1. The battered child syndrome, Caffey-Kempe syndrome, child abuse.
Danuta Deboa
The battered child syndrome,
Caffey-Kempe syndrome,
child abuse.

2. Intentional child treating, causing physical and mental injuries.
DEFINITION
Intentional child treating, causing physical and mental injuries.

3. History XIX w. Towarzystwo Zapobiegania Cierpieniu Dzieci.
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.

4. FORMS OF CHILD MALTREATMENT
PHYSICAL ABUSE, MALTREATMENT
SEXUAL ABUSE
EMOTIONAL ABUSE
NUTRITIONAL, PHYSICAL AND EMOTIONAL NEGLECT
NEGLECT OF MEDICAL CARE

5. MARKS 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

6. OTHER SYNDROMS OF MALTREATMENT
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).

7. NOT 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.

8. X – ray of 4 months old child. Infractio epiphysis femoris sinistri.
Beside this there were affirmed also fractures of ribs (fresh and old).

9. X – ray of 6 months old child
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.

10. X – ray of 10 months old child
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.

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

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

15. 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.

16. MRI of an infant 12 days after incident
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.

17. KT of the same infant two months after the incident
KT of the same infant two months after the incident. Visible large losses of cortex with advantage of occipital lobes.

18. KT of two months old infant one day after the incident.
Visible bleeding into side cell and also the swelling of the brain.

20. NOT 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.

22. CHILD SEXUAL ABUSE [CSA]
FREQUENCY OF OCCURENCE.
CHARACTERISTICS OF ENVIROMENT
MOSTLY REFERS TO GIRLS.
80 % OF NEGATIVE EXAMINATIONS.
SPECIAL EXAMINATION METHODS.

23. FAR 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.

24. BEHAVIOURAL INDICATORS
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

25. 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

26. 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.

27. 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.

28. 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

29. 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)

30. 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