Tapping into medical science

      Investigating child abuse has some unique qualities that other investigations lack. Young children may not be able to tell you what happened, and older children may be afraid to. However, physicians, especially those trained in pediatrics or forensics, may be able to tell you what the victim cannot.

   Medical knowledge can provide valuable evidence that can be used to support or refute a suspect's statements. X-rays can discover fractures and may show old, healing fractures, which can indicate previous abuse. A 4-month-old with earlier, unexplained fractures, for instance, has likely been abused. No one that young should have been involved in that many accidents. A CAT scan can show old and new blood in head injuries, says Dr. Cindy Christian, a forensic pediatrician at The Children's Hospital of Philadelphia.

   Some injuries found in a medical exam have qualities that indicate abuse. For instance, Christian notes an infant with internal bleeding in the head, fractured ribs and fractured limbs in the absence of a known accident points to shaken baby syndrome. The head injury and fractured limbs are likely the result of the child's head and extremities being violently shaken and flailing back and forth. Another indication of abuse, for example, is the tearing of the labial frenum, which is the small tag of skin between the upper gum and the upper lip that can be felt by placing one's tongue or finger between the two areas. This is often caused by blunt trauma to the mouth delivered with a high degree of force. In this case, there should also be other signs of trauma near the child's mouth.

   Anyone investigating child abuse cases should be educated on where this type of medical advice is available and what to do with this information when the investigation begins. It's helpful to establish where forensic capabilities are available in the community before this type of help is needed.

Medical data breaks silence

   Medical evidence can also speak for the child, when the child cannot. Older children can normally relate to a physician what happened and who injured him or her. But even if a child is old enough to tell what happened and who was responsible, it doesn't mean he or she will be willing to do so, especially in an abusive situation. Investigators can use medical information to support and confirm the child's account or to recreate what might have occurred. If the investigator has sound evidence from a forensic doctor who reports the injury is a clear indicator of abuse, and not an accident, disease or congenital problem, it is powerful information to confront a suspect with and to use in court.

   The younger the abused child, the more important it is to seek scientific medical data, because victim statements are not available and perpetrators may not provide accurate information. Frequently forensic doctors can narrow down the time frame when the injuries occurred, and if that is known, it may point straight to the offending caregiver. For example, in an actual case where an infant received a broken femur in the care of her grandmother, the child had stayed at the grandparents' home overnight. The grandfather reportedly had left for work earlier than when medical personnel determined the injuries might have occurred. Physicians said with high confidence that the femur of a young child is not easily broken, and would produce extreme, immediate pain when fractured and cause pronounced crying above the intensity of a normal cry. After obtaining a thorough, detailed interview with the grandmother, she led investigators exactly to when the fracture occurred when she told them the infant began crying uncontrollably in her care. When investigators confronted her, she finally admitted becoming frustrated with the baby while dressing her.

   In this case, it was known that a tremendous amount of force was required to fracture the infant's femur because an infant's bones are more flexible at that age, reports Brent Hafen and Keith Karren in "Prehospital Emergency Care & Crisis Intervention: Second Edition." However, it is important, when such information is known, to rule out the possibility that the child has been in an auto crash or other legitimate accident, or has a medical condition that would account for the injury. When those things are excluded by physicians, then investigators can focus their attention on the person or persons caring for the child during the time in question.

   Another unique aspect with investigations involving infants is that infants must have a caregiver nearby all the time, says Christian, and that person should know exactly what happened to them and why. When a caregiver doesn't provide a reasonable explanation for an infant's injuries, there is a problem with that person's credibility.

Who did it?

   Perpetrators of child abuse can be anyone involved with the child, such as parents, grandparents, older siblings, boyfriends or baby sitters; therefore, when interviewing those around the child, investigators should look for stressful times faced by the suspect and see if they correlate with the time frame of the injuries. Also look for periods when those involved may have taken off work or school unexpectedly. That may indicate who is responsible. Close attention to what the suspect is saying is essential. For example, one suspect in a severe child abuse case gave exact details of the morning's events, which appeared to make him look honest. However, an examination of his account showed he was giving the details before and after the event, and skipping over the time when the abuse took place. Paul Ekman, author of "Telling Lies: Clues to Deceit in the Marketplace, Politics and Marriage," reports the two basic methods of deception are outright lying or leaving out truthful (incriminating) information. In this particular case, the suspect was lying by omission.

   Look for stressors that may have caused caregivers to become frustrated and angry. A stressor is an event that produces a responsive action of the person affected, report Phillip Zimbardo and Richard Gerrig in "Psychology and Life, 14th Edition." Anger causes people to commit acts that cause injuries or perform normal legitimate tasks with greater force, which results in injury. For instance, someone might change a child's diaper and jerk his or her leg with great force.

   To pinpoint stressors, look for things such as lack of sleep, a rush for time, intoxication, drug use, or mental health issues with the caregiver. Inquire whether the child was sick or vomited around the time in question. Most importantly, look for a time when the child was crying and wouldn't stop. That may be the stressor itself or the result of the perpetrator's reaction to the stressor.

   The stressor may also come from other areas, such as situations where the mother is gone and a boyfriend was left home to care for the child. A common occurrence is when a young, single man becomes involved with a woman who has children. He may be suddenly overwhelmed with the responsibility and stress of parenting and may unleash his frustration or anger on the child. Young fathers and single mother's boyfriends are commonly the responsible party for children with head injuries, reports Christian.

Consider the injury

   There are two basic factors that cause an injury to occur — a mechanism and force, says Christian. What had to happen and how much force was necessary? Investigators must consider the caregiver's explanation and see if it correlates with what medical professionals say was necessary to cause the injury. For instance, spiral fractures are breaks that are caused by a twisting mechanism. During an interview, an investigator should know to observe for an explanation that involved a twisting motion. For example, if the child's leg got caught between the mattress and the bed frame as he was jumping, then that could account for the twisting mechanism.

   The force required to cause an injury is also an important factor to consider. Frequently, a perpetrator will attempt to blame an older, but still immature, sibling for the injury, such as striking the victim in the head causing head trauma. Consultation between the investigators and medical professionals may eliminate further suspicion or disprove the false account.

   At times, a suspect may claim the child rolled off the bed. Here, consideration should be given as to whether the child is old enough to roll or crawl. Even if the child is mobile, falling off a bed is rarely accepted by a forensic physician as having the required amount of force to cause a skull fracture.

   Consider where the injuries are on the child's body as well. If the child has bruises, cuts or fractures on more than one side of the body, the mechanism of injury had to be applied more than once, such as multiple blows.

   Frequently a child will have several injuries that occurred at different times. The occasions could be an escalation of violence leading to one major injury or a pattern of abuse.

   Burn injuries should also be examined. Burns that produce patterns can provide information to investigators. Several distinct round burns on a child's arm are most likely from a cigarette and not from the child playing with a lighter. One burn may be an accident, but several indicate intentional abuse. An inquiry of who smokes around the child and what that person has to say should be an investigator's focus.

   Scalding is also a form of child abuse; however, accidental scalding does occur. But consider this: If a child places one foot in a tub of scalding water, natural instinct indicates he or she will not voluntarily place the other foot in the water. If a child jumps in the hot tub with both feet, he is not going to sit down after feeling extreme pain on his feet. Instinct is going to cause the child to move away, according to Zimbardo and Gerrig. Therefore, when a caregiver says the child must have jumped in and sat down or stayed in the tub too long, an alarm should go off. A medical professional's opinion should be sought, but the experienced investigator should know this is a red flag.

   The patterns of the scalding or burns are also important to observe, document and photograph. Bath water between 109 and 113 degrees is painful to the touch for an adult. Water at 130 degrees has the ability to produce a full thickness burn to the skin of an adult in 30 seconds. Children's skin would be even more sensitive, adds Christian. Water temperatures and where the hot water heater thermostat is set should be documented, and photographs taken in cases of scalding.

Evidence collection

   There will normally be at least two scenes to collect evidence: Information gathered and collected at the medical facility and at the crime scene. Investigators must examine the location where the child was injured. Measurements from the top of the bed to the floor should be taken if the caregiver said the child fell out of bed. Photographs showing objects on the floor should be taken to support how the injury occurred. If a weapon was used to cause a blunt force injury, it may still be present at the scene. In one actual abuse case, a father used a ladle to strike his infant child in the head as she sat in her high chair eating. The ladle was found in the kitchen sink and retrieved as evidence.

Confronting the perpetrator

   A considerable amount of time should be given to talk personally with medical personnel to obtain available information before confronting a suspect. Caregivers and any witnesses should be interviewed without a hint of blame during the investigation's fact-gathering phase. At this point, the investigator wants the cooperation of all involved. Statements should be taken and recorded, so that if one of the witnesses becomes a suspect his statement is documented.

   When a suspect has been identified, a sympathetic investigative approach can help obtain a confession. The investigator should have identified what most likely caused the injury and the stressor. He or she should confront the suspect, emphasizing that doctors report the child's injuries were from a deliberate act and not an accident. The investigator should relay an understanding that the suspect's circumstances led him to simply lose control.

   By showing empathy, investigators can get suspects to eventually begin providing details about what happened. Reiterating what medical personnel reported often has a tremendous impact. It is harder for suspects to argue with a doctor's assessment.

   This interview also needs to be documented with a recording. Advising the suspect of his rights, even when he is not in custody, is a sound practice. This is one less aspect of the investigation to defend in court.

   At times, the case is not resolved and further assistance is required. A polygraph should be on the investigator's list of options. However, the polygraph examiner is going to expect a full investigation to be conducted prior to an examination in order to formulate proper test questions. The information is also necessary in the event that the subject fails the polygraph. A post-examination interview would then be conducted to arrive at the truth.

   Understanding that a thorough investigation from beginning to end is necessary, an investigator needs to gather all the information he can prior to confronting a child abuse suspect. He also needs to go a step further to address any questions that could be brought up in court later on. The involvement of forensic medical doctors and nurses is important from the beginning. If investigators fail to utilize this valuable resource, the defense team surely will during a trial. And remember, it's not always what an investigator did in an investigation; it may be more of what he did not do. The defense attorney will look for any instance where his client did not receive due process. A multi-disciplinary approach by police, child protective services and prosecution can result in a successful end to the child abuse case when modern forensic medical advice is used to its fullest.

   Sgt. Delmer Gross has been with the Indiana State Police for 20 years with experience in detective work and polygraph examination.