Inflicted skeletal trauma: the relationship of perpetrators to their victims

OBJECTIVE: Although inflicted skeletal trauma is a very common presentation of child abuse, little is known about the perpetrators of inflicted skeletal injuries. Studies exist describing perpetrators of inflicted traumatic brain injury, but no study has examined characteristics of perpetrators of inflicted skeletal trauma. METHODS: All cases of suspected child physical abuse evaluated by the child abuse evaluation teams at Vanderbilt University Medical Center (January 1996 to August 2000) and at the Children's Hospital at Denver (January 1996 to December 1999) were reviewed for the presence of fractures. All children with inflicted fractures were entered into the study, and demographic data, investigative data, and identity of perpetrators were collected. RESULTS: There were a total of 630 fractures for 194 patients. The median number of fractures per patient was 2, and the maximum was 31. Sixty-three percent of children presented with at least one additional abusive injury other than the fracture(s). Perpetrators were identified in 79% of the cases. Nearly 68% of the perpetrators were male; 45% were the biological fathers. The median age of the children abused by males (4.5 months) significantly differed from the median age of those abused by females (10 months) (p=.003). CONCLUSION: In the cases where a perpetrator of inflicted fractures could be identified, the majority were men, most commonly the biological fathers. Children injured by men were younger than those injured by women.     

Analysis of caretaker histories in abuse: comparing initial histories with subsequent confessions

OBJECTIVE: We hypothesize that perpetrators of abuse include elements of truth in their initial history and that an analysis of perpetrator confessions can teach professionals how to identify these initial truths. METHODS: The information from a consecutive sample of perpetrators' confessions concerning 41 children hospitalized because of injuries caused by child abuse was reviewed. The details about the injuries contained in the confessions were compared with the details provided when these children initially presented for medical care. Information about the perpetrator's gender and relationship to the child, the victim's age and gender, type of injury, family risk factors, the trigger of the abusive event, the circumstances surrounding the event, and the type of trauma were collected. RESULTS: A total of 45 perpetrators abused 41 children; 76% of perpetrators were male; 56% were the child's father; 34% were the child's mother. The perpetrators initially provided no explanation about how 68% of the children received an injury. In 91% of their initial histories, the perpetrators provided some element of truth about the circumstances or triggering event for the abuse. In 67% of confessions, crying was the circumstance that triggered the abuse. Mothers were more likely to describe the situation that triggered the abuse (85% of mothers versus 58% of fathers, p=ns), while fathers were more likely to describe accurately the circumstances surrounding the abuse (79% of fathers versus 62% of mothers, p=ns). CONCLUSIONS: Perpetrators of abuse provide initial truths in their presenting history. Child abuse professionals must take a careful history from all caretakers and "listen" for the "elements of truth." These truths are the child's behavior or circumstance that increased stress and triggered the abuse. Employing this method in a careful analysis of confessions can make a significant contribution to the capacity to identify child abuse. In addition, more information about the role of triggers may help to focus child abuse prevention strategies.     

Scarring for life: abuse with electric cords

The authors studied 78 cases of child abuse in which electric cords were used to discipline children. Abuse was usually chronic, and body scars and/or lacerations, usually linear or looped in shape, were found on 95% of these children. Black children over age 5 years were most often the victims. The most commonly injured and/or scarred body sites were the arms, thighs, and back. The majority of perpetrators were single female heads of household raising more than one child, who did not perceive their use of electric cords to discipline children as inappropriate.     

Patterns of reported child abuse and neglect

Confirmed reports of abuse and neglect logged in a large state registry file from 1977 to 1984 are analyzed. Boys tend to sustain more frequent and more serious injuries. Victims of male perpetrators tend to sustain more serious injuries. A modest same-sex perpetrator/victim pattern is revealed for physical abuse; males are more likely to physically abuse boys while females are more likely to physically abuse girls. Among younger victims (aged 12 and younger) boys outnumber girls in all reporting categories except sexual abuse. Among adolescent victims, female victims greatly outnumber male victims in all reporting categories. Similarities between adolescent physical abuse and spouse abuse are noted; males are are the predominant perpetrators and females the predominant victims. As expected, victim age emerged as a strong predictor of severity of physical abuse injury. Several other factors including social isolation, mental health problems, lower income, and unemployment of the father are identified as modest predictors of severity.     

Is race or ethnicity a predictive factor in Shaken Baby Syndrome?

OBJECTIVE: Previous studies have concluded that shaken baby syndrome occurs more often among Whites than among Blacks. The purpose of this study was to determine whether race is a predictive factor in Shaken Baby Syndrome when population and referral patterns are considered. METHODS: A retrospective medical record review of closed head injuries due to child abuse during the time period January 1992 to July 1997 was conducted at three pediatric tertiary care medical centers in North Carolina. Patients included children, ages 0-4 years, identified from medical record reviews and child abuse databases. Only North Carolina residents were included. The specific rates of shaken baby syndrome in Whites versus non-Whites in the referral area were computed. RESULTS: The difference in the rate of shaken baby syndrome from the referral area was not statistically significant among Whites versus non-Whites (26.7/100,000 versus 38.6/100,000, p = .089) Most of the perpetrators were male (68%), and most victims (76%), lived with their mothers and biologic father or mother's boyfriend. CONCLUSION: Race was not a significant factor in predicting shaken baby syndrome in the referral area studied, and therefore is not a useful factor in targeting groups for intervention.     

Understanding forearm fractures in young children: Abuse or not abuse?

This retrospective study describes the characteristics and mechanisms of forearm fractures in children <18 months adding to the evidence-base about forearm fractures. It also examines which features of forearm fractures in young children may help discriminate between abusive and noninflicted injuries. Electronic medical records were reviewed for eligible patients evaluated between September 1, 2007 and January 1, 2012 at two children's hospitals in Chicago, IL. The main outcome measures were the type of fracture and the etiology of the fracture (abuse versus not abuse). The 135 included patients sustained 216 forearm fractures. Most were buckle (57%) or transverse (26%). Child protection teams evaluated 47 (35%) of the patients and diagnosed 11 (23%) as having fractures caused by abuse. Children with abusive versus non-inflicted injuries had significant differences in age (median age 7 versus 12 months), race, and presence of additional injuries. Children with abusive forearm fractures often presented without an explanation or a changing history for the injury. Children with non-inflicted forearm fractures often presented after a fall. No particular type of forearm fracture was specific for child abuse. Any forearm fracture in a young child should be evaluated with special attention to the details of the history and the presence of other injuries. Young age, additional injuries, and an absent or inconsistent explanation should increase concern that the fracture was caused by child abuse.     

Intrafamilial sexual abuse: brother-sister incest does not differ from father-daughter and stepfather-stepdaughter incest

OBJECTIVE: Three groups of girls who were sexually abused (by either brothers, fathers, or stepfathers) were compared. The purpose was to identify the differing characteristics of the abuse, the family environments, and the psychosocial distress of these children. METHOD: Seventy-two girls aged between 5 and 16 were assigned to one of the three groups. Subjects were matched between groups on the basis of their actual age. Children completed measures of traumatic stress; their mothers completed the Child Behavior Checklist-Parent Report Form (CBCL) and other self-report questionnaires on family characteristics. Workers in child protective services completed information regarding the nature and severity of the abuse. RESULTS: Results suggested few differences in the characteristics of sexual abuse between the three groups. However, penetration was much more frequent in the sibling incest group (70.8%) than in the stepfather incest (27.3%) or father incest (34.8%) groups. Ninety percent of the victims of fathers and brothers manifested clinically-significant distress on at least one measure, whereas 63.6% of stepfather victims did. Compared with father and stepfather perpetrators, brothers were raised in families with more children and more alcohol abuse. CONCLUSIONS: The authors conclude that the characteristics of brother-sister incest and its associated psychosocial distress did not differ from the characteristics of father-daughter incest These findings suggest that theoretical models and clinical practices should be adjusted accordingly and that sibling incest should not necessarily be construed as less severe or harmful than father-daughter incest.     

Understanding humerus fractures in young children: Abuse or not abuse?

Fractures are the second most common abusive injury occurring in young children, particularly those under 2 years of age. The humerus is often affected. To better identify factors discriminating between abusive and non-abusive humerus fractures, this retrospective study examined the characteristics and mechanisms of injuries causing humerus fractures in children less than 18 months of age. Electronic medical records were reviewed for eligible patients evaluated between September 1, 2007 and January 1, 2012 at two children’s hospitals in Chicago, IL. The main outcome measures were the type of fracture and the etiology of the fracture (abuse vs not abuse). The 97 eligible patients had 100 humerus fractures. The most common fracture location was the distal humerus (65%) and the most common fracture type was supracondylar (48%). Child Protection Teams evaluated 44 patients (45%) and determined that 24 of those had 25 fractures caused by abuse (25% of the total study population).Among children with fractures determined to have been caused by abuse, the most common location was the distal humerus (50%) and the most common types were transverse and oblique (25% each); however, transverse and oblique fractures were also seen in patients whose injuries were determined to have been non-abusive. A younger age, non-ambulatory developmental stage, and the presence of additional injuries were significantly associated with abusive fractures. Caregivers did not provide a mechanism of injury for half of children with abusive fractures, whereas caregivers provided some explanation for all children with non-abusive fractures.     

Assessment of factors resulting in abuse evaluations in young children with minor head trauma

OBJECTIVE: The primary objective was to determine which of the examined factors prompted physicians to initiate a further abuse evaluation in young children with minor head injury. The recording of important historical elements in the charts of these patients was also evaluated. METHODS: Charts of 349 children less than 3 years of age with minor head injury were retrospectively reviewed. Age, race, sex, insurance status, findings on head CT, mechanism of injury, witnessing of event and delay in seeking care were analyzed for association with performance of skeletal survey and referral to Child Protective Services (CPS). RESULTS: Increased odds of CPS referral and increased odds of obtaining a skeletal survey were associated with positive findings on head CT, delay in seeking care, and unknown mechanism of injury. Despite a known association of age/ambulatory status with abuse, the age of the child was not associated with increased odds of abuse evaluation, and younger age was not associated with increased odds of documenting whether the injury was witnessed or when the injury occurred. Documentation of timing of injury was lacking in 29.2% of the charts. Witnessing of the event was undocumented in 48.7% of cases. CONCLUSION: Clinicians may not be using readily available, important information when considering the initiation of an abuse evaluation in young children. Clinicians seeing acutely injured children may need further education regarding developmental status and its effect on mechanisms of injury and the importance of detailed documentation in cases where abuse is a possible cause of injury. PRACTICE IMPLICATIONS: Historical factors associated with injuries in young children continue to be poorly documented. Increased pediatric training for emergency medicine physicians, clinical protocols for evaluation and documentation of injured children, and regular continuing medical education on child development and its implications on mechanisms of injury for clinicians practicing in acute care settings are needed changes that may bring about improvements.     

A matched cohort comparison of a criminal justice system's response to child sexual abuse: a profile of perpetrators

OBJECTIVE: This study was undertaken to examine whether alleged child sexual abuse perpetrators are handled differently by the courts than other alleged felony perpetrators. Comparisons were made from the time of prosecutorial case acceptance through prosecution to sentencing, with emphasis on judicial and prosecutorial decision-making and plea-bargaining. METHOD: Data were retrospectively abstracted on the entire defendant population of cases of sexual abuse of children and adolescents (ages 2-17) over a 5-year period. Using a case-flow analysis, comparisons were made between a child sexual abuse cohort and a cohort of matched felony cases from a single jurisdiction. RESULTS: Three important findings emerged. First, compared to other felons, abuse perpetrators were employed, had been married, were mostly European American, and were older than 30 years of age. Second, in the abuse cohort, as many as 14% had a previous sexual or violent record compared to 2% in the comparison group. Third, similar percentages of perpetrators in both groups were released on their own recognizance, had the charges against them dropped, and were found guilty. As well, no differences between groups were found in the proportion of individuals sentenced to jail, probation, counseling, or work release. CONCLUSIONS: Although the treatment of perpetrators of child sexual abuse was similar to the treatment of perpetrators of other felonies, the profile of the child abuse perpetrator was quite different. Knowledge about this profile may impact prosecution or treatment and recidivism rates, to the extent that recidivism is related to characteristics of the abuse perpetrator.     

Child physical abuse – High school students’ mental health and parental relations depending on who perpetrated the abuse

The aim of this study was to contribute to the research of child physical abuse (CPA) by examining if there were any differences in high school students’ mental health (in this study symptoms of depression and anxiety, self-esteem and sense of coherence) and/or, in how they perceive their parents, depending on whether or not they had been subjected to CPA during childhood. In addition, if high school students reported different mental health and/or, relationships with their parents, depending on if their mother, father or both parents were the perpetrators of CPA.A representative national sample of high school students (N = 3288, data collected 2009) participated in the study. Participants completed the following: questions about CPA and alleged perpetrators, the Hopkins Symptom Checklist, Rosenberg Self-Esteem Scale, the Sense of Coherence Scale and Parental Bonding Instrument.The results showed students who reported experiences of CPA were more likely to report symptoms of mental illness and negative perceptions of their parents’ parenting. However, there were no mental health differences depending on whether their mother, father or both parents were the perpetrators of CPA. Still, there were differences in perceived parenting indicating that mothers’ parenting was perceived as more negative when mothers only or both parents were perpetrators of the abuse than when only fathers were perpetrators.     

Epidemiology and etiology of reported cases of child physical abuse in Zimbabwean primary schools

OBJECTIVE: There were two objectives: First, to determine the nature and extent of physical abuse perpetrated on primary school pupils by their teachers; second, to determine why some teachers physically abuse their primary school pupils in Zimbabwe. METHOD: Epidemiological data of reported physical abuse by teachers in Zimbabwe between January 1990 and December 1997 were analyzed using information in their files. RESULTS: The study found that 78.9% of the perpetrators were male while 21.1% were female; 92.1% of the perpetrators were trained teachers while 7.9% were untrained; 58.7% of the victims were male while 41.3% were female; 91.4% of the cases were reported by the pupils themselves and 8.7% by the school head; 73.9% of these cases were reported to the Ministry of Education and 26.1% to the police. In this study, 80.4% of the victims were beaten, whipped or hit by their perpetrators; 10.9% were clapped or slapped; 4.3% were punched with fists; 2.2% each were kicked and pinched, respectively. CONCLUSIONS: The findings indicate that teachers perpetuate various forms of physical abuse and that this form of abuse is now on the increase. The findings indicate that some perpetrators use corporal punishment on female pupils against the stipulated Public Service (Disciplinary) Regulations. What is clear is that the Public Service (Disciplinary) Regulations seem not to be deterrent enough because the majority of the perpetrators are merely fined or reprimanded while only a very small percentage is discharged from the teaching service.     

Physically abusive fathers and risk assessment

OBJECTIVE: The purpose of this study is to identify factors that predict recidivism among families in which the father is the perpetrator of physical abuse and to compare these factors to the factors that investigators believe are related to higher risk. METHOD: A case-comparison design was used to understand risk among 137 predominantly Caucasian families in which a father had injured a child. RESULTS: The multivariate analysis showed that families in which the father was unemployed (greater time at risk), had younger children, was not the biological father of all of the children, did not take responsibility for his behavior, seriously injured a child, and maltreated a child in the past were more likely to re-abuse. These factors, along with whether the mother had a criminal history, correctly predicted recurrence for 83% of the families. The investigators correctly predicted recurrence for 70% of the families. CONCLUSIONS: The investigators placed too much emphasis on some variables that were not related to recurrence, such as the mother's mental health and whether she tried to protect her children. These results may be useful in adapting assessment systems that do not take into consideration the gender of the perpetrator.     

Perpetrators of early physical and sexual abuse among homeless and runaway adolescents

OBJECTIVE: To examine abuse specific variables among homeless and runaway adolescents and to look at perpetrators of childhood abuse. METHOD: A total of 372 homeless and runaway adolescents were interviewed using a systematic sampling strategy in metropolitan Seattle. Young people were interviewed on the streets and in shelters by outreach workers in youth service agencies. RESULTS: Approximately one-half of these young people reported being physically abused and almost one-third experienced sexual abuse. Females experienced significantly higher rates of sexual abuse compared to males, and sexual minority youth experienced significantly higher rates of physical and sexual abuse compared to heterosexual youth. Average duration of physical and sexual abuse was 5 and 2 years, respectively. Both types of abuse were rated as extremely violent by more than half of those who were abused. The average number of different perpetrators of physical and sexual abuse was four and three, respectively. Biological parents were the majority of perpetrators for physical abuse whereas nonfamily members most often perpetrated sexual abuse. Average age of perpetrators was late 20s to early 30s and the majority of perpetrators were male for both types of abuse.CONCLUSIONS: The pattern of exploitation and victimization within the family may have serious and cumulative developmental consequences for these youth as they enter the street environment. Early intervention programs are needed to break the cycle of exploitation and abuse that adolescents experience within the family. Without intervention, many of these youth may be at risk of future exploitation and re-victimization out on the street.     

Childhood sexual abuse among university students in Tanzania

OBJECTIVES: There are no prevalence data for childhood sexual abuse among Tanzanian university students. This investigation addressed this paucity. The nature of sexual abuse was also investigated. METHOD: Participants (N=487) from a university in Tanzania completed a questionnaire which assessed abusive childhood sexual experiences, gathering information about age of victim, duration of abuse, perpetrators, amount of force or persuasion involved, and potential causes of child sexual abuse. A number of individuals were also interviewed about their experiences. RESULTS: The overall prevalence rate for child sexual abuse was 27.7%, with rates being higher for females than for males. The average age of the victim when abuse occurred was 13.8 years. Perpetrators were generally unidentified by respondents; nonetheless, a surprisingly high proportion of female perpetrators was noted. There was a considerable amount of force or persuasion involved in the abusive behavior: betrayal of trust, bribes and physical force were cited frequently. Poverty and superstition were the primary explanations given for child sexual abuse. CONCLUSION: The study provides evidence for the existence of child sexual abuse in Tanzania. Poverty feeds the "sugar daddy/mammy" phenomenon and combined with various forms of superstition is an important factor in child sexual abuse in Tanzania.     

Referrals to a hospital-based child abuse committee: a comparison of the 1960s and 1990s

OBJECTIVE: Although reports of child maltreatment have increased yearly since national data were first collected in 1976, little information is available about changes in the characteristics of children reported. Therefore, to examine changes over time in recognition and reporting in a medical setting, we compared referrals to a hospital-based child abuse committee in the late 1960s and early 1990s. DESIGN: Retrospective, cross-sectional review of medical records and logs of the hospital's child abuse committee. SETTINGS: Ambulatory, emergency, and inpatient services at Yale-New Haven Hospital. Patients: Medical records were reviewed for 101 of the 165 children referred to the child abuse committee in 1968-1969 (early group) and 107 of the 843 children referred in 1990-1991 (late group). Cases of sexual abuse were excluded. RESULTS: Referrals for nonsexual abuse cases increased from 80 children per year in the early group to 181.5 per year in the late group; the late group was characterized by a larger number of newborn referrals (1% vs. 52%, p < .001). When non-newborns were compared, the two groups were similar with respect to gender and race, but the late group had fewer patients with private insurance (31% vs. 12%, p < .05). The late group also had more female-headed households (32% vs. 67%, p < .05) and more parents with a history of substance abuse (4% vs. 49%, p < .001). Excluding newborns, who were all classified as "at-risk," the types of problems were classified as abuse (41% early vs. 29% late), neglect (41% vs. 35%), and "at-risk" (16% vs. 35%). Although the types of injuries were similar: superficial injuries (20% vs. 16%), burns (9% vs. 8%), and fractures (6% vs. 4%), fewer maltreated children suffered physical injuries in the late group (71% vs. 49%, p < .05). CONCLUSIONS: A substantial change has occurred in referrals to the hospital's child abuse committee for abuse or neglect. Most referrals have become socially high-risk newborns and children or children with minimal injuries. This shift is likely due to broader definitions of maltreatment and earlier recognition of troubled families.