habilitated. The abusers are very troubled people who are sometimes isolated from society, either geographically, economically or emotionally. They often have little self-esteem, low frustration tolerance and unrealistic expectations of their children. NEEDS Therapeutic modalities such as families anonymous, acute day care centers, lay therapists or foster grandparents, and group and individual psychotherapy have been effective in other communities. Such modalities along with other innovative programs need development and funding in the District. INTERAGENCY COORDINATION An overall problem in this system is lack of coordination among the involved interagency services. As stated previously, there is no easy, effective way of checking whether a suspicious child has ever been battered before, or reported before, or been seen for an "accidental" injury before within the D.C. Metropolitan Area. The Youth Division has restrictions on supplying information to other agencies such as the S.R.A. and to hospitals. Once the child leaves the hospital we have little communication with Protective Services as to how the child-family are progressing. If they are placed in foster homes medical recommendations are provided to the agency involved in placement but there has been no feedback, to date, as to whether or not the recommendations from the extensive medical workup are followed. The families are confronted with multiple interrogations by the different personnel who become involved once they enter the system. There is no one person to whom they can relate nor anyone who is held accountable for them. NEEDS (1) A citywide conference needs to be organized to define roles and establish communication. (2) A permanent citywide coordination program needs to be established. (3) There needs to be a sharing of information between military and civilian institutions. CASE HISTORIES WHICH ILLUSTRATE THE FOREGOING PROBLEMS CASE A Brother A had been born to a heroin addicted mother and was admitted at 4 months of age to Children's Hospital with lethargy and rigidity of his whole body. On physical examination he was found to have bruises over one eye and left arm and bilateral subdural hematomas (bleeding over both sides of the brain) are required bilateral craniotomies to relieve the blood clots. Because of the multiple injuries that had no plausible explanation he was determined to be a battered child by the examining physician. He had suffered much brain damage and was only breathing and being fed by tubes. After 3 months at Children's, he was transferred to a chronic care hospital where he died about 3 weeks later. His Brother B was admitted to Children's at the age of 2, one and one half months after Brother A's admission. He was unconscious and in respiratory distress but later recovered. He had multiple old and new bruises over his whole body especially over the abdomen, sides and thighs. He had old scars on the back and several on the abdomen which appeared to be healed cigarette burns. He progressed well in the hospital and went to a foster home after discharge. These cases of the two brothers are examples of several problems which have been discussed previously: Brother A was at high risk at birth for battering because of his unstable environment due to having an addicted mother. He had to remain in the hospital after birth for some time and was therefore separated from his mother at a crucial time in social development. When Brother A was admitted there was no therapeutic program to help the parents and therefore the same frustrations or problems still existed and resulted in the battering of Brother B. The mother was not cooperative in efforts made by hospital personnel to help her. Nor did she want to bring Brother B in for physical examination prior to his final battering. CASE B This 5-year-old boy was brought to the emergency room of Children's Hospital by his grandmother after a school nurse and police officer went to the home to investigate reports by school personnel that the child had been limping and had bruises on his back. Medical examination revealed multiple abrasions and contusions and many old scars. The battered child team was immediately notified and there was excellent cooperation on the part of all agencies. 1. The child was at risk The mother had been battered as a child and had severe emotional problems. One child from the family had died at one year of age, no history was given as to cause of death. Another child died at approximately one year of age because "he hurt himself and made himself sick." Another child had died from a skull fracture. (These deaths occurred in other countries during military assignments.) Another child was battered in another state and the mother went to jail for a short period of time. The remaining children were placed in foster homes. At some point in time the family was reunited in the District of Columbia, but the father was on military assignment in another country when this 5 year old boy was injured by his mother. 3. Siblings A prompt trial was held and the 5 year old boy was placed in a foster home. As of this writing the two other children remain in the home with their mother and grandmother. The eldest child who had been battered received psychiatric care in another state but has had no further psychiatric follow up. The youngest to date is uninjured. School personnel continue to be alerted to the eldest child and a protective service worker makes home visits. 10. Parents The mother has a long standing history of psychiatric illness. Frequent moves in and out of the country and to other states has prevented rehabilitation. Jail was no solution (nor is it considered to be by us). The mother views her confinement in jail as the oldest child making her go to prison. Information requesting the father's history is unavailable. Currently the probation officer insures follow up in forensic psychiatry. 11. Interagency Cooperation Although there was tremendous cooperation once this child was battered, no one agency in the city knew of the previous history. This points out the need for civilian-military, as well as inter-state cooperation. CASE C Jenny is a 3 year old girl who came into Children's Hospital with burns of the knees and wrists. She also had puncture wounds of the knees. She was a depressed, anxious child crying frequently and totally confused about adults. The burns (which required grafting) were from being immersed in a boiling bath by her mother. The puncture holes were from thrusting a fork into the child's knees. During Jenny's 2 months in the hospital she was noted to be frightened and distrustful, but emerged somewhat after regular psychotherapy. This was the 4th Children's Hospital admission of Jenny. She came in at a few weeks of age for a subdural hematoma (blood clot under the skull). It was noted then that the parents were singularly indifferent about the child's welfare. At this point the court ordered psychiatric evaluation of the parents as a condition of the child's return home, but this was not carried out. She was returned home as a known risk with inadequate follow-up. She was readmitted at 7 months for burns over the arms, legs and chest. These burns were caused by her father putting a heater against her. A court hearing was held, the child was removed from home and placed as a ward of child welfare in a good foster home after first waiting in a receiving home (where she had multiple caretakers). When Jenny was 3, her mother petitioned to take her home. This was granted by the court as a trial visit. The child was abruptly and without preparation taken from her foster home and returned to her biological mother. After 3 weeks at home, the severe burns and puncture wounds were inflicted by the mother who was angry at the child for dirtying her dress. During her hospitalization, the grafts healed satisfactorily and the child was returned by the court to foster home care. However, she is without continuing psychotherapy. A sibling remains in the home with the abusing mother and without community follow-up. This case illustrates a high risk child who has had severe personality development distortions from traumatic events, and there has been no community follow-up of her psychiatric needs. It also illustrates problems of no rehabilitation of parents. The case also illustrates the lack of city wide coordination by the agencies. Lack of adequate information available for hospital, community agencies and courts. It illustrates lack of facilities, inadequate supervision. and rehabilitation. PROPOSED AMENDMENT H.R. 15779 AND H.R. 15918 In light of the needs previously discussed in this paper we are happy about most of the concepts in these bills which do speak to these problem areas. Parts of the bills need clarification and expansion and we will recommend some additions and deletions. The sections referred to below will correspond to those in H.R. 15779 and comparison made with H.R. 15918 when needed. Sec. 101 (a).-A Center for the Prevention of Child Abuse is badly needed in the District of Columbia, however, we do not think it should be an independent agency but should be a separate division under the Department of Human Resources with a Director appointed by the Commission. Through this legislation the Director must be held accountable for help given the abused child and his family so that this Center does not exist in name only. In addition to the "District of Columbia court system the metropolitan Police force, hospitals", etc., we hope that a Protective Service unit in the Department of Human Resources would be maintained from which social workers with expertise in this field could work for the Center, being assigned to families as soon as possible and remain assigned until the legal and therapeutic processes are finished. Contracting already existing community resources for services is excellent so that these families can be help in their immediate neighborhoods as much as possible. Sec. 101 (d) (2).—It seems necessary that the multi-disciplinary teams in the Center take on several different functions. There could be an "executive" team which would act as consultant to other teams in the community i.e. every hospital which treats children should have a multidisciplinary team. These community teams are the ones who will identify abused children and make some initial evaluation of the family. They would then refer the family to the "executive” team of the Center who would assign the family depending on their needs to the "therapeutic" team within the Center. The "therapeutic" team would either provide or seek out the psychiatric counseling, the continued medical care, and safe home environment referred to in Sec. 101 (d) (3). Whenever the term "investigate" is used, referring to one of the functions of the Center, it seems more accurate to say "evaluate". We believe the investigatory function should be with the Youth Division of the D.S. Police Department. Sec. 102 (a).-The need for a central registry has been emphasized before. Several questions arise: Why is it necessary to have the consent of "persons concerned" to transmit data to other jurisdictions? Sec. 102(b).-—The decision to expunge the record should be made by the Director in conjunction with the Police investigation. Sec. 102(d).This section points out that no where is it stated exactly what information should be contained in this central registry. Should it be only identifying information or whole file of investigation and evaluation material? If it is the latter, we do not think that a parent for example, should have access to his psychiatric evaluation. Sec. 102 (e).-90 days after the receipt of the report is often too soon to expunge material because frequently a trial does not take place within that amount of time. Sec. 201.-We are much in favor of the expansion of reporting of child abuse cases to "certain persons in child care" and for the reports to go to either the Director or to the Police and then each in turn reporting to the other. We do not think that it is the function of the Police in the preliminary investigation to determine "the stability of the parents or persons responsible for the care of the child, the quality of the home environment, the relationship of the child to the parents". This is the function of the multidisciplinary team involved who have this expertise. Both Police and team are needed once a child has been identified but have different roles. This is provided in H.R. 15918, Sec. 202, where the Director may request the Police to help in the investigation. We think they should help investigate except in cases which voluntarily present themselves to the Center. We favor the ability to have parents receive a psychiatric examination as part of the investigation prior to a trial and to have (siblings examined as stated in H.R. 15918, Sec. 202. Sec. 301 (b) (2) of H.R. 15918 is also a good and necessary addition. Sec. 202, where the Director may request the Police to help in the investigation. ing. Hopefully, this will serve only as a strong incentive for all required to report to do so. Sec. 208 (9) (c).—Are not these children dependent children rather than neglected children? Sec. 302.-Disagree with this section completely. H.R. 15918 Sec. 302 is much more reasonable ie. if the District of Columbia Council does not change this Act it should remain valid until new legislation is introduced. There are some omissions in both bills which need to be considered. How much and from where will the funding for the Center come? Who will take the cases to court? If the Police investigate, they should present the case in court; if the Center alone handles some cases it should have the right to petition the court if necessary. The authority of the Center over other public agencies is unclear. Strong and binding inter-agency agreements would need to be formulated. PREPARED STATEMENT OF FREDERICK C. GREEN, M.D., F.A.A.P. Mr. Chairman and Members of the Subcommittee, I appreciate the opportunity to testify before you today. There is a critical need in every state and community of this nation to have legislation on the books that will ameliorate or eliminate the brutality of child abuse and neglect. I am here to support such legislation for the District of Columbia as found in H.R. 15918. RECOMMEND H.R. 15918 I support this bill as opposed to H.R. 15779 for the following reasons: 1. Mandatory Reporting Although both bills mandate reporting by broad segments of the child serving population, H.R. 15918 does allow discretion in establishing the accountable investigative agency. Mandatory reporting to the police department is not required. Such an option seems to allow for a therapeutic approach to parents rather than a punitive approach. Because I feel that no matter how well trained a police investigator, the simple fact that he or she may be part of a law enforcement agency is potentially threatening and may be counterproductive in the management of some cases. 2. Objectives Recognition is given to the need "to preserve the existing family unit of the child" in both bills, even though neither bill gives the emphasis to this major objective of management that it deserves. For those of us who believe that the ideal place for childrearing is in the natural home, no matter how humble, with biological parents capable of meeting the child's necessary nurturing needs, I respectfully suggest that this dimension of supportive care to the parents be given greater priority. 3. Case Investigation The components of a complete investigation are clearly defined in Title II Section 202 and Section 205 of H.R. 15918. I particularly like the mandated home visit by a knowledgeable and sensitive member of the management team. 40-331-74——4 AMENDMENTS PROPOSED In spite of the fact that I am in general agreement conceptually with most Sections of these bills. I am compelled to identify certain parts of this legislation that I feel do not serve the best interests of the abused child or his family. 1. Organization and Function of the Center for the Prevention of Child Abuse It is axiomatic that any agency, no matter what its hierarchical position in government may be, that is dependent upon "coordinating" the resources of other agencies, without clearly identified adequate discretionary resources and/or a clearly defined major role in the budgetary considerations of the appropriate agencies on which its mission will be dependent, will have serious difficulty in assuring the adequate allocation of necessary resources or the capability of developing necessary new resources to carry out its assignment. 2. Team Composition In Title I Section 101 (d) (2), I regret that the multidisciplinary management team of the Center does not include among its "experts" a competent parent from the community. It would see imperative to me that the experts on the team have the benefit of the input of a resident of the community who is familiar with all aspects of life in that community, including the varying culturally determined childrearing practices. 3. Mandatory Psychological or Psychiatric Examination I must protest the mandatory psychological or psychiatric examination "of any member of that home" prior to the adjudication of the case. It is my opinion that this could lead to a fishing expedition that may be an unwarranted intrusion into the privacy of the family. I would not have this same objection if such examinations were mandated for the prime suspect. Post adjudication, psychological or psychiatric evaluation and treatment under appropriate circumstances would seem desirable. 4. Evaluation-Photographs of Abused Child All children physically abused and neglected to the point of having externally demonstrable signs, should be seen in a health facility. Since a major purpose of the photograph is to give base line data against which future healing of such injuries are to be compared, I would feel it appropriate that all photographs be taken only in health facilities and not to be the responsibility of any institution or individual legally mandated to report. 5. Religious Exemptions I recognize that Title II Section 208 exempts injured children “under treatment solely by spiritual means through prayer in accordance with the tenets and practices of a recognized church or religious demonination by a duly accredited practioner", is both politically wise and expedient. But I suggest to you that this is not necessarily in the best interests of the child. I suggest that a ruptured abdominal organ or a fractured skull may have a lethal outcome if appropriate medical intervention is withheld. Therefore, I feel that such injured children should be given the benefit of the best medical care available and the law should not be a part of withholding such treatment. 6. The Labeling of Informally Adopted Children as Neglected To classify all informally adopted children as being neglected will place a substantial number of such children and their "adoptive" parents at risk to the penalties of this Act. Although I recognize that such children are not protected in a number of ways, we must understand that many of these children remain in this status because of the lack of financial resources, ignorance or inaccessibility to legal counsel by such surrogate parents. To me, it would seem more appropriate for government to assure the availability and accessibility of such resources and services to complete the appropriate adoption procedures. Adjudicating such children neglected and possibly arbitrarily removing them from their psychological parents may be more destructive than constructive for all concerned. 7. Implementation I can foresee monumental difficulties in implementing this Act if the Director and the agency team become involved in individual case management |