Annerbck E M

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Acta Pædiatrica IS SN 0803–5253

REGUL A R A RTIC L E

Severe child abuse: a study of cases reported to the policeE-M Annerb¨ ack ([email protected])1, C Lindell2, CG Svedin1, PA Gustafsson1

1.Division of Child and Adolescent Psychiatry, Departmenet of Molecular and Clinical Medicine, Faculty of Health Sciences, University Hospital, 581 85 Linkoping, Sweden2.Centre for Public Health Sciences, University Hospital, 581 85 Linkoping, Sweden

Keywords

Child maltreatment, Child physical abuse, Reports,Severe, Social services

Correspondence

Annerback Eva-Maria, Division of Child andAdolescent Psychiatry, University Hospital,S-581 85 Linkoping, Sweden.Tel: +46-13-22-42-11 | Fax: +46-13-22-42-34 |

Email: [email protected]

Received

5 February 2007; revised 10 August 2007;accepted 16 August 2007.

DOI:10.1111/j.1651-2227.2007.00519.x

Abstract

Aim: To investigate the characteristics of severe abuse of children and possible differences in

comparison with less severe abuse.

Method: Cases of abuse reported to the police within a single police district (n = 142) in Sweden

were studied. The severe cases were compared to all the remaining cases.

Results: Severe abuse constituted 14% of the total cases and was reported by agencies to a greater

degree than minor cases. The suspected perpetrators were socially disadvantaged people in both

groups. Half of the most serious cases led to conviction in the courts, compared to 8% in the

reference group. The children who had been subjected to abuse were often already known to social

services and reports of child abuse had frequently been made.

Conclusion: In comparison between cases of severe and minor child abuse reported to the police, the results did

not show any crucial differences except the pattern of reporting and a higher occurrence of prosecution/

conviction in the severe cases. This finding places a responsibility on agencies outside of the justice system to

consider all cases of reported abuse as serious warning signals and to make independent evaluations to identify

risks and the possible need for child protection.

INTRODUCTION

The number of reports to the police about abuse of chil-dren in Sweden quadrupled between the beginning of the1980s and the end of the 1990s. Given this background, anational committee was created and charged with investigat-ing the question of child abuse. The committee filed its finalreport in 2001 (1). The position is taken in the report that,

compared with international experience, the occurrence of corporal punishment (e.g. spanking or smacking) is gener-ally less common in Sweden and even less in comparisonwith other Nordic countries, whereas there seems to be nodifference in the occurrence of severe child abuse betweenSweden and the other Nordic countries (2).

In a study comparing violence towards children in theUnited States and Sweden between 1976 and 1980 (3)researchers used the Conflict Tactic Scales (4) to obtainresponses from parents. In general the Swedish parents re-ported less lower-level violence towards children in Sweden(51.3%) than did parents in the United States (79.2%), butthere was no significant difference between reports from the

parents in the two countries as concerned the most serioustypes of abuse. In both countries, 4% of the children werereported to have been subjected to severe abuse. The sametypes of interviews were carried out again in Sweden in 2000(2). A major decrease in less severe forms of child abuse wasreported, 8.3% in 2000 compared with 51.3% in 1980. Asconcerned the more severe level of abuse, the results wereless certain. Apparently no reduction in severe abuse hadoccurred in Sweden between 1980 and 2000.

The occurrence of severe child abuse in England andWales between 1983 and 1987 has been investigated in a

study of the Child Abuse Registers in England and Wales(5). These researchers found that 0.6% of the 4037 injuredchildren studied had experienced fatal injuries and 9% dis-played very serious injuries. Those cases that were classifiedas severe included all cases in which the children had frac-tures, head injuries, internal injuries, or severe burns or inwhich ingestion of toxic substances was reported.

The Swedish Agency for the Prevention of Crime (SAPC-–BRÅ in Swedish) has made a survey of the cases reportedto the police of the abuse of children 0–6 years of age duringthe period 1990–1997 (6). The percentage of cases regardedas serious or very serious constituted 12% of the total. Thecriteria for placing a case in the category seriously injuredwere that medical evaluation or medical aid was needed andthat no physical problems were expected to occur after re-covery. The criteria for very seriously injured were that theinjuries were potentially life-threatening or at risk for giv-ing permanent harm. Reports filed by physicians and otherhealth-care professionals were primarily concerned with vic-tims who had serious or very serious injuries. The perpetra-tors were in 85% of the cases the biological parents, and two-thirds were men. The majority of the perpetrators was lesswell off economically and was less well educated than thepopulation in general. Those born outside of Sweden wereoverrepresented in relation to the proportion of foreign bornin the total Swedish population.

The number of unrecorded cases of child abuse is large,as indicated by the discrepancy between self-reported expe-rience in a variety of studies and the actual reports madeto the police (2,10). The most serious cases of child abuseought to be discovered first and foremost in children’s sec-tions of hospitals and clinics. This is especially true for the

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Annerback et al. Severe child abuse

youngest children who cannot speak. The identification of violence committed against these youngest children dependson the diagnostic skills of children’s health-care personnel(11–13) and also on their willingness to report cases to socialservices.

Aim

The aim of this study was to investigate the occurrence of severe child abuse among cases reported to the police. Towhat extent and in what ways do cases of severe child abusediffer from less severe kinds of abuse? An additional goal wasto determine who calls attention to the children’s situation

by reporting to the police or to social services and what wasalready known about these children and their families priorto the event in question. Finally, we wanted to determine theextent to which reports to the police lead to prosecution andto court judgments.

MATERIALS AND METHODS

All reports made to the police about suspected violence to-

wards children in a Swedish police district between 1986and 1996 have been collected (14) and further analyzed inthis study. The police district consists of four municipalitiesincluding a relatively large city, other smaller well-populatedareas and a rural area. The total population was 144817 in1986 and 159027 in 1996. The total number of reports of vi-olence directed towards children reported to the police was363; in 142 of these reports, the children were physicallyabused by a parent or other caretaker. In the other reports,the perpetrator was another child (n = 176), another un-known adult (n = 42) or a known adult outside the family(3). If a single child was reported more than once (whichwas the case for 20 reports), the most serious report, or the

first time the child was reported, has been chosen as the in-dex report. With the definition below, 20 children who hadsuffered severe child abuse constitute the study group. Thereference group consists of all the remaining children (n =102) (Fig. S1).

The study is based largely on the information found in thepolice reports. In addition to these reports, we have studiedthe records of court casesand the files kept by social services.In the files of social services, data of previous knowledge of the children and their families have been collected. Informa-tion about parental drug or alcohol abuse and psychologicalproblems were collected both from the police reports andfrom the files from social services.

Definitions

Child abuse intends physical violence against a child ex-ecuted by a parent or a caretaker.Caretaker means parent or the person who, instead of theparent, had the responsibility at the time of the abuse.

The definition of children in this study is a person youngerthan 18 years.

The definition of severe child abuse is based on the fol-lowing criteria (15,16):

- Demonstrable bodily injury is present and is documentedin the medical examiner’s report or other certification bya physician.

- The injury is clearly serious either because it indicates aserious physical threat or appears to have been caused

by an object or indicates repeated violence, e.g. from thepresence of bruises of varying age.

- The incident itself constitutes a serious danger such as anattempt to kill, even if the bodily injuries cannot be saidto be serious.

Parental drug or alcohol abuse and psychological prob-lems is designated when the police reports or the files fromsocial services contain information about such problems.

The socioeconomic status of the families has been deter-mined according to the Statistics Sweden, SEI (17).

Ethical considerations

Permission to make use of police reports and social services’files has been granted by the police department and by the

Department of social services. The court judgments are pub-lic documents in Sweden. The study was approved by theEthical Committee at the University Hospital in Link oping(DNR 98321 and 03-182).

Statistical methods

The results of this study are presented primarily as frequen-cies and percentages. In comparisons between groups, theChi-square test has been used.

RESULTS

Children

In both the groups there were somewhat more boys amongthe children subjected to abuse. The mean age of the chil-dren was 7 years and 1 month in the study group and 7 yearsand 6 months in the reference group. There were no signif-icant differences between groups with respect to gender byage (Table S1). In the study group 12 (60%) of the childrenwere living with both their biological parents and 8 withseparated parents. In the reference group 44 children (43%)were living with both their biological parents and 58 (57%)with separated parents.

Severe child abuse

Severe child abuse was present in 20 reports, i.e. 14% of thetotal number of reports of suspected abuse by a parent or acaretaker reported to the police and in 16% of the children.

Injuries to the children in the study group were docu-mented by the medical examiner’s office in 13 cases, by pae-diatriciansin five cases, and by other physiciansin two cases.(Table S2). In two of the cases, the incidents were extremelyserious, even though the children only had relatively minorinjuries. Two of the children who had suffered ear injurieshad received these in an effort to produce symptoms of ill-ness, a form of child abuse called Munchausen’s Syndrome

by Proxy (18). These two children were siblings.

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Table 1 Suspected perpetrator in study group and reference group

Study group/ Severe cases Reference group

(n = 20 children) (n = 102 children)

Men 9 (45%) 62 (61%)

Women 6 (30%) 24 (24%)

Two suspected perpetrators 5 (25%) 16 (16%)

(man and woman)

Biological parents 17 (85%) 81 (79%)Lowest socioeconomic 19 (95%) 33 (38%) (n = 87)∗,∗∗

status SEI (15)

Unemployed 10 (50%) 35 (38%) (n = 91)∗∗

Foreign born 10 (50%) 39 (38%)

∗p ≤ 0.001; ∗ ∗ internal dropout due to missing data in the files.

Reports to the police

Reports to the police were made by agencies (e.g. social ser-vices and hospital clinics) and by private individuals. Re-ports of incidents in the study group were made by agenciesin 16 cases (80%), and in the reference group in 53 cases(52%). The difference is significant (p ≤ 0.025). Only onecase (5%) in the study group had been reported to the police

by a biological parent, compared to 29% of the reports inthe reference group (p ≤ 0,025).

Suspected perpetrators

There were a total of 25 suspected perpetrators in the studygroup (in five cases there were two suspects). There were118 suspected perpetrators in the reference group (Table 1).

Parental drug or alcohol abuse and psychologicalproblems

In both groups the records indicated some form of drug oralcohol abuse in about one-third of the parents. Psychologi-cal problems were noted in 11 cases (55%) in the study groupand in 29 cases (28%) in the reference group (p = 0.025).

The legal process

A majority of the children in each group had been inter-viewed by the police (60 resp. 59%). The children who werenot interviewed (n = 50) were the youngest in both groups,Thirty-six of them were 5 years old or younger. All of the

suspected perpetrators in the study group had been inter-viewed. The perpetrators in all the cases of severe abuse thatfinally led to conviction (n = 10) had admitted that they hadabused the child. Eighty-seven percent of the suspected per-petrators in the reference group had been interviewed. Allexcept one of these denied having abused the child, evenif one-fourth of them did admit to having employed minorviolence as part of bringing up the child. Of the total of 18reports (13% of the total of 142 and 15% of the 122 children)that led to conviction (10 in the study group and 8 in thereference group), the charge was abuse in 15 cases, severeabuse in two, and attempted murder in one.

Social services’ prior experience with the children and

the families

In the cases of severe child abuse, 14 (70%) of the childrenwere already known to social services prior to the event inquestion. In all, 21 previous reports had been filed from dif-ferent actorswithin the Child carearea, e.g. child health-carecentre, preschools and schools (13 reports), private individ-uals (5 reports) and the parents themselves who had pointedout their need for help (3 reports). The previous reports had

been concerned with child abuse in eight children (40%),and in these cases, half of the suspected perpetrators werepersons other than those named in the most recently re-ported cases. The remaining reports pointed to the need forsupportive action in cases of known neglect, incidents in thehome and spousal abuse and finally the need for child careand help in the home was pointed out in connection withstressful family situations.

In the reference group 52 (51%) were previously knownto social services. In half of these cases the parents them-selves had reported the need for support. In 13 cases thereports had been made by agencies. In 10 cases the otherparent or other private individual’s had made reports, andin three cases there was no information describing how so-cial services had learned about the family. Six (6%) of theprior reports concerned suspected child abuse.

DISCUSSION

The results confirm previous studies with respect to the pro-portion of occurrence of cases of severe abuse. Direct com-parisons are nevertheless difficult to make because of dif-ferences in the definitions used (5,6). The finding that thesuspected perpetrators were primarily the biological parents,who were themselves overrepresented in groups facing diffi-culties as concerned employment, socioeconomic status andethnicity, confirms previous reports. Children who had beensubjected to severe child abuse in most cases lived with bothof their biological parents, a situation that differs from thatreported by the study made by BRÅ (6) of all types of casesreported to the police for children 0–6 years of age. The BR Astudy found that the majority of the children lived in familieswhere the parents were separated.

Reports to the police had been made by agencies in themajority of the severe cases. The source of reporting of casesdiffers in this respect from what was found in previous stud-ies where half of all reports were made by parents (6). The

children who have been subjected to severe abuse were ingeneral already known to social services, and reports of childabuse had frequently been made, which indicates that thesecases earlier had been presented as minor abuse.

Preliminary investigations by the police concerning seri-ous child abuse have led to prosecution and convictions inhalf of the cases of severe child abuse and in 8% of theremaining cases. The frequency of prosecutions and con-victions was not correlated with whether or not the childconfirmed abuse during the interview. Prosecution andconviction seems instead to depend on the admissionof abuse by the perpetrator and on other evidence like




Annerback et al. Severe child abuse

documentation of the injuries or in some cases if there weretestimony by a witness.

The reference group displayed many similarities with thegroup that had been subjected to severe child abuse and theresults in our study do not show the differences betweengroups that have been found in studies from other coun-tries, studies that have led to the assumption that ‘less severeand very severe abuse seem to be two related but quite dif-ferent phenomena’ (19). Those differences that were present

between groups concern, the pattern of reporting, the occur-rence of prosecution/conviction, low socioeconomic statusand parent’s psychological problems.

Reservations/Limitations

The conclusions that may be drawn from the results of thisstudy are limited to the extent that they apply only to casesof child abuse reported to the police. It is possible that thenumber of unreported abuse from families that are economi-cally and socially better off is even larger. Those families thatare not well off are the subject of agency attention by thepolice as well as the social services to a greater extent thanother societal groups, and people from this group are proba-

bly suspected more frequently of having committed a crime.Another limitation is the small number of the groups, butstill the severe cases represent the total number of cases re-ported to the police during 11 years in the designated policedistrict. Much remains to be learned by developing a moresystematic body of knowledge concerning these cases.

Interpretation

One noteworthy finding is the significant difference in thepattern of reporting between the two groups. Agencies andchildren’s clinics and schools observe and act upon the mostserious cases, whereas in the less severe cases there are noinjuries to be seen so actions are not taken. The childrendo not tell or are not able to tell anyone about problemsin the home to a great extent. The less severe cases wereoften reported by a parent in a separated relationship. Thatparents who are not living together do report each otherwhen there is a problem for the children may provide thesechildren with a kind of protection not available to childrenin intact families with two biological parents. Parents whoare living together may find that it is decidedly more difficultand even threatening to report the other parent to agenciessuch as the police and social services, when the children arehaving difficulty. Another common hypothesis proposed to

explain why separated parents more commonly report oneanother is that this action is one factor in a conflict overseparation.

The difference between the study group and the referencegroup may depend on the stage in the process at which areport is filed, so that the less severe cases were reportedat an earlier stage than the severe cases. The suppositionthat children with severe injuries have previously been pre-sented with less severe injuries was not supported by thefindings but by other research (20). This indicates that allreports of child abuse should be regarded as serious warn-ing signals that the children are at risk. In Sweden, where

the occurrence of violence towards children has decreaseddrastically and where changes in attitude were pervasive(4), violence towards children is regarded as strongly de-viant behaviour that must be considered in all its forms asserious.

That less than 10% of all cases reported to the police led toprosecution and conviction shows that the judicial processalone is not a solution, but rather that society at large needsadditional instrument to protect and help vulnerable chil-dren. This finding places a responsibility on agencies out-side of the justice system to make their own independentevaluations concerning the possible need to give the childprotection and to identify risks associated with the child’ssituation. What is needed is a practice where other agenciesmake their own assessments and determine the child’s situ-ation and the family’s need for help without relying on thequestion of guilt as seen in the police investigation.

ACKNOWLEDGEMENT

The study was made possible by grants from The Crime Vic-

tim Compensation and Support Authority (Brottsoffermyn-digheten) in Sweden.

References

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2. Statens offentliga utredningar. Barn och misshandel – Enrapport om kroppslig bestraffning och annan misshandel iSverige vid slutet av 1900-talet. (Children and Abuse – Areport of Physical Punishment and other types of Abuse inSweden). (In Swedish). Stockholm: SOU, 2001: 18.

3. Gelles RJ, Edfeldt AW. Violence towards children in the

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4. Straus MA. Measuring intrafamily conflict and violence: Theconflict tactic scales (CT). J Marriage Fam 1979; 41: 75–88

5. Creighton SJ, Noyes P. Child abuse trends in England andWales 1983–1987 . London: National Society for thePrevention of Cruelty to Children (NSPCC), 1989.

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7. Nordlund J, Temrin H. Barn som d odas av sina f or aldrar.(Children who are killed by their parents). (In Swedish). Apropa 2003; 2.

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in Sweden 1971–1980. Child Abuse Negl 1991; 15: 45–55.9. Socialstyrelsen. Statistik over avsiktligt v ald mot barn.

(Statistics of Intentional Violence against Children). (InSwedish). Stockholm, 2004: 107–12.

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11. Lundin B, Croner S. Munchausen by proxy—a literaturerewiew and Swedish case histories. L akartidningen 2001; 98:2302–11.

12. Hedb ack S. VÅrdprogram om barnmisshandel tvingar doktornatt ta st allning. (Medical programs force the Doctor to takeposition). (In Swedish). L akartidningen 2003; 100: 822–3.

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13. Duhaime A-C, Christian CW, Rorke LB, Zimmerman RA.Current concepts: nonaccidental head injury in infants – the“shaken-baby syndrom”. N Engl J Med 1998; 338: 1822–9.

14. Lindell C, Svedin CG. Physical child abuse in Sweden: A studyof police reports between 1986 and 1996. Soc Psychiatry Psychiatr Epidemiol 2001; 36: 150–7.

15. Svensk lag. Brottsbalken kap 3. (The Penal Code). Svenskf orfattningssamling.

16. Dale P, Green R, Fellows R. What really happened. London:National Society for the Prevention of Cruelty to Children(NSPCC), 2002.

17. Statistiska centralbyr an. Socioekonomisk indelning (SEI).(Socioeconomic status). (In Swedish). 2nd ed. Stockholm,1982.

18. Bodeg ard G. Munchausen by proxy syndromet. (M unchhausenSyndrom by Proxy). (In Swedish). Lakartidningen 2001; 19:4748–51.

19. Bardi M, Borgognini-Tarli SM. A survey on parent-childconflict resolution: intrafamily violence in Italy. Child Abuse Negl 2001; 6: 839–53.

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Supplementary material

The following supplementary material is available for thisarticle:

Table S1 Distribution of age and gender of children in thestudy group and the reference group.Table S2 Number of injuries by type in the study group (n =

20).Figure S1 Source material.

This material is available as part of the online article fromhttp://www.blackwell-synergy.com/doi/abs/10.1111/j.1651-2227.2007.00519.x(This link will take you to the article abstract).

Please note: Blackwell Publishing is not responsible for thecontent or functionality of any supplementary materials sup-plied by the authors. Any queries (other than missing mate-rial) should be directed to the corresponding author for thearticle.


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