Child Abuse & Neglect, Voi. 1, pp. 179-186. Pergamon Press, 1977. Printed in Great Britain.

THE HOSPITALIZED.aBUSED CHILD: AN INTERDISCIPLINARY APPROACH*

Caro le Kauffman, RN, N l ~ i a n d K a t h l e e n N e L l l RN, MS C h i l d r e n ' s H o s p i t a l N a t i o n a l Medical Cen te r , 2125 13th S t r e e t , H.W., Washington, D.C. 20009, USA

ABSTRACT

The i n t e r d i s c i p l i n a r y approach to f ami ly d i a g n o s i s and t r e a t m e n t o f c h i l d abuse o f t e n b e g i n s in the h o s p i t a l . The tone e s t a b l i s h e d a t t h i s t ime has c r u c i a l i m p l i c a t i o n s f o r the t r e a t m e n t program f o l l o w i n g d i s c h a r g e from the h o s p i t a l . There i s , however, a p a u c i t y o f i n f o r m a t i o n i n t he l i t e r a t u r e r e g a r d i n g the b e s t u t i l i z a t i o n o f t h i s c r i t i c a l phase o f t r e a m e n t . Of ten t h i s p e r i o d i s viewed as a t ime f o r a s se s smen t , d i a g n o s i s and t r e a t m e n t o f the p h y s i c a l i n j u r i e s w h i l e n e g l e c t i n g to r e c o g n i z e and u t i l i z e t he p o t e n t i a l f o r p lanned t h e r a p e u t i c i n t e r v e n t i o n dur ing the h o s p i t a l s t a y . This paper i d e n t i - f i e s methods and i n t e r v e n t i o n s i n implement ing a t r e a t m e n t p l an p a r t i c u l a r to t h i s p h ~ e o f the o v e r - a l l t r e a t m e n t o f t he c h i l d and f a m i l y .

INTRODUCTION

C h i l d r e n ' s H o s p i t a l N a t i o n a l Hed ica l Center i s a p e d i a t r i c h o s p i t a l w i th 213 i n - p a t i e n t beds and an ambula tory s e r v i c e w i t h 130,000 p a t i e n t v i s i t s pe r y e a r , o f which 37,000 a r e emergency room v i s i t s . The h o s p i t a l i s l o c a t e d i n an e c o - n o m i c a l l y and s o c i a l l y dep res sed a r e a o f the c i t y . Although the i n - p a t i e n t beds s e r v e the e n t i r e m e t r o p o l i t a n a r e a , the ambula tory ca re depar tment p r i - m a r i l y s e r v e s the nea r ne ighborhoods a d j a c e n t to the h o s p i t a l .

In t he p a s t y e a r 460 c h i l d r e n were e v a l u a t e d f o r c h i l d abuse and n e g l e c t . Of t h o s e , 44Z were con f ined as p h y s i c a l l y abused, 13g as n e g l e c t secondary to p a r e n t a l d e p r i v a t i o n and 15Z were s e x u a l l y a s s a u l t e d . 27Z or 114 o f the 460 c h i l d r e n e v a l u a t e d i n 1975 were h o s p i t a l i z a d . Ch i ld r en a re a s s i g n e d to u n i t s by age and c o n d i t i o n . There i s no c h i l d abuse u n i t pe r s e .

In 1975 C h i l d r e n ' s H o s p i t a l N a t i o n a l Medical Center r e c e i v e d a f e d e r a l g r an t from the O f f i c e o f Chi ld Development f o r the e s t a b l i s h m e n t o f a model demon- s t r a t i o n c e n t e r f o r the management and t r e a t m e n t o f c h i l d abuse and n e g l e c t . In the imp lemen ta t ion o f the g r a n t , the u n d e r l y i n g p r i n c i v l e i n s e l e c t i o n .

* P o r t i o n s o f t h i s paper were p r e v i o u s l y p u b l i s h e d by the au tho r s i n the American J o u r n a l o f Mate rna l and ChJ_ld Nurs ing , "Care o f the H o s p i t a l i z e d Abused Chi ld and His Fa~Lly: Nurs ing I m p l i c a t i o n s , " 1, 117-128 (1976)

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180 C. Kaufmann and K. Neill

training, and utilization of staff was that it would be multl-disciplinary and although each discipline by nature of education and experience would have spe- cific professional skills, each member would share generic skills. The generic skills and knowledge include:

• the etlology of child abuse • the essentials in the identification of child abuse • familiarity with pollcies and procedures of the extended co-,~unlty

agencies and the hospltal-based team • the capacity and willlngnes• to function as part of a multidlsci-

plinary team by understanding the rules and interfaces of team members

• the willingness and ability to make home visits comfortably with an understanding of the therapeutic use of such visits

• knowledge of child growth and development • knowledge of the principles of crisis intervention and skillful

in the appllcatlon of such knowledge • the ability to convert and direct concern for abused and neglected

children into emphathetlc understanding of abusive parents and into positive therapeutic behaviors with parents

In large measure the sharing of these generic skills have mitigated some, but not all, of the inherent problems of blending a multidisclplinary team and avoiding the problem of professional rivalry and mistrust. The interdisciplln- ary clinical staff at the Child Protection Center consists of nurses, social workers, pediatricians, child and adult psychologists, an adult psychiatrist and f,m41y advocates. With this number of staff and the array of hospital staff it was felt that client• would receive better service by decreasing the number of people who interact with the family. Thus, one member of the Child Protection Center is assigned as a case coordinator. Sharing generic skills ha• made this posslble.

Although the s t a f f o f the Chi ld P r o t e c t i o n Center have t h e i r l o n g e s t c o n t a c t w i th the f a m i l y once the c h i l d i • d i s c h a r g e d from the h o s p i t a l , the as •essmant and t r e a t m e n t beg ins the moment the c h i l d p r e s e n t • i n t he emergency room. The tone e s t a b l i s h e d a t t h i s t ime and dur ing h o s p i t a l i z a t i o n may have c r u c i a l i m p l i - c a t i o n s f o r the succes s o f the t r e a t m e n t program f o l l o w i n g d i s c h a r g e from the h o s p i t a l . Of ten the p e r i o d o f h o s p i t a l i z a t i o n i s viewed a • a t ime f o r a s s e s s - ment, d i a g n o s i s and t r e a t m e n t o f the p h y s i c a l i n j u r i e s w h i l e n e g l e c t i n g to u t i l i z e the p o t e n t i a l f o r p lanned t h e r a p e u t i c i n t e r v e n t i o n .

TREATHENT P ~ .

An i n c i d e n t o f c h i l d abuse p r e c i p i t a t i n g the h o s p i t a l i z a t i o n o f a c h i l d p r e - s e n t s what may appear t o be a paradox. In p e d i a t r i c • , p a r e n t s a r e viewed as a source o f suppor t and s e c u r i t y f o r t h e i r c h i l d r e n . Much of p e d i a t r i c c a r e i s d i r e c t e d a t m a i n t a i n i n g and s t r e n g t h e n i n g t h i s u n i t . Because the c h i l d who has been abused i s a t r i s k , the c h i l d may be removed t e m p o r a r i l y o r i n some i n s t a n c e s permanent ly from the f ami ly unit. P a r e n t a l r i g h t s may be suspended w i t h the f u t u r e o f t he f ami ly u n i t dependent upon f u r t h e r s o c i a l and p • y c h i a t r i c and c o u r t p r o c e d u r e • . Thu•, u n c e r t a i n t y pervades the c r i s i s , c o n f u s i n g r e l a - t i o n s h i p s f o r a l l ; the c h i l d , the p a r e n t , and those i n t e r f a c i n g w i t h the f a m i l y . F a i l u r e to r e c o g n i z e t h i s paradox and i t s e f f e c t on s t a f f can r e s u l t i n an un- p lanned and u n t h e r a p e u t i c m i l i e u .

The hospitalized child 181

In i d e n t i f y i n g s p e c i f i c methods i n implement ing a g o a l - d i r e c t e d t r e a t m e n t p l a n dur ing h o s p i t a l i z a t i o n , t h r e e f a c t o r s must be k e p t i n mind. F i r s t , i n t e r v e n - t i o n s wi th t he h o s p i t a l i z e d abused c h i l d and h i s p a r e n t s must be p r e d i c a t e d on a r e c o g n i t i o n t h a t c h i l d abuse i s a symptom of f ami ly d y s f u n c t i o n , t h a t a m a j o r i t y o f t h e s e f a m i l i e s can be he lped , and t h a t the i d e a l goa l o f most c h i l d abuse i n t e r v e n t i o n i s the s a f e r e t u r n o f the c h i l d to h i s f a m i l y . Secondly , t h a t a p p r o p r i a t e i n t e r v e n t i o n a t a t ime of c r i s i s o f f e r s t he o p p o r t u n i t y f o r a p o t e n t i a l l y more mean ingfu l and e f f e c t i v e impact on the fAmtly. Th i rd , a l l t hose who i n t e r a c t w i th the f~mt ly have the p o t e n t i a l f o r hav ing e i t h e r a p o s i - t i v e or n e g a t i v e impact on the f ami ly . Although a v a r i e t y o f f a c t o r s w i l l n e c e s s i t a t e i n d i v i d u a l i z i n g a t h e r a p e u t i c p l a n , a number o f goa l s can be i d e n t i f i e d :

• s e t t i n g a tone o f t r e a t m e n t r a t h e r than punishment f o r the p a r e n t s • promot ing a sense o f p a r e n t a l adequary whenever p o s s i b l e • s u p p o r t i n g the s t r e n g t h s o f t he p a r e n t - c h i l d r e l a t i o n s h i p • d e c r e a s i n g the trauma o~ h o s p i t a l i z a t i o n f o r the c h i l d and p a r e n t s • i d e n t i f y i n g p a r e n t a l end c h i l d needs and s h a r i n g t h e s e w i t h the

team • promot ing the c h i l d ' s r e t u r n to w e l l n e s s • implement ing the p r i n c i p l e s o f c r i s i s i n t e r v e n t i o n • b e g i n n i n g to model f o r t he p a r e n t s and c h i l d a l t e r n a t e ways o f

hand l ing b e h a v i o r , f e e l i n g s and i n t e r a c t i o n s w i t h o t h e r s

These goa l s a re a p p l i c a b l e i n the ambula tory s e t t i n g as w e l l as on the i n - p a t i e n t units.

Most f r e q u e n t l y abuse and n e g l e c t a r e i d e n t i f i e d i n the emergency room. When t h e r e i s a s u s p i c i o n t h a t t h i s has o c c u r r e d , a member o f the Ch i ld P r o t e c t i o n Center i s c a l l e d t o e v a l u a t e the s i t u a t i o n and i n i t i a t e c r i s i s i n t e r v e n t i o n . The team member meets w i t h the f a m i l y and e x p l a i n s h i s r o l e as a h e l p i n g pe r son and the p rocedu re s t h a t w i l l f o l l o w . In Washington the law r e q u i r e s t h a t the p o l i c e be n o t i f i e d . The s t a f f member o f the Chi ld P r o t e c t i o n Team s t a y s w i t h the p a r e n t du r ing the p o l i c e i n t e r v i e w and then accompanies the p a r e n t to the u n i t on which the c h i l d i s h o s p i t a l i z e d .

O r i e n t a t i o n t o the Uni t

Of t en , abus ing p a r e n t s a r e u n c e r t a i n about t h e i r welcome on the n u r s i n g u n i t and the r o l e they can have i n t h e i r c h i l d ' s c a r e . In our e x p e r i e n c e , most p a r e n t s have been l e g a l l y f r e e and encouraged to v i s i t t h e i r c h i l d . To make t h e i r v i s i t s more c o m f o r t a b l e , they need to be o r i e n t e d to h o s p i t a l r o u t i n e s , p e r s o n n e l , and r e g u l a t i o n s as w e l l a s the u n i t i t s e l f .

O b s e r v a t i o n and Data C o l l e c t i o n

In t h e push to "d i agnose" c h i l d abuse wi th q u e s t i o n s r e l a t i v e to how the i n j u r y o c c u r r e d and p r e c i p i t a t i n g f a c t o r s , the c h i l d abuse team and u n i t s t a f f can a l l too e a s i l y o v e r l o o k the need f o r the r o u t i n e d a t a n e c e s s a r y f o r p l a n n i n g c a r e f o r t he c h i l d du r ing the h o s p i t a l i z a t i o n ; f o r e n ~ p ~ e , b e d - t i m e r i t u a l s , p r o g - r e s s i n t o i l e t t r a i n i n g , f a v o r i t e s e c u r i t y o b j e c t , p r e f e r r e d foods , e t c . Ob- t a i n i n g t h i s i n f o r m a t i o n no t on ly p r o v i d e s da ta needed f o r p l ann ing c a r e bu t may a l s o s e r v e t o :

s communicate t o the p a r e n t s some r e c o g n i t i o n o f t h e i r p a r e n t a l r o l e

182 C. Kaufmann and K. Neill

• a s s e s s p a r e n t a l knowladsa, e x p e c t a t i o n s and p e r c e p t i o n s of t h e i r c h i l d

• demons t ra te t he s t a f f ' s r e c o g n i t i o n o f t h e i r c h i l d ' s needs as an i n d i v i d u a l and the JJnportance o f mee t ing t h e s e needs .

The p r o c e s s o f the da ta c o l l e c t i o n as v e i l as the on-gn ing o b s e r v a t i o n s o f p a r e n t - c h i l d - s t a f f i n t e r a c t i o n must be done v i t h s e n s i t i v i t y to t h e i r r e c e n t e x p e r i e n c e s w i t h tba p o l i c e , c o u r t s and o t h e r s . J o i n t i n t e r w l e v s by a n u r s e . phys ic~sn end s o c J ~ l worker can reduce the l i k e l i h o o d o f n e e d l e s s r e p e t i t i o n t h a t m my only s e r v e to f u r t h e r a l i e n a t e the f a m i l y .

Ward s t a f f , p a r t i c u l a r l y n u r s e s , a r e in a unique p o s i t i o n f o r o b s e r v i n g the c h i l d th roughout the course o f h o s p i t a l s t a y , a t v a r i o u s t imes and under d i f f e r e n t c i r c u m s t a n c e s , Valuable i n f o r m a t i o n can be d e r i v e d from o b s e r v a - t i o n s t h a t focus n o t on ly on the p a r e n t / c h i l d r e l a t i o n s h i p but a l s o the c h i l d ' s r e l a t i o n s h i p s w i t h o t h e r s i n c l u d i n g a d u l t s and c h i l d r e n , males and f ema les . Obse rva t ions should a l s o be made o f the c h i l d ' s r e sponse to t r e a t m e n t and p a r - t l c l p a t l o n i n u n i t a c t i v i t i e s . P a r e n t s ' r e sponses to the c h i l d ' s b e h a v i o r and t h e i r r e l a t i o n s h i p w i t h a d u l t s and a u t h o r i t y f i g u r e s a l s o become c l e a r through cop t lnued o b s e r v a t i o n .

C~us l s teucy i n Care

F~equent ly the "sys tem" f o r management o f c h i l d abuse cases r e q u i r e s t h a t the p a r e n t s r e l a t e to a l a r g e number o f i n d i v i d u a l s w i t h i n t he h o s p i t a l and the ~owmunity. R e l a t i n g to t h e s e many peop le can be v e r y con fus ing and d i s t u r b i n g 5o p a r e n t s who may a l r e a d y be unable to t r u s t o t h e r s . Maximizing the t h e r a - p e u t i c p o t e n t ~ o f the h o s p i t a l r e q u i r e s t h a t bo th the c h i l d and p a r e n t s have the o p p o r t u n i t y to r e l a t e to one i n d i v i d u a l w i t h whom they may b e g i n t o deve lop a t r u s t i n g r e l a t i o n s h i p . For t he abused c h i l d t h i s i s p a r t i c u l a r l y impor t an t s i n c ~ a b u s e d c h i l d r e n w i l l o f t e n demons t ra te u n c e r t a i n t y when i n t e r a c t i n g w i t _ h a d u l t s who r e l a t e to them d i f f e r e n t l y from t h e i r p a r e n t s . C o n s i s t e n t c a r e i s c r u c i a l i n t h e r a p e u t i c a l l y h e l p i n g the c h i l d i n t h i s s i t u a t i o n a l though a t t~me8 the c h i l d ' s b e h a v i o r may make t h i s d i f f i c u l t .

p ~ e p a r a t i o n f o r P roceuures :

As do a l l p e d i a t r i c p a t i e n t s , the abused c h i l d needs a g e - a p p r o p r i a t e p r e p a r a - t i o n f o r p rocedures to d e c r e a s e h i s f e a r s and p r o v i d e an a p p r o p r i a t e o u t l e t f o r h i s an~4etT. Almost a l l d i a g n o s t i c and t r e a t m e n t p rocedure s a r e s t r e s s f u l f o r c h i l d r e n . However, f o r one who has had p a r t i c u l a r l y t r a u m a t i c e x p e r i e n c e s a t the hands o f h i e c a r e t a k e r s , some o f our t r e a t m e n t s become even more o v e r - whelming. A p p l i c a t i o n o r removal o f a c a s t ; p h y s i c a l ~TAm~at ion o f the s e x u a l l y moles ted c h i l d , end w h i r l p o o l ba th s f o r the c h i l d who has been burned a r e some prime examples . In such 8 i tua t : tons the nu r se must p r o v i d e s u f f i c i e n t t ime i n he r c a r e p l an t o o f f e r suppor t end r e a s s u r a n c e to the c h i l d th roughout the p rocedure end to p r o v i d e a p l e a s a n t e x p e r i e n c e f o r him a t i t s c o n c l u s i o n . C a r e f u l l y e x p l a i n i n g the p rocedure and g i v i n g the c h i l d an o p p o r t u n i t y to p a r t i c i p a t e o r h e l p i n some way may a l s o reduce some of the t rauma. P a r e n t s , when a b l e , may a l s o he lp to p r e p a r e t h e i r c h J l d .

Management o f p r o b l e m a t i c a l b e h a v i o r s of t he abused c h i l d and p, a r e n t s

Of ten the behav lo r o f an abused c h i l d o r h l8 f a ~ t l y rpe sen t8 management p rob - lems. These d i s t u r b a n c e s can be a f u n c t i o n o f f a c t o r s i n c l u d i n g t h e i r p h y s i c a l

The hospitalized child 183

and emot iona l h e a l t h . Al though a c h i l d may behave i n a v a r i e t y o f ways, a number o f p r i n c i p l e s can be i d e n t i f i e d in gu id ing the development o f a p l a n o f c a r e •

• s t a f f must be a s s i s t e d i n d e a l i n g w i t h t h e i r f e e l i n g s about t he c h i l d ' s b e h a v i o r end the f a c t t h a t the c h i l d has been abused

• the approach must be n o n p u n i t i v e a l though the c h i l d ' s b e h a v i o r may be p r o v o c a t i v e

• s p e c i f i c r e sponses to the c h i l d ' s b e h a v i o r must be p lanned r a t h e r th~n the r e s u l t o f w e l l - i n t e n t i o n e d bu t u n t h e r a p a u t i c i n t e r v e n t i o n , f o r example; overwhelming the withdrawn c h i l d wi th too i n t e n s e a r e l a t i o n s h i p o r many peop le t r y i n g to q u e s t i o n the c h i l d to d e t e r - mine "wh¢ did it"

• the c h i l d must be p rov ided w i t h p o s i t i v e e x p e r i e n c e s end p l e a s u r e s i n c l u d i n g p a r t i c i p a t i o n i n a c h i l d l i f e program, p l ay w i t h o t h e r c h i l d r e n , c h o i c e s whenever p o s s i b l e , and the o p p o r t u n i t y to a t t e n d schoo l

• the c h i l d must be a f f o r d e d the o p p o r t u n i t y to con t inue the r e l a t i o n - sh ip w i t h the i n d i v i d u a l w i th whom he has the most i n t e n s e emot iona l r e l a t i o n s h i p ( p s y c h o l o g i c a l mother) u n l e s s t h l s i s unsa fe

• the c h i l d must be p rov ided an o p p o r t u n i t y to l e a r n t h a t e x p r e s s i n g f e e l i n g s and working through f e a r s and concerns i s "OK"

As wi th the c h i l d , t h e r e a r e a wide v a r i e t y o f b e h a v i o r s the h o s p i t a l s t a f f Nay encoun te r i n a p a t e n t who has abused a c h i l d . Regard le s s o f t h e i r p r e - s e n t l n g b e h a v i o r s , i n t e r v e n t i o n s must be d i r e c t e d towards e s t a b l i s h i n g a s u p p o r t i v e and, when p o s s i b l e , a t r u s t i n g r e l a t i o n s h i p r a t h e r than a t t e z p t l n g to a c h i e v e major changes i n the p a r e n t s . S p e c i f i c a r e a s o f focus should I n c l u d e :

m e n s i s t £ u g the p a r e n t s i n d e f i n i n 8 and be ing c o m f o r t a b l e wi th t h e i r r o l e w h i l e t h e i r c h i l d i s i n the h o s p i t a l

@ a s s e s s i n g p a r e n t a l needs , both as i n d i v i d u a l s end as p a r e n t s @ mede l ing , in a n o n t h r e a t e n i n 8 manner, a l t e r n a t i v e ways o f

managing the c h i l d ' s b e h a v i o r • a s s i s t i n g the p a r e n t s i n v iewing the abus ive b e h a v i o r as a problem

need ing t h e r a p e u t i c he lp r a t h e r than "bad" behav io r r e q u i r i n g new r e s o l v e "no t to have i t happen a g a i n "

• a s s i s t i n g and s u p p o r t i n g the p a r e n t s as the r a ~ f i c a t i o n s o f the problem become more c l e a r ; f o r example, the temporary p lacement o f t he c h i l d

P r o t e c t i o n o f t he c h i l d ' s end p a r e n t s ' r i R h t to p r i v a c y end c o n f i d e n t i a l i t y

Chi ld abuse i s o f t e n a t o p i c t r e a t e d d r a m a t i c a l l y by the p r e s s and media. Host i n d i v i d u a l s a r e v e r y c u r i o u s about i t . Hosp i t~ t s t a f f and p a r e n t s o f o t h e r c h i l d r e n i n the h o s p i t a l may have d i f f i c u l t y c o n t r o l l i n g t h e i r c u r i o s i t y which can on ly be d e s t r u c t i v e to e s t a b l i s h t n s a t h e r a p e u t i c me l i eu f o r the p a r e n t s . The p a r e n t s need to be o f f e r e d p r i v a c y i n s i t u a t i o n s t h a t a r e bound to s t i m u l a t e c u r i o s i t y , such as v i s i t s from the p o l i c e , a t t o r n e y s o r r e p r e s e n - t a t i v e o f c o , u n i t y a g e n c i e s .

F r e q u e n t l y , o t h e r p a r e n t s on the u n i t l e a r n t h a t t he c h i l d has been abused. When t h i s does happen they need some a s s i s t a n c e i n "M~Agin 8 t h e i r f e e l i n g s to reduce the amount o f h o s t i l i t y t h a t may be d i r e c t e d to the a b u s i v e p a r e n t s .

184 C. Kaufmann and K. Neill

Occasionally the abused child will freely tell others of the reason for his hospitalization. The curious questions of those around the child may tend to reinforce this behavior. He needs to be protected from others asking questions end being labeled and perceiving himself as an "abused child". The child's need to talk about the abuse should be directed to one individual.

P r e p a r a t i o n f o r d i s c h a r 6 e or p lacement

A recognized principle of discharge planning for hospitalized patients is that this process begins on the day of the patient's admission. Within the context of child abuse, a major component of discharge planning is assessment of the f-m~ly in terms of safety of the child in the home and treatment needs of the members. Community agencies that have members of their staffs working with the fam41y generally are contacted as a part of this assessment and planning process

Since upon d i s c h a r g e the c h i l d may be t e m p o r a r i l y p l aced i n a f o s t e r home or ano the r s e t t i n g to a l l ow f o r f u r t h e r d i a g n o s t i c and t h e r a p e u t i c work w i t h the p a r e n t s , the c h i l d has bo th a need and a r i g h t to be p repa red f o r the p lacement . To reduce the emot iona l tratmua of ano the r change i n envi ronment , s p e c i f i c measures to ease t r a n s i t i o n a r e e s s e n t i a l .

Informing the child of plans early enough to allow him to deal with some of his fears and concerns is vital. Visiting with the new caretaker prior to transfer, first on the hospital unit and later in the new setting with a trusted nurse along, will help the child to prepare for the move.

The p lacement o f the c h i l d a l s o c o n f r o n t s p a r e n t s w i th ano the r c r i s i s , t h a t o f r e c o g n i z i n g the s e r i o u s n e s s o f the s i t u a t i o n ; they w i l l need p r e p a r a t i o n f o r the p lacement , a s s i s t a n c e i n d e a l i n g wi th t h e i r f e e l i n g s , and he lp i n p l ann ing and p r o v i d i n g suppor t to t h e i r c h i l d . P r o v i d i n g p a r e n t s w i th the o p p o r t u n i t y to p a r t i c i p a t e c o n s t r u c t i v e l y i n t h i s t r a n s i t i o n unde r sco re s the message t h a t the ult4~te goal remains the safe return of the child t o them.

An o p p o r t u n i t y to meet w i th the new c a r e t a k e r to d i s c u s s the c h i l d ' s h a b i t s and needs and to p l an f o r v i s i t i n g t h e i r c h i l d a r e methods o f b u i l d i n g on p a r e n t a l s t r e n g t h s . But no t a l l p a r e n t s w i l l be a b l e to he lp t h e i r c h i l d through the s e p a r a t i o n , because o f t h e i r own d i s t r e s s . A s s e s s i n g t h e i r p o t e n - t i a l f o r be ing s u p p o r t i v e i s a shared team r e s p o n s i b i l i t y .

In some s i t u a t i o n s , the c h i l d may go d i r e c t l y home f o l l o w i n g h o s p i t a l i z a t i o n . As in a l l p e d i a t r i c s i t u a t i o n s , p a r e n t s need to be p repa red f o r the p o s t - h o s p i t a l i z a t i o n problems c h i l d r e n f r e q u e n t l y have , such as n i g h t m a r e s , s l e e p d i s t u r b a n c e s , o r r e g r e s s i v e b e h a v i o r .

O c c a s i o n a l l y a c h i l d v i i i be s e n t home by v i r t u e o f a c o u r t o r p o l i c e d e c i s i o n . This i s s t r e s s f u l when h o s p i t a l p e r s o n n e l b e l i e v e t h a t the home s i t u a t i o n i s dangerous to the c h i l d , and the s t a f f ' s f r u s t r a t i o n and f e e l i n g s o f h e l p l e s s - ness may o f t e n be expres sed as anger a g a i n s t the p a r e n t s . The goa l i n such s i t u a t i o n s i s to communicate the s t a f f ' s con t inued concern and a v a i l a b i l i t y and to pave p a r e n t s ' a c c e s s to con t inued fo l l ow-up c a r e and o t h e r community r e s o u r c e s such as homemakers, community n u r s i n g , p r e s c h o o l , or s p e c i a l p r o - grams f o r the c h i l d ' s d i s a b i l i t i e s , and perhaps t he rapy f o r t he p a r e n t s .

The hospitalized child 185

CONCLUSION

Although the preceding treatment plan may seem clearcut it is not always easy to implement. The reasons for this are many and include:

s the lack of training in child abuse and neglect in many of the disciplines' formal education,

• the difficulty in managing feelings towards the parents who abused their children while simultaneously working with parents who are devastated by their child's acute, chronic or terminal illness

• the problems of communication between CPC staff, hospital staff and community agencies,

• the complexity and multiplicity of the child abuse syndrome, s the frustration of caring for children whose hospital stay extends

beyond necessary hospitalization because of delays in court pro- ceedings and placement

• the difficulty in maintaining continuity of care when students, residents and staff rotate units and tours of duty

The most important of these are feellngs experienced by staff. It is only in the very recent past that schools of nursing, medicine and social service have defined the abused child and his family as a specific area for study and under- standing. As a result, the staff of most pediatric units or emergency rooms are unfamiliar with the unique problems and needs of these families and thus are vulnerable to experiencing and acting on the same anger and revulsion experienced by the lay public. It is only through continuln~ education pro- grams directed at all levels of staff who work in any capacity with these children and families chat one can hope to develop within the staff a capacity to relate therapeutically.

We have found it most effective to maintain a continuing series of educational activities for staff. These include yearly grand rounds presented by CPC inter disciplinary staff, monthly lectures co emergency room and ambulatory care staff, a yearly series of classes to ward personnel, case conferences, partici- pation in diagnostic conferences, and opportunity on the units to express and work through the feelings stimulated by child abuse. Unit staff as well as the child abuse team itself need feedback on the post discharge course for both children and families. Their co,~nltment to the difficult process of relating therapeutically to the child and family 24 hours a day for the period of hospitalization can be maintained only when they feel that they have had an impact that is positive (makes a difference).

The management of abused c h i l d r e n and t h e i r f a m i l i e s have p r o f i t t e d by the approaches o u t l i n e d in t h i s paper .

REFERENCES

1. Blumberg, M. L. , Psychopathology of the abusing pa ren t , Am, J . Psychother . 28, 20-29 (1974).

2. Fagan, C. M., The Ef fec t s of Hatermal Attendance Durin 8 H o s p i t a l i z a t i o n on the P o s t - H o s p i t a l Behavior of Youn~Chi ldren: A Comparative Survey, F. A. Davis, P h i l a d e l p h i a (1966).

3. Go lds te ln , J . and Ochers, Beyond the Best I n t e r e s t s of the Chi ld , Free P re s s , Glencoe, New York (1973).

186

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Green, F. C. , Ch i ld abuse and n e s l e c t . A p r i o r i t y problem f o r the p r i v a t e p h y s i c i a n , Ped. C l t n . North Am. 22, 229-339 (1975).

Kempe, C. H. and H e i f e r , R. E. E d s . , He lp ing the B a t t e r e d Ch i ld and Hie Fami ly , J . B. L i p p i n c o t t , P h i l a d e l p h i a (1972) .

N e i l l , K. and Kauf£man, C . , Care of t he H o s p i t a l i z e d Abused C h i l d and His Fami ly ; Nurs ing I m p l i c a t i o n s , Am. J . of M a t e r n a l Ch i ld Nurs ing 1, 117-123 (1976)