Abusive head trauma in Maine infants: medical,child protective,and law enforcement analysis

OBJECTIVE: To collect and compare the results of medical, child protective, and law enforcement evaluation of a sample of Maine children who were victims of abusive head trauma (AHT) in order to describe the clinical and evaluative characteristics as they relate to victims, families and perpetrators of such trauma and to improve the professional response to AHT in Maine.METHOD: Retrospective chart review of medical, child protective, and law enforcement records of all AHT victims admitted to two tertiary care hospitals in Maine or seen by the state medical examiner from 1991 to 1994.RESULTS: Nineteen children (age range 2 weeks to 17 months) were identified as victims of AHT (out of a total of 94 head trauma admissions) accounting for 20 hospitalizations during the study period. There was a history of prior injury in 30%, history of prior medical evaluations for possibly abuse related problems in 65%, while, on presentation, 75% had evidence or history of prior injury. The hospitals notified child protective services (CPS) in all 20 cases and correctly identified abuse in 18 (90%). Parental risk factors for abuse identified in CPS records included substance abuse (53%), domestic violence (42%), criminal history (32%), unrealistic expectations (42%), and attachment problems (32%). However, risk factors were inadequately assessed in 53% of homes. Law enforcement identified a likely perpetrator in 79% of cases and in the majority the identified suspect was the father. In the 15 cases where a perpetrator was identified by law enforcement, that person was alone with the child at symptom onset in 14 (93%).CONCLUSIONS: The medical response, at least at the inpatient level, was generally well done with regard to suspicion and reporting. Cases are possibly being missed at the outpatient level. Child protective risk assessment was limited overall yet in a third of the homes where AHT occurred, few if any risk factors were present to aid in identification and prevention. Law enforcement results suggest that a primary suspect for AHT is the caretaker alone with the child at the time of symptom onset.     

Child abuse in the eyes of the beholder: lay perceptions of child sexual and physical abuse

OBJECTIVE: The purpose was to explore the effects of victim and perpetrator gender, type of abuse, and victim-perpetrator relationship on university students' and non-students' perceptions of different kinds of child abuse. METHOD: One hundred and ninety-nine participants (including university students and non-student adults) evaluated each of 24 vignettes (within-subjects design) describing an abusive interaction between a child and an adult. The following four variables were manipulated: the victim's gender, the perpetrator's gender, the type of abuse (physical, relatively mild sexual, or relatively severe sexual), and the perpetrator's relationship to the victim (parent or babysitter). Participants rated each vignette on a number of dimensions: degree of trauma and severity, likelihood of general occurrence and reoccurrence, victim believability, and "repressibility" of the event. RESULTS: Significant interactions emerged on each dimension. For example, sexual abuse (whether mild or severe) was rated as being more traumatic and severe if perpetrated by a parent, but relationship type did not affect perceptions of physical abuse. In addition, significant perpetrator gender by victim gender interactions indicated that homosexual abuse was perceived as more traumatic and repressible than heterosexual abuse, but as less likely to occur; and male participants tended to be more affected by the gender of the perpetrator and abuse type than female participants. CONCLUSION: The results suggest that people have stereotypes about the circumstances and consequences of child abuse. These stereotypes are often, though not always, consistent with existing empirical findings.     

Forensic medical results and law enforcement actions following sexual assault: A comparison of child,adolescent and adult cases

BackgroundIn sexual assault cases, little research has examined differences in forensic medical findings and law enforcement response by victim age across the entire age range.ObjectiveThis study addressed this gap by comparing four victim age groups: adults, adolescents over the age of consent, adolescents under the age of consent, and children under 12.Participants and settingCases were randomly sampled from a statewide database of medical reports on sexual assault examinations conducted in hospital emergency departments, including only cases reported to law enforcement (N = 563).MethodsData were combined from a medical report database, from coding of medical documentation and crime laboratory reports, and from case data provided by law enforcement.ResultsRates for both younger and older adolescent victims and adult victims were comparable, with no statistically significant differences on most variables: penetration, perpetrator use of force, non-genital and genital injuries, presence of biological evidence, generating assailant DNA profiles, DNA match to suspect, hits in the FBI’s DNA database, and law enforcement unfounding (i.e., determining allegations to be false or baseless). Child victims were significantly less likely to have a non-genital injury, and their cases were significantly more likely to be founded by law enforcement. Arrests were significantly more likely when victims were under the age of consent.ConclusionsDespite significant differences by victim age, similarity between adolescent and adult cases was substantial. Both younger and older adolescents may be at higher risk of physical violence during sexual assault than previously recognized, and need greater attention in response systems.     

Teachers' recognition and reporting of child abuse: a factorial survey

OBJECTIVE: The major aim of this study was to determine the effect of characteristics of the case, the teacher, and the organizational setting on recognition and reporting of child abuse. METHOD: A factorial survey design was employed in which a probability sample of teachers (N = 480) responded to vignettes in which case characteristics were systematically manipulated. RESULTS: Analysis using OLS regression showed that case characteristics alone accounted for 50.30% of the variance in recognition and 51.08% of the variance in reporting: the strongest effects were from type and seriousness of abuse, positive behavior of the victim and positive psychology of the perpetrator. The inclusion of variables describing the teachers and the school explained only a very small additional proportion of the variance in teacher's responses. CONCLUSIONS: Teachers responses to child abuse are relatively unbiased by either the extraneous characteristics of the perpetrator or victim, the responding teacher, or the school setting. The findings do not appear to support the problem of "overreporting." There is evidence for "underreporting," particularly in less serious cases involving physical and emotional abuse. Teachers are undeterred by the many problems and fears that may accompany a report of child abuse to Child Protective Services. Teachers use discretion in reporting abuse they recognize.     

校园暴力的根源与消解——电影《少年的你》成长主题解读

青春创伤电影《少年的你》结合青少年题材与现实主义题材,对校园欺凌和校园暴力作出了深刻反映和深度反思。影片反映了家庭、学校、社会的缺位造成的青少年成长困境,对发生在施暴者、受害者、旁观者三者之间的校园暴力现象及其所诱发的人性异变与性格扭曲作出了生动图解与深刻揭露,并在最后展现出让主人公从知识、爱情、友谊及社会生态的修复中重建青春人格、实现自我拯救的美好意愿,由此完成主人公的成长叙事。     

Munchausen by proxy: a case, chart series, and literature review of older victims

The history of an older child victim of Munchausen by proxy (MBP) is described. He was referred for evaluation after repeated sinus surgeries for recurrent sinus infections believed to be related to a falsified history of an immunodeficiency. The perpetrator was the mother of this 14-year-old victim, consistent with the majority of such cases. This case prompted a review of cases of MBP in older children reported in our hospital as well as a literature search for other cases in older children. METHODS: This study was a chart review of children over 6 years of age who had been evaluated by social services at the Children's Hospital at the Cleveland Clinic and reported as cases of Munchausen by proxy to Child Protective Services between January 2001 and June 2003. Also, an OVID, Psychline, and Pubmed literature review of published cases of Munchausen by proxy were identified, and cases occurring in the older child were selected for review. RESULTS: Older children who are the victims of Munchausen by proxy may have an induced illness, but falsified reports of symptoms and medical history to coerce the child to undergo medical procedures may be more common. Collusion of the victim with the perpetrator may also become a factor as the child ages and adopts the deception. Given the complex relationship that exists between the parent and child, it is difficult to predict whether the victim either will assist the caregiver in maintaining the factitious illness or be able to recognize the falsification. CONCLUSIONS: Older children who are the victims of Munchausen by proxy may fear consequences of revealing the factitious illness. Physicians must consider the possibility of this diagnosis whenever there are discrepancies in a child's illness that makes a factitious illness a consideration.     

Child abuse: Betrayal and disclosure

ObjectiveThe current study tested several hypotheses about disclosure of childhood sexual, physical, and emotional abuse derived from Betrayal Trauma Theory [Freyd, J. J. (1996). Betrayal trauma: The logic of forgetting childhood abuse. Cambridge, MA: Harvard University Press]. We predicted that the duration of time from abuse to its disclosure would vary as a function of victim–perpetrator closeness.MethodsData collected from 202 undergraduate participants using a survey methodology were submitted to logistic regression analyses. The relative variance explained by other variables was also examined.ResultsCompared to survivors of emotional abuse (EA) who were in not very close (NVC) victim–perpetrator relationships, EA survivors in very close (VC) victim–perpetrator relationships were significantly more likely to wait 1 or more years to disclose, or never to disclose, than to wait a period of time less than 1 year (OR = 2.65). Further, survivors of physical abuse (PA) in VC victim–perpetrator relationships were significantly more likely to wait 1 or more years to disclose their abuse, if it was disclosed at all, than PA survivors of NVC victim–perpetrator relationships (OR = 3.99). Results for sexual abuse were not significant.ConclusionsFor EA and PA, VC victim–perpetrator relationships predicted longer durations of time from abuse to its disclosure than NVC victim–perpetrator relationships.Practice implicationsAlthough delayed disclosure may support necessary (albeit abusive) attachments with caregivers, it may also prolong the abuse and prevent receipt of support. Increased awareness that VC victim–perpetrator relationships may predict longer durations of time from abuse to its disclosure, and that these delays may serve a functional purpose, can help guide supportive and empathic responses to traumatic disclosures.     

Childhood sexual assault victims: long-term outcomes after testifying in criminal court

We report a longitudinal study of long-term outcomes of participating in criminal cases following child sexual abuse (CSA). In the 1980s, 218 child victim/witnesses took part in a study of short-term sequelae of legal involvement. Approximately 12 years later, 174 of them, as well as a comparison group of 41 matched individuals with no CSA history, were interviewed about their mental health and legal attitudes. Being young when the legal case started was associated with poorer later adjustment. Additionally, even when controlling for psychological problems at the start of the legal case and other familial, CSA, and life stressors, testifying repeatedly in childhood predicted poorer current functioning. These associations were often moderated by the severity of both the CSA and the perpetrator's sentence: Testifying repeatedly in cases involving severe abuse, and not testifying when the perpetrator received a light sentence, predicted poorer current mental health. In partial contrast to the mental health results, being older when the case began and the perpetrator receiving a lenient sentence predicted more negative feelings about the legal system. In addition, not having testified when the perpetrator received a light sentence predicted more negative legal attitudes. Individuals' emotional reactions while waiting to testify and while actually testifying were also associated with their current mental health and attitudes toward the legal system: Greater distress predicted poorer adjustment, especially in individuals who were adolescents when they went to court. Greater distress also predicted more negative attitudes. Finally, when the former CSA victim/witnesses were compared with individuals with no CSA history, the former reported poorer adjustment and more negative feelings about the legal system. Results have implications for multilevel-transactional models of development, for understanding developmental sequelae of legal involvement following childhood trauma, and for social policy concerning the treatment of child victim/witnesses.     

Neurological impairment in maltreated children

The neurological competency of maltreated children was assessed by comparing physically abused children not known to have sustained serious head trauma, neglected children, and normally raised children from the same socioeconomic milieu. Each child underwent physical and neurological examinations including EEGs, supplemented by perceptual-motor tests devised to detect subtle evidence of neurological dysfunction. Obstetrical and developmental histories, as well as intelligence test protocols, were available. Blind ratings by a pediatric neurologist using all available information revealed significantly more impairment in the maltreated groups with more than 50% of the abused children in the moderate or severely impaired category. The complex relationship between the maltreating environment and neurological disorders in these populations is discussed including the need to routinely search for evidence of subtle neurological impairment when maltreatment is known or suspected.     

Abusive head trauma: A perpetrator confesses

Objectives

To present a detailed confession from a perpetrator of Shaken Baby syndrome.

Methods

Case study.

Results

We present a confession of Shaken Baby syndrome describing how the perpetrator severely injured a 3 year old with repeated bursts of acceleration-deceleration (shaking). The child sustained retinal and intracranial hemorrhage. Details of the confession and circumstances by which it was obtained lead us to believe its accuracy.

Conclusions

Accurate perpetrator confessions offer useful windows into realities and pathophysiology of abusive head trauma.     

Triangles of abuse: a model of maltreatment

Research and clinical evidence support the view that the perpetrator (P), victim (V), and observer (O), all contribute to child abuse and neglect. This paper describes a model in which they have a necessary part in precipitating and sustaining the maltreatment. It appears they form a triangle or triquetra which rotates with time and circumstance. The perpetrator of sexual assault often becomes the victim when he is imprisoned. The victim of physical abuse may become the perpetrator of physical abuse in the next generation. Within each P, V, and O there is also a triquetra which rotates and which will determine how that individual behaves in the next instance. Knowing the relative preponderance of P, V, or O within each individual can help predict possible future abuse. Since therapists often determine their intervention by the view of the situation they adopt, it is important for them to understand their principal orientation towards either the perpetrator, victim, or observer. The legal model of abuse emphasizes individual accountability by viewing people as they are solely responsible for their behavior. This article rather than diminishing the responsibility of any individual, emphasizes the collective responsibility of all involved.     

The whiplash shaken infant syndrome: what has been learned?

In 1974 John Caffey described a form of abuse in infants which he called "The Whiplash Shaken Infant Syndrome." This syndrome involves vigorous manual shaking of infants by the extremities or shoulders, with whiplash-induced intracranial and intraocular bleeding, but with no external signs of head trauma. This article reviews the literature on whiplash shaken infant syndrome since Caffey's original review. The bulk of this literature focuses on the use of cranial computed tomography in the diagnosis of head injury in infants. Many questions remain regarding the incidence of this syndrome, and the long term morbidity resulting from this type of injury in infants. Caffey's recommendations for routine, regular examinations of the ocular fundi in all babies, and for a massive public educational program on the hazards of shaking infants have yet to be carried out.     

Parents’ behavior in response to infant crying: Abusive head trauma education

Abusive head trauma (AHT) is still too common, and probably underestimated. It is the leading cause of death from child abuse. Crying is thought to contribute to the act of shaking. Objectives of this study were to (a) assess parents’ knowledge about infant crying, their ability to manage crying, and their knowledge about AHT; and (b) assess the feasibility and the impact of a simple educational intervention about crying and AHT with parents shortly after their child's birth. A short questionnaire was completed orally by the parents of 190 consecutive newborns in a maternity hospital at day 2 of life. Then, during the routine examination of the child, the pediatrician gave parents a short talk about infant crying and AHT, and a pamphlet. Finally, parents were contacted by phone at 6 weeks for the post-intervention questionnaire assessing their knowledge about crying and AHT. Among 202 consecutive births, parents of 190 children were included (266 parents; 70% mothers) over a 1-month period and answered the pre-intervention questionnaire. The intervention was feasible and easy to provide. Twenty-seven percent of mothers and 36% of fathers had never heard of AHT. At 6 weeks, 183 parents (68% of the sample; 80% mothers) answered the post-intervention questionnaire. Parents’ knowledge improved significantly post-intervention. Parents found the intervention acceptable and useful. Health care professionals such as pediatricians or nurses could easily provide this brief talk to all parents during systematic newborn examination.     

Child sexual abuse: very young perpetrators

Three cases of child sexual abuse by child perpetrators are presented showing that sexual abuse of a child by a child may result in the victim becoming a perpetrator, thereby contributing to a potential reservoir of adolescent and adult perpetrators. Sexual play between children requires increased attention from caretakers to determine whether it is abusive, imitated from prior experience, and potentially transmissible to other children. Parents need to be informed, possibly through schools, that incidents of sexual interaction between children should be reported. To punish children for such behavior may protect the perpetrator and silence the victim(s).     

Association of adverse childhood experiences with shaking and smothering behaviors among Japanese caregivers

Shaking and smothering in response to infant crying are life-threatening child abuse. Parental childhood abuse history is known to be one of the most robust risk factors for abusing their offspring. In addition to childhood abuse history, other adverse childhood exposures (ACEs) need to be considered due to co-occurrence. However, few studies have investigated the impact of ACEs on caregivers shaking and smothering their infant. This study aims to investigate the association of ACEs with shaking and smothering among caregivers of infants in Japan. A questionnaire was administered to caregivers participating in a four-month health checkup between September 2013 and August 2014 in Chiba City, Japan, to assess their ACEs (parental death, parental divorce, mentally ill parents, witness of intimate partner violence, physical abuse, neglect, psychological abuse and economic hardship), and shaking and smothering toward their infants (N = 4297). Logistic regression analysis was used to examine the cumulative and individual impacts of ACEs on shaking and smothering. Analyses were conducted in 2015. A total of 28.3% reported having experienced at least one ACE during their childhood. We found that only witness of IPV had a significant association with shaking of infant (OR = 1.93, 95% CI: 1.03–3.61). The total number of ACEs was not associated with either shaking or smothering. Our findings suggest that shaking and smothering in response to crying can occur regardless of ACEs. Population-based strategies that target all caregivers to prevent shaking and smothering of infants are needed.     

Credibility assessment in child sexual abuse investigations: A descriptive analysis

A major challenge in cases of child sexual abuse (CSA) is determining the credibility of children's reports. Consequently cases may be misclassified as false or deemed ‘no judgment possible’. Based on a large national sample of reports of CSA made in Israel in 2014, the study examines child and event characteristics contributing to the probability that reports of abuse would be judged credible. National data files of all children aged 3–14, who were referred for investigation following suspected victimization of sexual abuse, and had disclosed sexual abuse, were analyzed. Cases were classified as either ‘credible’ or ‘no judgment possible’. The probability of reaching a ‘credible’ judgment was examined in relation to characteristics of the child (age, gender, cognitive delay, marital status of the parents,) and of the abusive event (abuse severity, frequency, perpetrator–victim relationship, perpetrator's use of grooming, and perpetrator's use of coercion), controlling for investigator's identity at the cluster level of the analysis. Of 1563 cases analyzed, 57.9% were assessed as credible. The most powerful predictors of a credible judgment were older age and absence of a cognitive delay. Reports of children to married parents, who experienced a single abusive event that involved perpetrator's use of grooming, were also more likely to be judged as credible. Rates of credible judgments found are lower than expected suggesting under-identification of truthful reports of CSA. In particular, those cases of severe and multiple abuse involving younger and cognitively delayed children are the ones with the lowest chances of being assessed as credible.     

Multiple perpetrator rape among girls evaluated at a hospital-based Child Advocacy Center: Seven years of reviewed cases

The aim of this study was to describe contextual events, abuse experiences, and disclosure processes of adolescents who presented to a hospital-based Child Advocacy Center for medical evaluation and evidentiary collection as indicated after experiencing multiple perpetrator rape during a single event (n = 32) and to compare these findings to a group of single perpetrator sexual assaults (n = 534). This study used a retrospective mixed-methods design with in-depth, forensic interviews and complete physical examinations of gang-raped adolescents. Patients ranged from 12 to 17 years (M = 14 years). Girls who experienced multiple perpetrator rape during a single event were more likely to have run away, to have drunk alcohol in the past month, and to have participated in binge drinking in the past 2 weeks. Acute presentation of these victims were rare but 30% had hymenal transections and 38% had sexually transmitted infections (STIs). Forensic interviews revealed alcohol was a common weapon used by offenders, and its use resulted in victims experiencing difficulty in remembering and reporting details for police investigation or physical and mental health care. Most victims were raped at parties they attended with people they thought they could trust, and they felt let down by witnesses who could have helped but did not intervene. Although relatively rare, multiple perpetrator rape during a single event is a type of severe sexual assault experience and has significant risks for deleterious health outcomes. These victims require health care by trained providers to diagnose physical findings, treat STIs, screen for trauma, and support victims.     

Association of perpetrator relationship to abusive head trauma clinical outcomes

The diagnosis of abusive head trauma (AHT) remains a significant public health problem with limited prevention success. Providing protection from further harm is often challenged by the difficulty in identifying the alleged perpetrator (AP) responsible for this pediatric trauma. The objective of this study was to evaluate demographic and clinical characteristics of children with AHT and the relationship between APs and their victims in a large, multi-site sample. Understanding the AHT risks from various caregivers may help to inform current prevention strategies. A retrospective review of all cases of AHT diagnosed by child protection teams (CPT) from 1/1/04 to 6/30/09 at four children's hospitals was conducted. Clinical characteristics of children with AHT injured by non-parental perpetrators (NPP) were compared to parental perpetrators (PP). There were 459 children with AHT; 313 (68%) had an identified AP. The majority of the 313 children were <1 year of age (76%), Caucasian (63%), male (58%), receiving public assistance (80%), and presented without a history of trauma (62%); mortality was 19%. Overall, APs were: father (53%), parent partner (22%), mother (8%), babysitter (8%), other adult caregiver (5%); NPP accounted for 39% of APs. NPPs were more likely to cause AHT in children ≥1 year (77% vs. 23%, p < 0.001) compared to PP. Independent associations to NPP included: older child, absence of a history of trauma, retinal hemorrhages, and male perpetrator gender. While fathers were the most common AP in AHT victims, there is a significant association for increased risk of AHT by NPPs in the older child, who presents with retinal hemorrhages, in the hands of a male AP. Further enhancement of current prevention strategies to address AHT risks of non-parental adults who provide care to children, especially in the post-infancy age seems warranted.