earn the reputa-tion in a community as representing more than thethreat of removing the child (Varon, 1964). So,services like those in Nashville, or at the BowenCenter in Chicago (discussed below) are to beseen as also operating in the direction of earlycasefinding. Indeed, the role of visible services infacilitating community referrals deserves researchin its own right.

Early Warning Signals

If the activities listed under Treatment (below) con-stitute defenses in depth against child neglect, thenspotting families most at risk of becoming neglectfulis our "DEW line." Early warning signals take anumber of forms. Some are structural variables,tending to pick out categories of families likely toprovide low levels of care c--ir their children; othersare very dynamic, momentary things: a chanceremark dropped by a mother following birth of ababy, or something observed about the behavior of

t 2621

a child in school. The two types of leadsstruc-tural and dynamicare described below.

1. Structural leads

Two broad types of families warrant considerationin the early identification of child neglect. Theyare the family already disorganized or dysfunc-tional, albeit not known, and the family that isknown to be potentially but is not yet neglectful.

To the woman who has been functioningmarginally as a mother, or operating with-, atenuous grip on her problems, any added stressmay break down her ability to cope. Hanson andHill (1964) have described families in danger ofbecoming disorganized under the impact of anatural disaster, a death, divorce, or any change inthe status of the family. We believe that the rele-vant research needed would show that ruralfamilies which collapse under the impact of mov-ing to the city were often poorly functioning intheir original settings. Sociological researchemphasizes how such families deal with mobility.Not all become neglectful but, until the stress haspassed, it would pay for social agencies and othersto be alert to the risk.

Beyond families of limited resilience are a group ateven greater risk of becoming neglectful: these arethe multiproblem families who score poorly onGeismar's (1973.) scales of family functioning.Such families are poor at problem solving, oftenisolated from their communities, and havediffusely conflictual relation-hips within thefamily.

From books like Geismar's 555 Families, it is possi-ble to sketch an empirical' listing of expectable lifecrises with which nearly all young families mustcope. Geismar focused on the coming of the firstbaby. Multiproblem families labor hard to managethe universal family crises, but they are swampedby problems outside the normal.

According to the famous series of studies con-ducted in St. Paul (Minn.), multiproblem familiescome to. the attention of social agencies rather soonafter marriage (Geismar and LaSorte, 1964). Thesame investigations, by the way, affirmed the in-tergenerational effects cited above. The degree of

22

^NIV.1421

unity in the husband's family of orientationshowed a strong relationship to the unity in thefamily of procreation: stable families reflect stablebackgrounds, on the average.

Other families at risk may be identified by whatcould be called the "structure of the life situation."Taylor (1973) has written a powerful documenta-tion of hardship, hunger, premature push toresponsibility, ,nd despair imposed on children inmigratory labor camps. Some are already har-vesters at age 7 or 8. Friedland and Nelkin (1971)cite a report by one participant observer. Left alonefor most of the day, the children formed a sub-culture of their own, as children so often do. Anoteworthy feature of this one, however, was theprimping and sexual provacativeness displayed bythe little girls.

Coles (1971) has written sympathetically of thedrift toward apathy and numbness in which con-strictions in the migrant children's personalitiescome to resemble the outer oppressiveness of theirlives. Similar constrictedness has been observedamong both adults and children in areas ofchronic poverty and unemployment (e.g., the so-called Black Areas of England in the 1930's).

The relationships among pregnancy at a youngage, close spacing of children, and child abusehave been discussed by Elmer (1963); comparablework on neglect has not yet been undertaken. Ofmothers on welfare in New York, Podell (1973)found that 58 percent had become pregnant forthe first time by age 19, and 56 percent of those 30years of age and over had five children or more.Among this group, the whites had fewer childrenthan blacks or Puerto Ricans. Asked how manychildren they would like to have had, six of tenwanted two children or fewer. Twenty-five percentof all the women said that if they "had it to do overagain," they would have had none! Although avery substantial majority were aware of birth con-trol devices, only 40 percent of those at risk ofbecoming pregnant were taking preventivemeasures. Therefore, it was no surprise to findthat, of the women separated from their husbands,60 percent had had additional children. If Podell'sfindings prove generalizable to other settings, itmay have to be concluded that being on publicassistance may, itself, be a kind of early warningsignal on statistical grounds.

27

From the structure of the situations of thesefamilies, we turn next to leads derived from struc-tural elements in the parents' personalities. In anexcellent paper on "high risk" children,Pavenstedt (1973) cites Dr. Doris Bennett's criteriafor spotting families whose youngsters will provelikely candidates for compensatory care:

Serious alcoholism, drug addiction, psy-chiatric disturbance, chronic physical ill-ness or mental retardation of one or bothparents; prolonged absence of motherfrom the home; fatherless homes in whichthe mother is totally unable to cope withrearing children due to her own emo-tional deprivation or depression; amother who is under 16 at the child'sbirth; chronic delinquency of eitherparent or older siblings; a history of oneor more cases of failure-to-thrive due toneglect in the family; one or more siblingspreviously removed from the home.by aprotective agency. (p. 393)

In a subsequent publication, Pavenstedt speaks ofthe need for preventative services for vulnerablechildren (Pavenstedt, 1973). After citing Bennett'scriteria and describing her as "a pediatrician prac-ticing in a neighborhood similar to ours,"Pavenstedt reports, "With these criteria she found143 (57% ) of 246 children 'at risk' in her case loadin children five years or under, 83 of them underthree." (p. 20) These are ominous figures from thevery low income neighborhoods in which thesedoctors practice. Pavenstedt also cites thevulnerability to neglect of children born to adoles-cent mothers. Another group at great risk arebabies with congenital defects or birth anomalies,born to mothers who are already overburdened.

Findings regarding the impact of maternal (orpaternal) retardation are still ambiguous(Sheridan, 1959; Borgman, 1969); that is, we can-not say at what level low IQ must, itself, be seen asan early warning signal. It is disappointing thatBorgman's study appears, thus f.n.r, to have beenthe only one in which someone thought tosystematically include intelligence measurement inappraising neglectful families. One complicationin prediction comes from the fact that persons withidentical IQ's by measurement may operate quitedifferently in relation to life tasks, depending on

other factors in their personalities. Yet there seemslittle doubt that below some level (might it beIQ 50?), sheer intellectual limitation plays adefinite role in parenting failure. "Mental retarda:tion is present in the largest group of families thatgive us constant concern." (Pavenstedt, 1971, p.66)

Alcoholism is associated with neglect sufficientlyfrequently to be regarded as an early warning sig-nal, especially when present in both parents. Intheir study of 100 alcoholic American Indianfamilies, Swanson, Bratrude, and Brown (1972)found starving children in 85 percent of thefamilies, not to mention the presence of abuse,truancy, promiscuityand alcoholism among thechildren themselves.

Drug addicted mothers constitute another groupwhose children are shockingly "at risk." We are,therefore, indebted to the zeal of Densen-Gerberand her colleagues at Odys'sey, House (see page 16)for their nonsentimental analyses of the eventstypically involved (Densen-Gerber, Hochstedler,and Weiner, 1973). Earlier, we mentioned that ad-dicted women often become pregnant to reassurethemselves about their femininity and that they arereluctant to induce abortion. At the same time, atleast some (not those retained in the OdysseyHouse program) refuse to stop using drugs.

The satisfaction for the addict comes when shefinds herself pregnant and "full." Ambivalent feel-ings toward this separate human assert themselveswhen the mother feels movement. Commonly, themother has no use for the child's father after con-ception; he served a purpose, and her difficulty insustaining all meaningful relationships also dis-rupts this one.

The odds of neglect are, of course, very great, sincemany women will not give up antisocial behavioror drug-taking even during the latter phases ofpregnancy. There is real danger, apparently, thatthe infant will be born a !dieted if the mother re-mains on drugs in the last trimester.

Addicts observed in the controlled treatment set-ting present unusual challenges. The Odysseyprogram emphasizes trying to help the patientassume motherhood and protect her baby. For thewoman who will neither abort nor submit to drug

2823

withdrawal, Odyssey House believes in commit-ment during the pregnancy, if necessary, in orderto take the mother off drugs against her will. Sucha threat would probably lead narcissistic women toopt for abortion.

Pavenstedt also reports that numerous neglectfulmothers had, in their own early lives, sufferedcatastrophic experiences, such as massive depriva-tion and family separations. Many had beenplaced in children's institutions or other foster caresettings when young; some had had psychoticparents and/or are, themselves, severely unstableor psychotic. They show indications of obviouschildhood neuroses and are, to use Pavenstedt'sexpression, "fragile" people still.

Yarden and Suranyi (1968) found that, of childrenborn to Israeli mothers who were schizophrenicduring pregnancy and who had subsequently beenplaced in foster case, only 8 out of the 44 childrenstudied could be returned to their families. Theynoted that a number of the children in placementwho made visits home were maltreated orneglected during these visits.

Returning a child to the home has to wait on thesuccess, if any, of treatment of the mother. If shebecomes only minimally functional outside thehospital, the need to care for another human beingmay be beyond her.

From our own experience of private and publicpsychiatric hospitals, we can state unequivocallythat it is a rarity in these United States when deter-mination of a women's readiness for dischargetakes heavily into account her probable suitabilityas a mother. Public policy favoring early deinstitu-tionalization could, without built-in safeguards,contradict public policy toward preventing neglect.Indeed, some psychotherapists still take thefatuous position that "having a child might betherapeutic" or "will hold the marriage together."We would hope social asencies routinely resistsuch reasons for approving adoptive placementsbut, while most do, a few do not.

2. Dynamic leads

Disturbances in the early mother-child relation-ship can be observed even when pregnancy first

24

occurs. A Swedish study giving the unfortunatelater fates of children born to mothers who had re-quested but been denied abortion will be citedbelow.

In the failure-to-thrive sr. drome, - the mothertypically reports some upset around the time ofbirth of the baby and views her child with an auraof detachment (Maginnis, Pivchik, and Smith,1967). Both Maginnis, et al., and Evans, Reinhart,and Succop (1972) report that the nonthrivingchildren in their studies were unplanned or un-wanted by their mothers. Unlike other neglectfulfamilies, however, these were neither spatiallymobile nor socially isolated, and they were usuallyself-supporting on at least marginal incomes. Butthey were not motivated to ask for help. To repeatan earlier theme, some of these early warning sig-nals are reminiscent of those regarding abusiveprents (Nurse, 1964; Okell, 1972). Fontana,(1972) shares this feeling: "In our view, thefailure-to-thrive cases seemed clearly linked todeliberate abuse. There was an indication of whatmight be called active neglect." (p. 23)

It may prove important to distinguish between "in-adequate" and "distorted" mothering (Whitten,Pettit, and Fischhoff, 1969). Indications of milddepression and of noticeably poor muscle tonuswere found in the babies of the unempathicmothers reported by Robertson (1962). Robertsonbelieves that, for a mother with a new infant, someanxiety is normal; in fact, absence of anxiety maybe an ominous sign. Also, infants who show theresponses reported by Robertson may be alertingus to further trouble.

Stone (1971) claims that symptoms of disorders inearly infant-mother interactionfor example, ababy who is hyperactive or unresponsive, or amother who shows neurotic reactionsare usuallyresponsive to brief psychotherapeutic "first aid."He goes on to state that "Recent studies of childabuse have revealed how frequently in the week orso beforehand [before abuse actually occurs] thefamily doctor had been consulted by a desperatemother." (p. 225)

With respect to child abuse, a number of clinicianshave now identified patterns that alert emergencyroom personnel; e.g., indifference on the part ofthe parent to the child's suffering, failure to visit

29

while the child is hospitalized, etc. We do not havecomparable ideas about potentially neglectfulparents, but the communicated wish not to have ababy may be an analogous warning.

Signals which may be picked up by teachers,counselors, nurses, and others in contact withmany children have been paraphrased by Fontana(1973) from a listing by the American HurnaneAssociation. Developed for detecting abuse, manywould probably also apply in the case of neglect.

A child who is frequently absent or late.Whether his problem is at home or inschool or within himself, known to hisparents or not, his habitual lateness or ab-sence strongly suggests a maladjustment.

A child who arrives at school too earlyand hangs around after classes withoutapparent reason. He may not be welcomeor cared for at home; he may hate hishome, or be afraid of it.

A child who is unkempt and/or inade-quately dressed. If he is dressed inap-propriately for the weather, if hisclothing is dirty and torn, if he ishabitually unwashed, if other childrendon't like to sit near him because theythink he smells bad, he is clearlyneglected.

A child who more than occasionally bearsbruises, welts, and other injuries. Will hesay how he got them? Does he complain ofbeing beaten at home? Or is he alwaysfighting?

A child who is hyperactive, aggressive,disruptive, destructive in behavior. Hemay be acting out his own hostility. Hemay be reflecting the atmosphere athome. He may be imitating his parents'behavior. He may be crying out for atten-tion and help.

A child who is withdrawn, shy, passive,uncommunicative. He is communicating.Whether he is too compliant or too inat-tentive to comply at all, he has sunk jntohis own internal world, a safer one, he

thinks, than the real world. His message isin his passivity and silence.

A child who needs, but is not getting,medical attention. He may have untreatedsores. He may have an obvious need fordental work. He may need glasses to seethe blackboard.

A child who is undernourished. What isthe reasonhonest poverty, or uncaringparents?

A child who is always tired and tends tofall asleep in class. Either he is not well,his parents are neglecting to regulate hisroutines, or he is simply unable to get tobed and to sleep because of familyproblems.

The parent who becomes aggressive orabusive when approached with a view todiscussing the child's apparent problems.

The parent who doesn't bother to show upfor appointments, or is so apathetic andunresponsive that he might as well havestayed at home.

The parent who is slovenly, dirty, andpossibly redolent of alcohol.

The parent who shows little concern forthe child or what he is doing or failing todo.

The parent who does not participate inany school activities or come to any schoolevents.

The parent who will not permit the childto participate in special school activitiesor events.

The parent who is not known to any of theother parents or children.

The parent whose behavior as describedby the child is bizarre and unusual.

The parent whose behavior is observed byschool personnel to be strange, bizarre, ir-rational, or unusual in any way.

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Policy Issues

We have treated neglect as if it were a diagnosablecondition. Therefore, it is important to noteasone of our consultants, Dr. Alfred Kahn, pointedout to usthat neglect is also (possibly primarily?)a social problem. Legally, neglect is, to a large ex-tent, what the local courts adjudicate it to be, andthe minimg5Q,4;1evel of acceptable parental care is amoveable line that changes with communitynorms.

No doubt, the systems for casefinding and report-ing also affectif not what is regarded asneglectful at least, the neglect that conies to ourattention. For instance, Mr. Walter Leefman of theMassachusetts Society for the Prevention ofCruelty to Children reported that the Society oncehad a spot announcement for 3 days on a localtelevision station in Boston. Sixty referrals werereceived on the first day. One may conclude,therefore, that community norms about "childcare that warrants reporting to the authorities" arecertainly susceptible to deliberate influencingthrough public interventionsand particularlythrough the use of the media.

26

The operative definition of neglect, in other words,is also manipulable, and professionals must decidewhether they should or should not participate inthe process of public definition. Of course, to donothing about educating the public is a form ofnegative participation, so there really is no escap-ing the decision.

Other policy issues have to do with the responsibleagent of neglect. Nearly all the arralyses abovepresume the parents to be the agents. How aboutsocietal neglect?the failure, for example, of ourwhole Nation to prevent what has been observedamong migratory laborers. Or the failure to pro-vide for universal medical care for children? Isneglect a sufficient national priority to warrantsome significant changes? Shall we designate it asagency neglect when children already removedfrom their own parents are subjected to repeatedreplacements in foster homes? Is agency neglect amisdemeanor, and, if so, who should be chargedwith it? Or is the term to be left in the realm ofrhetoric? What level of obtuseness, vacillation, orincompetence shall we designate as "profes-sionally unethical behavior" by judges or socialworkers? These are questions already raised; theyare not for the future.

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SEQUELAE

NOTHING STIRS SO GREAT A SENSE OFURGENCY that we move to do something aboutneglect as when we review what is known about itsconsequences: the pain and loss in the lives of thedamaged youngsters; the regret Ey what they areunable later to add to the society of which they area part; the enormous cost, ultimately, in the carethat has to be extended by a humanitarian societyto keep them afloat, or even alive, in view of theirhandicaps.

Evidence regarding the sequelae of neglect is con-stantly accumulating in a number of differentfields and, of course, under many different topicalheadings. At the same time, questions arise aboutwhether conclusions advanced are justified, andabout what the specific causative agents are.

We do not pretend to expertise in all the areas inwhich data are accumulating. All we can do,therefore, is to put together what seem to be theWell-accepted studies. Another introductory pointis simply this: neglect, by definition, can take manyforms, and so can the terrible marks it leaves.

Neurological and Other PhysicalSequelae

Young (1964) defined "severe neglect" as failureby parents to feed the young adequately. Evidentlythis failure can begin while the infant is still inuterothe subject of some interesting studies ofthe last decade.

Animal studies, which permit experimentalmanipulations unthinkable in humans, are a ma-jor source of provocative findings. Rats inade-quately fed during pregnancy produce pups whosebirth weights are below normal, and the deficitcannot be compensated for by adequate diets inthe period shortly after birth. Likewise, rat pups

suffering malnutrition in utero and during thepostpartum period have a deficit in number ofbrain cells, and this numerical deficit also cannotbe compensated for later in life (Vore, 1973).Studies indicate that not only are there fewer cells,but the size of the cells is also adversely affected byprotein deficiency.

Other animal studies show the brain to be mostvulnerable during its most rapid growth. After-ward it is more resistant to nutritional damage, butit is also less able to be positively affected.Problems with brain size are accompanied byalterations in distribution and appearance of nervecells in the brain and by poorer performance onlearning and other behavioral tests (e.g., coordina-tion). The earlier the nutritional deficiency andthe longer its duration, the more severe and per-manent the consequences for the brain and centralnervous system (Scrimshaw, 1969).

The human brain grows to a certain size, andthereafter begins the lifetime process of dying.Unlike the liver, for example, the brain is unableto replace cells. The evolutionary function of thisarrangement is thought to be this: that cell replace-ment would entail obliteration of connections,erasing learning. Hence, for the survival of thespecies, the individual is sacrificed.

Human brain tissue shows an increase in numbersof cells until about 12 months post utero; cells con-tinue to grow in size until around age 3. Malnutri-tion cas apparently cause up to a 60 percent deficitof brash cells (Vore, 1973). Children severelymalnourished during their first year may havehead cin umferences as much as 1 inch subnormaland i itt.,acranial volume 14 percent less(Scrimsha':vv, 1969).

Important studies have been done by Winick atthe University of Chile. The brains of children

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who died of mirasmus (see Spitz, below) beforeage 1 had less DNA on biochemical analysis, in-dicating fewer brain cells. Insofar as there is scien-tific debate on the issue at all, the burden of proofwould now be to show that a child can experienceprotein deficiency without central nervous systemdeficit.

"Kwashiorkor" is a condition reported in Indiaand Africa that affects young children. We wereintrigued to find it literally means "first-second" inthe Ga language of Ghana. The name derivesfrom the fact that the condition is observed whenthe firstborn is replaced on the breast by a second.The first child then develops such signs ofmalnutrition as edema, fatty liver, diarrhea, loss ofappetite, and profound apathy. Recently, theSenegalese psychiatrist, Dr. H. Collomb, specu-lated that Kwashiorkor may have psychological aswell as nutritional roots." "The psychosomaticmeaning of the Kwashiorkor , . . could then be in-terpreted as an expression of more or less brutalmodification of the mother-child relation-ship ... the Kwashiorkor might be a mentalanorexia developed on a foundation of severemalnutrition." (Collomb, p. 450) In any event,the disease constitutes a dramatic instance of earlynutritional deficit.

The interesting data from the major British cohortstudy have been mentioned already. Results on thechildren to age 7 were reported by Davie, Butler,and Goldstein in 1972. A later report brought thechildren to age 11 (Wedge and Prosser, 1973) con-trasting "disadvantaged" with "ordinary" children(see p. 20). Disadvantaged children were morelikely to have suffered hearing loss; five times morelikely to be absent from school for physical andemotional reasons; and they tended to be markedlybelow average in height for their age group.

Going beyond the connection between nutritionand physique, a number of investigators have alsobeen impressed by the interaction of physical andpsychological factors in child development. Themother who lets her child go hungry is deprivingthe infant in terms of closeness, sensitivity to hisneeds, and empathic stimulation. The hypothesisraised is that inadequate psychological motheringcontributes to indifferent appetite in the infant'and, therefore, pis a contributing factor tobiochemical changes.

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In line with this reasoning is the report by Powell,Brasel, and Blizzard (1967) of a group ofyoungsters admitted to Johns Hopkins MedicalCenter with a preliminary diagnosis of hy-popituitarism; however, it was found they did nothave this illness. But social studies showed them tocome from neglectful homes characterized bymarital- strife, alcoholism, abandonment, and thelike. When placed in a "caring" environment, thechildren made dramatic gains without receivinggrowth hormones at all.

In similar vein was the delineation of the failure-to-thrive syndrome by Bullard, et al:-,- (1967) inBoston, including stunted growth, developmentalretardation, and other evidences of malnutritionwithout identifiable organic basis. The Bostongroup, too, remarked on the intricate relationshipsbetween physical and emotional needs of the in-fants. Assessment of these needs is complicatedeven further by changes in the child as he movesthrough maturational stages during the first year.

Hepner and Maiden (1971) were involved instudies of malnutrition among offspring of the in-ner city poor of Baltimore. They found the child'snutritional statusverified by laboratory studiesthat took into account the demands of develop-mental growth spurtswas not related to income,to family expenditures for food, or even to specificcaloric intake. Rather, it correlated with themother's score on the cognitive/emotional phase ofthe Childhood Level of Living scale.

On the other hand, a cautionary note is soundedby Whitten, et al., (1969). They believe they haveshown that, among some children who might havebeen diagnosed victims of failure-to-thrive, weightgain could be induced Simply by ensuring betterfeeding, without improvement in other facets ofmothering. So the apathy noted in deprivedyoungsters may derive from simple starvation.They also make the point that, since it has becomecommon to use the third percentile in height andweight as the cutting point for diagnosing failure-to-thrive, many threatened youngsters go un-detected because their deficit is not that extreme.

It would be unfortunate if closely supervised feed-ing were neglected as a first-aid measure on thebasis that only by a major overhaul of the mother'spsychological makeup can anything effective be

33

accomplished. But to sustain close supervision offeeding may require psychological treatment of themother. When the failure-to-thrive interactionrests on her pathology, as it so often does, sheevades treatment.

The effects of malnutrition on later developmentof the human, then, are steadily being documentedby research. In addition, evidence suggests that theability of the young organism to make optimal useof food is strongly dependent on the relationshipbetween mother and child. From the number ofrequests we have received for our CLL scale(which was used by Hepner and Maiden), wehave reason to believe the latter hypothesis is beingsubjected to- further testing.

Earlier this year, the U.S. Senate Select Commit-tee on Nutrition and Human Needs was given thefollowing report: "Malnutrition appears to be thecommon denominator of each of theseproblemslow birth weight, infant mortality,mental retardation, and intellectual malfunction.Any attempt to break the cycle of poverty charac-terized by these phenomena must include nutri-tional intervention or this wastage of human lifewill continue unabated." (Quoted in THE NEWYORK TIMES, January 21, 1974.)

The relationship between malnutrition and childneglect, by whatever definition, is obvious.However, we become aware that there are in-stances in which the provision of food in a waythat assumes "normal, expectable parentalbehavior': will be a necessary co, ndition for helpingchildren, but it will not be*Csufficient one.Research is needed to see to what extent, and inwhat types of families, simply making more foodcheaply available will indeed improve children'snutrition.

Emotional Sequelae

Emotional sequelae of neglect can be inferred toan extent from the literature on maternal depriva-tion and related deficits in primary mothering.The dreadful effects of maternal deprivation havebeen documented by many, beginning with theliterature antedating and immediately followingWorld War II when the Nazi tyranny left many

thousands of young children without mothers,either because the mothers had been killed or wereotherwise separated from their children (Skeelsand Dye, 1939; Bakin, 1942; Spitz, 1945, 1946;Goldfarb, 1945; Newton, 1951; Winnicott, 1955;Bowlby, 1954; Oliman and Friedman, 1971).

Consistencies of research findings outweighmethodological defects in individual studies. By adepriving mother, we do not mean a consciouslyhostile, punitive "mom." Rather, we have more inmind a woman who, because of failures in herdevelopment, is simply not sufficiently competentto meet the heavy demands of "good" mothering,especially if her mate's inadequacies further un-dermine her and drain her energy.

The fate of infants deprived of maternal, indeed ofhuman, stimulation has been documented in ob-servations of some cared for in institutions (Skeelsand Dye, 1939; Bakin, 1942; Spitz, 1945, 1946;Decarie, 1965). The infants were found to beapathetic and listless, and their physical develop-ment was below normal. Intellectual developmentwas also retarded in comparison with that ofchildren reared in their own homes. Even moreshocking was the high mortality rate among the in-stitutionalized infants. The absence of human at-tention and stimulation was thought to lead to amassive form of infantile depression and with-drawal which Spitz labeled "mirasmus." Relatedreactions to the loss of "mothering" have been ex-amined very closely by Bowlby (1954).

Harlow and colleagues have reported fascinatingparallels with humans in the responses of infantmonkeys suffering forms of maternal depriva-tion (1971). Exposed to a dummya "surrogatemother"with cold water flowing through it, thelittle monkeys recoiled from the "mother" andretreated to a withdrawn fetal position. Monkeysso reared later proved unable to be coaxed into arelationship even by the "warm" mothers Harlowcalled "therapists." It was as if inborn, fixed actionpatterns in the infant primates had been massivelydisrupted by the "cold" mother. All of the in-stances of severe mother-child aggression observedin humans were found in monkeys who had beenseverely deprived of maternal care in their infancy.

Following Bowlby's original book on maternalseparation, a large number of studies show that

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similar effects on infants occur among many whoremain in their own homes. An interesting exam-ple of clumsy infant care is given in a report from awell-baby clinic by a colleague of Anna Freud's.Robertson (1962) described the passivity, flattenedaffect, and developmental retardation presentamong some of the infants. Closer scrutinyrevealed these babies to be the products of well-meaning, conscientious, but psychologically ob-tuse mothers.

The successful mother must be empatheticsen-sitive to her baby's momentary needs and to theprobable causes of her child's actions and reac-tions. She must be able to feel and convey pleasurein having the infant. The anxiety that is normal ina woman with a newborn hopefully will notdevelop into withdrawal or other pathologicaldefenses, but will quickly dissipate so her energiescan be invested in "good" infant care.

From direct observation, we know that the neonatein a marginal family is often cuddled at the whimof the parent rather than in line with his needs. In-vestigators then report apathetic, flat, affectless,withdrawn little children who exhibit attitudes ofhopelessness and defeat (Young, 1964; Loof, 1971;Pavenstedt, 1967; Bullard, et al., 1967; Polansky,Borgman, and DeSaix, 1972). The children ap-pear to have resolved, not with Trust but withBasic Mistrust, what Erikson (1950) labeled theinitial "life crisis."

A number of investigators (see also below) havecommented on the difficulty of measuring scien-tifically what is missing in the home environmentsof children who show apathy or, a related butperhaps less ominous residual, extreme aggressive-ness (Bullard, et al., 1967; Caldwell, 1970;Polansky, et al., 1972). Since identificationor itsprimitive equiv nt, incorporationstarts veryearly in life, it seems credible that an attitude offutility and/o1; despair might be taken over fromone's parents, as if futility were in the air onebreathes.

The mark of emotional deprivation is highly visi-ble to trained professionals who see the childrensomewhat older, in day care centers or the like. A,youngster may show what we have called "object-less clinging," meaning that he attaches himself toan adult, but in an unflattering way, since he will,

30

with little differentiation, reattach to almost anyother warm person. Even more damaged arechildren who will not relate at all. They seem tofear attachment or have no ability to achieve it.While _inability to relate is typically no\ extremeamong very young children, it can pres,ent aserious block to treatment when a youngster isreferred for counseling at age 8, 9, or 10.

Patterns of detachment, of which Bowlby (1969)has thus far written the most extensive theoreticalstatement, become very concrete in such socialwork settings as the BoWeil Center Project of theJuvenile Protective Association in Chicago(Sullivan, Spasser, and Penner, 1975). The centerencountered markedly greater difficulty in involv-ing the children who had not been reached untiltheir early adolescence. Among these, the patternof detachment appeared more fixed, and muchmore aggression was observed than seemed pres-ent in younger children from the same families.

A number of obviously necessary research direc-tions are worth pursuing. For one thing, investiga-tors have acted as though they were entrapped bywords. Because early care is called "mothering,"they have identified it with the female parent.Hence, we have little or no evidence regarding ma-jor deficits in "fathering," and only unsupportedgeneralizations about the ages at which it becomescrucial. Yet Harlow's studies showed that adultmonkeys of both sexes responded to advancesfrom the young with protective, cuddling reac-tions. A high proportion of all males in our culturehave similar responses to children. Should theseprove to be instinctive, what survival value hasnature locked into this fixed action pattern? Up tonow, we have been partly blocked in this search bythe relative elusiveness of fathers as research sub-jects, but that may be changing. More general ex-amples of the same sort of query lie behind the onealready raised: What is specifically lacking in theemotionally depriving home?

Cognitive Deficit

An enormous literature exists on the subject of in-tellectual decrements associated with and veryprobably caused by early childhood deprivation.The topic was given impetus during the late "war

35

on poverty" (Baley, 1965; Oliver and Barclay,1967; Caldwell, 1970; Scarr-Salapatek, 1971;Seltzer, 1973). Much of the literature deals withdeficits found among children being reared in im-poverished environments, meaning the childrenlive in homes that are within normal limits but thefamilies are economically poor or very poor.

The challenge has been to identify just what isspecific about the deprivation that lowers intellec-tual capacity. Seltzer (1973) has cogently raisedthis issue in remarking on the fact that, with large-scale programs of testing infants, the so-calledcultural decrement of poverty does not stabilizeand become visible until the child is around age 3.Why, he asks, not until this age? If the deficit iscumulative, what is accumulating?

Nor can it be logical to generalize about the type ofcare received by children of the poor. Geismar(1973) concluded that a very substantial propor-tion of poor young couples give their childrensurprisingly good protection and other kinds of at-tention.

Work and thought are needed to sort out factorsassociated with poverty that appear also highlyrelevant to understanding the impact of variousforms of neglect on cognitive development. Theprevailing thesis is that the richness of the environ-mentthat is, the amount of cognitive stimulationoffered the childaffects the rate and eventual up-per limits of intellectual growth. Since intelligenceseems to depend, in part, on the number of braincells and the proliferation of connections amongthem, a difficulty in such research will be to dis-tinguish nutritional effects from the psychologicalones. With so many neglected children poorly fed,but also left untended in their beds, offered littleverbal communication, taken nowhere, it will behard to separate the influences.

A very interesting issue has been the relationshipbetween cognitive and emotional malformationsresulting from deprivation. For a long time, thetwo were treated as essentially unrelated, since at-tention centered primarily on the cognitive deficitin academic, developmental psychology, and onemotional problems in clinical psychiatry andsocial work. Goldfarb (1945) was among the firstto comment that the two conditions tend to gotogether, perhaps because emotional conflicts

hamper learning. In the present context, weshould expect the infant of parents unable to pro-vide for "basic trust" to be doubly endangered,since such parents are also inept in areas neededfor cognitive development.

Another paper, published rather early in themovement toward compensatory care for poorchildren, also warrants mention here. In it, J.McV. Hunt (1964) remarked that, in his opinion,such evidence as we had made it seem likely thatfailure to nourish normal intellectual growthwor d be even more irreversible than comparablefailures in the emotional sphere. However, con-trary to Hunt, Ainsworth (1962) feels the per-sonality disorder may be less reversible than thecognitive deficit.

Antisocial Behavior

From theory as direct as the frustration-aggressionhypothesis, it is easy to understand why neglectedchildren would turn out to be hostile, angry, oreven dangerous people. But, from the theories ofBowlby and of Polansky, et al., of the "depriva-tion-detachment hypothesis" (1972), it is equallyeasy to predict that neglected children may becomewithdrawn, passive, apathetic. As the latter groupof researchers remarked, descriptions of theparents of withdrawn children rather closelyresemble those of parents of aggressive children.Very little of the literature deals with the problemsof differential etiologies (Polansky, et al., 1972).Because we know so little about each condition,we have not yet dared ask the more refined ques-tion: How do the etiologies differ from each other?

Many neglected little children who appear wan,clinging, and apathetic at ages 5 to 7 later turn outto be criminals and sometimes murderers. Fon-tana (1973) describes the early lives of a number offamous "killers" of our times, showing the extentto which such persons as Sirhan Sirhan, JamesEarl Ray, Lee Harvey Oswald, Arthur Bremer,and others were maltreated as children. A theoryhas been that abused children identify with the ag-gressor, and so are more prone to violence. But asubstantial proportion of children who areneglected are also violent.

3G

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In long-term contacts, the swing can be observedfrom withdrawal and odd behavior toward anti-social behavior. The group at the Bowen CenterProject, for example, saw this in families they weretreating. As each boy became 12, 13, or so, hebecame increasingly aggressive. Soon he became adelinquency problem, in trouble with the law. Hisyounger siblings were still mainly apathetic. Theaggressiveness of these boys may reflect inadequate"object-ties" and, therefore, absence of the iden-tifications that lead to internalization of controls.This can result in a schizoid stance in which otherhumans are treated as things rather than as objectsof love (Polansky, 1973a). But the fact remainsthat, while some neglected children survive with asemblance of intactness and others become simpleschizophrenics, another group emerge as anti-social, dangerous people. Since the number of thelatter is growing relative to the size of the popula-tion, it behooves us to learn more about theproblem of differential diagnosis and treatment.

Foster care of children is often the quick solutionto problems of abuse and neglect. Beck (1971) ob-served that more than 300,000 children are infoster care in this country at any one time and that,of these, 100,000 have no hope of ever returning to',heir own families.

Eisenberg (1962) reported on a number of years'experience in assessing children in foster carereferred for psychiatric evaluation. He found thatthe neglected child in foster care had many morepsychological problems than the aver age childplaced for less ominous reasons. He noted their in-articulateness; poor orientation to time, place, orpersons; apathy; suspiciousness; and (a classicallyprimitive defense) self-depreciation. Many were sounsocialized as to lack basic toilet training or tablemanners.

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Two studies from Europe offer further evidenceabout the behavioral sequelae of neglect. Forss-man and Thuwe (1971) in Sweden collected dataon children born to mothers who had sought buthad been denied abortions. The fates of these un-wanted children were revealed on followup 21years later. The subjects had had more psychiatricattention than normal and a higher rate of alcohol-ism. More of the males were refused by the Armythan was true of the general male population. Thegirls married earlier than average and becamepregnant at ages earlier than average for thepopulation as a whole. Educationally, 10.8 percentwere substandard compared with 5.0 percent ofthe total population. Their delinquency rate wastwice the average in Sweden. It should be notedagain that these children were unwanted beforebirth.

Britain's National Child Development Studycohort (Wedge and Prosser, 1973) has also beenrevealing with respect to antisocial behavior. Aquarter of the children rated "disadvantaged" (seep. 20) were considered "maladjusted" by theirteachers. One in every 11 of the "disadvantaged"had a juvenile court contact by age 11 comparedwith 1 in 300 "ordinary" children.

The neglected child, then, is more likely to bephysically deficient, intellectually at a disadvan-tage, and emotionally aloof, anxious, andchronically depressedbut prone to become ag-gressive and commit antisocial acts, some of whichare dramatically brutal. In view of the many find-ings suggesting that parents give their childrencare comparable to that which they, themselves,received as youths, these results are the more dis-turbing. For the study of the sequelae of neglectbecomes prelude to understanding its etiology.

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PREVENTION

NEGLECT TAKES MANY FORMS. Typically,it is chronic, pervasive, resistant to specific treat-ment, and transmitted in intergenerational cycles.Therefore, dollar for dollar, the best expenditureof funds would be on prevention (Polansky,1973b). More important than the cost in money,however, is the cost in human lives. Too long havewe had inadequate, thinly staffed, and poorlyfunded protective service programs for abused andneglected children (Levitart, 1966; H. Wasserman,1970; Schorr, 1974). And when the expectablehappens and the programs do not work, the blamefalls on the social workers who have had to makedo with what was available and on the "hopelesscharacter" of the parents (and even on thechildren) involved. The foundation -for preventivework appears to lie in what Kahn has so aptlytermed "child advocacy."

Child Advocacy

Reporting on a national survey, Kahn, Kamer-man, and McGowan (1972) write:

Examining what is now occurring na-tionally under the banner of child ad-vocacy, we find a core of organized ororganizable activity that is unique andcontinuous with the advocacy identifiedelsewhere in social welfare. . . . Thissomewhat more focused activity, whichmight be thought of as child advocacy, is aspecial function within society. It dealslargely but not solely with the social sec-tor per se, and it is defined as interventionon behalf of children in relation to thoseservices and institutions that impinge ontheir lives. (p. 63)

Intervention of the sort Kahn has been shrewdlyand energetically conducting for half a lifetime is

obviously sorely needed for incrvidual childrenand families, and for the large-scale State andFederal programs that are our first-line defensesagainst the downward spiral of child neglect. Whyare we not willing to commit more resources tothese programs? The need to maintain a decentfamily living standard is a primary essential for thewelfare of children. Proposals range from increas-ing children's coverage under Social Security, tochildren's allowances as an assist for poor families,to a minimum income for all (Schorr, 1974).

The usual explanation offered for maintaining thestatus quo in children's programs is that the publicwould not stand for increased expenditures.Which public? A recent survey by Carter, et al.,(1973) is surprising and heartening. The studycovered public attitudes toward social welfareprograms. It required interviewing 9,346 personsover age 18 in eight States so chosen as to provide anational cross-section. Results showed substantialsupport for welfare programs, including help forthe unemployed. People out of work wereregarded (by a primarily working America) as un-fortunate rather than blameworthy. The use ofpublic funds to provide social services was well ac-cepted. Child protective services were highlyvalued. Eighty-one percent of those interviewedjudged such services "a good use of public funds;"only 4 percent saw them as a waste (Table 10,p. 26). The authors concluded there is, in fact, apopular mandate to offer protective services withtax monies (p. 40). The connection from childprotection, after neglect has occurred, to prevent-ing its need is not easy for most of the public tomake, but neither is the public obtuse.

It is hard to write about certain matters with scien-tific detachment. For example, an Associated Pressdispatch of March 10, 1974, reports a nutritionallyenriched baby formula bci,tg given in Memphis(Tenn.) poverty areas to infants under a year, at a

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cost of 21 cents per day. During the 3-yearprogram, healthier babies were observed, and in-fant mortality halved from 40 per thousand to 20.Yet, THE NEW YORK TIMES (January 21,1974) reported that a lawsuit had been necessaryin order to instigate spending funds allotted by theCongress for the Special Supplemental FoodProgram for women, infants, and children. Thesequelae of early malnutrition have been docu-mented above, but assessing starvation does not re-quire elaborate research.

We see that prevention of neglect will requiresome changes in attitudes and values. Fortunately,there is more public readiness than has yet beenpermitted to find expression. Therefore, we canuse the child advocacy Kahn advocates.

Rights of Children

The current divorce rate of one to every three mar-riage. has led to a questioning of the nuclearfamily as a stable and stabilizing family structure(Balswick, 1974). We also assume we are a child-loving society that acts only for the child's best in-terests. Yet in most States, society will not takeresponsibility for a child unless the parents bla-tantly refuse to do so, or the child breaks the law.Farenthood is said to be legally a private venturefor personal satisfaction (Rodham, 1973; Schorr,1974). And our wish to preserve the freedom of themajority of parents conflicts with intervening forthe child in straits.

A potentially neglectful situation can be diag-nosed, and professional services offered, only tohave them refused by the parent as a result of fear,pathological mental processes, or sheer inade-quacy (Polansky, 1973a). A recent monographdealing with the admixture of social, psychologi-cal, and legal problems (which is now receivingwide distribution) is that of Goldstein, Freud, andSolnit (1973). They cite precedents going back toU.S. vs. Green in 1824, and Chapsky vs. Wood in1889, in which judges held that the needs of ti :echild ought to take precedence over blood ties antiparental rights.

Rodham (1973) has proposed three avenues ofredress: (1) that the legal status of infancy or

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minority be abolished; (2) that procedural rightsgranted adults also be granted children; and(3) that the presumption of identity of interestsbetween parent and child be rejected whenever thechild has interests demonstrably independent ofhis parents'; a competent child should be allowedto assert his own interests. Some of Rodham's sug-gestions appear unworkable.

Help for Families-at-Risk

The section on Early Warning Signals summarizeda number of the findings, clinical impressions, andspeculations thus far available for identifyingfamilies in considerable danger of becomingneglectful. To these we might add factors listed byHaselkorn (1966). Higl risk mothers includethose of low income, who are unmarried, whohave unwanted pregnancies Or unwanted children,who are teenagers, and who are hard to persuadeto visit clinics for prenatal care. In other words, weare already able to make some shrewd estimates ofmothers-at-risk and families-at-risk. The followingseeks to answer the question: What is\to be donewith this information?

1. Existing programs

Rather than start a rash of new programs, wewould urge that existing, established programs bestrengthened to move into preventative areas.When all our agencies, are taken togethere.g.,health and welfare departments, courts, publicschoolsmost families-at-risk are known to atleast one and often to two or more. Would it helpif all personnel were more attuned to the potentialof neglect; if staffs and programs were available tomove in when necessary and appropriate? Hereare some examples.

Any addicted woman found pregnant ought t beplaced under some sort of medical surveillance, asis done for persons with communicable diseases.Some believe she should be aborted.

As was usual "in the old days," school teachersshould get to know the parents of their students.Experienced and shrewd school personnel arefairly well able to recognize neglected children.

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But what is required to turn these skilled in-dividuals from their overwhelming feelings thatwhat they know does not really help toward mak-ing a plan for bringing resources to bear on behalfof children in need?

By offering to treat families with as many as twodelinquent children, Minuchin, et al., (1967) im-mersed themselves in whole nests of familialpathology. Not only are families of felons verylikely to be "on relief," but also to operate at a very,marginal level of child caring (Polansky, et al.,1972).

The "medical model" speaks of "putting a watchon" a suspicious lump or bodily change. Likewise,we need a form of social checkup whereby familiesleast able to cope will be helped at some pointbefore outright neglect has actually occurred.Competent parents do this even for their grownchildren and grandchildren. But who does this infamilies where no one has that extra competencethat means help can be extended to the weaker?

There are other reasons for strengthening existingprograms. Our expert consultants were in agree-ment- that basic housing, sanitary facilities, andhealth care available to families help in the pre-vention of neglect.

Finally, from our study of etiologies, it will berecalled that emotionally disturbed parents, dis-charged from institutional care to their families,may prove so disruptive or inadequate as to causechild neglect. Certainly, the readiness of the pa-tient to resume his or her parental role ought toenter into planning for discharge from mentalhospitals and, indeed, from all medical facilities.Discharge may have to be delayed, for example,until the parent has achieved a reasonable level offunctioning, since introduction of an ex-patientbarely able to survive outside the hospital cannotbut add further stress to an already overburdenedfamily system.

2. New programs

One new program (described on page 21) thatwarrants mention here is the system for handlingcases reported from Nashville (Bowman, 1973;Burt and Balyeat, 1974). The combination of

.4o

emergency services with the application of modernmanagement techniques to ensure coordination ofservices and tracking of cases to prompt disposi-tion helps to protect the child against what hasbeen termed "agency neglect."

As a new program, we might also cite the projectconducted by Pavenstedt (1973) and her col-leagues.

This paraprofessional training program,funded by NIMH and based in a Bostonfederal public housing project HealthCenter was designed to prepare personswith backgrounds similar to those in thecommunity as Family Intervention agentswho would identify vulnerable youngchildren and assist their families in highrisk environments, particularly in areasrelated to child care and development.(p. 120)

An extensive training program was offered, andtrainees were placed with two or three familieswith the goal of improving their general function-ing and, specifically, their child caring practices.'Using the MMPI (Minnesota Multiphasic Per-sonality Inventory), Polansky, et al.'s MaternalCharacteristics Scale, and Choler's Maternal At-titude Scale, trainees were measured for changeduring the period of training. While there was in-creased ability to relate to others, improved im-pulse control, and increased independence, an ex-pected step-up in verbal accessibility did not occuramong the trainees.

The training program showed promise, butchanges in national priorities created a seriousproblem for placing graduates of the program.While most were able to find employment, few arenow at work in the job for which they werespecifically trained. However, the idea ofparaprofessional "Family Intervention agents" willundoubtedly be revived.

3. Family planning

Sixty percent of all poor children are from familiesof four or more (Schorr, 1974). The multiproblemfamily, the poor family, the large family, theneglectful family are all associated (Young, 1964;

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Boehm, 1967; Miller, 1965). There are individualdifferences (Giovannoni and Billingsley, 1970;Geismar, 1973; Polansky, Borgman, DeSaix,1972) but, often, too many children, too littlemoney, and neglect are all found together.

Family planning includes birth-sequence plan-ning. Women who bear children too young (i.e.,below age 18) have a higher infant and maternalmortality rate (Haselkorn, 1966); children ofmothers over age 35 are more -prone to birthdefects, and the risk rises rapidly with increasingage. In addition, an infant displaced from beingthe center of attention by the rapid sequence ofbirths of two or three more suffers a type ofdeprivation which can be noted even in familieswith plenty of household help.

Programmatically, free and accessible contracep-tive information and supplies are the least expen-sive and among the most effective methods of pre-venting child neglect. It is thought that the poorhave more children than the affluent because thepoor do not have as much information orresources to plan their families effectively accord-ing to their own desires (Levitan, 1966; Podell,1970).

The highest proportion of couples who neveremploy birth control or who have children beyondthe number they intend is found among nonwhiteswho live in the rural South or who have ruralsouthern backgrounds (National Academy ofSciences, 1966). Consequently Johnson's (1972)findings on the rural nonwhite Southerner's at-titudes toward birth control and illegitimacy seempertinent. She found that the adolescent female'ssexual expectations were based on those of hermother, and that a mother's sexual expectations ofher daughter were based on her own sexual ac-tivity. Unmarried, sexually active women did notknow the attitude of their sexual partners towardcontraception; most importantly, low income non-whites approved of premarital sex but disapprovedof illegitimacy. These findings allow us to con-clude that illegitimacy rates may decrease as use ofeffective contraceptive measures become more ac-ceptable. An area to be studied further in trying toreduce illegitimacy among low income nonwhitesis the attitude of the male sex partner.

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The potential role of easily accessible abortion inpreventing child neglect has not yet been assessed,nor even approached. Yet the literature suggeststhat: (a) many women from the populations at riskdo not practice contraception and (b) unwantedchildren are more at risk of being neglected.Under these conditions, abortion would offer asecond line of defense in preventing neglect.

Abortion is very rarely of catastrophicit

conse-quence,quence, medically, and t s laden with long-runsocial impact in terms of population, poverty, andchild neglect (Reiterman, 1971). It is, of course,still controversial, although recent studies show themajority of the population in favor of its beingavailable to those who want it.

Subsidized sterilization is another possible preven-tative to child negleat. We observed that steriliza-tion, usually of the mother, has proved to be veryhelpful in families that give their children inade-quate care (Polansky, et al., 1971). The cessationof additional children can give an overwhelmedwoman a chance to meet the needs of the childrenshe already has. Sterilization also gives her childcaring a visible,.definite ending point which seemsto help morale in some families. Whether themother's sterilization is an aid to the childrenalready born warrants further research, since theproposition is rather widely believed by those inthe field.

An area of controversy has to do with public effortsto encourage birth control among poorer elementsof our society. Since black families average lowerincomes, and poor black families have somewhathigher birth rates, they become especially of in-terest to family planning programs. Examinationof the facts involved appears to be delicate becauseof sensitivities natural to a group already ,ex-periencing discrimination.

Some black writers have equated "birth control"with genocide. According to a few investigators,however, it does not appear that birth control is soregarded by most of those surveyed. Ninety-threepercent of the black subjects interviewed by Darityand Turner (1974) felt that family planningshould be taught at the junior high school level.

There is reason to believe that births out ofwedlock increase the chances a child will become

41

neglected; moreover, the dangers to children bornto very young mothers have already been cited. Alarge proportion of all illegitimate children areprogeny of teenage mothers-53 percent bywomen 19 years or younger (U.S. Department ofHealth, Education, and Welfare, 1975).

Obviously, creative ideas must be forthc( IT mg formeeting the needs of these target groups; then theeffectiveness of the approaches must be tested. Inall of this, research on child neglect shares in-terests with general programs for work on familyplanning.

4. flay care and other communityresources

Another approach to preventive help is provisionof services which relieve young mothers before thestrain they are under becomes intolerable. Suchservices can include homemaker services,neighborhood community centers, and day-care.Comprehensive group care of high quality mayenhance development of the young child at crucialphases (Robinson and Robinson, 197k). Caldwell(1970) urges high quality day care for primary pre-vention of neglect.. Yet, as others have noted,

41

quality care is neither cheap nor easy to provide(Pavenstedt, 1971; Emlen, 1974). We shall returnto that theme below. Meanwhile, it is to be notedthat day care centers and family day care homescan help to shore up a deteriorating home situa-tion.

The preventive functions of homemaker servicesseem obvious, of course. Many agencies believe inthem, but the shortage of funds for these services issuch that they tend to be limited to people alreadyin difficulty rather than employed as a preventativemeasure. Research, or at least the ordering of prac-tice wisdom, would be helpful in defining the con-ditions under which homemakers can make sub-stantial, preventive contributions.

Reviewing the scanty literature relevant to the pre-vention of child neglect, one is reminded of thecaveat with which this report began: that one hasto strain to find new programs conceivably relatedto preventing neglect, as such. Perhaps this isnatural to a social problem about which so little isfirmly known, but the unsatisfactory state of the artdeserves underscoring. Could it be that the mostimportant preventive program we have nationallyis the maligned and troubled Aid to Families withDependent Children?

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TREATMENT

BY THE TERM "TREATMENT," we refer toactions taken with the intention of bringing abouta change in the caliber of child care so that it is nolonger regarded as neglectful. Treatment aims tobring about a new, higher level of operation. Thetraditional treatment of neglect has involved tryingto motivate parents to improve their child care, orprotective removal of children, or both (Costain,1972; Kadushin, 1974). The aim here will be tosketch the current state of practice in this countryas well as some emerging trends. But first, let uspreface the description with some general com-ments.

Discussing measurement of the efficacy of socialservices, Weber and Polansky (1975) have written:

Evaluating social service intervention in-volves much more than just trying to findout what happened to the recipient of aparticular service. Ideally, it involvesdelineating what exactly was done; withwhom; under what circumstances; bywhom; at what point in time; with whatresults; from whose perspective; andwhether the "results were worth the pricepaid. (p. 183)

No study of the treatment of neglect approachesthese demanding criteria. The model of evaluativeresearch is presented to emphasize that, in general,no treatment modalities exist which applyuniformly to all clients in all situations. Considera-tion of the treatment of neglect creates an oddsituation. Because neglectful parents vary so, allgeneralizations must be made with reservations.But because a high proportion have much in com-mon (e.g., stressful environmental conditionscombined with marked personal immaturity), itmay be possible to advance at least someguidelines about how to approach such parents. Inthe long run, a treatment typology will be needed,

matching intervention to diagnosis (Kahn, 1963).We now only have the beginnings of differentialdiagnoses with implications for action.

Those who see neglect as typically a reaction tosituational stressfor example, the deserted wifewho is collapsing under the double load of youngchildren and a jobwill conclude that changing afamily's life conditions will be effective in relievingthe problem. Those who view neglect as usually areflection of pervasive character problems with alifelong history favor long-term psychologicaltreatment. The first viewpoint seems to promisequick results that will probably be short-lived; thesecond, expensive procedures that usually lead tovery substantial results.

Our own viewpoint is psychosocial which Hollis(1972) sees as an open theoretical system. Thisposture holds that, if a person has had a hard lifesince infancy, then the personality is scarredin ways not easily rectified. The scars limit theability to cushion further blows and the individualis inevitably weakened. Consequently, when con-fronted with stress, the person is less able to adapt.It follows from this logic that, if a man or womanbecomes a "neglectful parent" cut of this com-bination of past scarring and current stress, thefirst step is to see if the individual can be helped bygiving practical assistance. This will be followed, ifindicated, by an attempt to repair or compensatefor some of the internal damage the individual hasexperienced. Meanwhile, provision must be madeto protect the children. The programs we willsketch below elaborate on these possibilities.

Another caution requires insertion. To promotetheir synthesis, the research studies cited abovehave been treated uncritically. Now, a series oftreatment modalities will be similarly presented.But, first, it must be stated that few programs ex-istno matter how new and ,citingwhich do

43 39

not show deficiencies to those who know thembest. And in only a few places in the United Statesdo protective services even approximate the notionof good practice. Therefore, it is only prudent topresume that there are no panaceas anywhere and,also, that if an advanced or excellent form of prac-tice exists, this does not mean it is "generallyavailable" or even generally known.

Child protection is a field in which responsibleprofessionals willingly describe the difficulties theyhave encountered as well as their successes. Themajority of seriously and chronically neglectfulfamilies are doubtful treatment prospects forwhom there appear to be no quick, cheap solu-tions. Many are necessarily long-term cases andnot very rewarding. Six months is now thought ofas a substantial course of treatment in many men-tal health clinics; our consultants advised us thatthis is about the duration of a trial of treatment inprotective work. That is, if the family shows no im-provement in that time, then the prognosis foreventual, positive change is poor.

Social Casework

In this country, the most widespread ingredient inprograms to help neglected children is casework. Itis generally agreed that one person should contactand individualize each case. Among those practic-ing this skill in protective work, the theory of treat-ment most widely utilized appears to be the diag-nostic point of view which has been further refinedinto the psychosocial (Hollis, 1970) and ego psy-chological approaches (S. Wasserman, 1974).Rooted initially in psychoanalytic psychology, thediagnostic point of view means that treatmentshould be designed to fit the client's makeup, hispresent state, and his circumstances..

A recent paper by S. Wasserman is of particularinterest because, although it is primarily dedicatedto explicating a delimited theory of casework treat-mentthe ego psychologicalits major illustra-tion involves the treatment of a woman who mightbe considered a neglectful mother: Wassermanrecognized that -- without a characterologyi.e.,structural concepts of some sortit is not possibleto make the differential diagnoses which guidepractice:

40

Presently there appears to be a rejectionwithin the social work profession of thelabeling of clients in terms of a clinicaldiagnosis as 'neurotic' or 'character-dis-order.' Unless the worker is clear in hisassessment of the client's total situation(external and internal)his ego strengths,intact areas, gaps and weaknesseshismodel for intervention will be affected bycloudiness, groping and undifferentiatedkinds of action (or inaction). (F. 57)

With increasing use of time limits and the workingthrough of ending phases of treatment, this schoolof casework is increasingly at one with the func-tional approach. Similarly the diagnostic approachis by no means antagonistic to techniques associ-ated with behavior modification when indicated; ittries to include them in a range of options that alsoembraces support, clarification, and the like.

rt Among those actually doing casework treatment inneglect situations at this time, the major divisionappears to be between those operating from atheoretical base and those professing eclecticism or

. doing their best with no clear theory of treatmentat

What are the critical functions of the caseworkerin relation to neglect"; Here is an attempt to sum-marize briefly some areas of substantial agree-ment.

1. Identification and factfinding

It may be the responsibility of the director of socialservices in each county to receive and investigatecomplaints of abuse and neglect, but it is the staffof caseworkers who typically conduct the factfind-ing studies. In nearly all agencies, it is policy that,although every complaint warrants attention andusually investigation, judgment is suspendedregarding whether or not the complaint wasjustified until the facts are known. hence, the pur-pose of the first phase of work is to locate thefamily and to try to obtain their cooperation suffi-ciently to determine whether neglect is occurring.

Since the family seldom refers itself, the in-vestigatory phase requires tenacity, interpersonalskill, ingenuity, and sometimes both moral and

physical courage. The need is recognized for prac-tical guides to the inexperienced worker on mak-ing initial contacts; there is a surprising paucity ofpointed literature available.

One rather new trend that has emerged stemsperhaps from civil rights cases. It is that familiesapproached sometimes now say, "Talk to my law-yer." And this response is not confined to wealthyalcoholics!

The relationship between social mobility andsources of referral is an interesting issue. To adegree not generally known, relatives have alwaysbeen major originators of neglect complaints; e.g.,grandparents interceding to enlist protection fortheir grandchildren. Mr. Leefman of theMassachusetts Society for the Prevention ofCruelty to Children, reported that relatives are stilla major referral source there. In Georgia,generally, Mr White (the State's consultant onprotective services) noted that when the is an ex-tended family living in the community, membersof the family are the most apt to notify authorities.Otherwise, neighbors refer. On the other hand,Dr. Young observed that, in Newark, which hashad an 80 percent population turnover in the past20 years, the majority of neglect complaints comeout of the school system. In any event, neglectfulfamilies are nearly always third-party referrals and,initially, are unmotivated and often resistant tohelp.

2. Decisionmaking

What is to be done once the facts emerge? Deci-sions about disposition are shared in a variety ofways among the caseworker, his or her super-visor(s), and local courts of jurisdiction.

A number of alternatives are open in trying to findthe best ways to help the children. It may bedecided that there is no immediate cause for con-cern, and the agency withdraws from the case. Orwhile the case is not yet neglectful legally, it mayborder on it so that the caseworker may reach outto the family to offer services calculated to operatepreventively. Under extreme urgency, the childrenmay be summarily removed from their home; howand where will be discussed below. Even if thechild is removed, the caseworker may work with

45,

the family to try to strengthen them and their situa-tion so that the family may be reunited withoutdanger to the children (Sullivan, et al., 1974). Inshort, whatever the decision, and it may change asexperience with the family accumulates, the act ofselecting among alternative courses that, to a greatextent, will determine the long-term fate of afamily is an important function.

Without a court order, children may not beremoved from their parents without the latters'consent. Hence, the significant decision in all ex-treme instances rests with the court. We know thatin many places throughout the country, judges andsocial workers collaborate flexibly and shrewdly tocombine legal authority with practical and psy-chological help to bring about movement in cases.Yet we encountered no writing at all on this col-laboration. All child welfare references dealingwith the courts instruct workers regarding ap-propriate behavior as witnesses. If there are writ-ings that inform judges of their responsibilities incontinuing, collaborating work to salvage families,they were not brought to our attention.

We are not legal scholars, of course, so we wonderif the activity of judges that goes beyond the makingof decisions is codified anywhere. Most respectedjurists are more continuously involved withfamilies than their formal role-image would imply.The codification of metajudicial practice by thecourts in relation to child neglect appears to beanother arena in which immediate scholarly workis needed, combining social work research andlegal scholarship.

3. Equilibrium upsetter

Some programs aim at equilibrium maintenance.This is not the intent in the home deemedneglectful. Here, the downward spiral of neglectfulbehavior must be reversed. If the family is unableto mobilize movement, legal action or the threat ofit may function to-unfreeze the system.

4. Guide and liaison

Generally the caseworker is the link that puts the f,family in touch with needed resources, such as fi-nancial aid, services to improve housing, medical

41

care, homemaker and other services. In dealingwith the community and its agencies, the worker isa case-by-case child advocate. Without one persondefinitely responsible for this connective function,most other services may as well be inoperative.

In view of the early identification made by Eng-land's Family Service Units of the importance ofgiving concrete help, it is instructive to read one oftheir recent papers. The paper describes the helpthat was successfully given to a family referredby its physician because of his concern that thechildren's health was seriously endangered by thefamily's disorganized way of life. Concerning thefamily's needs and the help it received, Halliwell(1969) mentions the following principles: the needof an isolated family to gain and feel acceptance;the importance of giving any material or financialhelp within the context of a relationship (otherwiseit is felt to be impersonal and encouragespassivity); the importance of enabling the family touse resources by preparatory work on their anx-ieties and by accompanying them on referrals; con-tinued contact long after signs of improvement occur, lestthe family regress; and contact that includes hus-band and wife jointly. A day care center, a clinic,even what we call an "old clothes room" were allused by the family described. But the key element,in Halliwell's opinion, was what we term "work-ing within the relationship."

5. Information and counseling

The sheer need of some clients is for information;others have information but need help with mak-ing a judgment about it. Families may be helpedby offering them practical suggestions when theyare most appropriate to the need. The fact thatfamilies prove unable to use the suggestions may,itself, be indicative of other problems.

Counseling, of course, includes especially the areaof child caring. According to Kogelschatz, et al.,(1972) fatherless homes develop their own particu-lar styles and need be no worse off than others. Yetthe fact that the female head of household has noother adult with whom to discuss decisions maymake her the more in need of this kind of practicaldialogue.

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6. Individual change-agent

What is ordinarily termed "psychological treat-ment" is actually only one among a number ofcasework functions. Many neglectful familiesnever really receive psychological treatment. Ex-perience indicates that, unless the worker has hadsubstantial experience in interview treatment, it isunlikely that he or she will be able to carry out themore environmentally-oriented functions listedabove, since very similar skills and understandingof human behavior and its unconscious springsare required (cf. Halliwell's comment about"working within the relationship"). Efforts aimedat bringing about change within the individualfamily members, primarily through interpersonalinfluence, involve the following roles:

(a) Acting as attachment object to foster securityand growth and to heal depressiveness (Polansky,DeSaix, and Sharlin, 1972; S. Wasserman, 1974;Sullivan, Spasser, and Penner, 1974). Several ofour consultants remarked that treatment takes timein many neglect cases because so often it is necess-ary to "parent the parents." In view of this, whatdangers are introduced by staff turnover?

Whether because of their infantilism or for otherreasons, experience has shown that many of thesefamilies generalize their attachment beyond theworker (who originally involved them) to includethe agency that the worker represents. Even itsbuilding acquires symbolic meaning as a source offamiliarity and support.

(b) Acting as an identification object or model inhandling interpersonal contacts. The identifica-tion with the worker occurs unconsciously in thecourse of treatment, but this does not mean theworker is passive:

The client whose problems stem from amore characterological natureimpulse-ridden, acting out, lack of anxiety, orprimitive superego developmentwillgenerally necessitate considerable activityon the worker's part in terms of the ,en-vironment, the teaching of impulse-con-trol, the setting of limits, the pointing outof cause-effect relationships ... and par-

tializing experiences which can be toler-ated and assimilated. (S. Wasserman,1974, p. 561)

(c) Encouraging cognitive change, includingclarification and insight.

(d) Playing the role of behavior-modifier; that is,the worker is the source of reward/punishment forrelevant parenting behavior.

7. Family-functioning consultant

Family treatment is a structured modality in itself.Within this structure, the protective servicesworker usually attempts to improve the level ofoperation of the family system. Some of theworker's subsidiary aims include:

(a) Opening verbal communication within thefamily and trying to help the members to sustain it(Minuchin and Montalvo, 1966; Polansky, 1971).

(b) Resolving conflicts, especially between theparents, but often also between the children andtheir parents.

(c) Acting as supportive "good mother" to thewhole family (regardless of sex of the worker) untilsuch time as the parents can take o'er their ap-propriate social roles.

One reason for long-term contact in the treatmentof neglect is to ensure that gains made by a familyare consolidated and likely to be sustained. Severalauthors warn specifically of the tendency in suchfamilies for repetitive regressions to less satisfacto-ry child care after seeming advances have beenmade. Premature cessation of contact may beviewed by the family as abandonment. In anyevent, new patterns cannot be expected to remainfirmly in place until they have become habitual.Therefore, any marked advance must be conser-vatively regarded; that is, hopeful but probably

'`temporary. All experts agree that treatment andsupport should continue for months after thefamily has, on the surface, ceased to be neglectful.

It is desirable that all protective service workershave or acquire aptitude in all the functions listed.

The reason is that it is nearly impossible to be cer-tain which function will not be needed in a givenfamily and that the logical person to provide thevarious forms of help is the one whom the familyalready trusts and to whom they are already at-tached.

Out of their own difficult earlier lives, a high pro-portion of neglectful parents are suspicious of newrelationships. A family that begins by acceptingonly concrete assistance may gradually becomeamenable to psychological forms of treatment toensure greater resiliency against future crises.(This is a pattern frequently found, for example,in the Juvenile Protective Association of Chicago.)Who, then, is to offer the psychological help? Ifthe idea is somewhat threatening to the family, themovement into a new phase should be unobtrusiveand require no sharp break. Therefore, it is desira-ble if the same caseworker can carry the case for-ward.

It is generally agreed that casework in protectiveservices is one of the most difficult jobs in socialwork. Difficult at best, it becomes impossible if theadministration under which it occurs does notsympathetically support it. Even with less dis-turbed caseloads, there are staff problems in manypublic agencies. H. Wasserman (1970) reportedvividly some of. the reasons for high turnoveramong beginning child' welfare and AFDCworkers. One factor was that public assistancegrants were often far below the acknowledgedminimum necessary for health and decency.Kadushin (1974) reported a study showing that 27

percent of workers in child welfare agencies quitannually. In view of the skills to be acquired andthe preference that clients have continuity of at-tachment, high turnover threatens effectiveness ofcasework programs.

At present, a controversy is beginning over how tobest administer protective services. The predomi-nant pattern now is toward specialization. Someprivate agencies carry this function only; in largepublic agencies, protective services become thefull-time assignment of the protective servicesdepartment or unit. Even in smaller multipurposeagencies, workers who show aptitude for protectivework are likely to have disproportionately morefamilies who require protective services.

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As an experienced supervisor, the senior authorhas questioned this pattern of specialization. First,the unrewarding character of many such casesmay well "spoil" potentially good workers for thefield if they do not have some families that provemore verbally accessible and whose problems im-prove more readily. Second, concentration on onekind of client may distort the worker's perspective.Given an extremely limited client group, for exam-ple, the unwary newcomer to the field may not besensitized to recognizing mild mental retardation.

It appears that the separation of services fromeligibility determination for AFDC may also oper-ate to increase specialization in services to abusedand neglected children. Administrative and otherarguments exist on both sides of the question.Therefore, this is another issue on which researchis indicated.

A substantial proportion of all those in protectiveservices remain dedicated and energetic. Theirconcern for the children remains unabated, evenafter years in the field, and their compassion ex-tends also to the parents.

8. Placement

The next service traditionally available for the pro-tection of children is foster care plaement. As ageneral rule, placement is regarded as necessaryunder some circumstances, but it is not a preferredplan.

The field's attitude that efforts should be made toavoid placement is based on a number of factors.First, placement is inevitably disruptive to thechild's life and may have long-range ill effects onhis or her personality. Second, during long-termfoster care, it is often necessary for the child to beplaced and replaced, perhaps several times. So, thechild undergoes repetitive disruption of significantrelationships (Sherman, Neuman, and Shyne,1973). Third, desirable foster care facilities,especially foster homes, are at a premium andhave been since World War II. However, sincefoster care must be utilized for some children, anyarrangement, financial or administrative, that in-creases and improves foster care facilities, par-ticularly foster homes, strengthens the program.The use by States of AFDC funds to support

44

children in foster carean advance of the past fewyearshas been a saving feature in poor ruralcounties with zero budgets for foster care.

Institutions for "dependent and neglected"children still vary widely in quality; some thatdepersonalize and actually exploit children con-tinue to exist. Furthermore, a child who has beenneglected prior to placement is likely to havedeficits (see above) that require care with substan-tial "treatment" elementscare which few institu-tions are staffed to provide. Not all foster careprograms have adapted themselves to the fact thatthe "dependent and neglected" children currentlybeing placed are no longer "average-expectable"children.

Placement often results in shocking parents in away that motivates them to seek help, for example,with their alcoholism or other serious problems.But placement of the child can also lead to the dis-integration of the family (see below). It is worthmentioning here the finding of Fanshel and Shinn(1973) that care for a child with surrogate parentsis extremely expensive.

For all these reasons, advanced opinion in the fieldappears to be that placement must often be used,but as noted it must be employed with caution.Here is a brief summarization of generally agreedupon thinking.

It is desirable if removal of the children occursas part of a plan which the parents accept and inthe development of which they may even have par-ticipated. As caseworkers' skills steadily improve,more and more cases are reported in whichparents not only acquiesced to placement of theirchildren but have asked for it.

Jenkins and Norman (1972) surveyed the reac-tions of parents to having their children removed.The most frequent response was sadness; but thenext most frequent response was relief. After sometime, a number of parents experience feelings ofdistance toward their children, and of detachmentthat can lead to psychological abandonment of thechildren. A similar feeling was picked up in parentinterviews by Allerhand et al., (1966) in a followupstudy of children returned from Bellefaire, a treat-ment institution in Cleveland. Since placementalso entails a major disruption for the children, it

48

is also thought necessary to work it through with Fanshel and his colleagues at Columbia Univer-them, as it happens and in the months following. sity) should cast light on processes of interest here.

For most children, under most circumstances,the form of placement preferred is care in a fosterfamily home. However, one reason for use of in-stitutions has traditionally been linked to familysize. If four or five children are to be placed and itis de.,ired to keep them together, then they usuallyare beyond the capacity of any single foster familyto give them the care and attention they need.Other kinds of foster care have been emerging, in-cluding group foster homes and emergency fosterhomes which are available on a standby basisthrough use of a retainer. Where there may berecurrent, brief abandonment of children by im-pulse-ridden patents, an emergency foster homehas the advantage of obviating use of a strangesituation for the child with each placement.

It is also understood that many children fromneglect situations require facilities beyond theability of loving foster parents to supply (Eisen-berg, 1962). Therefore, the institution continues tohave a definite role.

As a general principle, there is respect for theneed of each child to maintain primary attach-ments: hence, the experimentation with variousalternatives to' foster care, including those inNashville, the Bowen Center in Chicago, and thelike (see below).

In order to maximize the possibilities ofreturning children to their own families, coordina-tion is needed among the protective servicesworker who should be continuing work with theparents; the foster care worker, if different, who issupervising the child; and the court personnel ifthe court is still active on the case. It cannot be saidthat intimate collaboration is the rule in this coun-try at this time.

A great many children from rural counties whohave been institutionalized elsewhere in theirStates are effectively out of touch with the originalagency and with their parents; the case is "open"in name only. Breakdown of communication be-tween agencies, and even between parts of thesame large agency, occurs in large cities as well. Astudy of the fates of a cohort of children in place-ment in New York (which is being completed by

Group Techniques

The use of group work and related techniques tohelp marginal and neglectful families covers awide range of possibilities. As with casework, thegroup format must be suited to the needs of theclient. The following is a rough division amongmodalities that have come to attention.

1. Socialization and resocializationgroups

A few agencies e.g., the Massachusetts Society forthe Prevention of Cruelty to Children and theJuvenile Protective Association in Chicago) haveset up group programs for neglectful parents. Tothose with analytically oriented group psy-chotherapy in mind, these are not really therapygroups. They can, however, be seen as aimed ateffecting enduring change within some of theirclientele and at doing something of a "repair job"for others. The format of early meetings,especially, follows the model of activity grouptherapy rather than the one-to-one analytic image.There may be crafts or other parallel-play ac-tivities, drinking of coffee and, occasionally, chat-ting. The pattern seems to resemble that used byGanter, Yeakel, and Polansky (1967) in work withparents of severely disturbed children.

LIDt'

Fot the withdrawn and socially isolated mother,for example, the opportunity to meet and chat withothers outside her home may provide pleasure, aboost in morale, a buffer against pervasive loneli-ness. Nevertheless, many neglectful parents havefelt community rejectionand, as a result, theyhave, themselves, withdrawn from others. So theydo not welcome group exposure. Only after somemonths of casework and with, perhaps, thereassurance of being accompanied by acaseworker may such a mother or father come to ameeting. It takes weeksmonths and months, insome instancesfor frightened and essentiallynonverbal clients to feel at home in the group andto begin to talk about their own problems. Mean-while, their attendance does combat isolation.

45

Reports have been received of attempts by workersin rural counties to introduce group experienceswith the same ends in view. Mothers seem farmore likely to come than fathers. Since most of themembers must be picked up and brought to themeeting, problems of transportation may becomeinsurmountable if only a handful will attend froman area of many square miles. Hence, group treat-ment can become a costly process, justifiable onlyif demonstrable gains are made among those tre-ated.

2. Parents' groups

Similar in aim but organized around a more visa-ble collecting point are groups of parents whosechildren are all, say, in the same day care centerprogram (e.g., the Bowen Center Project of theJuvenile Protective Association in Chicago). Theymay also be introduced simply as a means ofrecreation, as they are elsewhere in the sameChicago agency. In addition to their possibleusefulness in support of direct work with children,such groups can serve many of the psychologicalfunctions of the resocialization group.

3. Social action groups

In the settlement traditionso much older thanprofessional social workcommunity actionsought to help people become advocates for them-selves. Similar logic has been applied by Wardle(1970) to an attempt to treat low standards of childcare (among other social problems) in a poorneighborhood in England. The hope is that, in theprocess of working jointly on their very real com-munity needs, the participants may combatregressive and defeating trends within themselves,sublimate anger, and reduce their isolation fromothers.

Unfortunately, social action groups are likely torecruit persons who are not shywho are, other-wise, fairly intact. Neglectful parents who aredepressed, or withdrawn, or intellectually limitedmake unlikely candidates; they fall beneath thegrip of community action programs.

Group technique, therefore, is thought to havepromise, although the literature on its actual use

46

with neglectful parents is sparse, indeed. ParentsAnonymous, for examplea self-help organiza-tion of abusive parentstold us that they hadfound neglectful parents too unmotivated to join.

The present thinking is that casework and grouptechnique must be combined and mutually sup-portive. Anyone sophisticated in group work willrecognize its limitations as well as its promise forwork with neglectful families.

Parent-Child Community Programs

The average neglectful family requires multiplekinds of help. Money, medical attention, betterhousing, social and psychological servicesall areneeded. Usually, such help is fragmented, in thesense that the agencies responsible for assistanceand for services may be separately administered,separately financed, and so forth. A major task ofthe caseworker assigned as liaison is to enlist theaid of other agencies and to steer a familytypically already chaoticthrough a maze ofchannels to the help available. Referrals are easilymade, but they frequently come to nothing withoutfollowthrough.

Therefore, consideration has been given to bring-ing all the necessary components under one roof,using each as required for the given case, withoutthe lost time of interagency negotiations. Thisgives the client a place he knows and in which heis known. In addition to conserving effort, thereare great advantages for the client who can attachto "a center" as well as to a person. For example, ifone worker leaves, the client can more easilyreplace him psychologically from among otherfamiliar staff persons.

The outstanding example of this design was theBowen Center, under the auspices of the JuvenileProtective Association of Chicago. Financedoriginally with a grant from HEW, the BowenCenter combined casework, a day care center, aremedial school, parents' groups, emergency fostercare, and shelteringall in one building. Amongthe other remarkable achievements of this staff,one is of great significance to fellow profes-sionals. Because of their multiple services, staffwere able to sustain continuity with some clientsfor unusual lengths of time and to reach deeper

5 a

levels of communication. An outcome, th,refore,has been to provide us with case materialdemonstrating in great detail the psychologicaldynamics behind what, on the surface, seems to besimply "another inadequate family."

One thinks especially of the case of a woman,deprived in her own home, desperately attached toher husband, whose love for him turned to detach-ment when "he started running around on me."The family moved from Eastern Kentucky toChicago, where the husband's behavior proceededto change from sexual acting out to phobic with-drawal. He was soon unable to leave the house.Into this situation of bitterness and despair theBowen Center moved, offering concrete help: daycare for the neglected children (eight in all),remedial education for the older children whowere becoming delinquent, group experiences andindividual casework to each parent. At variousstages, the children had to be removed from thehome, but the relationship between parents andchildren survived these actions.

Space does not permit fuller explication, but it ap-pears that the community-based, multiple serviceagency founded in the psychosocial approachrepresents the major new treatment design forchild neglect. Conceivably, here is the "wave ofthe future."

Mental Health Centers

Community mental health centers seem to beassuming some of the functions formerly assignedto family service agencies. Moreover, since manyneglectful parents, as noted, have psychologicaldisabilities, the mental health center would seemthe appropriate place to which to send them. Un-fortunately, the experience, to date, has generallynot been promising.

Few center staffs are geared to take on families aschaotic as these. Unlikely to keep their appoint-ments, uncommunicative, they are apt to be writ-ten off as "too overwhelmed by environmentalproblems" or "unmotivated." Often it requires avery competent psychiatrist to help persons as non-verbal but severely anxious as are some of theseparents. Less well trained personnel often lose

5

sight of all dynamic elements in the face of obviouscharacterological disorders. The diagnosis of "in-adequate personality" is not revealing.

In some ways, the mental health center is struc-turally inept to the purpose of helping neglectfulparents. It offers few, if any, concrete services, andthere is legitimate question as to whether marshal-ing services outside the center for these clients ismaking the best use of staff time.

Which is not to say that no mental health cimtershave worked creatively in this field. Enzer andStackhouse (1966) described a program in whichlimited goals were set and specific treatment tech-niques developed for working with multiproblemfamilies in a child guidance clinic. Minuchin andMontalvo (1966) and Minuchin, et al., (1967)

have presented some classic discussions of ways ofproffering family therapy to families in the generalcategories that interest us. The problem they con-fronted was to find ways of penetrating the start-ling disorganization and severely limited verbalcodes of these families.

From experience, the mental health center seemsbetter designed as a resource than as the chieflocus for service to neglectful families.

Day Care

Some of the current thrust for subsidizing day carecenters is related to their releasing low incomemothers to work. They are also helpful to otherwomen who, although less driven by economicneed, nevertheless prefer to work outside thehome. A recent, extensive review of the literature isthat of Etaugh (1974). The following are some ofher most relevant conclusions:

(a) Young children can form as strong anattachment to a working parent as to anon-working one, provided that theparent interacts frequently with the childduring the times they are together;(b) Stable, stimulating-substitute care ar-rangements are important for the normalpersonality and cognitive development ofpreschool children whose mothers work.(p. 74)

47

Mothers who are satisfied with theirroleswhether working or nothave thebest-adjusted children.... Mothers inprofessional occupations tend to havehighly achieving children. (p. 90)

A form of protection to be offered the neglectedchild is supplemental mothering, and one way to dothis is through the congeries of services called daycare. This ranges, in actual practice, from thewoman who "babysits" a few children in herhome for other mothers who are at work, to thelarge commercial day care center franchised by acorporation. In countries like Sweden, "mothers'helpers" and day care centers are State-subsidizedamenities made available on a sliding fee scale.However, in our country, the use of homemakers.and of day care centers is more affected by finan-cial considerations. Such services, of course, areavailable-to the more affluent. For the poor, someday care centers are subsidized as part of the WorkIncentive (WIN) program to help families receiv-ing AFDC to become self-supporting.

In coping with neglect, placing a young child ingood day care means he receives good supervisionfor much of the day, plus supplemental feeding,bathing, health care, emotional nurture, cognitivestimulation, health care. Appropriately used, it canbe a viable alternative to placement.

Mothers and occasionally fathers may also be"reached" through the day care program. Parents'activities sponsored by the center may providethem with emotional support and may combatisolation. Working alongside staff, mothers andfathers acquire leads as to how their children maybe handled more successfully.

The Bowen Center revolved around its day careservice. There, as in a similar operation in Bostonfor abused children (Galdston, 1971), center staffhave to reach out aggressively. Very disorganizedfamilies must be wakened in the morning andtheir young children washed and dressed by thecenter personnel who fan out to bring them in forthe day's program.

Despite their high promise for making it possibleto meet significant needs of very young childrenwithout removing them from their homes, disturb-ing reports about a few day care centers must be

48

52

noted. Parents in low income neighborhoods whouse day care so that both can hold jobs arevulnerable to exploitation by day care operatorswhose interest is nearly entirely financial. For ex-ample, two-year-olds have been found sitting inlined-up chairslike comatose mental hospitalpatients in a back wardunder orders to remainsilent and "not to be a nuisance." Overcrowding,which has been observed, is tolerated in order toadd to the operator's income.

Thus, day care, like other well-intentioned socialinventions, is susceptible to the corruptibility towhich man is heir. We have been advised by thoseexpert in this field that strict standards for licens-ing and constant supervision are necessary, andthat such standards are readily acceptable to ethi-cal operators of day care facilities. Would it not beoutrageous if we found that we were tolerating aversion of child neglect and subsidizing it with taxmonies?

Engineered Ctommunities

The work of Sheridan (1956) in England wasmentioned earlier in relation to the impact on thelevel of child care when a mother is mentallyretarded. Sheridan offered the mothersnot all ofwhom were retarded by any meansa 4-monthseries of courses and training in child care. Themothers continued to reside at home.

We have had a few ambitious attempts in our owncountry in which the additional influence of a full-time residential arrangement has also been ex-plored. The Department of Human Resources ofthe District of Columbia (1965), for example, ex-perimented during the early sixties with an apart-ment house adapted to the purpose of helpingmothers improve their child caring and homemak-ing skills. Women on welfare whose child careseemed substandard were recruited to move intothe building, bringing their children with them. Inaddition to financial help, they were offered guid-ance with housekeeping, health care, child car-ingeven with personal grooming. The aim of theprogram was to improve the effectiveness of thewomen as mothers and homemakers, while hop,ing also for the concurrent rise in self-esteem and

morale which so often accompany a sense of ac-complishment. The success of the program wasnot evaluated, but it appeared promising.

We have also heard that Bertram Beck's HenryStreet Settlement on New York's Lower East Sidehas a unique program for families whose stan-dards are such that they have been ejected frompublic housing, or who are otherwise in need oftemporary shelter.

Other researchers, including our own group(Polansky, Borgman, and DeSaix, 1972) havebeen pushed by the immutability of manymultiproblem families to think about residentialprograms that are frankly treatment oriented. Fon-tana (1973) set up such a program to try to inter-rupt the intergenerational neglect cycle. Attachedto a hospital, his program was psychiatric in orien-tation. As in the District of Columbia experiment,mothers admitted brought their children withthem.

Several reasons are advanced for bringing inwhole family units. First, it obviates placement ofthe children while the mother is being "treated."Second, it keeps problems of child caring, andfeelings about one's children, very much in vividfocus for the parents being seen. Third, if motherand child are locked in a self-defeating interaction,it is advisable to try to treat them together.

Fontana's program was designed to admit resi-dents for 3-month cycles. This is regarded bymany as a minimal amount of time in which totreat and anticipate affecting at all a deep-seatedcharacter neurosis. In line with this, Fontanareports that the great resistance encounteredamong many of these infantile women is often dis-couraging to staff.

Even in the huge catchment area of New YorkCity, it is difficult to recruit cases for admission. Itis very unlikely there are few appropriate cases inthe city, or that Fontana's program has been un-publicized to possible referral sources since he islocated in so highly visible a position. Therefore,one wonders whether admission standards areunrealistically restrictive, or if neglectful motherssufficiently motivated to admit themselves are ex-tremely rare, or whether the treatment has beenunattractively presented to them.

53

Fontana's experiment seems important enough inprinciple and its initiator sufficiently dedicatedthat an outside evaluation may be called for to seewhat general leads might be.gleaned from itsfailures and successes and to prepare for replica-tions elsewhere. To many with long experience inthe treatment of character problems, inpatienttreatment remains a modality that is often not onlythe treatment of choice but the only treatment withany chance of success.

This brings up the question of the use of Statemental hospitals. Here, we are being subjected to aconflict in public policies between desire to protectchildren and the desire to free patients from theconfines of hospitals. We know of one instance inwhich a paranoid mother, a litigious woman whowas neglecting her children while she feuded withher neighbors, was finally committed after muchtrouble and no little risk to her concernedcaseworker. She was discharged within 2 weeks byher hospital psychiatrist on the grounds that therewas "no mental disorder." Evidently a borderlinepsychotic of the sort who reconstitutes very rapidlyin a controlled environment, she was not recog-nized as such by those in charge of her case. Soshe is back home, "destroying" her children. Inshort, State mental hospitals are not at this timeregarded as places where one will find the skill andintense treatment needed for handling thecharacter problems underlying neglect. They are aresource to which to commit an obviously psy-chotic parent.

Not all engineered communities are engineered-3yprofessionals. We must take cognizance of themovement in recent years to start communes.

Jerome Cohen (1974) of the University of Califor-nia at Los Angeles is conducting a fascinatingstudy of the child rearing patterns prevalent innontraditional family settings. So the next fewyears should give us more information than wenow have. From the occasional cases we haveseen, it appears communes serve their residents asa buffer to loneliness and isolation; they also helppersons with weak egos to adapt, since the moreintact members perform many ego-supportivefunctions.

How about the commune's values for children?The only report thus farand that so informal wecannot identify itis that young children are

49

much fondled in such communities but may begiven sketchy overall care. When walking andgeneral mobility are well-established, the childmay be rather suddenly ejected toward maturityin the same way that this occurs with an immatureparent in a traditional family in whose life thechild loses,the defensive function and becomes anaction center in his or her own right. So, the pic-ture thus far is mixed. It does seem probable thatthe commune will serve as a treatment resource forat least some young parents.

Some Further Questions

This survey has attempted exhaustiveness, but it is,of course, confined by its authors' orientations.The very significant involvement of the courts, lawenforcement officials, and other personnel hasbeen slighted. Also, issues of administrativeorganization and larger public policy have not yetbeen covered. With help from our consultants, wewill append some issues at the policy setting level,such as:

1. Should all the States have uniform lawswith respect to handling neglect? The needseems obvious for interstate compacts to pro-tect neglected children whose parents crossState lines. Indeed, in many States, a familycan now elude attempts to help them tochange by simply moving into a new county,thus either going undetected for months in thenew residence or involving themselves with awhole new set of officials who must again in-vestigate, decide, etc. Does the danger of childneglect justify limiting a family's freedom ofmovement?

2. Is a family hurt by being called"neglectful"? Is convenience in diagnosingand in administrative handling of a caseworth the risk involved in social labeling?

50

3. Where should responsibility for dealingwith neglect be lodged? As of now, respon-sibility tends to be divided in most States be-tween court and social agency. Is this the mostdesirable plan? Of all the arrangements beingusedand they vary markedlywhich seemmost efficient?

4. Within the juvenile or family court, howshould neglect be handled? What kinds ofcases should be dealt with administratively;which, judicially?

5. Anda surprisingly complicated issue ifall the above are taken into considera-tionwhen is a neglect case to be terminated? By whose decision, and based onwhat criteria?

Our study has attempted to abstract and integratewhat is known about child neglect in its own right,and about matters that impinge on it and seemrelevant to its understanding and handling. Thereader will have to decide for himself how well wehave succeeded with these aims. This much seemsclear, at least to us. While it is not true that"nothing is known," there is also surprisingly littlethat has yet been well established. Few studies inthis field, including those of our own group, havebeen replicated; very little practice has been sub-jected to any but the most cursory evaluation.

In view of where we stand in "the state ofknowledge of child neglect," it appears that quite alot of good is being done at least to salvage the livesof thousands of youngsters. As always, it seemslikely that much more is known by the most com-petent workers than is generally being used. But,this is not a field of which it can now he truly said,"Action, not more knowledge, is needed." Weneed both.

REFERENCES

Ainsworth, M.D. 1962. The Effect of MaternalDeprivation: A Review of Findings and Controver-sy in the Context of Research Strategy. In"Deprivation of Maternal Care: A Reassessmentof Its Effects" (pp. 289-357). Geneva: WorldHealth Organization.

Allerhand, M.E., Weber, R.E., and Haug, M.1966. "Adaptation and Adaptability: TheBellefaire Followup Study." New York: ChildWelfare League of America.

American Humane Association. 1966. "In the In-terest of Children: A Century of Progress."Denver: The Association, Children's Division.

Bakin, H. 1942. "Loneliness in Infants." AmericanJournal of Diseases of Children 63:30-40.

Balswick, J. 1974. Personal communication.

Bandler, L. 1967. Family Functioning: A Psy-chosocial Perspective. In E. Pavenstedt, ed., "TheDrifters" (pp. 225-254). Boston: Little-Brown.

Barbero, G.J. and Shaheen, E. 1967. "Environ-mental Failure to Thrive: A Clinical View."American Journal of Pediatrics 71:639 -644.

Barbero, Gj., Morris, M.G., and Redford, M.T.1963. Malidentification of Mother-Baby-FatherRelationships Expressed in Infant Failure toThrive. In "The Neglected-Battered Child Syn-drome." New York: Child Welfare League ofAmerica.

Battle, E. and Rotter, J.B. 1963. "Children's Feel-ing of Personal Control Related to Social Classand Ethnic Group." Journal of Personality31:482-490.

Bayley, N. 1965. "Comparisons of Mental andMotor Test Scores for Age 1-5 Months by Sex,Birth Order, Race, Geographical Location, andEducation of Parents." Child Development36:379-411.

Beck, M.B. 1971. The Destiny of the UnwantedChild: The Issue of Compulsory Pregnancy. In C.Reiterman, ed., "Abortion and the UnwantedChild" (pp. 59-71). New York: Springer Publish-ing Co.

Belcher, J.C. 1972. "A Cross-Cultural HouseholdLevel-of-Living Scale." Rural Sociology 37:208-220.

Belcher, J.C., Crader, K.W., and Vazquez-Calcederrada. 1973. "Determinants of Level ofLiving in Rural Puerto Rico." Rural Sociology38:187-195.

Bennett, F. 1968. The Condition of FarmWorkers. In L. Ferman et al., eds., "Poverty inAmerica" (pp. 178-184). Ann Arbor: Univ. ofMichigan Press.

Besner, A. 1968. Economic Deprivation in FamilyPatterns. In M. Sussman, ed., "Sourcebook inMarriage and the Family" (pp. 193-200). Boston:Houghton Mifflin Co.

Bleiberg, N. 1965. "The Neglected Child." NewYork Journal of Medicine 65:1880-1886.

Boehm, B. 1967. "The Community and the SocialAgency Define Neglect." Child Welfare 43:453-464.

Bonem, G. and Reno, P. 1968. "By Bread Aloneand Little Bread." Social Work 13:5-12.

Borgman, R.D. 1969. "Intelligence and MaternalInadequacy." Child Welfare 48:301-304.

O'd 51

Bowlby, J. 1954. "Maternal Care and MentalHealth." Second Edition. Geneva: World HealthOrganization.

1969. "Attachment and Loss."Volume I. New York: Basic Books.

Bowman, J. 1973. "Comprehensive. EmergencyServices to Neglected-Dependent Children:Emergency Service Program." Nashville, Tenn.:Department of Public Welfare. (Mimeographed.)

Bullard, D.M., Jr., Glaser, H.H., Heagarty, M.C.,and Rochik, E.C. 1967. "Failure to Thrive in theNeglected Child." American Journal of Ortho-psychiatry 37:680-690.

Burt, M. and Balyeat, R. 1974. "A New System forImproving the Care of Neglected' and AbusedChildren." Child Welfare 53:167-179.

Caldwell, B.M. 1970. "The Effect of PsychosocialDeprivation on Human Development in Infancy."Merrill-Palmer Quarterly 3:260-270.

Carter, C.W., Fifield, L.H., and Shields, H. 1973."Public Attitudes Toward Welfare: An OpinionPoll." Los Angeles: Univ. of Southern CaliforniaRegional Research Institute in Social Welfare.

"'''Chesser, E. 1952. "Cruelty to Children." NewYork: Philosophical Library.

Cohen, J. 19'74. Personal communication.

Coles, R. 1971. "Children of Crisis: Migrants,Sharecroppers, Mountaineers." Volume II.Boston: Little, Brown.

Collomb, H. 1973. The Child Who Leaves andReturns or the Death of the Same Child. In E.J.Anthony and C. Koupernik, eds., "The Child inHis Family." Volume H. "The Impact of Diseaseand Death" (pp. 439-452). New York: John Wiley.

Costin, L.B. 1972. "Child Welfare: Policies andPractice." New York: McGraw-Hill.

Couch, S. Personal correspondence.

52

Court, J. 1970. "Psychosocial Factors in ChildBattering." Journal of Medical Women's Federation52:99-104.

Darity, W.A. and Turner, C.A. 1974. "ResearchFindings Related to Sterilization: Attitudes ofBlack Americans." (Digest of paper.) American

Journal of Orthapsychiatry 44:184-185.

Davie, R., Butler, N., and Goldstein, H. 1972."From Birth to Seven." London: Longman.

Decarie, T.C. 1965. "Intelligence and Effectivityin Early Childhood." New York: InternationalUniv. Press.

Densen - Gerber, J., Hochstedler, R., and Weiner,M. 1973. "Pregnancy in the Addict." (Un-published-mimeographed.) New York: OdysseyHouse.

Densen-Gerber, J., Weiner, M., and Hochstedler,R. 1972. "Sexual Behavior, Abortion, and BirthControl in Heroin Addicts: Legal and PsychiatricConsiderations." Paper presented at AnnualMeeting of American Academy of ForensicSciences. New York: Odyssey Ho.use.(Mimeographed.)

District of Columbia Department of HumanResources. 1965. "Toward Social and EconomicIndependence: The First Three Years of the Dis-trict of Columbia Training Center." Washington,D.C.: The Department.

Eisenberg, L. 1962. "The Sins of the Fathers: Ur-ban Decay and Social Pathology." Amer' ican Journalof Orthopsychiatry 32:5-17.

Elmer, E. 1963. "Identification of AbusedChildren." Children 10:180-184.

Emlen, A.C. 1974. Day Care for Whom? In A.Schorr, ed., "Children and Decent People" (pp.88-113). New York: Basic Books.

Enzer, N.B. and Stackhouse, J. 1966. "A ChildGuidance Clinic Approach to the MultiproblemFamily." Paper read at National Conference onSocial Welfare, June 1966.

56}

Erikson, E.H. 1950. "Childhood and Society."New York: W.W. Norton.

Etaugh, C. 1974. "Effects of Maternal Employ-ment on Children: A Review of Recent Research."Merrill-Palmer Quarterly 20:71-98.

Evans, S.L., Reinhart, J.B., and Succop, R.A.1972. "Failure to Thrive: A Study of Forty-FiveChildren and Their Families." American Academy ofChild Psychiatry Journal 11:440-457.

Fanshel, D. and Shinn, E.B. 1973. "Dollars andSense in Foster Care of Children: A Look atFactors." New York: Child Welfare' League ofAmerica.

Fell, G. 1974. Personal communication.

Fontana, V.J. 1973. "Somewhere a Child is Cry-ing." New York: Macmillan.

Forssman, Hans and Thuwe, Inga. 1971. OneHundred and Twenty Children Born After Ap-plication for Therapeutic Abortion Refused. In"Abortion and the Unwanted Child" (pp.123-145). New York: Pringer.

Friedland, W.H. and Nelkin, D. 1971. "Migrant:Agricultural Workers in America's Northeast."New York: Holt, Rinehart, and Winston.

Galdston, R. 1971. "Violence Begins at Home:The Parents' Center Project for the Study and Pre-vention of Child Abuse." American Academy of ChildPsychiatry Journal 10:336-350.

Canter, G., Yeakel, M., and Polansky, N.A. 1967."Retrieval from Limbo: The Intermediary GroupTreatment of Inaccessible Children." New York:Child Welfare League of America.

Geismar, L. 1973. "555 Families: A Social Psy-chological Study of YOung Families in Transi-tion." New Brunswick, NJ.: Transaction.

Geismar, L. and LaSorte, M. 1964. "Understand-ing the Multiproblem Family: A ConceptualAnalysis and Exploration in Early Identification."New York: Association Press.

5

Gil, D.G. 1970. "Violence Against Children."Cambridge, Mass.: Harvard Univ. Press.

Giovannoni, J.M. 1971. "Parental Mistreatment:Perpetrators and Victims. " Journal of Marriage andthe Family 33:649-657.

Giovannoni, J.M. and Billingsley, A. 1970. "ChildNeglect Among the Poor: A Study of ParentalAdequacy in Families of Three Ethnic Groups."Child Welfare 49:196-204.

Goldfarb, W. 1945. "Psychological Privation inInfancy and Subsequent Adjustment." American

Journal of Orthopsychiatry 15:247-255.

Goldstein, J., Freud, .A., and Solnit4J. 1973."Beyond the Best Interests of the 'hild." NewYork: Free Press.

Halliwell, R. 1969. "Time-Limited Work with aFamily at Point of Being Prosecuted for ChildNeglect." Case Conference 15:343-348.

Hanson, D. and Hill, R. 1964. Families UnderStress. In H. Christensen, ed., "Handbook ofMarriage and the Family" (pp. 782-816). Chicago:Rand McNally.

Harlow, H.F., Harlow, M.K., and Suomi, S.J.1971. "From Thought to Therapy: Lessons from aPrimate Laboratory." American Scientist59:538-549.

Haselkorn, F., ea. 1966. "Mothers-At-Risk: TheRole of Social Work in Prevention of Morbidity inInfants of Socially Disadvantaged Mothers."Garden City, NJ.: Adelphi Univ. School of SocialWork.

Henshel, A.M. 1972. "The Forgotten Ones."Austin: Univ. of Texas Press.

Hepner, R. and Maiden, N. 1971. "Growth Rate,Nutrient Intake and 'Mothering' as Determinantsof Malnutrition in Disadvantaged Children."Nutrition Reviews 29:219-223. .

Hollingshead, A. 1964. Class Differences inFamily Stability. In S.N. Eisenstadt, ed., "Com-prarative Social Problems" (pp. 265-270). NewYork: Free Press.

53

Hollis, F. 1970. The Psychosocial Approach to thePractice of Casework. In R.W. Roberts and R.H.Nee, eds., "Theories of Social Casework" (pp.33-75). Chicago: Univ. of Chicago Press.

Hunt, J. McV. 1964. "The Psychological Basis forUsing Preschool Enrichment As an Article forCu lw ral Deprivation." Merrill-Palmer Quarterly10:209-248.

Isaacs, S. 1972. "Neglect, Cruelty, and Battering."British Medical Journal 3:224-226.

Jeffers, C. 1967. "Living Poor." Ann Arbor,Mich.: Ann Arbor Publishers.

Jenkins, A. and Norman, E. 1972. "Filial Depriva-tion and Foster Care." New York: ColumbiaUniv. Press.

Johnson, C. 1973. "Child Abuse: State Legislationand Programs in the Southeast." Athens, Ga.:Regional Institute of Social Welfare Research,Univ. of Georgia.

Kadushin, A. 1974. "Child Welfare Services."Second Edition. New York: Macmillan.

Kahn, A. 1963. "Planning Community Servicesfor Children in Trouble." New York: ColumbiaUniv. Press.

Kahn, AJ., Kamerman, S.G., and McGowan,B.G. 1972. "Child Advocacy." New York: Colum-bia Univ. School of Social Work.

Koel, B.S. 1969. "Failure to Thrive and Fatal In-juries as a Continuum." AmericanJournal of Diseasesof Children 118:565-567.

Kogelschatz, J.L., Adams, P.L., and Tucker, D.M.1972. "Family Styles in Fatherless Households."American Academy of Child Psychiatry Journal11:365-383.

Komarovsky, M. 1969. Blue-Collar Marriages. InJ. Roach et al., eds., "Social Stratification in theUnited States" (pp. 195-200). Englewood Cliffs,N.J.: Prentice-Hall.

Kromrower, G.M. 1964. "Failure to Thrive."British Medical Journal, 1337-1380.

54

Levitan, S. 1966. Alternative Income SupportPrograms. In H. Miller, ed., "Poverty AmericanStyle" (pp. 166-186). Belmont, Calif.: Wadsworth.

Lewis, H. 1969. "Parental and CommunityNeglect: Twin Responsibilities of Protective Ser-vices." Children 16:114-118.

Light, R.L. 1973. "Abused and NeglectedChildren in America: A Study of AlternativePolicies." Harvard Educational Review 43:556-598.

Looff, D.H. 1971. "Appalachian Children: TheChallenge of Mental Health." Lexington, Ky.:Univ. Press of Kentucky.

Maginnis, E., Pivchik, E., and Smith, N. 1967. "ASocial Worker Looks at 'The Failure to Thrive.' "Child Welfare 46:333-338.

Massachusetts Society for the Prevention ofCruelty to Children. 1973. "Statewide StatisticalReport for 1972." Boston: The Society.

Meier, E.B. 1964. Child Neglect. In N.E. Cohen,ed., "Social Work and Social Problems" (pp.153-199). New York: National Association ofSocial Workers.

Melson, E.F. 1956. Interpreting, Testing, andProving Neglect. In "Caseworker and Judge inNeglect Cases" (pp. 20-31). New York: ChildWelfare League of America.

Miller, W. 1965. Lower-Class Culture As aGenerating Milieu of Gang Delinquency. In S.N.Eisenstadt, ed., "Comparative Social Problems"(pp. 151-160). New York: Free Press.

58

Minturn, L. and Hitchcock, J.T. 1966. "TheRajputs of Rhalapur, India," New York: JohnWiley.

Minuchin, S. and Montalvo, B. 1966. "AdaptingFamily Therapy for the Low SocioeconomicGroup." Philadelphia Guidance(Mimeographed.)

Minuchin, S., Montalvo, B., Guerney, B., Ros-man, B., and Schumer, F. 1967. "Families of theSlums." New York: Basic Books.

Morris, M. 1968. Psychological Miscarriage: AnEnd to Mother Love. In R. Perrucci, ed., "TheTriple Revolution" (pp. 241-251). Boston: Little,Brown.

Morris, M.G. and Gould, R.W. 1963. Role Rever-sal: A Necessary Concept in Dealing with the Bat-tered Child Syndrome. In "TheNeglected/Battered Child Syndrome" (pp. 29-49).New York: Child Welfare League of America.

Mulford, R.M. 1956. The Caseworker in Court.In "Caseworker and Judge in Neglect Cases" (pp.3-8). New York: Child Welfare League ofAmerica.

Mulford, R.M., Cohen, M.I., and Philbrick, E.1967.. Psychosocial Characteristics of NeglectingParents: Implications for Treatment. In "Neglect-ing Parents" (pp. 5-15). Denver: AmericanHumane Association.

National Academy of Sciences. 1966. Reduce theFlow of Unwanted Babies. In H. Miller, ed.,"Poverty American Style" (pp. 300-304). Belmont,Calif.: Wadsworth.

New York Times. 1974. "Report to the U.S.Senate Select Committee on Nutrition andHuman Needs." (January 21)

Newberger, E.H. 1973. "The Myth of the BatteredChild Syndrome." Current Medical Dialogue40:327-334.

Newberger, E.H., Hagenbuch, J., Ebeling, N.B.,Colligan, E.P., Sheehan, J.S., and McVeigh, S.H.1973. "Reducing the Literal and Human Cost ofChild Abuse: Impact of a New Hospital Manage-ment System." Pediatrics 51:840-848.

Newton, N. 1951. "The Relationship Between In-fant Feeding Experience and Later Behavior.

Journal of Pediatrics 38:28-40.

Nurse, S.M. 1964. "Familial Patterns of ParentsWho Abuse Their Children." Smith College Studiesin Social Work 35:11-25.

Okell, C. 1972. "The Battered Baby Syndrome:Recent Research and Implications for Treat-

5 9

ment." Community Health (Public Nursing Section,Royal Society of Health) 23:89-95.

Oilman, J. and Friedman, S. 1967. "ParentalDeprivation in Psychiatric Conditions." Diseases ofthe Nervous System 28:298-303.

Oliver, K. and Barclay, A. 1967. "Stanford-Binetand Goodenough-Harris Test Performances ofHead Start Ch i I dren . " Psychological Reports20:175-179.

Parsons, T. and Bales, R. 1955. "Family Socializa-tion and Interaction Process." New York: FreePress.

Pavenstedt, E. 1973. "An Intervention Programfor Infants from High Risk Homes." Americanfour-nal of Public Health 63:393-395.

Pavenstedt, E., ed. 1967. "The Drifters: Childrenof Disorganized Lower-Class Families." Boston:Little, Brown,

1,971. The Meanings ofMotherhood in a Deprived Environment. In E.Pavenstedt and V. Bernard, eds., "Crises ofFamily Disorganization: Programs to Soften TheirImpact on Children" (pp. 59-74): New York:Behavioral Publications.

Piven, F. and Cloward, R. 1971. "Regulating thePoor: The Functions of Public Welfare." NewYork: Pantheon Books.

Podell, L. 1970. "Studies in the Use of Health Ser-vices by Families in Welfare: Utilization of Pre-ventive Health Services." Springfield, Va.: U.S.Technical Information Service.

1973. "Family Planning by Motherson Welfare." Bulletin New York Academy of Medicine49:931-937.

Polansky, N.A. 1969. "Powerlessness AmongRural Appalachian Youth." Rural Sociology34:219-222.

1971. "Ego Psychology andCommunication: Theory for the Interview."Chicago: Aldine - Atherton.

55

1973a. Beyond Despair. In A JKahn, ed., "Shaping the New Social Work" (pp.55-76). New York: Columbia Univ. Press.

1973b. "Services to theNeglectful Family: A Comprehensive Program."Athens, Ga.: School of Social Work, Univ. ofGeorgia.

Pulansky, N.A. and Pollane, L. 1975. "MeasuringAdequacy of Child Caring: Further Develop-ments." Child Welfare (hi press):

Polansky, N.A., Borgman, R.D. and Desaix, C.1972. "Roots of Futility." San Francisco: Jossey-Bass.

Polansky, N.A., Borgmati, R.D., DeSaix, C., andSmith, B.J. 1970. "Two Modes of Maternal Im-maturity and Their Consequences." Child Welfare49:312-323.

Polansky, N.A., DeSaix, C., and Sharlin, S.A.1971. Child Neglect in Appalachia. In "SocialWork Practice" (pp. 33-50). New York: ColumbiaUniv. Press.

. 1972."Child Neglect: Understanding and Reaching theParent." New York: Child Welfare League ofAmerica.

Powell, G.F., Brasel, J.A., and Blizzards R.M.1967. "Emotional Deprivation and Growth Retar-dation Simulating Idiopathic Hypopituitarism:Clinical Evaluation of the Syndrome." New Eng-land Journal of Medicine 276:1271-1278.

Raab, E. and Selznick, G. 1959. "MajorProblems." New York: Harper and Row.

. 1974. "Territorial Boundaries ofRural Poverty: Profiles of Exploitation." Lansing,Mich.: Center for Rural Manpower and PublicAffairs.

Roach, J. and Gurrslin, 0. 1969. An Evaluation ofthe Concept "Culture of Poverty." In J. Roach etal., eds., "Social Stratification in the UnitedStates" (pp. 202-213). Englewood Cliffs, N.J.:Prentice-Hall.

Robertson, J. 1962.Mothering As An Influence onEarly Development. In "Psychoanalytic Study ofthe Child" Volume XV (pp. 245-264). New York:Basic Books.

Robinson, H.B. and Robinson, N.M. 1971."Longitudinal Development of the Very Young ina Comprehensive Day Care Program: The FirstTwo Years." Child Development 42:1673-1683.

Rodham, H. 1973. "Children Under the Law."Harvard Educational Review 43:487-514.

Rosenheim, M.K. 1966. "The Child and His Dayin Court." Child Welfare 45:17-27.

Scarr-Salapatek, S. 1971. "Race, Social Class, andIQ." Science 144:1285-1295.

Schorr, A. 1968. How the Poor Are Housed. In L.Ferman et. al., eds., "Poverty in America" (pp.349-368). Ann Arbor:' Univ. of Michigan Press.

. 1974. "Children and Decent Peo-ple." New York: Basic Books.

Scrimshaw, N.S. 1969. "Early Malnutrition andSocial Central Nervous System Function." Merrill-Palmer

Quarterly 15:375-387.

Rainwater, L. 1969. The Negro Lower-ClassFamily Life. In J. Roach et al., eds., "SocialStratification in the United States" (pp. 218-220).Englewood Cliffs, N.J.: Prentice-Hall.

Reiterman, C., ed. 1971. "Abortion and the Un-wanted Child." New York: Springer.

Reul, M. 1973. "What It Is Like To Be Hungry."School Food Services Journal (May).

Seltzer, R. 1973. "The Disadvantaged Child andCognitive Development in the Early Years."Merrill-Palmer Quarterly 19:241-252.

Sharlin, S.A. and Polansky, N.A. 1972. "The Pro-cess of Infantilization." American Journal of Ortho-psychiatry 42:92-102).

Sheridan, M.D. 1956. "The Intelligence of 100Neglectful Mothers." British MedicalJournal, 91-93.

1959. "Neglectful Mothers."Lancet, part 2, 722-725.

Sherman, E.A., Neuman, R., and Shyne, A.W.1973. "Children Adrift in Foster Care." NewYork: Child Welfare League of America.

Skeels, H.M. and Dye, H.B. 1939. "A Study of theEffects of Differential Stimulation on MentallyRetarded Children." Proceedings of American Associa-tiOn on Mental Deficiency 44:114-136.

Slater, P. 1970. "The Pursuit of Loneliness:American Culture at the Breaking Point." Boston:Beacon Press.

Smith, S.M. and Hanson, R. 1972. "Failure toThrive and Anorexia Nervosa." Postgraduate Medi-cal Journal 48:382-384.

Spitz, R.A. 1945. Hospitalism: An Inquiry Into theGenesis of Psychiatric Conditions in Early Child-hood. In "Psychoanalytic Study of the Child"Volume I (pp. 53-74). New York: InternationalUniversities' Press.

1946. Hospitalism: A FollowupReport. In "Psychoanalytic, Study of the Child"Volume II (pp. 113-117). New York: Interna-tional Universities Press.

Stone, F.H. 1971. "Psychological Aspects of EarlyMother-Infant Relationships." British Medical

Journal, 224-226.

Sullivan, M., Spasser, M., and Penner, L 1975."The Bowen Center Project." Chicago: JuvenileProtective Association. (Mimeographed.)

Swanson, D., Bratrude, A., and Brown, E. 1972."Alcohol Abuse in a Population of IndianChildren." Diseases of the Nervous System 7:4-6.

Taylor, R.G. 1973. "Sweatshops in the Sun: ChildLabor on the Farm." Boston: Beacon Press.

U.S. Department of Health, Education, andWelfare. 1975. "Monthly Vital Statistics Report:Summary Report, Final Natality Statistics, 1973"'(January, p. 11). Rockville, Md.: The Department,Public Health Service, National Center for HealthStatistics.

61

Varon, E. 1964. "Communication: Client, Com-munity, and Agency." Social Work 9:51-57.

Vore, D. 1973. "Prenatal Nutrition and PostnatalIntellectual Development." Merrill-Palmer Quarterly19:253-260.

Wardle, M. 1970. "The Lordsville Project: Experi-mental Group Work in a Deprived Area." CaseConference 16:441-446.

Wasserman, H. 1970. "Early Careers of Profes-sional Social Workers in a Public Welfare Agen-cy." Social Work 15:93-101.

Wasserman, S.L. 1974. Ego Psychology. In F.J.Turner, ed., "Social Work Treatment" (pp.42-83). New York: Free Press.

Weber, R.E. and Polansky, N.A. 1975. Evaluation.In N.A. Polansky, ed., "Social Work Research"Revised Edition (pp. 182-201). Chicago: Univ. ofChicago Press.

Wedge, P. and Prosser, H. 1973. "Born to Fail."London, England: Arrow Books.

White, J. 1974. Personal communication.

Whitten, C.F., Pettit, M.G., and Fischhoff, J.1969. "Evidence that Growth Failure from Mater-nal Deprivation Is Secondary to Undereating."Journal of the American Medical Association209:1675-1682.

Winnicott, D. 1955. "The Depressive Position inNormal Emotional Development." British Journalof Medical Psychology 28:89-100.

Wylegala, V.B. 1956. Court Procedures inNeglect. In "Caseworker and Judge in NeglectCases" (pp. 9-19). New York: Child WelfareLeague of America.

Yarden, P.E. and Suranyi, I. 1968. "The EarlyDevelopment of Institutionalized Children ofSchizophrenic Mothers." Diseases of the NervousSystem 29:380-384.

Young. L. 1964. "Wednesday's Children: A Studyof Neglect-Abuse." New York: McGraw-Hill.

Zalba, S.R. 1966. "The Abused Child: A Surveyof the Problem." Social Work 11:3-16.

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