CHAPTER IV

DESCRIPTION OF CHILD ABUSE: Extensive studies of the mistreatment of children fill the literature. Poisoning, burning, smothering, beating, exposure to weather extremes, never changing diapers, starving, hair pulling, scalding enemas, as well as placing babies in ice cold water and in the refrigerator, never holding or hugging, and constantly screaming at the child, are all methods employed by the caretakers to abuse children. The unbelievable carnage consistently imposed on children in this culture continues without significant abatement. The descriptions of child abuse over the last two decades have not become more novel, only more frequent. For purposes of brevity only two studies of child abuse will be discussed. The reader may find additional references in the bibliography. (Banagala & McIntire, 1976; Curphey, 1965; Furst, 1976; Jaffa, et al, 1975; Jomeg & Schit, 1974; Kenney, 1976; Orton, 1975; Peckering, et al, 1976; 1966)

Johnson and Morse (1968) studied 101 cases of traumatic child abuse in Denver. All of the children were under fourteen years old. Two-thirds of the children had been severely injured. Eight children had skull fractures; five had subdural hematoma; eleven had limb fractures; twenty-seven had wounds or punctures; six had burns; and sixty-eight had bruises or welts. Of these children 40% had received previous injuries, and 20% received additional injuries as found by a follow-up study. Two of these children eventually received fatal injuries.

Weston (1968) conducted a study of 60 fatal cases. He separated his study into three sections: 1) cases from neglect; 2) cases of single episode traumatic injury; and 3) cases of multiple episode traumatic injury.

1. Cases from neglect: there were 24 terminal cases caused by neglect. Seventeen of them had been six months of age or younger; six were between seven and eleven months old; one was thirteen months old. Six of the children had less than 50% of their expected weight; ten, between 53% and 63% of their expected weight; eight, between 78% and 85% of their expected weight.

Of these children, eleven had severe diaper rash; seven had moderate diaper rash; one had minimal diaper rash. Nine of the children had been extremely dirty, and five of these had been encrusted with dirt. Four children had been infested with maggots. Six had bronchopneumonia. One child's genitals had been completely denuded with boiling water. One child died five hours after being brought to the hospital with a string tied around his penis and with blood vomit and feces.

2. Cases of single episode traumatic injury: There were thirteen cases of single episode traumatic injury. Seven children were under six months of age. One child was eight months old. Four children were between one and two years old; one was six years old.

Death was caused by subdural hemorrhage in six of the cases. Two children died of concussions of the brain, lungs, and heart. One died of laceration of the liver, and one of laceration of the spleen. One child died of craniocerebral injuries. Another died of shock with unattended thermal burns. One child died of subdural hematoma.

The causes of injuries leading to the deaths had been as follows: Four children had been struck by hand; one had been throw out into a bassinet which overturned; one’s head had been banged against the crib; one had been beaten with a bottle; one had been struck with a plastic toy gun; one child had been dropped into scalding water.

The reason given by the parents for the administrations of the fatal injuries were as follows: six children for excessive crying; three children for urinating or defecating on the floor or in the bed: one child for not finishing eating.

3. Cases of multiple episode traumatic injury: There were 23 cases of multiple episode traumatic injury. Seven children were younger than one year old. Eight children were between one and two years old. Seven were three years old. One child was five years old.

Death was caused by subdural hemorrhage in twelve cases. Four died of laceration of the liver and two of laceration of the mesentery. Three children died of cerebral contusions. One child died of intracranial hemorrhage. One died of Waterhouse-Friderichsen syndrome (burn reaction).

The causes of injuries leading to the deaths were as follows: fifteen had been beaten with one or more of the following: hand, fist, shoe, cord, ruler, strap, belt, switch, and stick; two children had their heads banged against a wall and one’ head had been banged against a bathtub; one child had been immersed in a sink of a hot water; one child had been placed on a hot radiator, and one had been placed on a gas burner; one child had his chain yanked out from under him; one child died of injuries from unknown causes.

The reasons given by the parents for the administration of the fatal injuries were as follows: six children had been killed for urinating or defecating; five had been killed for crying; two had been killed for not eating; one child had been killed for drinking a sibling's bottle; one had been killed for splashing water, one for smearing feces, one for having a temper tantrum, and one for needing love and attention.

Over 66% of the deaths of the infants in Weston's study were precipitated by urination, defecation, or crying. The Author's extensive review of the literature and experience in fifteen years of clinical practice has indicated that the antecedent stimulus in 70% of the cases of abuse of small children to be defecation, urination, or crying. The implications of this phenomenon for the treatment of child abusers will be examined in great detail in part four of this paper.

Reading the description of child abuse is difficult. Observing child abuse is even more difficult. Counseling of abusing parents can only be successful through study of this problem.

The descriptions of abuse discussed in this section were focused on the young child who has been abused by an individual. Descriptions of the abuse of the older child are as horrible. Descriptions of cultural and societal abuse are no different. The antecedent stimuli involved in the abuse of the older child are most often-sexual behavior and disobedience.

This concludes the discussion of the various types of child abuse. A discussion of the detection of child abuse follows.

DETECTION OF CHILD ABUSE: Detection of child abuse is accomplished by (1) physical examination of the child, (2) observation of the behavior of the child, and finally, (3) observation of the behavior of the caretaker. Persimmon et al., 1977)

Physical Examination of the Child: The physical examination of the child t detects child abuse usually consists if radiological, visual and tactile tests or if the child is decreased an autopsy is performed.

Radiologists first brought the unexplained fractures of bones of children to the attention of the medical community and speculated that fractures in different stages of healing were the result of child abuse. Radiological examination of the living or decreased child helped in the identification of about 40% of the identified cases of child abuse. X-rays of multiple fractures in different stages of healing are often the only evidence that can be used in court to verify abuse. (Ferguson, 1964; Helfer & Kempe, 1968)

Sussman (1968) believed that skin lesions should be used for diagnosis of child abuse. Skin lesions of the abused child are often found on the trunk or buttocks. The abuse childs’ lesions often had the shape of the instrument used. Accidental lesions were found at the extremities on a shape injured child and had non-specific and non-defined shapes. Lesions and scratches were numerous and at different stages of healing on the abused child. Lesions from accidental injury were few and were in similar stages of healing. Bleeding in the abused child was purpuric (cutaneous bleeding and almost never petechial (subcutaneous bleeding).

Hamlin (1968) stated that "subgaleal` hematoma (severe hemorrhage between the scalp and the skull) unless it is otherwise proven should be attributed to hair pulling."

Sudden infant death can frequently be attributed to child abuse according to Helpern (1976). He stated:

There may have been an undetected traumatic injury that may have been the result of abuse or neglect… an injury that would escaped discovery had the circumstances of finding the infant dead in the crib led the physician to the conclusion that this was "sudden infant death syndrome:" without ordering a complete autopsy. (p. 157)

Curphey (1965) outlined three steps to follow when performing an autopsy on a child to determine if death was caused by abuse: one, take a full skeletal x-ray. Two, take color photographs of any external bruises. Three, make incisions into swollen or suspected areas, especially the abdominal area which are not likely to show local swelling.

Observation of the behavior of the child: Studies of abused children who have been hospitalized found:

When the children were brought into hospital, some whimpered and attempted to hide under the sheets and demonstrated extreme fright when physical contact was attempted.

Others, showed apathy which resembled shell shock in adults.

They sat motionless without facial expression and were unresponsive to all attempts to evoke recognition of the external world.

They were whinny, destructive, sensitive, uretic, and hyperactive or listless.

They were stunted in growth and retarded in maturation.

When their parents entered the room the children withdrew from them.

After they were in the hospital for awhile the desire for food and contact with caretakers seemed to be one in the same. (Buchanan & Oliver, 1977; Gladstone, 1965; Gould et all .. 1964; Johnson & Morse, 1968)

Observation of the Behavior of the Caretaker; Pollock (1968) developed a set of questions to be asked of parents when they brought their children to the hospital. The questions were directed at the parent-child relationship and were to be asked by the physician handling a suspected case of child abuse.

Does your child cry a lot? How do you manage your child’s crying? How do you feel inside when the baby cries? Does it ever make you feel like crying? Significant answers to this set relate to anxiety and anger or feelings of despair.

Does it upset you when you left alone? What do you do when your spouse fails to listen to you? Have you ever been afraid to be alone with your baby? Can you usually call some one to help at these times? During stressful periods battering parents express many fears of being alone.

Does it make you feel anxious to have someone watch you feed your baby? Do you ever get the feeling that others are critical of how you feed or take care of the baby? Do others people understand the problems you have with your child? These questions reveal the amount of pressure these people have felt all of their lives to respond to the needs of others.

When do you feel children are old enough to understand what is expected of them? How well do you feel your children understand you? Can they tell when you are upset and do they help? These questions reveal how the parents may be turning to the child for satisfaction of their own needs. (p. 152)

The abusive parent normally does not volunteer any information about how the child was injured. When the abusive parent does explain the child’s injuries, he will often contradict himself. (Gross, 1976)

Abusive parents typically are critical of the child for being injured. They seldom looked at or touched the child in the clinic or hospital. The parents exhibited apparent disinterest in the condition of the child, treatment, follow-up care, or hospital discharge date. Characteristically, the parents constantly criticized the child and showed no remorse or guilt over the condition of the child. The behaved impulsively. The parents seldom visited the child in the hospital. When confronted with the question of child abuse, the parents denied it. (Allan, 1966; Benaron, 1969; Berlow, 1967; Helfer et al, 1977; Scholoeser, 1964)

Another aspect of the detection of child abuse to be considered is the response of the physician when he encounters a case. Cameron (1975) reported that according to some authorities, less than a third of cases of abuse seen by doctors were reported to authorities. This failure to report was not just neglect on the part of the physician alone. Often when a physician made a report of a child abuse he suspected he never received follow-up action by the authorities. This problem, lake of follow-up, plagues not only the physician but also all other health care personnel and the general public. Young (1976), in researching the attitudes of physicians concerning child abuse, concluded:

There were a number of significant differences between physicians’ attitudes and behavior concerning child abuse in 1969 and 1974. The so-called "new look" at child abuse is not statistically demonstrated in this study. (p. 127)

Education about child abuse obviously must be a necessary prerequisite for its detection. The general public, physicians, and other professionals who have contact with children need education about child abuse and child abuse laws. (Blue, 1965; Fontana, 1966; Hamlin, 1968; Miller, 1969; Paull, 1967; Scott, 1977)

Canadian and American community surveys of adults suggest that extrafamilial sexual abuse (ESA) of children reveal that approximately 20% of all respondents report interfamilial sexual abuse (ISA) (Russell, 1986; Wuatt & Peters, 1986). When noncontact abuse is included, the estimates reach 71% of the samples (Finkelhor, 1984).

Canadian National Population Survey (Badgley, 1984) revealed similar trends. Approximately 18% of all identified cases in a 2,008 sample were incestuous, another 18% involved strangers, and 57% involved friends or acquaintances. Research shows 67% of female psychiatric patients between the age of 13 and 17 reported sexual abuse compared to 12% of males (Beitchman, Zuker, Hood, daCosta, Akman, Nash, Hulsey, Sexton, Harralson, & Lambert, 1993; Pribor & Dinwiddie, 1992).

Victim and Perpetrator Denial

According to some reports, abused children commonly deny the abuse, or later recant their allegations. Such denials and recantations tend to compromise the child’s credibility and complicate the legal response to sexual abuse allegations. The threat of harm as well as the possibility of being humiliated, not believed, or blamed render the disclosure of child sexual abuse difficult for some victims. Thomas & Johnson (1979) found that for the majority of young adolescents, direct contact with helping agencies is forbidden because of the perceived stigma that is attached and the lack of anonymity which subsequently could lead to family disruption, rejection, and shame.

Theorists and researchers have attempted to explain why sexually abused children deny or recant sexual abuse. Koverola & Foy (1993) have reported that victims of sexual abuse often display symptoms of PostTraumatic Stress Disorder (PTSD). Children suffering from PTSD often enter an "avoidance phase" in which they deny abuse or recant because they cannot cope with the anxiety aroused by traumatic memories. They state: "Anxiety about court appearances or a change in the home environment may lead to denial or recantation. Children may recant if they feel isolated from their natural support systems". (Koverola & Foy, 1993)

Certain cultural groups might recant more often than others due to cultural taboos regarding sexual abuse. Research by Farrell (1998) suggests that loyalty to family members or fear of their reaction to abuse allegations may also contribute to some denials, Recantations, and reluctance to disclose.

An empirical study of the disclosure process by Sorrenson & Snow (1991) examined 117 cases in which a finding of sexual abuse was supported by medical evidence, perpetrator confession, or criminal conviction. They found that most disclosures of abuse were accidental (74%) and that many victims (22%) recanted their statements only to re-affirm them later (93%). Seventy-two percent of victims initially denied abuse, and 78% were reluctant to discuss the abuse. The disclosure process includes five states: (1) initial denial that the abuse occurred; (2) tentative disclosure or reluctance to discuss the abuse; )3) active disclosure or a complete statement about the abuse; (4) recantation of the allegations; and (5) reaffirmation of the allegations (Sorrenson & Snow, 1991).

The studies that have examined recantation have yielded results ranging from and 8% recantation rate (Jones, 1987) to a 27% rate (Gonzalez et al, 1993). Victims most often made a first disclosure to an immediate family member (35%), extended family member or friend (16%), or school official (13%). Case files did not indicate whether the initial disclosures were accidental or intentional. Ninety-six percent (226) of the victims made a partial or full disclosure of abuse during at least one interview. The victim validated eight cases without a disclosure. Six-percent (13) of the victims initially denied that abuse had occurred. This figure was significantly lower (Prop = 13.1, p < .001) than the 72% rate of initial denials reported by Sorrenson and Snow (1991). In over one-half of the cases involving denial, the victim made a complete disclosure of abuse within the same interview as the denial, or in the next interview. Ten-percent (24) of victims displayed reluctance to discuss the topic of abuses, or specific aspects of the abuse. This figure was significantly lower (Prop = 12.7, p < 001) than the 78% reluctance rate ("tentative disclosure") reported by Sorrenson and Snow (1991). Three-percent (8) of victims recanted their allegations to police. This figure was significantly lover (Prop = 5.5, p < 001) than the 22% recantation rate reported by Sorrenson and Snow (1991). When the eight victims who never disclosed and therefore could not recant were eliminated from the analysis, the recantation rate was 4%, a figure significantly lower (Prop = 5.5, p < 001) than the rate reported by Sorrenson & Snow (1991). Four of the eight victims who recanted apparently did so in response to pressure from caretaker. (Gonzalez et al, 1993).

Denial does not constitute evidence that a child has not been abused. It is possible that the victim was in the "avoidance phase". Denial of abuse occurs in 6% of validated cases. This finding indicates denial does not constitute definitive evidence that a child has not been abused. If a child initially denies abuse, additional interviewing may still be appropriate, especially if there is reliable independent evidence of abuse. Reluctance to disclose abuse was recorded in 10% of case files. A child’s reluctance to describe abuse can be brief and expressed nonverbally. In all likelihood, the 10% figure for reluctance underestimates the frequency with which children hesitate or snow discomfort before disclosing abuse.

Findings do not support the view that disclosure is a quasi-developmental process with stages that can be resolved. Most children (78%) entered the active disclosure stage at the first interview and never progressed to any other stage. Denials and recantations did not appear to follow any particular temporal or sequential pattern as proposed by Sorrenson and Snow (1991). The question, "How Do Children Tell" cannot yet be answered with any certainly (Bradley & Wood, 1996).

An interview with the child is of central importance in the investigation of whether a child has been sexually abused. The interview becomes subjected to considerable scrutiny by the child protection services and by the civil and criminal courts. A central area of concern has been the issue of the interviewer’s possible preexisting bias and subsequent leading style and type of questions. A recommendation made to change the practice on whether interviewers should know the nature of the allegation found that there are no ill effects and significantly more disclosures among children interviewed without prior knowledge of the allegation available to the interviewer. Jones (1995) stated that the "Interview blind approach involves greater attention to rapport and pacing the interview, combined with a gradual progression of inquiry from open ended to more closed and direct styles of questions."

The way in which children are interviewed can make the difference between prosecution, protection and continued abuse. The newer cognitive interview style uses progression plus rapport building, pre-interview instructions, and memory jogging techniques to increase disclosure information without compromising accuracy. Even when these structured interview techniques are used, children's out-of-court statements have usually been considered hearsay and must meet additional requirements if they are admitted in court. In the interview technique for "allegation blind", the interviewer has knowledge only of the child’s names for their own body parts and the names of significant others in their family. The "allegation blind" concept parallels asking interview questions on a progression from open-ended to leading and employs a graduated process of interviewing with more information if necessary. Pre-interview knowledge of the abuse allegation seems to have little effect on the disclosure of child sexual abuse in this investigative setting.

Clayton, Payne, and Erbaugh (1996) carried out a study in an outpatient hospital affiliated Child Sexual Abuse Assessment Unit where children are evaluated via a videotaped interview and/or an audiotaped exam. In the formal interview setting, the "allegation blind" interview techniques, with its perceived increased objectivity by the courts yielded a higher disclosure of child sexual abuse than did the traditional allegation informed interview technique. The statistical difference between the disclosure of "allegation blind" and "allegation informed" was p = .0378. Once a child became 4 years of age, they had more disclosures of abuse than nondisclosures or inconclusive disclosures as compared to 2 or 3 years old. This pattern held true of all children interviewed "allegation blind", but not for 6 year olds who were interviewed "allegation informed". The older the child, the more likely they were to discuss abuse. They legal outcome of 39 videotaped interviews from the first 2 years of the study was reviewed. Thirty-four had been conducted "allegation blind", two were "allegation informed" and four were cases where an initial "allegation blind" interview was followed by a second or third "allegation informed" interview. In all, 79% of the defendants pled guilty, and less than 5% resulted in acquittal by a jury. The remainder were dismissed or continued. Concerns of how children are interviewed about child sexual abuse allegations continue to surface. We need to develop an individual and a national database on case characteristics, assessment techniques, and case outcomes in the judicial system so that all child sexual victims can benefit from the knowledge we gain. There have been a number of cases centered around satanic ritual abuse in which the cases have been thrown out of court and prosecutors brought up on trial for their unethical prosecution of the case. (Rather, 1999)

In a large proportion of validated sexual abuse cases, the victim’s statement constitutes the only evidence that abuse has occurred. "Twenty-five percent of girls experiencing penetration of the anus or vagina report their sexual abuses to the authorities before admission to the hospital" (Kumar et al., 1996).

One commonly held view is that most accounts of sexual abuse gradually unfold over a period of time. Few children relate the full story on one occasion. There is often a struggle by the child to overcome fear and reveal sensitive information. The first disclosure is to someone other than a child abuse investigation, usually a family member, friend or teacher before the investigative interview. Should the involved child report sexual abuse to the teacher, she reports to the Child Protective Agency and the fears that cause the reluctance to report become reality. Typically, the police are called and the perpetrator is jailed. "The child is rejected by family and friends and is subjected to probing questions by police and perhaps medical personnel with whom they are unprepared to cope" (Thomas & Johnson, 1979).

Children’s abilities to describe experiences of sexual abuse were studied to evaluate the relative effectiveness of two rapport-building techniques for eliciting information. Fourteen interviewers conducted 51 investigations of child abuse with children ranging from 4.5 to 12.9 year of age. In 25 of the investigations, interviewers used a script including many open-ended utterances to establish rapport, whereas in 26 of the investigations the same interviewers used a rapport-building script involving many direct questions. Both scripts took about 7 minutes to complete. Children who had been trained in the open-ended condition provided 2 ½ times as many details and words in response to the first substantive utterance as did children in the direct introduction condition. Children in the open-ended condition continued to respond more informatively to open-ended utterances in the unscripted portion of the interview. Two-thirds of the children mentioned the core details of the incident in their responses to the first substantive utterance and 20% mentioned core details more vaguely. These results demonstrate that children respond more informatively to an open-ended invitation when they have previously been trained to answer such questions rather than more focused questions. These results demonstrate the sensitivity of children to the goals and expectations of forensic interviewers. Structured interview protocol also increase the amount of information provided by young interviewees (Sternbert, Lamb, Hershkowitz, Yudilevitch, Orback, Esplin, & Hovav, 1997).

This concludes the discussion on the detection of child abuse. A review of the effects of child abuse follows.