MALTREATMENT IN CHILDHOOD

Jorge Paulete Vanrell, MD

Incidence| Age Distribution | The Agressors | Main Causes of Aggression
| Diagnosis | Conduct | Images of Cases

At least theoretically, we think of a child as a human being protected by her family environment, from which it should stem, in a natural and spontaneous way, all the emotional and material attentions needed for her normal development. Sadly, however, there are occasions when family or home becomes a hostile environment for the little ones, resulting in physical and sexual abuses or even in death.

The media often reports, in vivid detail, of cases of children who are kept chained to the wall in dark rooms, for days, weeks or even months; of very small children who are restricted to their cradles for many days; or who are put to hanging from their hands tied to shower pipes. They tell us of children who are subjected to extreme temperatures; being forced to sit naked on blocks of ice or on the top of kitchen stoves, or being burned with cigarette embers. We have seen a case where the left hand of a small child was immersed by her mother into boiling water ir order to punish her for using that hand to write, instead of the right one. The medical literature also has horrid details about deaths being provoked by forced inhalation of powdered pepper, as a form of disciplinary punishment by their parents; or about the many cases of children who die of hunger, because they had their feeding suspended for long times, while they didn't change their "undesirable" behavior...

Unfortunately, these are not sporadic events or old stories which happens only in far-away countries. Along the times, maltreatment of children has been rationalized by adults using the most diverse reasons we can think of, from religious practices and beliefs, to disciplinary and educational objectives; or even, in the widest sense possible, by economical imperatives. For example, extreme physical abuse exherted on children in order to exploit their work is not exactly new. It was a frequent practice during the Industrial Revolution, even in countries which were considered advanced societies at the time, such as the United Kingdom or the United States, and it is still practiced today.

Exploitation of the work of minors (sometimes 4 or 6-year old children) is common, and we see them performing dangerous or exhausting activities in order to earn a few cents a day, sometimes working under physical or moral chains, in stone quarries, in sisal plantations and mills, in wood burning coal furnaces, or even prostituting their frail bodies in posh beach resorts, serving the overarching interests of sexual tourism. They form an amorphous and ghostly legion of the disposessed and the forgotten, children without a present and without a future.

How Frequent is Child Abuse ?

Statistics compiled in the United States in 1966 estimate a figure which varies from 250,000 to 500,000 cases of child abuse being reported by infance protection services, per year. This figure increased to more than 1.2 million cases in 1986, and doubled again to 2.4 million cases a year, in 1996.

Other countries, such as Brazil, have no reliable national statistics, but only a few sparse records obtained in infancy protection agencies which are far from reflecting the present reality in these countries. They oftentimes describe only regional or local realities.

The first case of child abuse reported in Brazil was made by Canger Rodrigues et al., in 1974, followed by three cases observed by Teixeira (1978 and 1980), who is one of the foremost researchers in our country on the subject of the  "Battered Baby Syndrome".

This syndrome refers to the most frequent form of aggression against children which is physical punishment, i.e., by slapping, punching, kicking or biting, by throwing the infant or the baby to the ground or by swirling the child through the air, sometimes kicking her head against the wall or the furniture.

In second place comes thermal aggression, by burning or freezing using embers, boiling water or hot plates, and ice. Chemical aggression is also common, by forcing the child to drink alcoholic beverages, or by subduing them with narcotics or substances of abuse, or by denying water or food. Sometimes, aggression is sexual: parents rape their own children. Many times, several of these forms of aggression are combined, in refined tortures which are performed by the parents, step parents, boyfriends, etc., with no escape possible for the victim.

A common result of the battering is that normal development is arrested and speech and walking are inhibited. The baby does not react or defend himself against battery, or run away from it, due to physical impossibility. Children who could denounce their aggressors, are unable to do so. For parents who lose the most basic behaviors of preservation and protection of their own children, they are the  "ideal" victims, because they are totally unable to provide evidence against their aggressors. This facilitates repetition of aggression, which becomes hidden from society for a long time. This happens so not only with small babies and infants, but also with children of school age.

As a more concrete example, we show below a basic analysis of the incidence of child abuse in the city where we work, in Brazil. It is based on data acquired in the sector of forensic medicine and in medical emergency rooms and services.

AGE DISTRIBUTION

Age 0-6 7-12 13-18
Frequency
%

60

25

15

AGGRESSORS

Mother Father Both Caretaker

43 %

33 %

10 %

14 %

MAIN CAUSES OF ABUSE

Alcoholism Family
Disarray

Mental
Diseases

Behavioral
Disturbances

50 %

30 %

10 %

10 %

RECOGNIZING THE ABUSED CHILD

Child Behavior

The simplest clinical procedure should be silent and unaided observation of the child's behavior. This is usually sufficient to obtain data required to establish with a reasonable certainty that maltreatment has taken place and to characterize it. Secondary data, such as malnutrition or delay in growth may indicate affective deprivation or food withdrawal.

Battered children usually have many forms of emotional or behavioral disturbances, such as apathy, sadness and fear of contact. They adopt protective postures or behaviors, such as shielding their face with their hands or forearms, or by closing their eyes upon close inspection by the attending professional. These may be interpreted as spontaneous forms of defense in situations which the child feels as being similar to those where she was victimized or punished.

Physical Evidence

Systematic examination is the main tool here, particularly regarding unexplained or unusual lesions, which do not fit the reasons given by the child's parents or caretakers.

multiple skin echimoses in several regions of the body, appearing in several colors (the so-called "rainbow lesions").
lesions reflecting finger marks on the arms and thorax;
orbital hematome ("black eye"); or in commonly non-exposed regions;
healed lesions in the ears, producing scars and deformities ("boxer's ear" or "cauliflower ear");
chin or forehead bruises;
lip lacerations or tooth loss, bite marks (often attributed by caretakers to an "excess of affection");
cigarette burns; scalding burns;
hemorrhagic skin marks which reflect precise forms of objects, such as ashtrays or broom handles;
lesions on the genital organs, repeated lesions of long bones with different times of consolidation;
severe and unexplained head/brain trauma, trauma of internal abdominal organs.

The observer should increase attention to details of these and other unexplained lesions particularly when:

there are contradictions among the caretakers' testimonials, when they were questioned separately and without communication between them;
there was an unexplained delay in calling for medical assistance, particularly when the severity of the lesions is evident, even for a lay person;

the multiplicity and origin of the lesions are incongruent with simplistic explanations offered by the caretakers;
successive episodes of previous lesions were reported by caretakers to different physicians or hospitals, usually in order to avoid crossing information taken from medical records;
there is evidence for malnutrition, improper body care, etc., configuring what is known as the Neglected Child Syndrome.

WHAT TO DO

When physical abuse has been properly detected, the following conduct should be taken:

Transport the child to emergency medical services;
Take radiographs from the whole body;
Assemble a medical committee formed by the attending physicians, pediatrician, orthopedist, radiologist, forensic physician, nurses and social workers involved in the case;
Intern the children in the hospital, particularly when the Battered Baby Syndrome has been diagnosed;
Notify or call the proper police authority;.
Notify, whenever possible, the proper judicial authorities, such as the jurisdiction for crimes against minors, public prosecutor office, etc., particularly when there are special law statutes concerning the protection of infants and adolescents.


Images of Real Cases


Resources on the Internet


Author: Jorge Paulete Vanrell, MD, DSc, LLB, BSE, forensic physician and specialist in occupational medicine, professor of psychopathology in the Course of Clinical Psychology, in São José do Rio Preto, São Paulo, Brazil. He is also professor of forensic medicine in the Law School in the same city, and professor of forensic medicine and criminology in the Police Academy of São Paulo. He was a fellow, Department of Pathology, Dartmouth Medical School, NH, USA (1970). Invited Researcher, Department of Genetics of the Universidad Nacional Autonoma de Mexico (UNAM, 1971).

Images: Silvia Helena Cardoso, MSc, PhD