The battered child syndrome, Caffey-Kempe syndrome,

child abuse.

The battered child syndrome, Caffey-Kempe syndrome,

child abuse.

Danuta Deboa

DEFINITION

Intentional child treating, causing physical and mental injuries.

History History

Cesar Valentinian I in 365 abolishes the law, that treated children as private

property of parents.

XIX century – Society of children’s suffering prevention.

1908 –in Polish medical literature the battered child syndrome was first

described by forensic pathologist from Kraków- Prof.L. Wachholz , „Children

– victims of parents”.

1946 Caffey J. /Amer. J.Roentgenol../ Multiple fractures in the long bones of

infants suffering from chronic subdural haematoma

1962 Kempe Henry The battered child syndrome, JAMA / definition/

20 XI 1989 United Nations „Card of law for children”.

XIX w. Towarzystwo Zapobiegania Cierpieniu Dzieci.

Prof. L. Wachholz „Dzieci jako ofiary znęcania się rodziców”.

1929 r. dr Parrisot „O znęcaniu się nad dzieckiem”.

1961 r. Henry Kempe „The Battered Child Syndrome”.

1989 r. Konwencja o Prawach Dziecka ONZ.

ICD X.

Cesar Valentinian I in 365 abolishes the law, that treated children as private

property of parents.

XIX century – Society of children’s suffering prevention.

1908 –in Polish medical literature the battered child syndrome was first

described by forensic pathologist from Kraków- Prof.L. Wachholz , „Children

– victims of parents”.

1946 Caffey J. /Amer. J.Roentgenol../ Multiple fractures in the long bones of

infants suffering from chronic subdural haematoma

1962 Kempe Henry The battered child syndrome, JAMA / definition/

20 XI 1989 United Nations „Card of law for children”.

XIX w. Towarzystwo Zapobiegania Cierpieniu Dzieci.

Prof. L. Wachholz „Dzieci jako ofiary znęcania się rodziców”.

1929 r. dr Parrisot „O znęcaniu się nad dzieckiem”.

1961 r. Henry Kempe „The Battered Child Syndrome”.

1989 r. Konwencja o Prawach Dziecka ONZ.

ICD X.

FORMS OF CHILD MALTREATMENT FORMS OF CHILD MALTREATMENT

PHYSICAL ABUSE, MALTREATMENT

SEXUAL ABUSE

EMOTIONAL ABUSE

NUTRITIONAL, PHYSICAL AND EMOTIONAL

NEGLECT

NEGLECT OF MEDICAL CARE

PHYSICAL ABUSE, MALTREATMENT

SEXUAL ABUSE

EMOTIONAL ABUSE

NUTRITIONAL, PHYSICAL AND EMOTIONAL

NEGLECT

NEGLECT OF MEDICAL CARE

MARKS ON THE SKIN TYPICAL FOR NOT ACCIDENTAL TRAUMAMARKS ON THE SKIN TYPICAL FOR NOT ACCIDENTAL TRAUMA

Numerous marks with quite clear edges

Finger’s and hand’s marks (cheeks, shoulders, chest)

Choking and pinching marks

Pinching marks

Biting marks

Imprints of objects

Numerous marks with quite clear edges

Finger’s and hand’s marks (cheeks, shoulders, chest)

Choking and pinching marks

Pinching marks

Biting marks

Imprints of objects

Exhaustion of child

Above 2 hours lasting brake between the incident and contact

with the doctor.

Incredible parent’s relation, disagreeing with child’s age.

No witness of incident.

Instead of parents, relatives or friends contact the doctor.

Child’s behaviour is too submissive (for example – it doesn’t cry

during painful dressings).

Exhaustion of child

Above 2 hours lasting brake between the incident and contact

with the doctor.

Incredible parent’s relation, disagreeing with child’s age.

No witness of incident.

Instead of parents, relatives or friends contact the doctor.

Child’s behaviour is too submissive (for example – it doesn’t cry

during painful dressings).

OTHER SYNDROMS OF MALTREATMENTOTHER SYNDROMS OF MALTREATMENT

NOT ACCIDENTAL BONE FRACTURESNOT ACCIDENTAL BONE FRACTURES

Child’s age (from 1st year of living 60 %, above fifth year of living

only 15 %)

Incredible results of parent’s interview, disagreeing with child’s

age.

Child’s age (from 1st year of living 60 %, above fifth year of living

only 15 %)

Incredible results of parent’s interview, disagreeing with child’s

age.

X – ray of 4 months old child.

Infractio epiphysis femoris sinistri.

Beside this there were affirmed also

fractures of ribs (fresh and old).

X – ray of 4 months old child.

Infractio epiphysis femoris sinistri.

Beside this there were affirmed also

fractures of ribs (fresh and old).

X – ray of 6 months old child.

Fractura epiphysis distalis humeri

dextrae. There is also quite easy to see

the splintered piece of bone – „as the

hand of the bucket”. Beside this there

were also affirmed fractures of eighth

left rib, bases of farer bones: femoral

right and right bone of tibia.

X – ray of 6 months old child.

Fractura epiphysis distalis humeri

dextrae. There is also quite easy to see

the splintered piece of bone – „as the

hand of the bucket”. Beside this there

were also affirmed fractures of eighth

left rib, bases of farer bones: femoral

right and right bone of tibia.

X – ray of 10 months old child.

Visible fracture of femoral left trunk of

bone. There is also visible very strongly

developed osseous structure of bone,

binding the fragments of bone.

Beside this there were also affirmed old

fractures of back fragments of few ribs.

The picture suggests, that the incident

that caused the injuries mentioned above

took place about three weeks earlier.

X – ray of 10 months old child.

Visible fracture of femoral left trunk of

bone. There is also visible very strongly

developed osseous structure of bone,

binding the fragments of bone.

Beside this there were also affirmed old

fractures of back fragments of few ribs.

The picture suggests, that the incident

that caused the injuries mentioned above

took place about three weeks earlier.

Placement and types of fractures not caused by accident in group of children under third year of life.

Placement and types of fractures not caused by accident in group of children under third year of life.

WHISPLASH BABY SYNDROM („SHAKED” CHILD) WHISPLASH BABY SYNDROM („SHAKED” CHILD)

Kids under first year of living (usually under sixth month).

Injuries of neck spinal column.

Symmetrical bleedings inside the skull.

Lack of bruises in area of head’s layers.

Kids under first year of living (usually under sixth month).

Injuries of neck spinal column.

Symmetrical bleedings inside the skull.

Lack of bruises in area of head’s layers.

MRI of an infant 12 days after incident. Visible large bleeding on the brain and to the brain’s cortex, with advantage of occipital lobes.

MRI of an infant 12 days after incident. Visible large bleeding on the brain and to the brain’s cortex, with advantage of occipital lobes.

KT of the same infant two

months after the incident.

Visible large losses of cortex with

advantage of occipital lobes.

KT of the same infant two

months after the incident.

Visible large losses of cortex with

advantage of occipital lobes.

KT of two months old

infant one day after the incident.

Visible bleeding into side cell and

also the swelling of the brain.

KT of two months old

infant one day after the incident.

Visible bleeding into side cell and

also the swelling of the brain.

NOT ACCIDENTAL SCALDS WITH LIQUIDSNOT ACCIDENTAL SCALDS WITH LIQUIDS

Symmetrical scalds of hands and legs.

Other visible coexisting numerous scars and bruises.

Other accidents of scalds in the same family.

Symmetrical scalds of hands and legs.

Other visible coexisting numerous scars and bruises.

Other accidents of scalds in the same family.

CHILD SEXUAL ABUSE [CSA] CHILD SEXUAL ABUSE [CSA]

FREQUENCY OF OCCURENCE.

CHARACTERISTICS OF ENVIROMENT

MOSTLY REFERS TO GIRLS.

80 % OF NEGATIVE EXAMINATIONS.

SPECIAL EXAMINATION METHODS.

FREQUENCY OF OCCURENCE.

CHARACTERISTICS OF ENVIROMENT

MOSTLY REFERS TO GIRLS.

80 % OF NEGATIVE EXAMINATIONS.

SPECIAL EXAMINATION METHODS.

FAR RESULTS OF CSAFAR RESULTS OF CSA

Painfullness and infections of sexual organs.

Headaches, stomachaches, muscleaches.

Fears.

Suicidal thoughts.

Frequency of CSA i and absences in work.

Emotional relationships and older age of victim.

Painfullness and infections of sexual organs.

Headaches, stomachaches, muscleaches.

Fears.

Suicidal thoughts.

Frequency of CSA i and absences in work.

Emotional relationships and older age of victim.

Area of behaviour Indicators

Acute traumatic response Newly manifested clinging behaviour and irritability in young children

Regression Loss of bowel and bladder control; thumb sucking; withdrawal

Sleep disturbances Night terrors; sleepwalking; bedwetting; inability to sleep alone

Eating disorders Feeding difficulties in infants and pre-school children; anorexia nervosa; overeating

School problems Change in performance; loss of concentration; enhanced distractibility

Social problems Anger or acting-out among peers; altered levels of activity with either shortened attention span and 'hyperactivity' or

depression and inactivity; poor peer relationships; restricted social life in adolescents; inappropriately sexualized behaviour

Behavioural sequelae Poor self-esteem, depression; guilt; suicidal gestures; acting in a sexually inappropriate way for age or excessive

preoccupation with masturbation; delinquency; running away, substance abuse, prostitution; psychosomatic gynecological and gastrointestinal complaints

BEHAVIOURAL INDICATORS

MEDICAL INDICATORS OF SEXUAL ABUSE Male and female Males Females

Bruising, scratches, bites Pain on urination Vaginal discharge

Sexually transmitted diseases Penile swelling Urethral inflammation

Bloodstains on underwear Penile discharge Lymph gland inflammation

Bruising or swelling of genital area inconsistent with history Pregnancy

Pain in anal, genital, gastrointestinal or urinary areas Recurrent atypical abdominal

pain

Genital injuries (unexplained or inconsistent with history)

Injury to inner lips, petechiae on roof of mouth

Restraint marks, 'fingertip' bruising

Enuresis or encopresis

Obtaining a History from Child Victims of Sexual Abuse

General

Provide a comfortable environment

Language and technique should be developmentally appropriate Allow sufficient time to avoid any coercive quality to the interview Establish rapport with the child

Questioning

Initial questions should be non-directive to elicit spontaneous responses.

Leading questions should be avoided. If used, responses to these questions should be

carefully evaluated.

Non verbal tools, e.g., dolls, drawings, may be used to assist the child in communication. Anatomically detailed dolls should be used primarily for the identification of body parts and clarification of previous statements.

Anatomically detailed dolls may be used in interviews of non-verbal children Psychological testing is not required for the purpose of proving sexual assault.

At some point, the child should be questioned directly about the abusive relationship.

The Forensic Evaluation Specimens to be collected

General

• Outer and underclothing if worn during or immediately following the assault

• Fingernail scraping

• Dried and moist secretions and foreign material observed on the patient's body.

• Use Wood lamp to detect semen.

Oral Cavity

Swabs for semen (2) if within 6 hours of the assault

Culture for GC and other STD

Saliva - for reference

Genital Area

Dried and moist secretions and foreign material

Comb pubic hair. Collect all loose hair and foreign material

Vaginal swabs (3)

Wet mount

Dry mount slides (2)

Culture for GC and other STD's

Anus

Dried and moist secretions and foreign material

Rectal swabs (2)

Dry mount slides (2)

Culture for GC and other STD's

Blood

Blood type

RPR

Pregnancy test (blood or urine)

Alcohol/toxicology (blood or urine)

Urine

Urinalysis

Pregnancy test (blood or urine)

Alcohol/toxicology (blood or urine)

Other

Saliva. Use clean gauze or filter paper

Head hair. Cut and remove

Pubic hair. Cut and remove