Child abuse and neglect has been recognized as an important public health problem in the west since 1960s ⁽¹⁾. Child abuse and neglect is defined in different ways in various cultures. In general, any commission or omission of acts by adult caretakers that imposes a negative impact on physical, psychological, and social wellbeing of a child is considered child abuse and neglect ^(2,3).

Child abuse has existed throughout the history of mankind, but studies in this field have emerged since the last century. For the first time in 1962, a pediatrician, Henry Kempe, set forth a diagnostic category and coined the term "Battered Child Syndrome". After a 12 year contentious period, all 50 states in the USA passed child protection laws for the prevention of child abuse and neglect ^(1,4). Child abuse and neglect may take many forms from inflicted injuries to failure to thrive due to inadequate feeding, from sexual abuse to emotional abuse, all of which limit the child's physical and mental development ^(2,3).

The risk factors setting up the stage for child abuse and/or neglect may be extra-familial or intra-familial. Economic, social, environmental, and cultural risk factors including poverty, low educational level, unemployment, violence, and substance abuse may lead to child abuse and neglect. Intra-familial risk factors include parental physical or mental health problems, certain characteristics of the child, parent deprivation, and unrealistic expectations of the family about the child's capabilities ⁽⁵⁾.
Child abuse and neglect was recognised in developed countries during the latter part of the last century and prevention programs were established ^(2,4). Developing countries have joined the western countries in recognising this issue as a socio-medico-legal public health problem within the last couple of decades ^(6-8).

In Turkey, Turkish Society for the Prevention of Child Abuse and Neglect has led the way to increased professional awareness of this important entity. The medical field, however, has not been involved in these efforts to a desirable extent, until 1990s. As the medical field began to get more involved in the recognition of child abuse and neglect, physicians have started publishing on child abuse and neglect, as well ⁽⁶⁾. In this paper, we present five cases diagnosed with child abuse and neglect, two of which had a fatal course. We hope these cases will guide physicians in Turkey and in other developing countries to be more diligent about the signs of child abuse and neglect.

Case 1

Two and a half year-old male, youngest child of a family with four children was brought to the emergency room of a University Medical School Hospital because of bleeding from the right ear and projectile vomiting after falling from a top bunk bed. Physical examination revealed no abnormalities except for bleeding from the right ear. He was observed for 24 hours after his vital signs were stabilised and was discharged to his parents with a diagnosis of head injury. Six days later, he returned to the same hospital complaining of right facial asymmetry while talking. Physical examination revealed superior posterior tympanic hematoma in the right ear. Computerised tomography (CT) of the head verified the tympanic hematoma and revealed right temporal linear fracture. Treatment for right peripheral facial paralysis was prescribed and he was again discharged to his parents.

Four months later, he returned to the hospital for a third visit because of falling from a balcony, a distance of 3-4 meters. Physical examination revealed, left peri-orbital edema and red fresh bruising, superficial abrasions over the right temple and cheek, and deformity and pain on palpation of the left forearm, all of which indicated acute trauma. X-ray of the left forearm revealed acute spiral fracture of the ulna and the radius. His abrasions were dressed, and his forearm was cast in the emergency room. Since the attending physician suspected inflicted trauma, hospitalisation was suggested. The father refused hospitalisation and discharged his son against medical advice, which prompted a forensic report to the police department. The father was tried for abusing his son and sentenced to one year, six months of jail time. There was no report filed with the Child Protective Services. There was no recommendation to assess the other children in the family, either. No expert witness was invited to trial.

Case 2

Six year-old girl, the second of four children in her family, was brought to the University Medical School Hospital by her stepmother with loss of consciousness and a story of falling from a sofa. Physical examination revealed absence of pupillary light reflex with fixed, dilated pupils, and absence of breathing and pulse. She was intubated but did not respond to cardiopulmonary resuscitation. She was pronounced dead after thirty minutes of resuscitation. Postmortem examination of the child was performed one day after death, which revealed numerous different colored old and new bruising between 0.5-1 cm on her neck, chest, back, and lower extremities, a red-purple old bruise of 1 cm over her right eyebrow, another red-purple old bruise of 0.5 cm on the right side of her forehead, and an old wound with dried scabbing of 6 cm at the back of her left shoulder. In internal examination, there was a widespread red new ecchymosis on the internal surface of her occipital scalp and over the vertex, and a linear occipital fracture. There were also occipital subdural hemorrhage, subarachnoidal hemorrhage at the left temporal lobe, and brain edema. The cross sections of her lungs were edematous, and there was a laceration at the right renal capsule. The cause of death was brain damage due to blunt head trauma. The eyes were not removed for retinal examination. Forensic report was filed with the police department.

At the end of the forensic investigation, her stepmother confessed that she slammed the child against a wall because of bedwetting. After the stepmother hit the child's head against the wall, she also kicked her until the child became unconscious. To resuscitate her, stepmother took her to the bathroom, shook her by the shoulders and wetted her head by the use of a hose. The girl slipped from her hand and hit her head against the wall again, which started wheezy breathing but she did not gain consciousness. The stepmother was convicted with involuntary manslaughter in Criminal Court. On appeal, seven months later, she was acquitted. There was no report filed with Child Protective Services. None of the other siblings was assessed for possible abuse. No expert witness was invited to trial.

Case 3

Three month-old male infant, the only child of his family, was referred to the University Medical School Hospital from a local hospital. On admission, physical examination revealed confusion, bilateral peri-orbital red fresh bruise, 2 x 3 cm size blue-purple old bruise on his cheeks bilaterally, 1 x 2 cm size red, new bruise on his forehead, edematous swelling of his upper lip, 2.5 x 4 cm size collapsed vesicle on the big toe of his right foot, and 5x2 cm size scabbing old lesion with peripheral hyperemia on his left foot. The latter two lesions appeared to be healing burn lesions. At the university hospital, head CT revealed subarachnoid hemorrhage. One day later, repeat head CT revealed bilateral fronto-temporo-parietal subdural hematoma, right occipital subdural hematoma, and right temporal parenchymal hemorrhage. Abdominal CT revealed linear laceration of the spleen and minimal perisplenic fluid accumulation. Full skeletal survey and eye examination were not done. In two days, his respiratory status deteriorated and he was intubated.

His mother reported his father beat the child up. After his treatment in the intensive care unit was completed, he was discharged to his mother. The child was neurologically stable on discharge. Forensic report was filed with law enforcement. His father was arrested. There was no report filed with Child Protective Services.
His mother testified in court that his father physically abused the child on many occasions causing umbilical hemorrhage from a beating at two weeks of age, left subcostal and periorbital ecchymosis from a beating at two months of age, and inflicted burns by pressing his feet against a hot stove at 2.5 months of age. She denied any medical visits for any of these inflicted injuries. The father was convicted with intentional child endangerment and sentenced to two years, two months, and twenty days of jail time. No expert witness was invited to trial.

Case 4

A four year-old female child of a single mother with no other children who works as a prostitute was brought to the emergency room of a University Medical School Hospital five hours after she fell from a chair. On physical examination her vital signs were unstable, she was unconscious with a Glasgow coma scale of three and had low blood pressure (60/30 mmHg). She was immediately intubated. Head CT revealed 1.5 cm wide subacute subdural hematoma around the right fronto-temporo-parietal convexity, which caused left midline shift. She was taken to the operating room for evacuation of the hematoma pressing on the right hemisphere. During the operation she had cardio-respiratory arrest. Despite extensive resuscitation, she was unresponsive and was pronounced dead.

Postmortem examination and autopsy were performed within 24 hours. External examination revealed 10 x 10 cm red fresh bruise on the left side of her upper abdomen, four blue-purple old bruising of 1 to 1.5 cm size on the front of the right thigh, knee, and shin, and left shin. Internal examination revealed multiple ecchymotic lesions of different colors under the scalp, a sutured fronto-temporal wound, and 0.6 cm defect on the underlying bone tissue, due to the operation procedure. Cerebral and cerebellar examination revealed acute edema, subdural hematoma, and enlargement of the third ventricle. Abdominal examination revealed petechial bleeding on the anterior surface of the liver and a hematoma of 5x8 cm on the left side of omentum major. The eyes were not removed for retinal examination. Due to suspect physical abuse, a forensic report was filed with the law enforcement. There was no report filed with Child Protective Services. The mother was tried for negligence after which she was acquitted. No expert witness was called to trial.

Case 5

Four year-old male child of a family with three children was brought to the University Medical School Hospital by his father complaining of vomiting after he woke up following a fall six hours prior to coming to the hospital. His mother and father provided a different fall history. His father reported the child fell down while walking but his mother reported he fell from a sofa. The assessment at the emergency room revealed a child in coma with Glascow coma scale of four, irregular breathing, left midriatic pupil (4 mm), left deviation of the eyes, and hemiparesis on the right side. The cranial CT revealed 3.5 cm size left-temporo-parietal epidural hematoma. He was taken to the operating room. Epidural hematoma was drained via left temporal craniectomy. Skeletal survey and retinal examination were not done. Inconsistent history of trauma prompted a forensic report to law enforcement. On discharge to his parents, he had residual right upper extremity paresis and limited medial vision on his left eye.

His father was tried criminally for physically abusing his son. Criminal investigation revealed that he got annoyed with being interrupted by the child playing near him while he was praying. He pushed the child toward the wall. The child lost his consciousness subsequent to impact from the wall. After the father was tried for involuntary child endangerment, he was acquitted. No expert witness was invited to trial. There was no report filed with Child Protective Services, nor was there an abuse assessment of the other children of the family.

Click here to view Table 1

Five cases of physical abuse were reported to the police department in compliance with the code in Turkey when physicians suspected child maltreatment. Two of these cases had a fatal outcome, one had residual neurological handicaps, and two were lost to follow up. Thus, it is appropriate to think that this series consists of most severely and overtly abused cases and represents the tip of the iceberg of physically abused children in the region. The strength of this study is to bring up the weaknesses of the child protection system in the region to the attention of the medical and child protection communities.

Cases display certain characteristics that are typical of societies at the crawling stage of developing a contemporary and humane response to child abuse and neglect ⁽⁹⁾. All children presented with head trauma that accounts for the high morbidity and mortality in this series (Table I). All but one presented with a past medical history of physical findings indicating recurrent abuse. All but one was an older child, possibly indicating delayed diagnosis of abuse. Two of three surviving children were discharged to the suspected perpetrator. Two of the acquitted perpetrators had inflicted fatal abuse on their children.

Literature on child abuse and neglect from the 1960s indicates that the medical field has led the way to establishing proper child protection in developed countries ⁽⁹⁾. Suspicion for abuse is heightened most commonly in health care settings when children present with unusual injuries. Because of that, the pioneers of recognition of child abuse and neglect have traditionally been medical professionals including Ambrois Tardieu (1860), S. West (1888), John Cafey (1946), and Henry Kempe (1962) ^(10-13). In Turkey, the medical field has become involved in the management of child abuse and neglect within the last decade ^(6,14,15). These efforts led to the establishment of increasing numbers of hospital based multidisciplinary teams in major cities. These teams initiated collaborations with community agencies such as Child Protection Services, prosecutors, law enforcement officers, and school staff attempting to establish regional organization of child protection services ⁽¹⁴⁾.

Despite these grass root activities Turkey still lacks a distinct child protection law with clear, culturally competent definitions of various categories of child abuse and neglect and structured social and legal intervention strategies. Due to these factors, the socio-legal management of child abuse and neglect is vague in Turkish code. Reporting of suspected abuse is still mandated through law enforcement rather than child protective services. Lastly, there is no provision in the code regarding professional mandatory education on response to child abuse and neglect.

Based on these nation-wide problems in the field, Sivas has lacked an awareness of child abuse and neglect as a public health problem. Thus, regional collaboration among agencies to address this issue properly has been non-existent. Even within the university medical school, there has been no curriculum on child abuse and neglect to increase the medical community's awareness of this issue. Thus, the fact that there have been five reports of suspect child abuse within the last six years is an improvement for Sivas region, indicating a positive trend to increased awareness of the at least most severe forms of abuse.

In none of the trials, an expert witness was called for testimony. Only in two of the cases, was there any conviction. Ironically there was no conviction in the two fatal cases. The court system in Turkey is the agency that is least interested in getting involved in multidisciplinary collaborations related to child abuse cases. Because of that, the outcome of the prosecution of these cases is poor even in severe incidents ⁽¹⁶⁾.

None of the cases in this series was reported to Child Protective Services. In none of the three children with siblings, were the siblings assessed for possible abuse. This is in clear contrast with the global contemporary and humane approach to child abuse and neglect. Since the target agency for mandatory reporting in Turkey is law enforcement, the prosecutor decides whether to prosecute these cases or not. When the decision is not to prosecute, there is no opportunity for social services for these needy families. When the decision is to prosecute, only occasionally judges will be broad-minded enough to establish court-ordered social services. Since child abuse and neglect is a social problem, approaching cases from a social services perspective would be much more cost effective and humane.

Suspicion for recurrent abuse was considered at least in all but one of the cases. Professional and public awareness of intra-familial physical abuse is very low in Turkey and Sivas due to lack of structured professional education on and management of child abuse and neglect. These children may have been observed being abused by many lay and professional individuals without any report to any agency before presenting to the University Medical School Hospital. Physical abuse is a spectrum, which many present with various clinical pictures. The lesions range from minimal bruising and abrasions caused by inflicted trauma to lesions, which can cause death such as inflicted head trauma and internal organ injuries ^(17,18). In every society, as awareness and professional education are heightened, the recognition gradually moves from the most apparent, severe cases to less apparent, mildly injured cases ^(6,19).

Skeletal survey has proven to be very helpful in establishing diagnosis inflicted trauma especially in subtle cases ^(20,21). When done properly skeletal survey can improve diagnosis at least in 20% of the cases ⁽²²⁾. If not done when the child was alive, forensic pathologist may and should order a post-mortem skeletal survey. However, again due to the lack of professional structured response to child abuse and neglect, skeletal survey was not done in any of these cases.

These cases display a typical distribution of risk factors for child abuse. Single parenthood, low socio-economical status, anger management problem, step parent, parental psychopathology, staircase children, and multiparity were all risk factors observed in this case series. Other risk factors including isolated living conditions, teenage parenthood, low educational status, and parental substance abuse should also be considered in assessing suspect abuse cases ^(23,24).

Perpetrators of physical abuse are usually the parents or baby-sitters ⁽¹⁷⁾. In severe battering involving head trauma, fathers and stepfather figures have been reported 70% of the time ⁽¹⁹⁾. In our series, perpetrator in three cases was the father, all of which survived. In the two fatal cases on the other hand, perpetrator was the mother and the stepmother. Especially with the fourth case, there is a possibility that the male involved in the prostituting mother's life may have actually perpetrated and the mother may have taken the responsibility out of fear.

In conclusion; neurological deterioration, fractures, burns, and other soft tissue injuries unexplained by the history of trauma and lesions at various stages of healing without proper explanation must lead to suspicion of child abuse. Detailed history must be taken from the members of the family and relatives to clarify the circumstances surrounding observed injury. When suspicious, full skeletal survey should be ordered. Ophthalmology consultation is of paramount importance in cases presenting with head or facial trauma. Physicians are mandated to file a report with law enforcement when suspicious of abuse. Although not required by law, physicians should also report such cases to Child Protective Services with a recommendation of having other children under the care of caretakers in question, assessed. In fatal cases autopsy and postmortem skeletal survey may provide invaluable information ^(25-27). Determining whether bruises occurred before death or are due to rigor mortis, palpating especially the ribs, removing all bones that raise suspicion for fracture, removing the eye globes to assess for retinal hemorrhage, removing the cervical spine posteriorly to assess for axonal injuries are some of the key steps of the autopsy when inflicted head trauma is in question ^(25-28). The next step for each university hospital should be to establish a hospital based multidisciplinary team to develop structured clinical guidelines for institutionalised response to child abuse and neglect. These teams should also lead their communities in developing regional collaborations among the medical facilities, child protective services, prosecutor's office, and law enforcement. Primary prevention efforts by public education are also a very important task.

Physically abused children may present with findings ranging from minimal soft tissue lesions to intracranial injury leading to death. Child abuse is an important public health problem most prevalent in children under five years of age. Timely medical diagnosis of child abuse through detailed history and physical examination is of paramount importance to prevent further abuse and establish supportive services to the families.

We present five cases in this paper, two of which had a fatal outcome. We hope the presentation of these cases and apparent previous chronic abuse in their past medical history will help the medical community revisit their responsibility in preventing child abuse. These cases also indicate that there is great need for education to increase public and multidisciplinary professional awareness of child abuse. Interdisciplinary community collaboration is also very important in recognition, proper management, and prevention of child abuse.

Key words: Child abuse, physical abuse, neglect.

Table 1. Characteristics of cases

NA: Not Applicable, SDH: Subdural Hematoma, SAH: Subarachnoid Hemorrhage,
EDH: Epidural Hematoma

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