Emotional Abuse and Mental Injury

A Critique of the Concepts and a Recommendation for Practice

CHARLENE KAVANAGH, PH.D.

The imperative to include emotional abuse and neglect in state child abuse reporting
statutes has been burdened with inadequate definitions of mental injury and inconclusive
studies of etiology. Confusion has been increased by legal standards that require the
reporting of injury in situations where observable injury often does not occur. Research on
the effects of deviant parenting on the psychological and physical state of the child is
reviewed in an attempt to delineate reliably occurring, objectifiable injury. With the
exception of psychosocial dwarfism, no objective abnormal physical or psychological syn-
drome has been reliably demonstrated in the child whom most would term emotionally
abused or neglected. An approach to the problem is suggested and a legal position is
recommended.
Journal of the American Academy of Child Psychiatry, 21, 2:171-177, 1982.

Emotional abuse of children has received increasing
attention in recent years. Judges are "finding" it,
clinicians treating it, and researchers studying it. But
the question remains: What is it? The National Com-
mittee on Child Abuse and Neglect, Washington, D.C.,
has defined mental injury as "an injury to the intellec-
tual or psychological capacity of a child as evidenced
by an observable and substantial impairment in his
ability to function within his normal range of perform-
ance and behavior, with due regard to his culture"
(Lauer (1978), p. 1). Participants at a 1977 NIMH
workshop in Houston, Texas, proposed that emotional
abuse and/or neglect "can be diagnosed in the pres-
ence of parental acts of omission and commission with
or without intent, when paired with a child's emo-
tional, behavioral, and overall developmental devia-
tions of sufficient degree as to suggest an imperative
need for intervention for the child's safety and well-
being" (Lauer (1978), p. 1).
This dual focus on parental fault and condition of
the child is also apparent in legal definitions ofreport-
able emotional abuse and neglect on record in a ma-
jority of state statutes in this country. However, in
most statutes one of the issues rather than both is
stressed. Some states emphasize parental behavior,
such as unwillingness to provide "proper care" (Cali-
fornia), refusal to provide "personalized attention that
Dr. Kavanagh is an Assistant Professor in the School of Medi-
cine (Department of Pediatrics) and School of Nursing at The
University of Wisconsin-Madison (600 Highland Ave., Madison,
WI 53792), where reprints may be requested.
This paper was funded in part by a grant from the State of
Wisconsin's technical assistance child abuse monies.
0002-7138/82/2102-0171 $02.00/0 © 1982 by the American Acad-
emy of Child Psychiatry.
171
will tend to advance a child's physical, mental, moral,
emotional, and general well-being" (Delaware), "com-
mission or omission of any act or acts which materially
affect normal emotional development" '(Montana),
and "failure to exercise a minimum degree of care"
(New York). Other states focus on the child's condi-
tion, that is, his being "denied proper care ... emo-
tionally" (Connecticut), being "denied proper parental
love, or adequate parental association [with subse-
quent] emotional maladjustment" (Idaho), behaving
"unnaturally and unrealistically in relation to normal
situations, objects, and other persons" (Maryland),
being "likely to suffer serious harm [and having] sus-
tained a wound, injury ... or mental condition" (Ten-
nessee) (Katz et al. (1975».
Whether the focus is on parent or child, similar
questions arise. Is it possible to demonstrate a causal
relationship between parental behavior and psycho-
pathology in the child? What is the normal state of
affairs that the child is being compared to, or the
"proper care" that is the parent-standard? If we can
agree on standards of child development and parenting
behavior, how are we to assess a child's psychological
condition or a parent's parenting for comparison to
those standards? Is parental intent relevant? What is
the purpose of attempting to define emotional abuse
or neglect: To assure the minimum or maximum well-
being of children? To prevent specific and likely sig-
nificant harm? To justify state intervention in family
l:e ?
ure:
A review of the medical and legal literature provides
few definitive answers to these questions. Neverthe-
less, it is useful for the analysis of central issues and
the formulation of core principles from which to pro-
ceed.
172 CHARLENE KAVANAGH

Defining Abuse vs. Justifying Intervention the need to specify the harms which justify interven-
tion, if only to be able informatively to weigh the risks
Abrams (1979) has suggested that the problem of
of both, they do not solve the problem of how to assess
defining abuse should be considered separately from
consistently and competently emotional damage in
that of justifying state intervention. She argues that a
children. Because of the dearth of theory, conclusive
definition does not justify intervention. Proposing a
research, and agreement in the areas of child devel-
broad definition of abuse and neglect' as an index of
opment and psychopathology, it is much more difficul t
when to offer voluntary services to families, she main-
to diagnose childhood depression (Malmquist, 1976),
~ns that the state's right to intervene coercively in
for example, than a fractured femur, even when the
Instances of abuse can only be justifiably exercised to
diagnostician is an expert. .
protect the minimum needs of the child. Although
Abrams does not define "minimum needs," she 'sup- Effects of Deviant Parenting on Psychological
ports her position by citing the inadequacy of a "best State of the Child
interest" standard (since there might always be an-
Given the present lack of consensus regarding ade-
other environment that would be better in some way
quate parenting behavior, we might begin by examin-
for the child), as well as our Constitutional tradition
ing the extreme case, the situation which clearly de-
regarding the parental right to raise children without
parts from community norms, in order to discover
state interference as long as the child suffers no harm.
dynamics which might also be operative in more subtle
I~ contrast, while also supporting this principle of
manifestations of deviant parenting, and their effect
family autonomy, the Institute of Judicial Administra-
on the psychological state of the child.
tion-American Bar Association Standards (Kaufman,
One study of the extreme case was reported by
1977) define abuse specifically for the purpose of iden-
Sameroff (1978). He compared infants of schizophrenic
tifying when coercive intervention is warranted. Be-
women to those of normal mothers. Although the
cause there is no consensus regarding 'proper child-
severity of mental illness in the schizophrenic mothers
rearing, and, except in instances of serious harm we
did seem to "contribute to difficult temperament" (p.
are often unable to improve a child's situation' via
174) in the infants (defined by Thomas and Chess
coercive intervention (Kaufman, 1977), the IJA-ABA
(1977), as irregular, nonadaptive, low in initial ap-
Committee has attempted to define "serious harm" or
proach, and involving intense reactions of negative
the "substantial likelihood" of its imminent occur-
mood), other variables, namely race and socioeco-
rence. Clear definitions, this group contends, will pre-
nomic group, number of previous children, and anxiety
vent arbitrary discriminatory interventions based on
level in the mother were also associated with infant
individual value judgments which are likely to be
temperament descriptions. The variable most highly
harmful themselves, especially if they result in unnec-
correlated with infant temperament at 4 months of
essary disruption of fanIilies.
age was the mother's prenatal anxiety score. However,
The IJA-ABA Standards mandate that coercive
this maternal anxiety measure was not associated with
intervention in the case of emotional abuse is justified
the in!'ant's developmental level at age 30 months, and
only when the child is suffering (or has a considerable
so ultimately seems of questionable significance.
probability of suffering in days or weeks) serious emo-
Greenberg (1970), in a study of 42 infants less than
t~onal ~amage, as evidenced by severe anxiety, depres-
30 months of age with atypical behavior (defined as
sion , WIthdrawal, or untoward aggressive behavior to-
rhythmic hypermotility, feeding problems with sig-
ward self or others, and the child 's parents are unwill-
nificant lag in rate of weight gain, and self-biting),
ing to provide treatment for him. While this definition
found that their mothers were significantly more re-
~oes not re~uire demonstration of parental causality,
jecting, demanding, neglecting, and punishing than
~t does require expert testimony. For this reason any
control mothers of infants who did not exhibit deviant
Judgment of emotional damage (as a result of abusive
behavior. The atypical infants' mothers were de-
p~en~ing) is necessarily subject to individual judge
scribed as apathetic and reticent to communicate, and
bias smce the state of the art, t hough progressing
as reporting their own mothers to have been rejecting,
(DS~-III, 1980) presently lacks reliable, valid criteria
demanding, neglecting, etc . Despite the study's meth-
for diagnosis and diagnosis-related treatment of emo-
odological inadequacy (the sample was neither ran-
tional disorders (Mischel, 1968; Wiggins , 1973). Thus
dom nor inclusive of all atypical infants from the
even though the IJA-ABA Standards rightly identify
specific pediatric service studied), it does offer reason-
able criteria for atypical behavior in infants as well as
1 This ~efinition incorporates a concept of parenting "which fails an association between that behavior and maternal
t? rec?grnze or respect the child's right to make autonomous deci-
SIOl~S ~n matters which are neither critical to protecting the child's
characteristics.
basic mterests, nor make claims on others" (p. 161). In another study (Wolff, 1970), over half of the
 EMOTIONAL ABUSE AND MENTAL INJURY
mothers of children referred to a psychiatric clinic for
reactive behavior disorders were found to have clini-
cally recognizable personality disorders compared to
one-fifth of mothers of nonreferred children. Despite
this study's reasonable sample size (N = 100) and good
methodology (mothers were assessed via interview
and blind expert raters with acceptable inter-rater
reliability), its results must be considered with caution
since "referred" children may represent a biased sam-
ple of the population of all children with behavior
disorders.
In a prospective study of 200 families of psychiatric
patients, Rutter (1970) found that the rate of emo-
tional disturbance in the children was highest when
both parental personality disorder and marriage prob-
lems existed. According to the researcher, ". . . on the
whole, patterns of child-rearing seem to be less influ-
ential on children's psychological development than
are the quality of relationships in the home" (p. 195).
Despite methodology that included blind raters, ran-
domization, and use of standardized instruments and
controls, the association between domestic discord
and, for example, antisocial disorder in boys cannot be
considered a cause and effect relationship. A third
undetermined variable associated with both parental
strife and antisocial behavior (e.g., peer group disrup-
tion due to family mobility) could be the proximate
cause of the child's emotional disorder, as could ge-
netic factors.
Anthony (1969, 1970, 1974, 1978) concluded from
studies of children of psychotic parents that the vul-
nerable child (e.g., one who still engages in magical
thinking) is likely to experience "breakdown" (An-
thony (1978), p. 591) as a result of his parent's illness.
This breakdown may mirror the parent's psychosis or
may be characterized by the child's confusion, sadness,
and fear. Other symptoms include underachievement
in school, overinvolvement in fantasy, apathy, and
"micropsychotic episodes" (Anthony (1978), p. 592).
Lander, Anthony et al. (1974) contend that this ad-
verse impact of parental psychosis on the child can be
predicted on the basis of the child's level of identifi-
cation and involvement with the mentally ill parent,
as well as his suggestibility and submissiveness. In fact
"high vulnerable children [are] several times as likely
to be rated by psychologists and psychiatrists as show-
ing severe disturbances in perceptual and cognitive
functioning, in efficiency of defenses, and amount of
clinical disturbance" (p. 332). However, in another
study (1969), Anthony reports an inverse relationship
between severity of disturbance in the parent and
degree of disturbance in the child. He explains this
puzzling finding with the suggestion that the complete
lack of attention displayed by the most disturbed
parent is perceived by the child as less stressful than
173
the threatening posture of the moderately disturbed
parent. He also speculates that in some cases the
childhood disturbance might not become manifest un-
til adult life. Another reason for such disparate data
might be the limitations of psychological testing iden-
tified by Franklin, Anthony et al. (1974) in their at-
tempt to distinguish children of psychotic parents
from those of normals. They concluded that instru-
ments which rely heavily on subjective interpretation
and which are culturally biased were the major source
of variance in their data, rather than any real differ-
ences in the children studied.
In addition to offering contradictory data, these
studies have often not involved blind diagnosticians or
validated criteria of emotional disturbance in children.
In short, despite the wealth of clinical description,
Anthony's data raise more questions than they answer.
In a report of a pilot phase of a methodologically
rigorous, longitudinal study, Erlenmeyer-Kimling
(1978) states that 22% of children (N = 67) with one
schizophrenic parent and 38% of children (N = 13)
with two schizophrenic parents were receiving "help"
for emotional or school-related problems, compared to
4% of children (N = 125) with parents classified as
normal or as having some other psychiatric diagnosis.
Though these preliminary findings appear significant,
one could challenge the choice of "receiving help" as
the criterion for assessment of emotional disturbance
in the child. The help could reflect professionals' con-
cern for children who live with psychotic adults and
have little or no relationship to symptomatology in
the child.
Reports of the effect of extremely deviant but
nonpsychotic parental behavior on the psychological
state of the child have been concerned with alcohol or
drug-addicted, brain damaged, and pathologically
grieving parents. They can be summarized as follows:
1. Conflicting and inconclusive evidence exists re-
garding the psychological effect on children of parental
substance abuse, largely due to the poor methodology
and lack of clear definitions which characterize studies
in this area (El-Guebaly and Offord, 1977), Interest-
ingly, even a relationship between parental alcoholism
and physical abuse of children has not been demon-
strated (Steele and Pollock, 1968), and this in the
context of acceptable research methodology.
2. Clinical reports indicate that the drug-addicted
mother, due to drug-induced lethargy or withdrawal,
has a decreased capacity for direction of care-taking
energies toward the child which results in the child's
inconsistent relief from tension (Coppollilo, 1975).
Coppollilo hypothesizes that, as a result, the child,
without an object associated with tension relief for
emotional investment, might suffer impaired psycho-
social development.
174 CHARLENE KAVANAGH
3. One clinician's report of work with minimally and
moderately brain-injured parents and their children
concludes that due to the brain-injured parent's self-
centered, impulsive, impatient, rigid, depressed, and
sometimes paranoid behavior, his/her child often is
ignored, neglected, bullied, or belittled either by the
patient or the overtaxed spouse (Lezak, 1978). Asso-
ciated emotional problems in the child, however, are
not documented.
4. Tooley (1975) concludes that parent-counseling
after the death of a child can forestall pathological
mourning, for example, "emotional abuse" of a child
whom the parents begin to use as a displacement
object for their own guilt and self-hatred. While To-
oley's focus on prevention is noteworthy, his example,
too , adds to the confusion regarding emotional abuse
since scapegoating is classified as a form of abuse
without documentation of associated psychopathology
in the child.
Effects of Deviant Parenting on Physical State
of the Child
While the psychological effects of deviant parenting,
even in extreme cases, are difficult to quantify or
predict, the physical effects are less so. For example,
sensory deprivation early in life, like severe malnutri-
tion, adversely effects brain development (Birch, 1972;
Frankova, 1974;Nagera, 1978;Scrimshaw, 1969). Here,
too, predictive validity is imperfect; however, there is
greater concensus and more convincing data.
Powell et al. (1967) and Money (1977) in well-de-
signed, experimental studies have made the strongest
argument for a causal relationship between emotional
abuse and a complex of symptoms now known as
psychosocial dwarfism, a type of nonorganic failure to
thrive which typically has an onset after 8 months of
age and whose major manifestation is the failure of
the infant to gain in length (DSM-III, 1980).
In 1967, Powell reported 13 children with hypopi-
tuitarism which resolved following hospitalization
with no special medical or psychiatric treatment. Mar-
ital problems, alcoholism, absent fathers, and emo-
tional problems in parents were common. All the
children displayed bizarre eating and drinking patterns
(such as eating from garbage cans, gorging and vom-
iting), retarded speech, temper tantrums, and IQs of
less than 80 (in the eight patients tested). While the
children did not appear malnourished, they were short
(30 to 66% of the mean for the chronological age) and
underweight for age. These findings, in addition to the
dramatic response to a change in environment in all
cases, led Powell to conclude that "short stature may
be one aspect of a continuum of the adverse effects of
a distorted parent-child relationship [and, in fact.]
may be the first suggestion of such a disturbed rela-
tionship" (p. 1278).
In a later study, Powell (l967) documented the
specific absence of growth hormone release in the
emotionally deprived/abused child as well as the
prompt recovery of this function upon change in en-
vironment. Money (1977) renamed the syndrome "re-
versible hyposomatotropism" and added enuresis, en-
copresis, defiant-aggressiveness, insomnia, pain agno-
sia, and self-injury to the list of associated behaviors.
Reactive attachment disorder of infancy (DSM-III,
1980), commonly referred to as nonorganic failure to
thrive, is another syndrome which, though associated
with both emotional and caloric deprivation (DSM-
III, 1980; Elmer et al., 1969; Evans et al., 1972; Hufton
and Oates, 1977; Reinhart, 1979; Whitten et al., 1969),
is more strongly associated with deviant parenting
than any purely psychological disorder. It also offers
the advantage of being more reliably assessed than
many emotional disturbances of childhood as a result
of diagnostic criteria (e.g., falling weight percentile;
lack of visual tracking, smiling, spontaneous reaching;
weak rooting and grasping response to feeding at-
tempts (DSM-III, 1980)) which are less susceptible to
individual observer bias than, for example, those for
childhood depression (i.e., hyperactivity, aggressive
behavior, self-depreciation (Shaw, 1980)).
Though studies of nonorganic failure to thrive offer
no clear understanding of the relative contributions of
nutritional and emotional deprivation to its etiology
(Evans et al., 1972; Whitten et al., 1969), most report
50 to 90% of the infants as having mothers who are
depressed or have a diagnosis of character disorder
(Elmer et al., 1969; Evans et al., 1972; Hufton and
Oates, 1977; Jacobs and Kent, 1977; Reinhart, 1979).
While control group data is lacking, the number of
disturbed mothers in failure to thrive infant samples
seems high . It is speculated that the infant's failure to
develop, often associated with eating problems, is sec-
ondary to the resulting dyssynchronous mother-child
relationship (Brazelton et al., 1980) and possibly in-
volves a neuroendocrine response and/or the devel-
opment of depression in the infant (Evans et al., 1972;
Reinhart, 1978). Prognoses range from optimistic
(Mitchell et al., 1980) to pessimistic (Evans et al.,
1972), to cautious in the light of both positive and
negative outcomes observed (Bullard et al., 1967;
Glaser et al., 1968). However, most clinicians describe
a similar picture 6 months to 11 years after initial
diagnosis offailure to thrive. Follow-up has most often
been inconsistent, minimal, or lacking, but even in
cases where adequate services have been available
(Evans et al., 1972),42 to 60% of the patients demon-
strate continued failure to thrive, 10 to 15% show
evidence of serious physical abuse, and 7 to 20% are
 EMOTIONAL ABUSE AND MENTAL INJURY
classified as intellectually impaired. Mitchell et al.
(1980) are atypical in their report of continued failure
to reach the third percentile for weight without other
sequelae and in their use of rural primary care popu-
lation and matched controls. They conclude that social
turmoil, not failure to thrive, predicts later develop-
mental deficits.
In summary, there seems to exist a strong associa-
tion between nonorganic failure to thrive and inade-
quate or distorted parenting, or at least between ca-
loric deprivation in infants and emotional disturbance
in their mothers. Of additional concern is the evidence
of a connection between failure to thrive and physical
abuse. Koel (1969) reported two cases of fatal trauma
following a diagnosis of failure to thrive. Smith and
Hanson (1974) reported that 17% of 134 battered chil-
dren sampled had been previously hospitalized for
failure to thrive, and 60% were failing to thrive at the
time studied. Both percentages were significant when
compared to matched non-abused controls. In their
failure to thrive follow-up studies, Bullard et al. (1967),
Evans et al. (1972), and Oates and Hufton (1977)
reported a 10 to 15% rate of serious abuse as well as
abuse related deaths.
Conclusions
This review of the medical, legal, and behavioral
science literature on emotional abuse/neglect leaves
many questions unanswered. With the exception of
psychosocial dwarfism, no objective, abnormal physi-
cal or psychological syndrome has been reliably dem-
onstrated in the child whom most would describe as
emotionally abused or neglected. Weare thus left with
the problem of legal standards that require the re-
porting of injury in a situation where observable injury
does not always (or in any reliable fashion) follow
abuse.
We must conclude that definitions of emotional
abuse and mental injury, to be scientifically and ethi-
cally supportable, should neither be parent focused,
emphasizing parental rejection, control, and prohibi-
tions (Tangen, 1977), nor child focused, attending to
failure to thrive, developmental delays, behavior dis-
orders, emotional states, and a variety of psychoso-
matic illness (Tangen, 1977; Lauer, 1978). Rather,
definitions should consider the association between
parent and child variables and the concept of predic-
tive validity as applied to them. As has been pointed
out, many theories can account for data or outcomes
post hoc; however, the true measure of a theory's
value is its ability to predict in such fashion as to
provide more valid information than that supplied by
knowledge of base-rates or chance estimates (Wiggins,
1973; Mischel, 1968).
From this perspective, the present situation is dis-
175
couraging. Although the incidence of maternal psy-
chopathology, family disruption, separation and loss,
neglect, conflict, isolation, harsh-punitive or inappro-
priate child-rearing practices is greater in the histories
of psychiatric patients and others showing overt mal-
functioning than in so-called "normals," none of these
factors predicts developmental outcome or psychopa-
thology (Escalona, 1974; Garmezy, 1974). In fact, ac-
cording to Escalona (1974), the only factor that is
predictive of psychosocial and cognitive impairment is
poverty. Even the diagnosis of parental schizophrenia,
if used to predict the risk of psychosis in children, will
miss most of the children who are potential schizo-
phrenics, since 88 to 90%of schizophrenics do not have
a schizophrenic parent (Gottesman and Shields, 1972).
Early mother-child relationships neither predict de-
pressive or psychopathic outcome (Malmquist, 1976)
nor explain it . The absence of even post hoc explana-
tory power in this case is apparent in a large (N = 659)
study of psychiatric inpatients and outpatients and
normal controls reported by Jacobsen et al. (1975).
They concluded that childhood deprivation was re-
lated to acute depressive illness in adult patients;
however, their findings did not support this conclusion.
The emotional abuse variables (deprivation, shaming,
rejection, punitiveness) were not present to the great-
est degree in inpatients. In fact, deprivation and pun-
ishment were more common in the childhood experi-
ence of normals. The only variable that did occur
significantly more often in the inpatient data was
physical abuse.
Ackerman et al. (1970) stated that what is needed is
research that considers the interactional nature of the
family system and begins to propose (a) systems for
evaluation of deviant child behavior within a devel-
opmental context, and (b) classification of psychiatric
disorders in children that can be joined to principles
of family diagnosis and family psychology. Such re-
search, if long-term and longitudinal, "must addition-
ally consider the serious problem of the confounding
effect of time not only in changing social and political
realities correlated with (our) dependent variables, but
also the progressions and their techniques that are
employed to investigate those dependent variables"
(Franklin et al. (1978), p. 323).
If, as a result of such research, we begin to approach
a definition of emotional abuse and to establish the
predictive validity of that definition, we will again
need to address the issue of purpose. Should the goal
be detection for the purpose of mandating treatment,
or screening in order to offer preventive services?
Escalona (1974) has cautioned against the danger of
externally imposed change and, instead, recommends
early detection of developmental disorders as well as
services which are varied and culturally relevant. Dan-
176 CHARLENE KAVANAGH
iel et al. (1978) stress the need for family and child
health programs dire cted at the population as a whole,
rather than only at those considered at risk. They
have additionally criticized the practice of screening
for families at risk for abusive parenting due to the
false positive frequency of as high as 85%. The costs of
incorrect diagnosis and misallocation of scarce re-
sources, they conclude, may not be worth even the
best screening program's 75% success rate.
In summary, present knowledge would support the
following position regarding the inclusion of psycho-
logical/emotional abuse and/or neglect in state child
protection statutes:
1. With the exception of psychosocial dwarfism, it
is not possible at present to define psychological abuse
satisfactorily, to predict mental injury on the basis of
parental behavior, or to reliably diagnose it on the
basis of physical or psychological characteristics of the
child without unacceptable social costs attached to
mislabeling. It is also not possible to reliably identify
the etiology of emotional disturbances in children, or
to prognosticate about the effect of treatment of those
disorders. Therefore, it is inappropriate to include
"parenting which has caused mental injury" or "pa-
rental refusal to obtain treatment for childhood dis-
turbances labeled as emotional" (again, with the ex-
ception of psychosocial dwarfism) in child abuse re-
porting statutes.
2. While an association has been demonstrated be-
tween infants who fail to thrive and psychological
disturbance in their mothers, lack of control group
data and retrospective data gathering limit our ability
to establish a cause and effect relationship in regard
to these variables. However, because sequelae of fail-
ure to thrive (e.g., continued growth failure, intellec-
tual deficits) are serious, especially with minimal or no
intervention, and because of the relationship which
has been demonstrated between nonorganic failure to
thrive in infancy and serious, sometimes fatal, physical .. ics: a critical review. Amer. J . Psychiat., 134:357-365.
abuse, it seems appropriate to require reporting of
parental refusal of services and follow-up in all cases
of serious failure to thrive (reactive attachment dis-
order of infancy (DSM-III, 1980)). Evidence of contin-
ued serious failure to thrive and/or inflicted physical
injury upon mandated follow-up should be sufficient
cause for mandated services (and continued follow-up)
which, if not accepted or sufficient to prevent further
physical injury, would lead to consideration of termi-
nation of parental rights.
More importantly, energies should be focused not
on reporting laws, but on (a) increasing available and
acceptable health care, education, social services, and
counseling for all families, and (b) research to discover FRANKOVA, S. (1974), Interaction between early malnutrition and
what services are necessary and sufficient to ensure a
minimum level of family health. Until these goals are
achieved, it is inappropriate to involve the law and its
adversarial process in an attempt to achieve a mini-
mum level of psychological health in children and
families. Doing so can only serve to magnify our short-
comings in this pursuit.
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