Post-mortem radiological examination in infants:: Evidence of child abuse?

We examined the value of post-mortem radiological examination of infants who were brought in for medico–legal autopsy. Twenty children between the age of 1 month and 15 months died under the picture of SIDS. No radiological or other signs of previous child abuse were seen in our autopsy material. A fatal case of child abuse with several metaphyseal fractures is reported. Some fractures were not visible on gross examination, but could be demonstrated by radiography and histology. In our material no association between SIDS and child abuse was found. In suspected cases of child abuse, particularly rib fractures and metaphyseal fractures should be sought. We recommend that post-mortem radiography is performed in such cases. If fractures are demonstrated, they should be verified by histologic examination.     

Increased risk of fatal intoxication and polypharmacy among psychiatric patients at death

Patients suffering from psychiatric disorders have an excess mortality and a shorter life span expectancy compared to the general population. Furthermore, they are treated with multiple drugs and are known to have an increased risk of drug abuse. In this study, we aimed at investigating the pharmaceutical drug and drug of abuse profiles of the deceased included in the Danish prospective autopsy‐based forensic study on psychiatric patients, SURVIVE. Using the postmortem systematic toxicological analysis results, we identified 129 different consumed compounds in our population (n = 443). Polypharmacy (≥5 compounds) was detected in 39.5% of the deceased. Deceased with a psychiatric diagnosis or who died from a fatal intoxication had significantly more compounds at the time of their death compared to having either no psychiatric diagnosis or another cause of death, respectively. Evidence of drug abuse was present, as 29.8% of our total population had consumed either methadone or illicit drugs of abuse, excluding tetrahydrocannabinol. Of those deceased with a psychiatric diagnosis, 33.6% had either consumed methadone or illicit drugs of abuse, a greater number than those without a psychiatric diagnosis. Fatal intoxication was the most frequent cause of death (40.6%) with methadone as the major intoxicant. Here, we found that those without a psychiatric diagnosis had fewer fatal pharmaceutical drug intoxications compared to the psychiatric diagnosis groups. Our findings add further context to understanding the excess mortality of psychiatric patents, since there is an increased occurrence of fatal intoxication, polypharmacy, and drug abuse in this population.     

Poisonings with diphenhydramine--a survey of 68 clinical and 55 death cases

The antihistaminic drug diphenhydramine (DPH) is mainly used as a sedative, hypnotic and antiemetic. In many countries it is over-the-counter available, very common, and generally regarded as a harmless drug. Sixty-eight non-fatal and 55 fatal poisonings with DPH alone or in combination with other drugs were investigated in the Institute of Legal Medicine of the University Hospital Charité between 1992 and 2004. The analytical investigations were performed by HPLC with photodiode array detector (HPLC-DAD). The DPH concentrations ranged from 0.5 to 8.9 microg/mL in the non-fatal cases and from 0.3 to 119 microg/mL in fatal cases. The intoxication symptoms stated during emergency admission were inconsistent, with somnolence, sedation and retardation on one hand and tachycardia, anticholinergic syndrome, agitation, hallucinations, confusion, tremor, convulsions, delirium and coma on the other. In three cases rhabdomyolysis occurred. A concentration above 5 microg/mL can be regarded as potentially lethal. In many of the survivors the time course of the concentrations of DPH and the metabolites desmethyldiphenhydramine (DM-DPH) and diphenylmethoxyacetic acid (DPMA) were investigated. Whereas DM-DPH is present in blood from the very beginning because of the high first pass metabolism, DPMA is slowly formed over several metabolic steps. For this reason, the concentration ratio DPMA/DPH can be used for an approximate estimation of the time between drug intake and sampling in clinical cases or of the survival time after drug ingestion in death cases. In some of the deaths the concentrations in heart blood were much higher than in venous blood. This is explained mainly by agonal aspiration of the vomited gastric content. Besides the majority of suicidal cases also a case of child maltreatment and a case, in which the drug was forcibly administrated in a drug facilitated crime, were investigated. From the results it follows that diphenhydramine is not less poisonous than other prescribed hypnotics. However, despite the hallucinogenic effects, an abuse for recreational purposes was not observed until now.     

Prosecuting child sexual abuse in rural Kentucky: Factors influencing case acceptance by prosecuting attorneys

This study examined the relationship between felony prosecutors’ discretion and the legal and social factors present in cases of child sexual abuse. Prosecuting attorneys from 20 rural circuits in Kentucky were targeted for semistructured interviews in order to determine what influences them to accept or not accept a case for prosecution. Findings show a relationship between rural Kentucky prosecutors’ decision to accept a case and the availability of physical evidence, victims’ age and competence, potential trauma inflicted upon the victim, and the situation in which the allegation of sexual abuse originated. The relationship between prosecutors’ discretion and various factors is discussed regarding the impact on other criminal justice officials in their pursuit to combat child sexual abuse in Kentucky and in other rural communities as well. Winner of 1997 Outstanding Graduate Paper Award, Southern Criminal Justice Association     

Fatal child abuse-maltreatment syndrome. A retrospective study in Ontario,Canada, 1990-1995

Child death due to repeated episodes of physical assault or neglect has been termed the child abuse-maltreatment syndrome (CAMS). We characterized the injuries in a series of fatally abused or maltreated child to delineate objective diagnostic criteria for the CAMS for use by clinicians and pathologists. All deaths (age <17 years) investigated by the Office of the Chief Coroner for Ontario, Canada during the time period 1990-1995 were reviewed. Cases of CAMS were defined as death due to lethal recent injury or malnutrition in the presence of significant old (healing or healed) injuries indicative of repeated episode of inflicted trauma. The nature and frequency of the various injuries was determined. The frequency of the shaken baby syndrome, and the types and frequency of ano-genital injuries were also studied. Twenty-one cases of fatal CAMS were found in the study period. Most cases had significant recent head injury with intra-cranial hemorrhage (71%). Other significant recent injuries commonly observed included blunt injuries of the skin and soft tissues (67%), blunt abdominal trauma with visceral injuries (14%), and fractures (18%). Eight cases (38%) fulfilled accepted criteria for the shaken baby syndrome. Many children with fatal head injuries had evidence of older head trauma (38% of all cases). A significant minority of cases had evidence of malnutrition due to neglect (10%) or ongoing ano-genital injuries (10%). Most cases of child homicides due to repeated episodes of abuse or maltreatment involve head trauma including shaken baby syndrome. Fractures of long bone and ribs, the classical markers of child abuse, were relatively infrequent compared with head injury. A proportion of cases had ano-genital injuries due to repeated sexual abuse or punitive maltreatment. All clinicians and pathologists must recognize the wide spectrum of injuries in child abuse to ultimate protect the victim or other children in an at-risk situation.     

Fatal child neglect in West Germany 1 January 1985 to 2 October 1990. Results of a multicenter study]

Up to now reliable data were available on cases of lethal child neglect in the area of the Federal Republic of Germany prior to reunification (the former West Germany). In a multicenter study we therefore examined the police and court records for such cases occurring in the period from 1 January 1985 to 2 October 1990 in nearly the entire area of Federal Republic of Germany. RESULTS: The study center received information on 19 cases of lethal child neglect. Extrapolated to all institutes of legal medicine, this corresponds to 20 cases and thus 3.5 cases a year in the whole of West Germany in the period studied. There is to be added a dark-field which cannot be limited more precisely. However, the cases of fatal child neglect might have occurred much more seldom than fatal child abuse caused by use of physical violence. Slightly more than half the victims were younger than 1 year, the oldest one was 7 10/12 years old. Most frequently the children died of starvation and thirst. Mostly the mothers/nursing mothers killed the child alone or together with the victim's father/stepfather. In the majority of the cases there was not a close affection between parents and child. Nearly 30% female/male perpetrators suffered from chronic alcohol abuse. Only 15 (= 56%) of 27 female/male perpetrators were sentenced to imprisonment (period between 7 months on probation and 10 years). Mitigation circumstances existed for nearly half the persons sentenced to imprisonment. It is true that child neglect is a rarer crime, but the experts of legal medicine always have to indicate errors made during the external inspection of the corpse (among others failures to see indications of neglect).     

Fatal acute intracranial injury, subdural hematoma, and retinal hemorrhages caused by stairway fall

We describe an infant with an acute subdural hematoma, a fatal head injury, and severe hemorrhagic retinopathy caused by a stairway fall. His cerebral and ocular findings are considered diagnostic of abusive head trauma by many authors. Our literature search of serious injuries or fatalities from stairway or low-height falls involving young children yielded 19 articles of primary data. These articles are discrepant, making the classification of a young child's death following a reported short fall problematic. This case report contradicts the prevalent belief of many physicians dealing with suspected child abuse that low-height falls by young children are without exception benign occurrences and cannot cause fatal intracranial injuries and severe retinal hemorrhages. The irreparable harm to a caregiver facing an erroneous allegation of child abuse requires physicians to thoroughly investigate and correctly classify pediatric accidental head injuries.     

Legal responses to child sexual abuse cases in the Children’s Court of Victoria: study findings on a case-management approach

Child sexual abuse cases present Children’s Courts with distinctive challenges. The highly conflictual nature of child sexual abuse cases means they do not lend themselves to the usual adversarial court processes that characterise the conduct of Magistrate Court matters in Australia. With this in mind, the Children’s Court in Victoria established for 12 months in 2013 a pilot specialised judicial list (known as the ‘D’ List) which offered an intensive Magistrate-led case management approach to child sexual abuse cases in the Family (child protection) Division of the Court. The operation of the List was evaluated to assess the suitability and effectiveness of this approach, and to investigate the challenges associated with managing and deciding this class of cases. The findings confirmed that the List provided better management of cases and reduced delay. Given this, the Court is continuing the judicially proactive intensive case management approach and dedicated list for child sexual abuse matters and extending it to regional courts; believing it to be a more effective approach to managing and deciding this complex class of cases.     

Type and Severity of Abuse as Predictors of Psychiatric Symptoms in Adolescence

There has been little previous research about histories of child maltreatment and psychological symptoms in adolescent psychiatric patients. This study investigated whether type and characteristics of child physical and/or sexual abuse predicted individual differences in symptoms. Participants were 187 patients in day or residential treatment facilities. Abuse was assessed using structured interviews with the adolescent, the therapist, and the caseworker. Participants completed a standardized, self-report measure of internalizing and externalizing symptoms. Adolescents with histories of dual abuse (i.e., sexual and physical abuse) had elevated depression and anxiety compared with nonabused patients. Histories of any type of abuse were associated with elevated posttraumatic symptoms. Among physically abused patients, severity and duration of abuse predicted individual differences in depression and anxiety, whereas severity and concomitant sexual abuse predicted elevated posttraumatic symptoms. Among sexually abused patients, the characteristics of sexual abuse did not predict individual differences in symptoms. Thus, child abuse, particularly dual abuse and severe physical abuse, predicted elevated internalizing symptoms, even in comparison with other adolescent psychiatric patients. The need for replication is discussed.     

A 36-year history of fatal road rage in Marion County, Oregon: 1963-1998

This paper documents the 36-year history, with five examples, of fatal road rage in Marion County, Oregon. Relevant details (all that were available) from each case are presented. Alcohol intoxication was present in four of our five cases. We include two deaths by gunshot at close range, two deaths as a result of a motor vehicle traffic accident, and one natural death. All subjects were males. Three were Caucasian and two were Hispanic. The three subjects in Cases 1, 2 and 3 were complete strangers to the occupants of the other involved vehicles. The subjects in Cases 4 and 5 (along with the occupants of their own vehicles) were acquaintances of the occupants of the involved vehicle. There appears to be no previous forensic, medical or psychiatric literature on road rage as such. We present an initial psychiatric evaluation of the perpetrators of this type of fatal assault. There are no specific statutes in Oregon, at the state or county levels, regarding road rage. However, the city of Gresham, Oregon, recently enacted an ordinance regarding road rage. We stress the need for further study of this phenomenon, especially through the use of the psychological-psychiatric autopsy.     

Late-form hemorrhagic disease of the newborn: a fatal case report with illustration of investigations that may assist in avoiding the mistaken diagnosis of child abuse

Hemorrhagic disease of the newborn (HDN) is usually a self-limiting hemorrhagic disorder of childhood that occurs as a result of vitamin K deficiency. It may be defined as early or late form depending on the time of onset related to birth. HDN is recognized as one of several bleeding disorders that can mimic the findings of nonaccidental head injury and may lead to a mistaken diagnosis of child abuse. We present a single fatal case of late-onset HDN with illustration of hematologic assays that can be performed to assist the pathologist in making the correct diagnosis of HDN.     

Fatal unintentional intoxications with tramadol during 1995-2005

Tramadol is an extensively used centrally acting analgesic and is considered a safe drug devoid of many serious adverse effects of traditional opioids. However, recently, toxicity and an abuse potential of tramadol have been reported. This study examined fatal unintentional tramadol intoxications among Swedish forensic autopsy cases between 1995 and 2005. All fatal intoxications were selected, in which toxic concentrations of tramadol (>1 microg/g femoral blood) had been detected, and where the forensic pathologist considered the intoxication unintentional and the fatal outcome at least partly explained by tramadol. Toxicology analyses, police reports, autopsy protocols and medical records were scrutinized. A total of 17 cases (eleven men and six women) of fatal unintentional tramadol intoxications were identified. For these cases the median age was 44 years (range 18-78 years) and the median tramadol concentration was 2.0 microg/g (range 1.1-12.0 microg/g). Other pharmaceutical substances, illicit drugs or ethanol were detected in addition to tramadol in all of these cases. In fact, intoxication with multiple drugs was considered the cause of death in 10 (59%) cases. However, in seven cases tramadol was the only substance present in toxic concentrations. A history of substance abuse was identified in 14 (82%) subjects and a present tramadol abuse in 8 (47%). These results suggest that fatal intoxications with tramadol may occur unintentionally and that subjects with a history of substance abuse may be at certain risk. Precaution is therefore warranted when prescribing tramadol in such patients.     

Suicide by asphyxiation due to helium inhalation

Suicide by asphyxiation using helium is the most widely-promoted method of "self-deliverance" by right-to-die advocates. However, little is known about persons committing such suicides or the circumstances and manner in which they are completed. Prior reports of suicides by asphyxiation involving helium were reviewed and deaths determined by the North Carolina Office of the Chief Medical Examiner to be helium-associated asphyxial suicides occurring between January 1, 2000 and December 31, 2008 were included in a new case series examined in this article. The 10 asphyxial suicides involving helium identified in North Carolina tended to occur almost exclusively in non-Hispanic, white men who were relatively young (M age = 41.1 T 11.6). In 6 of 10 cases, decedents suffered from significant psychiatric dysfunction; in 3 of these 6 cases, psychiatric disorders were present comorbidly with substance abuse. In none of these cases were decedents suffering from terminal illness. Most persons committing suicide with helium were free of terminal illness but suffered from psychiatric and/or substance use disorders.     

Child and elderly victims in forensic autopsy during a recent 5 year period in the southern half of Osaka city and surrounding areas

To outline the recent features of child and elderly victims from the medico-legal perspective with special reference to abuse and neglect, a retrospective investigation of forensic autopsy cases over a 5 year period (1994-1998) in the southern half of Osaka city and surrounding areas (a population of 1.57 million) was undertaken. Among 646 autopsy cases, there were 53 child cases (under the age of 15 years, about 80% below 6) and 121 elderly cases (65 years old and above). Nearly half of the child deaths and more than half of the elderly deaths were described as accidental. Fire and traffic victims were much more frequent in the elderly. Child victims included those of neonaticide/infanticide (n=6), physical abuse (n=10), unintentional fatal infliction (n=2), neglect (n=2), mutual suicide (n=2), suicide (n=1) and murder (n=3). Child abuse and neglect were domestic maltreatment by the parents. In this series, there was a comparable number of fatalities due to maltreatment in the elderly (n=13) and in children, and non-domestic violence was more frequent in the elderly than domestic violence. Elderly females tended to be battered by their sons or grandsons in domestic violence cases, whereas males were predominantly attacked by younger males in non-domestic violence. The other elderly victims included those of self-neglect (n=2), murder (n=7) and suicide (n=9). Non-domestic homicide of the elderly occurred mainly in the center of the city, whereas domestic maltreatment of children and the elderly was sporadic, although somewhat more frequent in the peripheral zone of the city and the surrounding areas. The above profile of child and elderly abuse suggests a substantial influence of social and familial backgrounds.     

Lethal child abuse (through the use of physical force) in the German Democratic Republic during the period 1 January 1985 to 2 October 1990. Results of a multicenter study

No reliable data are available on cases of lethal child abuse (by active force) in the area of the former German Democratic Republic. In a multicenter study we therefore examined the police and court records for such cases occurring in the period 1 January 1985 to 2 October 1990 in the entire area of the former German Democratic Republic. RESULTS: The study center received information on 39 cases of lethal child abuse which correspond to approximately 7 cases per year. However, a low percentage of undetected crimes which cannot be determined more precisely has to be taken into consideration. Almost 40% of the victims were younger than 1 year, 73% of the victims showed indications of repeated ill-treatment. The effects caused by using direct blunt forces, against the head in particular, were by far the most frequent causes of death. The male contact person (the victim's father, brother or stepfather as well as the life companion of the child's mother in particular) killed the child in most of the cases. As far as it is known, 37% of the male/female offenders suffered from chronic alcoholism; 32% of the male/female offenders were under the influence of alcohol when the crime happened. 83% of the male/female offenders who were found guilty made a confession shortly after the crime had happened or during the interrogations. Almost all the male/female offenders were sentenced to prison (the duration of the imprisonment varied between one year and for life). Due to the considerably lower section rate compared to the one in the German Democratic Republic, it is to fear that each second fatal child abuse is not detected in the new federal states.     

The incidence of alleged sexual abuse in 603 family court cases

The conflict and animosity that sometimes accompanies child custody disputes can give rise to the propagation of allegations of child sexual abuse. To characterize the magnitude of the problem, the present study attempted to determine whether and to what extent child sexual abuse allegations predominate in family court litigation. The entire one-year caseload of a county family court docket was systematically reviewed and coded. Methodical evaluation of 603 family court files yielded base rates of pertinent allegations and other information profiling the cases. The findings did not support the contention that sexual abuse allegations are commonplace in child custody disputes. Sexual abuse allegations were made in 2% of cases in which custody or access was contested and in only 0.8% of the cases overal. Implications of the findings for future research were discussed.The authors gratefully acknowledge the assistance of the Honorable William R. Campbell and Barbara Scott, Clerk of Court for the South Carolina Fifth Judicial Circuit, as well as the contributions of Angie Newton, Frank Robinson, and Kimberly Ellis in the data collection process.     

The case of two trials: Father-son incest

Although efforts for investigating and prosecuting child abuse cases have increased little attention has been paid to juror response to child testimony. This paper, developed as part of a pilot study to test a questionnaire for polling jurors' opinions in child sexual abuse cases, analyzes a case in which there was a reversal of outcome at retrial. Poll results of the jurors' opinions suggest the need for testimony from law enforcement and child sexual abuse experts to explain children's perception, memory, and recall of a reported experience.     

Characteristic Features of Severe Child Physical Abuse—A Multi-informant Approach

Minor child physical abuse has decreased in Sweden since 1979, when a law banning corporal punishment of children was passed, but more serious forms have not decreased. The aim of this study was to examine risk and background factors in cases of severe child abuse reported to the police. Files from different agencies (e.g., Social services, Adult and Child psychiatry and Pediatric clinic) for 20 children and 34 caretakers were studied. An accumulation of risk factors was found. It is concluded that when the following four factors are present, there is a risk for severe child abuse: 1) a person with a tendency to use violence in conflict situations; 2) a strong level of stress on the perpetrator and the family; 3) an insufficient social network that does not manage to protect the child; 4) a child that does not manage to protect him or herself. Thus, multiple sources of information must be used when investigating child abuse.     

Medico-Legal Evaluation of Adolescent Parricide Offenders: Thirty Nine Cases from Turkey

Parricide which is defined as the murder of one’s parents is a rare event. We describe a consecutive series of adolescent parricide offenders referred to the Council of Forensic Medicine for medico-legal evaluation. Majority of the adolescent parricide offenders were male with a frequency of 79.5%. Age of the offenders ranged from 12 to 18 years old with a median age of 15.13. The majority of the victims were the fathers of the offenders (27; 69.2%). Firearms and cutting devices were the most frequently used weapons. The history of abuse in the family as a motive for the murder was detected in 51.2% of the offenders. The major abuse type was physical abuse. There was no history of psychiatric disorders in the majority of the offenders (37; 94.9%). After the medico-legal evaluation of the adolescent parricide offenders in the Council of Forensic Medicine, psychiatric disorder was diagnosed only in 4 offenders. Schizophrenia was the final diagnosis in 3 cases and paranoid disorder (otherwise unclassified) in only 1 offender. Our study confirmed the frequency of mental illness among adolescent parricide offenders to be very low when compared to adult offenders. Adolescent parricide offenders differ from the other perpetrators particularly in terms of motives of the murder and psychiatric illnesses. Abuse in the family seems to play an important role in these murders. Therefore, it is extremely important that individuals in the legal, criminal justice, social work, psychology, educational and other professional communities be more conscious and informed of child maltreatment and family violence and more research is essential in understanding and preventing adolescent parricide offenders.     

Treatment of Concurrent Substance Dependence,Child Neglect and Domestic Violence: A Single Case Examination Involving Family Behavior Therapy

Although child neglect and substance abuse co-occur in greater than 60% of child protective service cases, intervention outcome studies are deplorably lacking. Therefore, a home-based Family Behavior Therapy is described in the treatment of a woman evidencing child neglect, substance dependence, domestic violence and other co-occurring problems. Treatment included contingency management, self control, stimulus control, communication and child management skills training exercises, and financial management components. Results indicated improvements in child abuse potential, home hazards, domestic violence, and drug use, which were substantiated by objective urinalysis testing, and tours of her home. Validity checks indicated the participant was being truthful in her responses to standardized questionnaires, and assessors were “blind” to study intent. Limitations (i.e., lack of experimental control and follow-up data collection) of this case example are discussed in light of these results.