Child abuse with fatal sequelae in an Essen autopsy sample]

In the Institute of Forensic Medicine in Essen/Germany 24 cases of lethal child battering or neglect have been observed over 17 years from 1973 to 1989. The medicolegal and morphologic findings in these cases are presented and compared to the literature. The patterns of abuse/neglect in Essen compare to those frequently reported in the literature: skull/brain traumas caused by blunt impact, multiple hematomas, bone fractures, and symptoms of malnutrition, vitamin deficiency, and general neglect. In many cases the abuse could be shown to have been chronic. In the seven years 1983-1989 the cases of lethal child mistreatment and neglect amounted to 0.18 percent of all autopsies. Five cases of lethal sexual assault in children during the same period are compared to the mistreated cases.     

Clinical forensic medicine and its main fields of activity from the foundation of the German Society of Legal Medicine until today

The fields mainly covered by clinical forensic medicine are subject to time-related changes which are described on the basis of the German literature of the 20th century. Some fields of forensic sexual medicine (diagnosis of virginity, proof of criminal abortion, potentia coeundi, potentia generandi, potentia concipiendi) have become less important in the daily work of medicolegal institutes, whereas victims of rape and sexual abuse continue to form a major part of the forensic examination material in the German-speaking countries. The evaluation of suspected physical child abuse has grown in importance since the 60s, and it is essentially the merit of Elisabeth Trube-Becker that this problem is now dealt with also in scientific medicine. More recently, medicolegal experts are increasingly confronted with further groups of persons: victims of domestic violence, abused/neglected seniors, refugees from countries where torture is used. A new special field, which established itself only in the 90s, is the estimation of age with regard to the criminal responsibility of suspects who have no identity papers or pretend to have none. A phenomenon frequently observed in the last two decades is the non-accidental self-infliction of injuries. Whereas in the first half of the 20th century the motive for self-mutilation was typically to evade military service, this category of injury was later mainly seen in the context of insurance fraud; more recently most forensically relevant self-inflicted injuries refer to simulated offenses (fictitious sexual offenses and robbery, attacks allegedly having a political background). One of the traditional fields of clinical forensic medicine continues to be the evaluation of victims and suspects following bodily harm and attempted homicides. In the field of civil law medicolegal experts are particularly often concerned with controversial consequences of traffic accidents (e.g. alleged whiplash injuries after rear-end collisions at low velocities).     

Medicolegal aspects of witnessed suicide due to gunshot to the head. Part 1: Circumstances and psychopathology

In the USA the frequency of witnessed suicide, i.e. suicide committed in the presence of at least one further individual, is reported to range between 5 and 15%. As up to now no detailed analysis of this special issue has been given in the medicolegal literature, this article presents and discusses a number of cases including 8 males and 1 female (age 19-58 years, mean 41.2 years) who had all committed suicide by inflicting a gunshot to the head. In 3 cases post-mortem blood alcohol concentrations of 1.73, 1.88 and 2.23 g/kg respectively were observed. Toxicological tests produced negative results. 5 cases had a medical history of psychiatric disorder with endogenous depression in 3, chronic alcohol abuse and drug abuse with concomitant psychosis in one case each. As far as the motives were known, domestic arguments were of prevailing importance. With one exception the suicides were committed at home. In 6 cases one witness was present, in 2 cases 2 individuals and in one case 22 persons witnessed the suicide. The reported cases are discussed in comparison with the psychiatric-psychological classification according to McDowell et al. with the aim to provide a solid and comprehensive medicolegal method to distinguish between homicide and suicide. Furthermore aspects of psychiatric sequelae and psychological support of the witnesses, which are also of importance for the forensic pathologist called to the scene, are discussed.     

Elderly sexual offenders: two unusual cases*

The aim of this case report is to describe two cases of sexual abuse by elderly subjects for which the Judge commissioned an expert psychiatric-forensic opinion. The elderly are generally believed to commit nonviolent crimes, whereas the two cases we observed feature forcible rape committed by elderly offenders, who showed no form of mental disease and had rationally planned their offense. They had never previously committed similar acts and had no history of homosexuality; both had been married for many years before the death of their wives and had adult children. Finally, no previous episodes of rape emerged in their personal histories during interrogations. The sociocultural context in which the crimes were committed was identical and arouses interest as regards both the method employed and how the crimes were discovered. The legal authorities then commissioned accurate investigations including medicolegal and psychiatric-forensic evaluations of the offenders and their victims.     

A case of Munchausen syndrome by proxy with subsequent suicide of the mother

Munchausen syndrome by proxy is a subtle and difficult to diagnose form of child abuse in which the carer (usually the mother) simulates, manipulates or produces symptoms of illness in the victim. In most cases the detrimental effect is caused by applying foreign substances or by airway obstruction. In the presented case a 20-month-old girl developed a spreading soft-tissue infection resistant to treatment on the left upper arm after vaccination, which required a number of surgical interventions. Repeatedly, microorganisms from the intestinal flora were isolated from the wound secretion. After the girl suffered respiratory and circulatory arrest, which required resuscitation measures, chemical toxicological tests revealed not medically prescribed benzodiazepines in serum and urine. When the mother, a trained nurse, was confronted with the allegation to have manipulated the symptoms of the illness she committed suicide. The forensic autopsy of the suicide produced numerous hints suggesting chronic self-damaging behaviour described as Munchausen syndrome. This case shows a number of manipulation forms with the maintenance of a chronic skin and soft tissue infection belonging to the rarer forms of inflicting damage to the child. It also illustrates that confrontation with the allegation of Munchausen syndrome by proxy creates a very stressful emotional situation that may lead to a suicidal act.     

Emotion Regulation Mediates the Relationship between a History of Child Abuse and Current PTSD/Depression Severity in Adolescent Females

Although experiencing child abuse (i.e., physical abuse, sexual abuse, exposure to violence) is associated with a variety of mental health difficulties, simple exposure to abuse does not produce symptoms in every individual. The current study explored emotion regulation as a mediator in the relationship between a history of child abuse and symptoms of posttraumatic stress and depression. Adolescent females (ages 11–17 years) were asked to retrospectively report on their exposure to child abuse, current symptoms of PTSD/depression, and emotion regulation abilities. Caregiver report of adolescent emotional difficulties was also obtained. Analyses revealed that child abuse-exposed females, when compared to females without a trauma history, had worse emotion regulation abilities and increased mental health difficulties. Moreover, emotion regulation significantly mediated the relationship between child abuse and all assessed mental health symptoms. These findings extend previous work from adult samples, underscoring the importance of assessing emotion regulation abilities in abuse-exposed youth.     

The quality of written expert testimony in alleged child sexual abuse: An empirical study

Abstract

The purpose of this study was to empirically evaluate written expert testimonies in cases of suspected child sexual abuse in Sweden. A total of 121 expert testimonies were rated with an instrument developed for the study, the SQX-12 (Gumpert et al., 2001) which is a 12-item checklist aimed to reflect consensus-established concepts of quality. Reports from different professional groups were compared, as were reports produced before and after the 1991 publication of national guidelines. The results suggested that the reports produced by professionals using statement analysis generally were of higher quality than reports written by professionals from child- and adolescent psychiatry. There was a slight increase in report quality, as measured by the SQX total score, over the studied years. However, it is concluded that the overall quality of written expert testimony on child credibility still does not reach the recommended level in Sweden.     

Expert Testimony Regarding Child Witnesses: Does It Sensitize Jurors to Forensic Interview Quality?

Does expert testimony on forensic interviews with children help adults distinguish between poorly conducted and well-conducted interviews? This study evaluates the effects of social framework expert testimony regarding child witnesses in a case involving allegations of child sexual abuse. A 2 (Expert Testimony: present or absent) × 3 (Child Forensic Interview Quality: poor, typical, or good) × 2 (Child’s Age: 4- or 10-year-old) factorial design was used to examine whether expert testimony is prejudicial or beneficial to jurors (N = 463). The results revealed that, without expert testimony, mock jurors did not consider the forensic interview quality when reaching a verdict. However, with expert testimony, mock jurors were more likely to render guilty verdicts if the interview quality was good versus poor. Further expert testimony increased mock jurors’ knowledge about child witnesses. These findings suggest that expert testimony related to the impact of interview techniques on the reliability of children’s reports may assist fact-finders in evaluating child abuse cases.     

Documentation of torture and cruel,inhuman or degrading treatment of children: A review of existing guidelines and tools

The documentation of individual cases of child torture is of paramount importance to bring justice to, and help heal, individuals and sensitize societies. Our objective is to systematically review medical guidelines for the recording of individual cases of child torture or cruel, inhuman or degrading treatment (CIDT). We searched CINAHL, Embase, the Guidelines International Network, Lilacs, Medline, the National Guideline Clearinghouse, PsychInfo and all websites of the organizations participating in the updating of the Istanbul Protocol for guidelines or studies on how to document torture, CIDT or abuse in persons under 18 years. We did not find a comprehensive guideline that encompassed all aspects of the documentation of child torture, as does the Istanbul Protocol for adults. An expert opinion guideline on how to document sexual torture in children was found, and in addition we identified 13 consensus-based guidelines for the evaluation of abuse in children or specific aspects thereof. We strongly recommend a child specific, comprehensive guideline on the documentation of torture and CIDT in children.     

Crime scene investigation in child-abuse cases

Although child abuse and neglect continue to appear in the medical literature frequently, little regarding scene investigation in such cases has been discussed. Many explanations have been offered for this deficit, the most common one is based on the time delay between infliction of the injury and discovery. At the Armed Forces Institute of Pathology, child-abuse cases submitted for consultation repeatedly show deficits in the scene investigation and its documentation. Since the discovery of child abuse is dependent on either physical evidence of repetitive punitive measures or an injury pattern not in agreement with the alleged circumstances, it behooves the assigned investigator to make every attempt to document the scene(s) as in any other criminal investigation.     

The detection of ephedrine by solid-phase immunoenzyme analytical and gas chromatographic methods

Comparative analysis of ephedrine derivative content in 96 urine specimen obtained from people suspected in abuse with these drugs. Physical and chemical methods of the analysis (gas and thin-layer chromatography) as well as ELISA were used. It was stated that the latter is specific for determination of compounds related to ephedrine by structure and it allows one to detect its analogues in 87 cases. Gas chromatography made it possible to detect ephedrine derivatives in 94 specimen tested and thin-layer chromatography--in 64 specimen tested. The given ELISA may be recommended for medicolegal expert purposes and narcology practice.     

Expert testimony in child sexual abuse cases

We presented participants with syndromal, witness credibility, or anatomically detailed doll evidence to determine (a) whether these different types of expert evidence exert differential influence on participants' judgments and (b) whether the influence of this evidence could be better explained by the relative scientific status or the probabilistic qualities of the research presented. Additionally, we investigated whether a strong or weak cross-examination of the expert would be more successful in discrediting the information provided in the expert's testimony. Findings suggest that participants are less influenced by expert testimony based on probability data (i.e., syndromal evidence) than by expert testimony based on case history data (i.e., credibility of anatomically detailed doll evidence). Participant responses did not differ as a function of the strength of the cross-examination of the expert. As expected, women were more likely to respond in a pro-prosecution direction than were men. Implications for the use of expert evidence in child sexual abuse cases are discussed.     

Abuse and neglect: a ten-year review of mortality and morbidity in our elders in a large metropolitan area

Elder abuse and neglect refers to an act or omission resulting in harm, including death, or threatened harm to the health or welfare of an elderly person. Between one and two million elderly Americans experience some form of mistreatment annually. A ten-year (1992-2001) retrospective case review of morbidity and mortality among elders (age > 60 years) was conducted at a State Medical Examiner's Office serving a major metropolitan region in Kentucky and Indiana. This study addresses cases of two categories: 1) medicolegal autopsies and 2) examinations of living subjects pursuant to a Clinical Forensic Medicine Program. The authors present 74 postmortem cases, in which 52 deaths were attributed to a homicidal act and 22 deaths were suspicious for neglect. Of the 22 living victims of elder abuse and neglect, 19 cases constituted physical and/or sexual assault and three individuals suffered from neglect. This study summarizes the characteristic features of elder abuse in both postmortem and living cases and underscores the necessity for multi-agency collaboration in order to reach an accurate conclusion in case work. Policies established by a well-established elder abuse task force promote the collaborative interaction necessary to formulate criteria for prevention of abuse and death within this vulnerable population.     

Forensic-medical aspects of dermatoglyphics of the hands and feet

Issues on possibility of using capillary patterns of hands and feet in medicolegal examination of unidentified dead bodies and unknown persons, in cases of disputed paternity and maternity and child substitution are considered. Up-to-date theories on inheritance of dermatoglyphics features, their racial, sexual, age and occupational variability as well as interrelationship with some genetic diseases are analysed. Ways of researches in the field of dermatoglyphics of hands and feet for expert practice are outlined.     

Flunitrazepam: an evaluation of use, abuse and toxicity.

The benzodiazepine flunitrazepam is extensively prescribed to patients with insomnia in many countries, but has also become popular among alcohol- and drug abusers. Several reports indicate that it is used as a date rape drug and suggest that it may precipitate violent behavior. Furthermore, flunitrazepam is involved in many fatal intoxications in Sweden. This study was designed and conducted to explore the negative consequences of flunitrazepam abuse in Sweden, and to assess the trends in its use and abuse. The occurrence of flunitrazepam in cases referred to the Department of Forensic Chemistry in Link?ping, Sweden 1992-1998, was investigated in detail. The detections were studied separately for different groups; medicolegal death investigations, drug abuse cases, driving under influence cases, and other medicolegal cases. These data were further compared with the sales, and seizures by the Swedish Customs and the Swedish Police. During 1992-1998, 641 fatalities occurred, where the cause of death was attributed to intoxication with flunitrazepam solely (130) or in combination with other drugs, or concomitant conditions (511). In 78% of all driving under influence cases, where flunitrazepam was detected, the analyses also disclosed the presence of illicit drugs. A similar association was seen in drug abuse cases. The seizures reported by the Swedish Customs revealed a substantial and increasing illegal trade. Cases, where flunitrazepam seemingly induced violent behavior were identified, and one of these is described in some detail. It is concluded that the abuse pattern and the toxicity of flunitrazepam should be kept in mind by forensic investigators and that this panorama also should be considered when decisions about the registration and classification of flunitrazepam are made in different countries.     

Childhood Abusive and Supportive Experiences, Inter-Parental Violence, and Parental Alcohol Use: Prediction of Young Adult Depressive Symptoms and Aggression

Issues in both the children of alcoholics and child abuse literatures were addressed in an attempt to disentangle the effects on young adults of growing up in alcoholic homes versus abusive homes. Using multiple regression, retrospective reports of parental abuse (emotional, physical, and sexual) and parental support (love/support, independence, and fairness), witnessing violence between parents, and parental alcohol use were used as predictor variables for outcomes noted by both literatures. When the effects of all other predictors were statistically controlled, parental alcohol use was not significantly related to depressive symptoms or aggression. Different abusive and supportive behaviors, depending on sex of parent and sex of participant, were significant predictors of both depression and aggression. Results underscore the importance of including and controlling for inter-parental violence and for different types of child abuse (especially emotional abuse) and parental supportive behaviors in investigations of outcomes related to abusive and alcoholic families. Implications for treatment of individuals from these families are discussed.     

Do Jurors “Know” What Isn’t So About Child Witnesses?

Are expert witnesses needed in child sexual abuse cases to educate jurors about children’s memory, suggestibility, and reactions to abuse, or do jurors already know what such experts could tell them? To cast light on this question, we surveyed jurors and jury-eligible college students and compared their beliefs with what is known via scientific research regarding children’s memory and ability to testify, reactions to interrogation, and reactions to sexual abuse. We also asked participants to infer results of four widely cited studies of children’s suggestibility. Participants’ beliefs were consistent with findings from research on some issues (e.g., that children can be led to claim that false events occurred) but diverged from the scientific consensus on other issues (e.g., whether children can remember painful events in infancy). Similarly, participants sometimes overestimated and sometimes underestimated the level of suggestibility observed in empirical studies. Individual differences in accuracy were related to participants’ gender, education and ethnicity, and there was considerable disagreement among participants on many questions. Implications of findings for the admissibility of expert testimony in child abuse cases are discussed.     

Genomic "dactyloscopy" in the expertise of disputed paternity and the determination of biological relationship

Genome "dactyloscopy" (DNA fingerprinting) is a principally new way of personal identification based on analysis of human genetic material (DNA); the difference in DNA structure of different subjects is the scientific basis of this method. This ensures opportunity to estimate biological relationship of persons positively. The authors were the first to demonstrate using certain expert material the adequacy and potentials of DNA fingerprinting by M 13 probe for medicolegal expert practice in most complicated cases of relationship determination requiring positive identification of paternity and maternity.     

Attrition and Conviction Rates of Sexual Offences in Europe: Definitions and Criminal Justice Responses

The “loss” of cases within the criminal justice chain, especially from police to conviction level is known as attrition – a phenomenon that can be observed in every criminal justice system and for every offence type. But is this attrition particularly strong for sexual offences as theories based on the so-called “rape myths” suppose? This question is dealt with by this paper; it studies the different conviction ratios of sexual offences in Europe and tries to evaluate the resulting findings. The data presented are based upon the work done by the expert group for the European Sourcebook (ESB) of Crime and Criminal Justice Statistics and a special EU-funded project on "Defining and Registering Criminal Offences and Measures, Standards for a European Comparison". In order to gain a basis for comparison, the differences between the national legal concepts and definitions are discussed. Then attrition and conviction rates (understood as the ratio of suspected to convicted persons) are examined, firstly for different crime types in order to show the relative importance of attrition in the field of sexual offences, secondly with a special focus on rape, sexual assault and sexual abuse of minors in some European countries. Beyond these mere statistical data the question whether there are particular reasons for the selection process in cases of sexual offences is raised.