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Child Abuse The Forensic Investigation Michael Ward, MD Chief Medical Examiner Greenville, South Carolina Child Abuse • The physical, sexual, or mental injury, exploitation or negligent treatment of a child under the age of 18 years, by a person responsible for the child’s welfare. • Six patterns of abuse -Physical abuse -Sexual abuse -Intentional drugging -Medical neglect -Nutritional deprivation -Emotional abuse Child Abuse • In the United States, 1 – 2% of children reported to be abused. • Incidence is 700 to 1,200 per million. • 2,000 – 4,000 deaths per year. • Age-range: – One-third less than one year. – One-third 1 – 6 years – One-third 6 – 18 years Child Abuse • The Abuser – – – – Parents (father more often than mother) Other caregivers (boyfriends, babysitters) Physically or emotionally exhausted Alcohol or other drugs often involved Injuries in Child Abuse • Blunt injuries to any body surface most common injury. • Head injury most common fatal injury. • Blunt trauma to abdomen also common. • Skeletal injuries, burns, drownings are also seen. General characteristics of child abuse • • • • • Injury unexplained by the history given. Delay in seeking care. Changing, evolving, or inconsistent history. Inappropriate affect of caregivers. “Trigger event” precipitating loss of control of caregivers. Non-accidental Head Injuries • Formerly known as “Shaken Baby Syndrome” • Common findings include: – – – – Subdural hemorrhage Retinal hemorrhage Diffuse axonal injury May or may not have external injuries Non-accidental Head Injuries • The term Shaken Baby Syndrome has lost popularity in the United States and Great Britain. Many investigators disagree on the biomechanics of shaking infants, and many feel these injuries do not happen in this way. For this reason, many forensic pathologists have dropped the diagnosis of Shaken Baby Syndrome for the more general description of Non-accidental Head Injuries. Subdural Hemorrhages • Results from tearing of bridging veins extending from arachnoid to dura. • Hemorrhages are generally small and are markers of trauma. • Not a space occupying hemorrhage. • May be exceptionally small, or associated with focal sub-arachnoid hemorrhage. Subdural hemorrhage Head injuries may or may not be present Retinal Hemorrhage • Variably sized and located hemorrhages within, behind, or on top of the retina. • At the posterior pole of the eye, tend to be flame shaped hemorrhages. • Laterally, may be dot/blot hemorrhages or retinal tears. Differential Diagnosis of Retinal Hemorrhage • Birth Trauma-seen in 1/3 of vaginally delivered babies, resolve quickly (weeks). • Increased intracranial pressure-arteriovenous mismatch. • Shaken baby syndrome • Head trauma-Tearson syndrome, severe head injuries, acceleration-deceleration injuries. Differential Diagnosis of Retinal Hemorrhage • • • • • • Sepsis Coagulopathy Subacute bacterial endocarditis Sickle cell disease Acute leukemias Congenital infections Subdural hemorrhage Subdural hemorrhage: Cross sections of optic nerves Subdural hemorrhage, optic nerve Diffuse Axonal Injury • Result from shear-force type injuries to the brain. • May be associated with cerebral white matter tears, often seen at gray-white junction. • Disruption of neuronal axons with formation of axonal “retraction balls”, best seen with silver impregnation or immunohistochemical stains. • May take several hours to form. Child abuse • Head injuries are the most common cause of death. • Other injuries include: – Blunt trauma to abdomen Child abuse • Head injuries are the most common cause of death. • Other injuries include: – Blunt trauma to abdomen – Skeletal injuries Child abuse • Head injuries are the most common cause of death. • Other injuries include: – Blunt trauma to abdomen – Skeletal injuries – Thermal burns Child abuse • Head injuries are the most common cause of death. • Other injuries include: – – – – Blunt trauma to abdomen Skeletal injuries Thermal burns Sexual abuse Child abuse • Head injuries are the most common cause of death. • Other injuries include: – – – – – Blunt trauma to abdomen Skeletal injuries Thermal burns Sexual abuse Neglect Children are our most precious resource, we must strive to protect them! [...]... are the most common cause of death • Other injuries include: – Blunt trauma to abdomen Child abuse • Head injuries are the most common cause of death • Other injuries include: – Blunt trauma to abdomen – Skeletal injuries Child abuse • Head injuries are the most common cause of death • Other injuries include: – Blunt trauma to abdomen – Skeletal injuries – Thermal burns ... Head injuries may or may not be present Retinal Hemorrhage • Variably sized and located hemorrhages within, behind, or on top of the retina • At the posterior pole of the eye, tend to be flame shaped hemorrhages • Laterally, may be dot/blot hemorrhages or retinal tears Differential Diagnosis of Retinal Hemorrhage • Birth Trauma-seen in 1/3 of vaginally delivered babies, resolve quickly (weeks) • Increased... Axonal Injury • Result from shear-force type injuries to the brain • May be associated with cerebral white matter tears, often seen at gray-white junction • Disruption of neuronal axons with formation of axonal “retraction balls”, best seen with silver impregnation or immunohistochemical stains • May take several hours to form Child abuse • Head injuries are the most common cause of death • Other injuries... babies, resolve quickly (weeks) • Increased intracranial pressure-arteriovenous mismatch • Shaken baby syndrome • Head trauma-Tearson syndrome, severe head injuries, acceleration-deceleration injuries Differential Diagnosis of Retinal Hemorrhage • • • • • • Sepsis Coagulopathy Subacute bacterial endocarditis Sickle cell disease Acute leukemias Congenital infections Subdural hemorrhage Subdural hemorrhage: ... or immunohistochemical stains • May take several hours to form Child abuse • Head injuries are the most common cause of death • Other injuries include: – Blunt trauma to abdomen Child abuse. .. surface most common injury • Head injury most common fatal injury • Blunt trauma to abdomen also common • Skeletal injuries, burns, drownings are also seen General characteristics of child abuse •... Thermal burns Sexual abuse Child abuse • Head injuries are the most common cause of death • Other injuries include: – – – – – Blunt trauma to abdomen Skeletal injuries Thermal burns Sexual abuse