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Fatal Child Abuse: A Study of 13 Cases of Continuous Abuse

A parent who continuously physically abuses her/his child doesn’t aim to kill the child but commits an accidental filicide in a more violent outburst of anger. Fatal abuse deaths are prevented by recognition of signs of battering in time. Out of 200 examined intra-familial filicides, 23 (12%) were caused by child battering and 13 (7%) by continuous battering. The medical and court records of the victim and the perpetrator were examined. The perpetrator was the biological mother and the victim was male in 69 per cent of the cases. The abused children were either younger than one year or from two-and-a-half to four years old. Risk factors of the victim (being unwanted, premature birth, separation from the parent caused by hospitalization or custodial care, being ill and crying a lot) and the perpetrator (personality disorder, low socioeconomic status, chaotic family conditions, domestic violence, isolation, alcohol abuse) were common. The injuries caused by previous battering were mostly soft tissue injuries in head and limbs and head traumas and the battering lasted for days or even an year. The final assault was more violent and occurred when the parent was more anxious, frustrated or left alone with the child. The perpetrating parent was diagnosed as having a personality disorder (borderline, narcissistic or dependent) and often substance dependence (31%). None of them were psychotic. Authorities and community members should pay attention to the change in child’s behavior and inexplicable injuries or absence from daycare. Furthermore if the parent is immature, alcohol dependent, have a personality disorder and is unable to cope with the demands the small child entails in the parent’s life, the child may be in danger.


Introduction
Child homicides, filicides, are often committed in context of psychosis, 1-3 mood disorder, suicide or abuse. [4][5][6] Acute psychotic filicides involves severely mentally ill parents who kill the child without a comprehensive motive, in a state of mental psychosis. Altruistic filicides are committed with the motive of relieving the child of real or most often imaginary suffering, and usually involve a suicide attempt by the parent. In neonaticides, the unwanted child filicide category, the perpetrator often conceals the pregnancy and gives the birth and kills the child in secrecy.
Spousal revenge filicide occurs when the perpetrator kills the child specifically to emotionally harm child's other parent. 7,8 Fatal abuse filicide indicates battering or physical abuse, which causes the death of the child. The filicide is unintentional, accidental and due to single or recurring battering. [7][8][9] The child is often a victim of multiple nonfatal episodes of abuse as disciplinary reasons. 10 Often there is a continuum of violence from mild and infrequent to severe and frequent. 7,11 Prior to the fatality the perpetrator often gives warning signals to professionals and members of their personal network by alerting them to the abusive incidents. 8 Previous abuse has been confirmed in many studies. 8,[12][13][14][15][16][17] Henry Kempe, 11 who originally coined the term battered child syndrome, assumed the battering to escalate and cause the death of the battered child in 11% of the cases. Children reported to service agencies for suspected child abuse have even a three-fold greater risk of death. 18 Child maltreatment and neglect exists with child abuse but maltreatment itself is seldom coded but has been detected even in 40% of the child homicides. 19 The true incidence of fatal abuse and neglect is unknown as inflicted injuries are sometimes misdiagnosed as unintentional accidents or caused by a Sudden Infant Death Syndrome. 20,21 The fatal abuse is associated with prematurity, developmental disorders, health problems of the child and the victim has often been neglected and separated from the parent after the birth 12,22 unlike filicide victims from other categories. The victim is also often the first-born and in many cases the only child of the family. 23,24 The assault happens often in a situation when the child is crying and the perpetrator is alone with the child. 24 Abusive perpetrators are defined as young, immature, uneducated and have violent and chaotic backgrounds. Personality disorder, has been found to be common diagnosis. [25][26][27] Despite the fact that the diagnosed personality disorder may diminish the responsibility, the child abuse perpetrators are convicted with long sentences. [28][29] This study is a part of series of investigations of retrospective, register-based research of intra-familial child filicides in Finland during 25 years. The aims of this part of the study are to investigate a sample of 13 cases, where the signs of recurrent battering of the victims were detected. The study describes demographic data of the parent and the victim, the health of the victim, the mental health of the perpetrator, as well as the signs of battering and discusses the factors increasing the risk for battering and the fatal abuse.

Materials and Methods
The sample, ethical approval and methods are presented in our previous publications. 27,30,31 .
In the sample of 65 filicides studied more thoroughly, the data was obtained from medical forensic, police and court records, which included forensic psychiatric examination when required by the court. All the victims were killed as a result of parent's violence. In most cases the aim of the perpetrator was to kill the child or children of psychotic, altruistic or suicidal intentions unlike in 23 cases, where the filicide was caused by battering. The death was accidental and was caused by a single or recurrent aggressive outburst to keep the child calm or to make him/her obey the parent. In 13 cases the battering occurred twice or was recurrent and a continuum of separate episodes of battering. Data were examined with descriptive statistics using SSPS-statistics (means, standard deviation, 95% confident interval, and the percentage for categorical variables.); however because of the small sample size, statistical tests of significance were frequently not feasible.

Results
Nine of the thirteen perpetrating parents were biological mothers (69%), three biological fathers (23%), and one a stepfather (8%). The mean age of the perpetrators was 26,1 years (SD 6.4, CL95% 22.3-30.0). In two cases both parents repeatedly battered the child, but the mother caused the death (cases 7 and 9 in Table 1). The perpetrators were married or cohabiting except one single mother (case 6) and one divorced mother (case 8). The other parent was non-biological father in two cases and both stepfathers battered the child constantly (cases 9 and 13). Almost all perpetrators, especially mothers, had a low socioeconomic status (except in the case 4), and 70 percent of them lived in urban areas. The victim was female in four (31%) and male in nine (69%) and cases. Maternal perpetrators killed six male and three female children, and paternal perpetrators killed three male and one female children. The victims were either younger than 1 year (46%) or from 2 1/2 to 4 years old in 46 percent of cases. The mean age of the victims was 1.6 years (SD 1.4, Cl95% 0.8-2.5). Eight victims were the firstborn and five were the second of the family's two children. Three children were born prematurely (cases 3, 5, 11), two had a physical illness (cases 5, 11) and one child was diagnosed as developmentally retarded (case 10). Two of the victims had been taken into care but were returned to the biological parent/s only a few months before the fatal assault (cases 7,9). Five children (38%) had been separated from the perpetrator by hospitalization or custodial care from the birth or not being a biological parent (cases 5,7,9,11,13). The parents abused the child when trying to keep the crying infant calm (cases 1-6) or when trying ensure the child's obedience (cases 9-13) . Often there was no evidence of the bad behavior by the child, and the overly demanding parent interpreted the child's developmental skills and behavior as a sign of disobedience or the child looking at the parent as criticism or complaint. Stress caused by the demands placed on the parent when taking care of the child, lack of social support, an unstable mental state were evident in most cases.
The examined perpetrators were diagnosed with a personality disorder in over 90% of cases, mostly borderline, narcissistic, dependent or immature personalities with difficulties in controlling affects. Two perpetrators had IQ under 85 and one parent 87. Two perpetrators were diagnosed having non-psychotic depression and none of the perpetrators were psychotic unlike in the rest of the examined cases. Thirty-eight percent abused alcohol and were even intoxicated during the fatal assault (cases 3 and 5). The perpetrator was a victim or a perpetrator of domestic violence in 46% of cases (cases 3,5,7,8,11,13). The most common injuries from previous battering were skin and soft tissue traumas caused by the parent hitting the child with a fist, a stick, a belt and head traumas caused by throwing the child against a doorframe, a wall or a floor. Often the child had numerous bruises and cuts all over the body caused by the frequent battering. In nine cases the injuries of the previous battering were very serious, causing head traumas and fractures. However, the less critical injuring was long lasting, cruel and recurrent hitting of the child of disciplinary reasons (cases 8,9,12,13).
Only two perpetrators gave warning signals and some perpetrators even became even more isolated preceding the fatal assault.
The demographic data of the victims and perpetrators, short case description, previous and fatal injuries, diagnosis, responsibility and sentence of the perpetrator are presented in Table 1. In six cases the other parent knew about the abuse of the child (cases 3, 5, 7, 9, 10, 12). The daycare authorities had noticed the bruises and the loss of hair in two cases (cases 8, 11) but believed the parent's explanations, and not even clear signs of abuse were examined. Social workers and public health nurses visited the home of one child several times and noted the change in the child's behavior, but did not act in time (case 13). Two mothers who had a newborn infant, battered the child within few days. Their mental state deteriorated rapidly but they were not psychotic (cases 1 and 2). During the fatal assault medical help was often late in arriving since the parent was reluctant to take the child to the hospital as the bruises and scars could be easily have been detected as intentionally inflicted injuries.
Eleven perpetrators were given sentences from 6 months to a life sentence (Mean 5 years 8 months). One mother, whose responsibility was not examined was on probation and one mother was pronounced not responsible for her actions and not sentenced.
The following cases illustrate the pathways to filicide, how rapidly the violence can escalate and turn fatal. These cases demonstrate also the impact of domestic violence and the over generational transmission of violence.

Patient #13
Neighbors and visitors had called the public health nurse and social service officials several times about their concern for the safety of a four-year-old boy who lived with his mother and stepfather in a small village. The family had moved to the area some months earlier and the nurse and the health center doctor had seen the family twice and pronounced the child healthy. Following the neighbors' calls the nurse made a house call and noted that in four months the child's behavior had changed; the child was frightened and did not play in the same way as during the previous visit. The mother denied having any difficulties or worries about her son or the stepfather. Local social services officials had visited the family once prior to the neighbors' concern for the child's well being. During a later house call they failed to notice any matters of concern, like bruises on the child, whom they met briefly in the entryway dressed in winter clothing. The parents denied having any problems with their son. The social service officials contacted the public health nurse, who promised to make another house call. During the next visit the four-year-old boy was standing stiffly beside his bed. The nurse took him on her lap and the child sat there for one-and-a-half hours holding his head against the nurse's shoulder. The nurse viewed this behavior as a call for protection. She called the social services officials and conveyed her concern about the child's behavior. Three days later, the boy died after the stepfather had battered him. The cause of death was a subdural hemorrhage causing odema and aspiration of vomit. The autopsy showed over 20 bruises and several scars were found on his body. The bruises and scars were caused by separate incidents of battering over days and months. The mother reported to the police that both she and her child had been victims of domestic violence several times during the previous months. The stepfather had beaten the child with a belt, kicked him, pulled his hair, squeezed him, thrown him down and threatened him with a knife. The boy had started wetting his bed, which was a further excuse for physical abuse. The fatal battering occurred after a bedwetting incident and the stepfather beat the child's head against the floor. The child climbed into his bed and became unconscious. The stepfather did not permit the mother to call for help and the child died during the night.
The mental examination was not required but the perpetrator was sentenced 6 years 2 months for severe abuse and manslaughter. The perpetrator claimed in the investigations that he suspected others to think that he cannot take care of the family and that they will encourage the wife to divorce him. The actions taken by the authorities made him even more anxious and increased his outbursts of violence.

Patient #4
The public health nurse was worried about a 2½-month-old male child who, in addition to colic symptoms, was very sensitive to touching and handling. The baby was sent to the children's hospital where no injuries or signs of disease were found. Ultrasound and x-ray investigations were performed. Later, at the age of 3½ months, additional examinations including further x-rays were made. Only a slight suspicion of rachitis was mentioned in  the hospital records. At the age of 4½ months the child was brought to the hospital and after resuscitation he died five hours later. In the autopsy several injuries were found. A recent fracture of the skull and a subdural hemorrhage and a diffuse contusion of the brain were noted as the causes of death. Furthermore, a pelvic fracture, a hemorrhage in the medullar canal in the lumbar area and several hemorrhages in the scalp were found. Old injuries in different phases of healing included subdural hemorrhages, several rib fractures and a fracture of the right radius. A re-examination of the x-rays taken two months earlier indicated visible fractures of several ribs; they had previously gone unnoticed.
After a lengthy interrogation the child's father admitted that he had hit and squeezed the baby several times over the course of months. He claimed, however, that the injuries that caused the child's death were due to an accidental fall. He had obsessional need to batter the baby, when ever left alone with the baby and when he felt helpless. The mother had noticed that the baby's cry turned more tense, when the father hold him. However she had no suspicion of the battering since the father was very caring and worried about the well-being of the baby.
In the mental examination the father was diagnosed as having a personality disorder; dependent personality with psychotic features, lack of empathy, repressed anger and no emotional contact to his childhood experiences. His intelligence was above the average.
In the perpetrator's childhood, his father abused alcohol and was unpredictable. When he was drunk during the weekends, he was very violent towards his wife and threatened to kill her. He also was suicidal and told stories about a father who killed his children.

Discussion
Although fatal child abuse is a rare even and more like a top of an ice-berg among the dangerous conditions many children are living in, many of these deaths could have been prevented. The Arizona Child Fatality study claims that 61% of child abuse deaths were considered to be preventable and much of the responsibility for prevention rests with community members (relatives and neighbors), who are aware of the abuse, but failed to report the family to social services. 32 Almost half of the other parents in this study knew about the battering but often the violent behavior of the family members and domestic violence hindered the other parent to put an end to the abuse. The parents and families were often isolated and out of reach of the authorities, especially medical expertise.
The injuries were seen in daycare or by other authorities but they failed to act in time. The signs of battering were inexplicable injuries or a change in the child's behavior, for example, depression, withdrawal, anxiety or the irritability of the baby or being absent from daycare.
The most common previous injuries were in skin and soft tissue 33 and the fatal injury was a head trauma. 34 After the fatal battering, the parents did not dare to take the unconscious child to the hospital as signs of the inflicted injuries could be seen. None of the parents wanted to kill the child intentionally. The more fatal violence escalated rapidly in most of the cases even when the continuous battering had lasted months or even two years.
When compared with the other filicide cases in the sample the victims were younger and more often born unwanted. The relationship and attachment with the child could have been affected by the separation from the parent. It was caused by the prematurity and hospitalization of the child as seen in three cases or the child being in care since birth as was the case in two cases. The parents who were separated from the child did not seem to have the biological need to protect the child nor did they seem to be attached to the child. These parents, as well as the stepfathers had too high demands for the child and often the battering abuse started when the child failed to stand-alone with dressing up, eating etc. or the small child wed his/her bed.
IIn the two cases, numbered 7 and 9, the battering was causing exceptional suffering for the child, since both the parents were battering the child. In both cases the father was very violent and the IQ of the mother was under 85. The child had been taken in custody and returned to the parents only few months earlier. The parents' motive to get the child back home was to get economical benefits.
The first two cases involved an infant and a very tired mother who was inpatient and angry. The first mother had an older child who was only one year old and either child was sleeping well. The other was very disappointed and angry at his husband. The situation deteriorated rapidly but could have been prevented with the help in nursing the babies.
Almost all perpetrators were diagnosed as having a personality disorder; borderline, narcissistic, dependent or immaturity. All perpetrators had difficulties in controlling their affects and anger. None of the perpetrators were psychotic and only two were diagnosed depressed unlike in the main sample of filicides other than fatal abuse cases.
Personality disorder was an important construct in explaining the poor parenting of the perpetrator. Egocentricity and impulsivity, lack of empathy and remorse, as well as shallow and labile affects are typical personality traits found with abusive perpetrators. 26 These features could be detected in the interviews of these perpetrators. Poor marital relationships, domestic violence, isolation and alcohol abuse deteriorated even more the parents' capability to cope with the stressful situations with the child.
The sample of 13 cases is small and does not allow any statistical comparison nor we cannot exclude previous battering in the corpus material, because battering does not leave permanent injuries and the disclosure of the battering may impair a parent's situation in legal proceedings.
The prevention of abuse and fatal abuse includes sufficient mental health services and support for the parents, which should be offered without delay. The signs of battering may be detected in daycare, by health care nurses and relatives and prompt interventions are needed since the battering may relapse quickly.