Forensic Science, Medicine, and Pathology

, Volume 10, Issue 3, pp 413–422

A brief history of fatal child maltreatment and neglect



Child abuse encompasses four major forms of abuse: physical abuse, sexual abuse, psychological abuse, and neglect. The United States retains one of the worst records of child abuse in the industrialized world. It has also been determined that a large portion of these cases are missed and go undocumented in state and federal reporting agencies. In addition, disparate risk factors have been identified for physical abuse and neglect cases, but substance abuse has been found to be a significant factor in all forms of abuse. Fatal child maltreatment and neglect investigations require a multi-pronged and multidisciplinary approach requiring the coordination and information gathering from various agencies. A major difficulty in determining the accidental or non-accidental nature of these cases is that the account surrounding the events of the death of child is acquired from the caretaker. In this review, we outline common diagnostic characteristics and patterns of non-accidental injuries and neglect as a result of nutritional deprivation.


Child maltreatment Neglect Etiology of non-accidental trauma Risk factors 


  1. 1.
    World Health Organization World Report on Violence and Health. Child abuse and neglect by parents and other caregivers. 2002. 13 Dec 2013.
  2. 2.
    US Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. Child maltreatment 2011. 2012. 31 Dec 2013.
  3. 3.
    United States Government Accountability Office. Child maltreatment: strengthening national data on child fatalities could aid in prevention (GAO-11-599). 2011. 31 Dec 2013.
  4. 4.
    US Department of Health and Human Services Administration for Children and Families Administration on Children, Youth and Families Children’s Bureau. Child abuse and neglect fatalities 2011: statistics and interventions. 31 Dec 2013.
  5. 5.
    Ross AH, Abel S, Radisch D. Pattern of injury in child fatalities resulting from child abuse. Forensic Sci Int. 2009;188:99–102.PubMedCrossRefGoogle Scholar
  6. 6.
    Adamson P. Innocenti report card 11. UNICEF. 3 Jan 2014.
  7. 7.
    Brown J, Cohen P, Johnson J, Salzinger S. A longitudinal analysis of risk factors for child maltreatment: findings of a 17-year prospective study of officially recorded and self-reported child abuse and neglect. Child Abuse Negl. 1998;22:1065–78.PubMedCrossRefGoogle Scholar
  8. 8.
    McGee RA, Wolfe DA, Yuen SA, Wilson SK, Carnochan J. The measurement of maltreatment: a comparison of approaches. Child Abuse Negl. 1995;2:233–49.CrossRefGoogle Scholar
  9. 9.
    Belsky J, Vondra J. Lessons from child abuse: the determinants of parenting. In: Cicchetti D, Carlson V, editors. Current research and theoretical advances in child maltreatment. Cambridge: University Press; 1989. p. 153–202.CrossRefGoogle Scholar
  10. 10.
    Chadwick DL, Castillo EM, Kuelbs C, Cox SA, Lindsay SP. Missed and missing cases of abusive injuries: the magnitude and the measurement of the problem. Child Abuse Negl. 2010;34:943–50.PubMedCrossRefGoogle Scholar
  11. 11.
    Flaherty EG. Does the wording of the mandate to report suspected child abuse serve as another barrier to child abuse reporting? Child Abuse Negl. 2006;30:341–3.PubMedCrossRefGoogle Scholar
  12. 12.
    Ragan KL. Fatal child maltreatment: the challenges of identifying the causes and incidence of deaths from abuse and neglect. In: Ross AH, Abel S, editors. The juvenile skeleton in forensic abuse investigations. New York: Humana Press; 2011. p. 7–17.CrossRefGoogle Scholar
  13. 13.
    Kempe CH, Silverman FN, Steele BF, Droegemueller W, Silver HK. The battered child syndrome. J Am Med Assoc. 1962;181:17–24.CrossRefGoogle Scholar
  14. 14.
    Jason J, Andereck N. Fatal child abuse in Georgia: the epidemiology of severe physical child abuse. Child Abuse Negl. 1983;7:1–9.PubMedCrossRefGoogle Scholar
  15. 15.
    Palusci V, Covington T. Child maltreatment deaths in the U.S. national child death review case reporting system. Child Abuse Neglect. 2013. doi:10.1016/j.chiabu.2013.08.014.
  16. 16.
    Damashek A, Nelson MM, Bonner BL. Fatal child maltreatment: characteristics of deaths from physical abuse versus neglect. Child Abuse Negl. 2013;37:735–44.PubMedCrossRefGoogle Scholar
  17. 17.
    Asser S, Swan R. Child fatalities from religion-motivated medical neglect. Pediatrics. 1998;101:621–5.CrossRefGoogle Scholar
  18. 18.
    Knight LD, Collins KA. A 25-year retrospective review of deaths due to pediatric neglect. Am J Forensic Med Pathol. 2005;26:221–8.PubMedCrossRefGoogle Scholar
  19. 19.
    Palusci V, Wirtz S, Covington T. Using capture-recapture methods to better ascertain the incidence of fatal child maltreatment. Child Abuse Negl. 2010;34:396–402.PubMedCrossRefGoogle Scholar
  20. 20.
    Ross AH. Fatal starvation/malnutrition: medicolegal investigation from the juvenile skeleton. In: Ross AH, Abel S, editors. The juvenile skeleton in forensic abuse investigations. New York: Humana Press; 2011. p. 151–65.CrossRefGoogle Scholar
  21. 21.
    Ubelaker DH, Montaperto KM. Biomechanical and remodeling factors in the interpretation of fractures in juveniles. In: Ross AH, Abel S, editors. The juvenile skeleton in forensic abuse investigations. New York: Humana Press; 2011. p. 33–48.CrossRefGoogle Scholar
  22. 22.
    Bilo RAC, Robben SGF, Van Rijn RR. General aspects of fractures in child abuse. In: Mattei P, editor. The fundamentals of pediatric surgery. New York: Springer; 2011. p. 1–13.Google Scholar
  23. 23.
    Cramer KE, Green NE. Child abuse. In: Green NE, Swiontkowski MF, editors. Skeletal trauma in children, vol. 3. 3rd ed. Philadelphia: Saunders; 2003. p. 587–605.Google Scholar
  24. 24.
    Kellogg ND. Evaluation of suspected child physical abuse. Pediatrics. 2007;119:1232–41.PubMedCrossRefGoogle Scholar
  25. 25.
    Kemp AM, Dunstan F, Harrison S, Morris S, Mann M, Rolfe K, Datta S, Thomas DP, Sibert JR, Maguire S. Patterns of skeletal fractures in child abuse: systematic review. BMJ. 2008;337:1–8.CrossRefGoogle Scholar
  26. 26.
    Falcone RA, Makoroff K. Child abuse. In: Mattei P, editor. The fundamentals of pediatric surgery. New York: Springer; 2011. p. 169–73.CrossRefGoogle Scholar
  27. 27.
    Clarke NMP, Shelton FRM, Taylor CC, Khan T, Needhirajan S. Incidence of fractures in children under the age of 24 months in relation to non-accidental injury. Injury. 2012;43:762–5.PubMedCrossRefGoogle Scholar
  28. 28.
    Gill DF. Identifying child abuse. Clin Rev. 2012;22:29–36.Google Scholar
  29. 29.
    King J, Diefendorf D, Apthorp J, Negrete VF, Carlson M. Analysis of 429 fractures in 189 battered children. J Pediatr Orthop. 1988;8:585–9.PubMedGoogle Scholar
  30. 30.
    Leventhal J, Thomas S, Rosenfield N, Markowitz R. Fractures in young children. Distinguishing child abuse from unintentional injuries. Am J Dis Child. 1993;147:87–92.PubMedCrossRefGoogle Scholar
  31. 31.
    Rang M, Wenger D. Children are not just small adults. In: Rang M, Wenger D, Pring ME, editors. Rang’s childrens fractures. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2005. p. 1–10.Google Scholar
  32. 32.
    Humphries AL. Basic juvenile skeletal anatomy and growth and development. In: Ross AH, Abel S, editors. The juvenile skeleton in forensic abuse investigations. New York: Humana Press; 2011. p. 19–31.CrossRefGoogle Scholar
  33. 33.
    Galloway A. Broken bones: anthropological analysis of blunt force trauma. Springfield: C.C. Thomas; 1999.Google Scholar
  34. 34.
    Abel S. Non-accidental skeletal trauma. In: Ross AH, Abel S, editors. The juvenile skeleton in forensic abuse investigations. New York: Humana Press; 2011. p. 61–77.CrossRefGoogle Scholar
  35. 35.
    Kleinman PK. Diagnostic imaging in infant abuse. Am J Roentgenol. 1990;155:703–12.CrossRefGoogle Scholar
  36. 36.
    Carty H. Non-accidental injury: a review of the radiology. Eur Radiol. 1997;7:1365–76.PubMedCrossRefGoogle Scholar
  37. 37.
    Maguire S, Cowley L, Mann M, Kemp A. What does the recent literature add to the identification and investigation of fractures in child abuse: an overview of review updates 2005–2013. Evidence-Based Child Health: A Cochrane Rev J. 2013;8:2044–57.CrossRefGoogle Scholar
  38. 38.
    Harlan SR, Nixon GW, Campbell KA, Hansen K, Prince JS. Follow-up skeletal surveys for nonaccidental trauma: can a more limited survey be performed? Pediatr Radiol. 2009;39:962–8.PubMedCrossRefGoogle Scholar
  39. 39.
    Karmazyn B, Lewis ME, Jennings SG, Hibbard RA, Hicks RA. The prevalence of uncommon fractures on skeletal surveys performed to evaluate for suspected abuse in 930 children: should practice guidelines change? Am J Roentgenol. 2011;197:w159–63.CrossRefGoogle Scholar
  40. 40.
    Glencross B, Stuart-Macadam P. Childhood trauma in the archaeological record. Int J Osteoarchaol. 2000;10:198–209.CrossRefGoogle Scholar
  41. 41.
    Swischuk L, Hernandez JA. Frequently missed fractures in children (value of comparative views). Emerg Radiol. 2004;11:22–8.PubMedCrossRefGoogle Scholar
  42. 42.
    Caffey J. The whiplash shaken infant syndrome: manual shaking by the extremities with whiplash-induced intracranial and intraocular bleedings, linked with residual permanent brain damage and mental retardation. Pediatrics. 1974;54:395–403.Google Scholar
  43. 43.
    Lancon JA, Haines DE, Parent AD. Anatomy of the shaken baby syndrome. New Anat. 1998;253:13–8.CrossRefGoogle Scholar
  44. 44.
    Hymel KP, Spivak BS. The biomechanics of physical injury. In: Reece RM, Ludwig S, editors. Child abuse: medical diagnosis and management. 2nd ed. Hagerstown, MD: Lippincott Williams and Wilkins; 2001. p. 1–22.Google Scholar
  45. 45.
    Gerber P, Coffman K. Nonaccidental head trauma in infants. Childs Nerv Syst. 2007;23:499–507.PubMedCrossRefGoogle Scholar
  46. 46.
    Hymel KP, Makoroff KL, Laskey AL, Conaway MR, Blackman JA. Mechanisms, clinical presentations, injuries and outcomes from inflicted versus non-inflicted head trauma during infancy: results of a prospective multicentered, comparative study. Pediatrics. 2007;119:922–9.PubMedCrossRefGoogle Scholar
  47. 47.
    Piteau SJ, Ward MGK, Barrowman NJ, Plint AC. Clinical and radiographic characteristics associated with abusive and nonabusive head trauma: a systematic review. Pediatrics. 2012;130:315–23.PubMedCrossRefGoogle Scholar
  48. 48.
    Battered child syndrome: investigating child abuse and homicide. US Department of Justice. 2002. 3 Jan 2014.
  49. 49.
    Piteau SJ, Ward MG, Barrowman NJ, Plint AC. Supreme court of the United States. 2007. 3 Jan 2014.
  50. 50.
    Findley KA, Barnes PD, Moran DA, Squier W. Shaken baby syndrome, abusive head trauma, and actual innocence: getting it right. Hous J Health Law Policy. 2012;12:209–312.Google Scholar
  51. 51.
    Tuerkheimer D. The next innocence project: shaken baby syndrome and the criminal courts. Wash Univ Law Rev. 2009;87:1–58.Google Scholar
  52. 52.
    Moreno JA, Holmgren B. Dissent into confusion: the Supreme Court, denialism, and the false “scientific” controversy over shaken baby syndrome. Utah Law Rev. 2013;2013:153–217.Google Scholar
  53. 53.
    Hobbs CJ. Skull fracture and the diagnosis of abuse. Arch Dis Child. 1984;59:246–52.PubMedCentralPubMedCrossRefGoogle Scholar
  54. 54.
    Kleinman PK, Marks SC. A regional approach to the classic metaphyseal lesion in abused infants: the distal femur. Am J Roentgenol. 1998;170:43–7.CrossRefGoogle Scholar
  55. 55.
    Dwek J. Radiographic approach to child abuse. Clin Orthop Relat Res. 2011;469:776–89.PubMedCentralPubMedCrossRefGoogle Scholar
  56. 56.
    American College of Radiology. ACR appropriateness criteria 2009. PhysicalAbuseChildDoc9.aspx. 3 Jan 2014.
  57. 57.
    Pandya NK, Baldwin K, Wolfgruber H, Christian CW, Drummond DS, Hosalkar HS. Child abuse and orthopaedic injury patterns: analysis at a level 1 pediatric trauma center. J Pediatr Orthop. 2009;28:618–25.CrossRefGoogle Scholar
  58. 58.
    Pandya NK, Baldwin K, Kamath AF, Wenger DR, Hosalkar HS. Unexplained fractures: child abuse or bone disease. A systematic review. Clin Orthop Relat Res. 2011;469:805–12.PubMedCentralPubMedCrossRefGoogle Scholar
  59. 59.
    Kleinman PK. Prevalence of the classic metaphyseal lesion in infants versus high risk for abuse. Am J Roentgenol. 2011;197:1005–8.CrossRefGoogle Scholar
  60. 60.
    Haney SB, Boas SC, Kutz TJ, Starling SP. Transverse fracture of the distal femoral metadiaphysis: a plausible accidental mechanism. Pediatr Emerg Care. 2009;25:841–4.PubMedCrossRefGoogle Scholar
  61. 61.
    Merten DF, Radkowski MA, Leonidas JC. The abused child: a radiological reappraisal. Radiology. 1983;146:377–81.PubMedCrossRefGoogle Scholar
  62. 62.
    Hechter S, Huyer D, Manson D. Sternal fractures as a manifestation of abusive injury in children. Pediatr Radiol. 2002;32:902–6.PubMedCrossRefGoogle Scholar
  63. 63.
    Barsness KA, Cha E, Bensard DD, Calkins CM, Patrick DA, Strain JD. The positive predictive value of rib fractures as an indicator of nonaccidental trauma in children. J Trauma. 2003;54:1107–10.PubMedCrossRefGoogle Scholar
  64. 64.
    Kraft JK. Imaging of non-accidental injury. Orthop Trauma. 2012;25:109–18.CrossRefGoogle Scholar
  65. 65.
    Mulpuri K, Sloboogean BL, Tredwell SJ. The epidemiology of nonaccidental trauma in children. Clin Orthop Relat Res. 2011;469:759–67.PubMedCentralPubMedCrossRefGoogle Scholar
  66. 66.
    Cadzow SP, Armstrong KL. Rib fractures in infants: red alert! J Paediatr Child Health. 2000;36:322–6.PubMedCrossRefGoogle Scholar
  67. 67.
    Tun K, Choudhary AK, Methratta S, Boal DK. Radiological features of non-accidental injury. J Radiol Nurs. 2012;32:3–9.CrossRefGoogle Scholar
  68. 68.
    Love JC, Derrick SM, Wiersema JM, Pinto DC, Greele C, Donaruma-Kwoh M, Bista B. Novel classification system of rib fractures observed in infants. J Forensic Sci. 2013;58:330–5.PubMedCrossRefGoogle Scholar
  69. 69.
    Feldman K, Brewer D. Child abuse: cardiopulmonary resuscitation and rib fractures. Pediatrics. 1984;73:339–42.PubMedGoogle Scholar
  70. 70.
    Yang K, Lynch M, O’Donnell C. “Buckle” rib fracture: an artifact following cardiopulmonary resuscitation detected on postmortem CT. Leg Med. 2011;13:233–9.CrossRefGoogle Scholar
  71. 71.
    Kleinman PK, Marks SC, Blackbourne B. The metaphyseal lesion in abused infants: a radiologic–histopathologic study. Am J Roentgenol. 1986;8:585–9.Google Scholar
  72. 72.
    Defilippi C, Santoro B, Pautasso P. Bony lesions from non-accidental trauma. In: Martino F, editor. Imaging of pediatric bone and joint trauma. Milan: Springer; 2011. p. 187–202.CrossRefGoogle Scholar
  73. 73.
    Duffy SO, Squires J, Fromkin JB, Berger RP. Use of skeletal surveys to evaluate for physical abuse: analysis of 703 consecutive skeletal surveys. Pediatrics. 2011;127:e47–52.PubMedCrossRefGoogle Scholar
  74. 74.
    Cardoso H, Magalhães T. Evidence of neglect from immature human skeletal remains: an auxological approach from teeth and bones. In: Ross AH, Abel S, editors. The juvenile skeleton in forensic abuse investigations. New York: Humana Press; 2011. p. 125–50.CrossRefGoogle Scholar
  75. 75.
    Welch G, Bonner B. Fatal child neglect: characteristics, causation, and strategies for prevention. Child Abuse Negl. 2013;37:745–52.PubMedCrossRefGoogle Scholar
  76. 76.
    Berkowitz CD. Fatal child neglect. Adv Pediatr. 2001;48:331–61.PubMedGoogle Scholar
  77. 77.
    Kellogg ND, Lukefahr JL. Criminally prosecuted cases of child starvation. Pediatrics. 2005;116:1309–16.PubMedCrossRefGoogle Scholar
  78. 78.
    Collins KA. Intentional starvation/malnutrition and dehydration in children. In: Griest K, editor. Pediatric homicide. Medical investigation. Boca Raton: CRC Press; 2010. p. 169–85.Google Scholar
  79. 79.
    Mehta NM, Corkins MR, Lyman B, Malone A, Goday PS, Carney L, Monczka JL, Plogsted SW, Schwenk WF. Defining pediatric malnutrition: a paradigm shift toward etiology-related definitions. J Parent Enter Nutr. 2013;37:460–81.Google Scholar
  80. 80.
    Gomez F, Galvan RR, Cravioto J, Frenk S. Malnutrition in infancy and childhood with special reference to kwashiorkor. Adv Pediatr. 1955;7:131–69.PubMedGoogle Scholar
  81. 81.
    Waterlow JC. Classification and definition of protein-caloric malnutrition. Br Med J. 1972;2:566–9.CrossRefGoogle Scholar
  82. 82.
    Madea B. Death as the result of starvation. Diagnostic criteria. In: Tsokos M, editor. Forensic pathology reviews, vol. 2. Totowa, NJ: Humana Press; 2005. p. 3–26.CrossRefGoogle Scholar
  83. 83.
    Fleagle JG, Samonds KW, Hegsted DM. Physical growth of cebus monkeys, Cebus albifrons, during protein or caloric deficiency. Am J Clin Nutr. 1975;28:246–53.PubMedGoogle Scholar
  84. 84.
    Piercecchi-Marti MD, Louis-Borrione C, Bartoli C, Sanvoisin A, Panuel M, Pelissier-Alicot L, Leonetti G. Malnutrition, a rare form of child abuse: diagnostic criteria. J Forensic Sci. 2006;51:670–3.PubMedCrossRefGoogle Scholar
  85. 85.
    Sawyer AJ, Bachrach LK. Rationale for bone densitometry in childhood and adolescence. In: Sawyer AJ, Bachrach LK, Fung EB, editors. Bone densitometry in growing patients. Guidelines for clinical practice. Totowa: Humana Press; 2007. p. 1–13.CrossRefGoogle Scholar
  86. 86.
    Binkowitz LA, Henwood MJ. Pediatric DXA: technique and interpretation. Pediatr Radiol. 2007;37:21–31.CrossRefGoogle Scholar
  87. 87.
    Crabtree NJ, Leonard MB, Zemel BS. Dual-energy X-ray absorptiometry. In: Sawyer AJ, Bachrach LK, Fung EB, editors. Bone densitometry in growing patients. Guidelines for clinical practice. Totowa: Humana Press; 2007. p. 41–57.CrossRefGoogle Scholar
  88. 88.
    Ward KA, Mughal Z, Adams JE. Tools for measuring bone in children and adolescents. In: Sawyer AJ, Bachrach LK, Fung EB, editors. Bone densitometry in growing patients. Guidelines for clinical practice. Totowa: Humana Press; 2007. p. 15–40.CrossRefGoogle Scholar
  89. 89.
    Yeste D, del Rio M, Carrascosa G. Densidad mineral ósea en lactantes y niños (0–4 años) a nivel de columna lumbar. Patrones de normalidad. Anales Españoles de. Pediatria. 1998;49:248–52.Google Scholar
  90. 90.
    del Rio L, Carrascosa F, Pons M, Yeste G, Domenech FM. Bone mineral density of the lumbar spine in white mediterranean Spanish children and adolescents: changes related to age, sex and puberty. Pediatr Res. 1994;35:362–6.PubMedCrossRefGoogle Scholar
  91. 91.
    Alp H, Orbak Z, Kermen T, Uslu H. Bone mineral density in malnourished children without rachitic manifestations. Pediatr Int. 2006;48:128–31.PubMedCrossRefGoogle Scholar
  92. 92.
    Schmitt BD. The child with nonaccidental trauma. In: Kempe CH, Heller RE, editors. The battered child. 4th ed. Chicago: University of Chicago Press; 1980. p. 128–46.Google Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  1. 1.Department of Sociology and AnthropologyNC State UniversityRaleighUSA

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