Battered baby syndrome or Maltreatment syndrome in children or non-accidental injuries of childhood or Caffey’s syndrome.

Cruelty on infants and children is not new. Destruction of newborn infants, stringent measures including physical torture and pain at home and in teaching institutions to introduce discipline and teaching programme, child labour system, all may extend upto cruelty and negligence on children. These atrocities are not new, as it were not the matter of past alone. The problem was unveiled by Silverman (1953) and Wooley and Evans (1955), in its exact shape, magnitude and significance, who established the deliberate traumatic character of certain specific types of “pathological lesions” first detected by J. Caffey (1946), a paediatric radiologist (Caffey’s syndrome). Caffey observed serious injuries of bones in some children, though he thought that, the injury to bones of these children were pathological in nature. Subsequent investigations of these cases proved them to be non-pathological and non-accidental, rather the result of disproportionate physical assault on the children, and on this basis, Kempe et al in 1962, used the term “Battered Baby Syndrome” for this condition. At present the more popularly accepted term is “Non-accidental injury of childhood”.

Identification of the battered child –

CRUELTY AND ATROCITY ON CHILDRENThough cruelty on children does not bear any relationship with the age of the child, the battered children are mostly within the ages of 1 – 5 years, with most of the seriously battered victims being of 2-3 years of ages. The age preponderance obviously indicate that vulnerability lies with inability to complain or express their sufferings properly. Obviously, while considering maltreatment syndrome or battered child syndrome, infants are not included.

The vulnerable children are the victims of indignition, intolerance or impatience of parents, guardians or persons under whose supervision they are expected to develop with affection and care. They are treated harshly and often physically assaulted with infliction of minor to severe bodily injuries. They are sometimes brought to the doctor with vague history, narrated by the parents for sustaining the injuries, like, fall from a stair or a table or that the baby “bruises very easily”. The disproportionate defay in consulting the doctor, the gap between the history and the severity of the injuries, repeated presentation with same type of history and injury, and presence of evidence of old injuries of different intervals, all convergingly point towards the fact that the child is an unfortunate victim of Caffey’s syndrome.

Aetiology –

Lack of education, tolerance, understanding and self control on the part of the parents or the guardians are the immediate precipitating factors. It is often seen that parents who were the victims of maltreatment during their childhood are the persons who maltreat their children. Such parents become disproportionately violent on their children on trivial issues like sustained cry by the child, refusal to take food, soiling the towel or dress. The real cause thus can be said to be some psychological deficiency or psychic problems of the parents. At the time of assaulting the child the parent or the guardian lack in the sense of judgement and reality and fail to think about the consequences. Family discord and lack of understanding and cohesion between the parents is another important cause. Apathy, alcoholism on the part of either parent are also countable.

There is no preponderance on the basis of race, religion, geographic distribution or nationality. But there is some degree preponderance of male child than female child to be the victim of atrocities.

Factors related to battering of children : Predisposing factors –

Minor assault of children by parents or guardians for chastisement during their childhood, is not uncommon or uncalled for. It is severe beating of the children, which leads to bodily injury of the children, that are often grievous and in occasions may be fatal also.

A. The child factors

1. Age – The majority of the victim children are around 2 yrs of age, as they can neither protest nor narrate the matter properly to others.
2. Sex – This condition is more common with male children. A ratio’of about 2 : 1 is observed, involving male and female children, respectively.
3. Status of the child – Illegitimate and unwanted children are more often the victims of battering.
4. Usually the victim is the single child in the family.
5. The child may be a mentally abnormal one.

B. Parent/Guardian factors

1. Both parents or either of them or a senior member of the family, who may or may not be the guardian of the child may be the offender. Parents may be unmarried couple ; as is commonly seen in some Western society.
2. Usually the parents are young.
3. Low educational status.
4. Reckless life style, often habitually indulging to intoxications.
5. Often the parents themselves were the victims of  battering, during their childhood.
6. Psychological factors – Low tolerance threshold, impulsive nature, aggressive personality, imbalanced temperament.

C. Socio familial factors

1. Low social background.
2. Lack of parity between members of the family. Lack of peace in family.
3. Financial hardship.
4. Trouble at the place of work.

D. Precipitating factors

1. Act of disobedience by the child.
2. Frequent crying may create annoyance.
3. Refusal to take food.
4. Soiling of dress or bed clothes.
5. At times any trifle act of the child may annoy the mentally charged father or mother.

Some features – which are more or less constant in these cases –

1. The parents of the battered children seek medical aid for their children rather late or when the condition of the children becomes serious.

2. They present vague history of accident to be the cause of the injuries, e.g. fall from stair, or cot or a similar story, which does not appear consistent with the type of injuries or time narrated by the parents. Often the parents give a history of tendency of the child to bruise easily.

3. Often old healed injuries are detectable in the victims.

4. In many cases the parents later admit to have assaulted their children but “only mildly” and for chastisement.

5. Apart from the similarities mentioned above, there are may also be similarities in the baby, parental and socio-economic factors.

Type and nature of injuries sustained by the victims —

The injuries are usually bruise, abrasion, fracture of bones (skull, ribs and limb bones) and less commonly laceration (usually on the head). Accompanying internal injuries may be in the form of intracranial haemorrhage, injury to lung, or liver and less commonly to kidneys. Burns and scalds are also common. The injuries may be caused by hand, foot, stick, belt, shoe or any household article, hot water, burning cigarette, hot frying pan, etc. The head of the child may be struck against a wall or the head may be strongly shaken or a bunch of hair suddenly pulled to jerk the head violently. Sudden violent jerking of the head may cause whiplash injury inside the head, causing haemorrhage and contusions at places.

The injuries may be of any type and extent. There may be bruise or bruises of any size, abrasions, fracture of bones, injury to the internal organs including laceration of the intra-abdominal organs, contusion, laceration of the brain, intra-cranial haemorrhages, injury to the spinal cord and even retinal detachment. Some of the victims are subjected to burn injuries.

Medicolegal aspects of the problem –

In some cases the victim battered children even die. In these circumstances, the offender parents or the guardians of the children in this country may be charged for commission of culpable homicide amounting or not amounting to murder and in England for murder or manslaughter. In other cases where the babies suffer injury, the offender parents or the guardians may be charged for causing simple or grievous hurt. But often the cases are so misrepresented and the victims being unable to open their mind, the interpretation of the injuries may be wrong. Even Caffey, who was the first to record such injuries in the victim children were misled and made to believe that fracture of bones in those victims were due to the fragile nature of the bones of the victims.

This being one aspect of the problem, on the other side, reasonable arguments have been forwarded that such acts of assault on the youngsters should not be viewed at par with assaults in other circumstances. Absolute mental soundness of the parents are questioned when they beat their own children mercilessly and seriously. Such parents instead of punishment, require sympathetic psychological treatment. This may not be true in all cases. But the vast majority of these cases may possibly demand such consideration.

Among other circumstances of cruelty on children, infanticide has been dealt elsewhere. Abandonment of a child has separate provision under the law. Incidents of cruelty at home may not remain limited within assault and injury. It may be, e.g. providing the child insufficient food, inadequate care, protection and education. Reports of child slavery (though banned) are available in this country. Kidnapping or seducing a girl child for immoral traffic and sexual assault on young girls are the other examples of atrocities on the children. There are provisions in law for dealing with these offences. In a highly populated country of the world pre-delivery determination of sex and abortion of female foetuses is posing a social problem. This is an extreme act of cruelty.

Dealing with the problem

As discussed in the aetiological factors, the problem is a complex one. The factors responsible indicate that defect lies deep in the parents or guardian’s developmental, personal and environmental factors. Cruelty on children is an offence and there are provisions of punishment to the guilty parents. The problem of using the legal penal provisions, however, cannot be ignored. The legal punishment can’t have fruitful effect on other possible offenders, which is clear from the nature of the parental and socio-familial factors responsible. Secondly, by sending the erring parent inside the jail, who is the only earning member of the family, actually punishment is imposed on other family members, to get nothing in return. Hence, for successful dealing of these cases, a more practical approach should be there. Along with the legal provisions, there should be a programme to eradicate the causes, which create such hostile parents. In many cases the parents may need psychoanalysis and treatment, rather than imprisonment.

Some advocate to include mental torture on children, in the battered child syndrome. Socio-aetiologically, there is no difference between physical battering and mental torture. But, from diagnostic point of view, mental torture is a more difficult variety of cruelty on children and is equally difficult to be treated or dealt properly.

Child labour and sexual offences on children including child prostitution are the other varieties of cruelty or tortuous treatment of children. These problems have different backgrounds which are more socio-economic in nature and use of stern legal and executive measures may help to eradicate the problems successfully from an otherwise healthy society.