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).     

Estimation of stress in child neglect from thymic involution.

It is difficult to evaluate the extent of stress in cases of suspected child abuse/neglect in a medico-legal autopsy. We have previously reported that stress due to abuse/neglect was found to have led to thymic involution. To elucidate the influence upon thymocytes differentiation, we compared the proportion of the thymocyte subpopulation in the thymus of a neglected child with one in an age-matched control obtained from cardiac surgery. We found that the relative number of CD4+ CD8+ double positive (DP) thymocytes decreased in the neglected child. It was presumed that the selective decrease in the number of the immature DP thymocytes with CD3- to low bcl-2low caused the thymic involution in the neglected child. It was suggested that an alteration in the proportion of thymocytes subpopulation might be used as an index of stress in cases of child abuse/neglect.     

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.     

Thymus of abused/neglected children.

Forty-six cases of child abuse/neglect autopsied during the period of 1967 to 1990 were investigated. The weight and histological findings of the thymus were compared with those of control children. In most abused and/or neglected children, the weight of the thymus decreased conspicuously. Involution correlated well to the degree and period of maltreatment. In cases without weight loss of the thymus, i.e. spasmodic abuse by a mentally deranged parent or foster parent, a short history of maltreatment was noted. On the other hand, marked involution was observed in cases of prolonged physical abuse and/or neglect. Microscopically, a decrease in the number and pyknosis of lymphocytes were observed in the involuted thymus. Atrophy of the thymus was more conspicuous in the cortex than in medulla. Immunohistochemically, CD-1a positive cells (immature thymocytes) decreased in cases with thymic involution. This involution appears to be an important index of the degree and duration of child abuse/neglect. Furthermore, thymic involution in the early stage of childhood may also be related to insufficiency of the immune system.     

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.     

Using recidivism data to evaluate project 12-ways: An ecobehavioral approach to the treatment and prevention of child abuse and neglect

Many programs and projects have been remiss at looking at outcome variables such as recidivistic child abuse and neglect. Presented here are program evaluation data which examine recidivism data over 5 years across more than 700 families. Families receiving services from Project 12-Ways, a multifaceted in-home ecobehavioral approach, were compared with families indicated in the same region who received child protective services other than those offered by Project 12-Ways. Families who receive services from Project 12-Ways are less likely to reinjure or neglect their children again.     

Maltreatment of handicapped children: A critical review

Despite increased interest in child abuse and neglect in the past decade, little research attention has been focused on maltreatment in handicapped populations. This is surprising given that many handicapped children display characteristics (e.g., chronic and pervasive behavioral disturbances, decreased social initiations with caregivers) that are associated with high risk for assault and neglect in nonhandicapped children. Numerous investigations have found an overrepresentation of handicapped children in maltreated samples, and results of more recent efforts reveal a high incidence of abuse and neglect in handicapped populations. Although these data underscore the high risk for maltreatment in handicapped children, a number of important issues warrant further empirical examination. Moreover, generalizations and interpretations of findings from previous research have been obfuscated by methodological shortcomings. The present paper reviews the literature concerning abuse and neglect of handicapped children. Research strategies and issues are delineated and current problems in this field are discussed. Suggestions for directions future research might take are offered.     

The Impact of Model Court Reform in Arizona on the Processing of Child Abuse and Neglect Cases

Arizona juvenile courts have taken a series of steps over the past five years to improve the quality and timeliness of court proceedings in child abuse and neglect matters. These efforts encompass both procedural reforms to front‐load the early hearing process as well as reforms that require a clearly demarcated permanency hearing and permanency determination process. A comparative analysis of the impact of these changes in four selected counties reveals that child abuse and neglect cases are handled in a more timely manner; that children are spending considerably less time in out‐of‐home placements; that courts are becoming more specific in the orders generated at dependency hearings (particularly initial hearings); and that the State and federal governments have realized sizeable savings in placement costs.     

Personality Disorders in a Sample of Parents Accused of Physical Abuse or Neglect

The objective of this study was to provide a psychological profile of parents who have been formally accused of child maltreatment. A clinical group of 16 parents accused of physical abuse and 22 parents accused of neglect were compared with 18 parents from a control group. The MCMI-III was administered individually for each parent. Both groups of maltreatment showed significant differences on different scales of the MCMI-III. No difference was seen between the parents of both groups of child maltreatment. Many parents of both child maltreatment groups reported at least one form of abuse during their childhood, suggesting that a childhood marked by abuse or neglect on the part of a parent could result in personality disorders and that these disorders may have something to do with the intergenerational transmission of abuse.     

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

No reliable data are available on cases of lethal child neglect 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: A total of 9 cases were reported to the study center. This does not include undetected cases, whose number, though indeterminate, is probably small due to the general obligation to perform autopsies on all children dying before their 16 birthday. Just over half of all victims were less than one year old, the oldest was 3 1/2 years old. Starvation and severe dehydration were by far the most common causes of death; in half of cases these occurred in combination with hypothermia. Most often mother killed their children by neglect, either alone or together with the victim's father. In the majority of cases no close bond existed between the parents and the child. Seventy percent of the perpetrators were chronic alcoholics. All 10 of the perpetrators were sentenced to imprisonment for periods ranging from one year to life long. Mitigating circumstances were presented at the sentencing phase of the trial on behalf of 20% of those convicted. The experience of legal medical and pathological institutes in the former German Democratic Republic underscores the need to perform an autopsy on all deceased infants and young children. Only this can ensure that no cases of lethal child neglect are overlooked.     

A 25-year retrospective review of deaths due to pediatric neglect

Neglect, defined as the failure of a caregiver to adequately provide safety, food, clothing, shelter, education, protection, medical/dental care, and supervision for a child in his/her care, is a relatively uncommon but important cause of child mortality. A retrospective review of pediatric deaths (age 18 years or less) referred to the Medical University of South Carolina Forensic Pathology Office for autopsy over the past 25 years revealed 16 deaths due to some type of pediatric neglect. Cases were analyzed as to age, sex, race, cause and manner of death, autopsy findings, ancillary studies, past medical history, social/family history, and caregiver. Six cases of malnutrition/starvation and/or dehydration were identified, composing the most common cause of death in the neglect cases identified and the majority of the homicides due to neglect. Other deaths in which neglect contributed significantly included toxic ingestions (2 cases), hyper-/hypothermia (2 cases), unusual drowning/aspiration (4 cases), electrocution (1 case), and delayed/absent medical therapy (2 cases, including one of the previously mentioned ingestions). Of these additional cases, 7 were certified as accidental manner, 2 as natural, and 1 as a homicide. Cases which fell into a "gray zone" in which the appropriateness of invoking neglect was a matter of opinion or societal convention were excluded from the review; examples included conventional accidental drowning, choking on food or aspiration of foreign body, overlying/wedging during sleep, accidental hanging, and motor-vehicle traffic accidents (pedestrians, unrestrained passengers). The findings of this review reinforce the fact that malnutrition/starvation and dehydration compose the most common form of lethal pediatric neglect while highlighting less common forms of neglect and the difficulty of determining manner of death in cases in which neglect plays a more questionable role than in seemingly clear-cut malnutrition/starvation and dehydration cases. We demonstrate the typical victim and scenario that investigators will encounter in cases of fatal pediatric neglect, often a child under the age of 1 year who has been deprived of food and/or drink for some time, or an older, more independently mobile child who has not been adequately supervised. These children may or may not have a demonstrable prior history of maltreatment or (nonfatal) neglect, and review of medical records is an important part of the investigation. We additionally discuss key gross autopsy findings, appropriate specimen collection, helpful ancillary studies, microscopic findings of significance, potential mimickers of neglect, and other special considerations in cases of pediatric neglect.     

ALLEGATIONS AND SUBSTANTIATIONS OF ABUSE IN CUSTODY‐DISPUTING FAMILIES1

In this study of 120 divorced families referred for child custody evaluations and custody counseling, multiple allegations of child abuse, neglect, and family violence were raised in the majority of cases. About half of the alleged abuse was substantiated in some way with one fourth involving abuse perpetrated by both parents. Different kinds of allegations were raised against mothers compared with fathers. Implications of these findings for social policy, family court interventions, and the provision of coordinated services within the community are discussed.     

Irrational behavior in exposure to cold. Paradoxical undressing in hypothermia

One December morning the naked bodies of two alcoholics were found on an open place in the center of the city of Essen. The phenomenon of paradoxical undressing due to vital hypothermia is described and the significant influence of alcohol on hypothermia and confusion in connection with hypothermia is pointed out. Compared to the results of other authors, external and internal signs of lethal hypothermia were analysed in a retrospective series of 30 cases (autopsy material in the region of Essen, investigation period from 1979-1989).     

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.     

Domestic violence: a complex health care issue for dentistry today

As a natural outgrowth of the dental professional's role in recognizing and reporting child abuse the topic has been broadened in recent years to domestic violence, that is child, spouse/intimate partner, disabled and elder abuse. Forty years ago in the US there were 662 cases of child abuse reported to authorities. Today that reported number is in excess of 3 million per year [D. Wiese, D. Daro, Current trends in reporting and fatalities; the results of the 1994 annual 50 state survey, National Committee to Prevent Child Abuse, Working Paper 808, 1995]. The "dirty secret" of spousal/intimate partner violence is believed to affect 3-4 million individuals per year in the US. Studies have also found that between 50 and 70% of these perpetrators also abuse their children or those of their intimate partner [J. Kessman, Domestic violence, identifying the deadly silence, Texas Dent. J. (2000) 43]. Just as child abuse is most often manifested in the head or neck regions, likewise the evidence of physical violence to intimate partners and the elderly can be seen in the head or neck regions. The insidious part of partner and elder abuse is that often the largest component of these behaviors is psychological, emotional and indirect neglect, which leave no physical evidence [M. Bowers, Forensic Dental Evidence: An Investigator's Handbook, Elesevier, San Diego, CA, 2004, p. 119].     

Risk Factors Associated with the Chronicity of High Potential for Child Abuse and Neglect

The present 4-year follow-up study involves 56 mothers who were evaluated by social agencies as being abusive and neglectful or at high risk for child abuse and neglect. The aim of the study is to analyze the relationship between psychosocial risk factors (relating to the history and current situation of the mothers) that were present at the time the families were initially recruited and the fact that some of the mothers continue to show a high potential for child abuse and neglect (chronic abuse and neglect), whereas others were able to overcome the problem (transitory abuse and neglect). Results indicate that the following variables are particularly associated with situations involving chronic problems of abuse and neglect: initial level of severity of potential for abuse and neglect; dual-parent status; a large number of children at the time of intervention (3.13 times more risk of chronicity for large families); the fact that as a child the mother herself had been placed in a foster home (3.7 times more risk); that she had been sexually abused (3.5 times more risk); and that as an adolescent she had run away from home (3.02 times more risk). Our results indicate that mothers who have a combination of more than eight risk factors are four times more likely to be in the chronic group.     

Childhood panhypopituitarism presenting as child abuse: a case report and review of the literature

Childhood panhypopituitarism may be acquired or congenital. Children with panhypopituitarism can present clinically with diabetes, growth failure, decreased bone density, and morbid obesity. In the forensic setting without the proper history, it can be misdiagnosed as child abuse or neglect. We report a case of a 3-year-old black girl who was admitted to the emergency room with apnea and subsequently died. While at the emergency department, it was discovered that the child had a fractured left hip and was severely growth retarded for age. The coroner wanted to rule out child abuse and/or neglect and requested an autopsy based on the physical findings identified by hospital staff. Significant findings at autopsy included small for age (15th percentile for age), hypoplastic brain/pituitary gland/adrenal gland/thyroid gland, abnormally formed skull with an occipital protuberance, a fractured left hip with decreased bone density, and central adiposity. Subsequent to the autopsy, it was discovered that at 6 weeks of age the child suffered from group B streptococci meningitis that resulted in panhypopituitarism. The panhypopituitarism then resulted in seizure activity, diabetes insipidus, and growth retardation. The authors hope this case report and review of the literature will assist investigators, pathologists, and clinicians in making a distinction between neglect or inflicted injury of child abuse and panhypopituitarism that can present with similar signs and symptoms.     

Mandatory Child Abuse Reporting Laws: Issues and Implications for Policy

Child maltreatment has been deemed a national emergency, with more than 2.5 million cases of abuse and neglect reported each year. Social policies designed to address child maltreatment include state statutes requiring professionals to report suspected child maltreatment to authorities. Mandatory reporting laws, while of potential benefit in the identification of abused and neglected children, can often result in higher or lower rates of reporting of abuse. The present paper reviews the functions of mandatory reporting statutes in professional contexts. Factors related to both low and high rates of reporting are discussed. In addition, suggestions for social policy are reviewed.     

Biology, childhood trauma, and murder: rethinking justice

This article reviews recent findings in the developmental neurophysiology of children subjected to psychological trauma. Studies link extreme neglect and abuse with long-term changes in the nervous and endocrine systems. A growing body of research literature indicates that individuals with severe trauma histories are at higher risk of behaving violently than those without such histories. This article links these two research areas by discussing how severe and protracted child abuse and/or neglect can lead to biological changes, putting these individuals at greater risk for committing homicide and other forms of violence than those without child maltreatment histories. The implications of these biological findings for forensic evaluations are discussed. Based on new understanding of the effects of child maltreatment, the authors invite law and mental health professionals to rethink their notions of justice and offender accountability, and they challenge policymakers to allocate funds for research into effective treatment and for service delivery.     

Knowledge of child abuse and neglect in nursing students: Assessment and perspectives

Misdiagnosis of child abuse and neglect can delay early treatment. Some authors have pointed out that nurses can miss child abuse and neglect diagnoses due to a lack of knowledge. It is unclear whether the lack of knowledge is due to students' insufficient preparation in nursing school and/or a deficiency in continuing education. An 18-item questionnaire was administered to final-year nursing students to assess their degree of knowledge on child abuse and neglect and to evaluate if the lack of knowledge was due to insufficient teaching/training during nursing school. The students were also asked to evaluate themselves by assigning a score to their knowledge. A statistical comparison was performed to define whether sufficient/insufficient results were associated with the following variables: sex, pediatric or general nursing student, attending pediatric lectures, training in pediatric wards/ambulatories, and attending specific lectures on child abuse and neglect. The study population comprised 175 students (154 females, 20 males, 1 unknown). Exactly 66.3% of the participants had ≤9/18 correct answers. Of all students, 77.7% self-evaluated their level of knowledge as ≤5/10. The comparisons yielded statistically significant differences between the groups with sufficient objective knowledge and those unrelated to training in pediatric wards/ambulatories or pediatric nursing students. Overall, there was little objective knowledge on the subject, which may be related to insufficient teaching/training in nursing schools. Useful corrective strategies include further teaching on child abuse and neglect, preferably using a practical approach. Further, common teaching/training programs should be conducted by both pediatric and general nursing schools.