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Acta Pdiatrica ISSN 08035253

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Severe child abuse: a study of cases reported to the police
E-M Annerb ack (eva-maria.annerback@vattnet.com)
1
, C Lindell
2
, CG Svedin
1
, PA Gustafsson
1
1.Division of Child and Adolescent Psychiatry, Departmenet of Molecular and Clinical Medicine, Faculty of Health Sciences, University Hospital, 581 85 Link oping, Sweden
2.Centre for Public Health Sciences, University Hospital, 581 85 Link oping, Sweden
Keywords
Child maltreatment, Child physical abuse, Reports,
Severe, Social services
Correspondence
Annerb ack Eva-Maria, Division of Child and
Adolescent Psychiatry, University Hospital,
S-581 85 Link oping, Sweden.
Tel: +46-13-22-42-11 | Fax: +46-13-22-42-34 |
Email: eva-maria.annerback@vattnet.com
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 nding 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 the
1980s and the end of the 1990s. Given this background, a
national committee was created and charged with investigat-
ing the question of child abuse. The committee filed its final
report 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 comparison
with other Nordic countries, whereas there seems to be no
difference in the occurrence of severe child abuse between
Sweden and the other Nordic countries (2).
In a study comparing violence towards children in the
United States and Sweden between 1976 and 1980 (3)
researchers used the Conflict Tactic Scales (4) to obtain
responses 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%), but
there was no significant difference between reports from the
parents in the two countries as concerned the most serious
types of abuse. In both countries, 4% of the children were
reported to have been subjected to severe abuse. The same
types of interviews were carried out again in Sweden in 2000
(2). A major decrease in less severe forms of child abuse was
reported, 8.3% in 2000 compared with 51.3% in 1980. As
concerned the more severe level of abuse, the results were
less certain. Apparently no reduction in severe abuse had
occurred in Sweden between 1980 and 2000.
The occurrence of severe child abuse in England and
Wales 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 injured
children studied had experienced fatal injuries and 9% dis-
played very serious injuries. Those cases that were classified
as severe included all cases in which the children had frac-
tures, head injuries, internal injuries, or severe burns or in
which ingestion of toxic substances was reported.
The Swedish Agency for the Prevention of Crime (SAPC-
BR in Swedish) has made a survey of the cases reported
to the police of the abuse of children 06 years of age during
the period 19901997 (6). The percentage of cases regarded
as serious or very serious constituted 12% of the total. The
criteria for placing a case in the category seriously injured
were that medical evaluation or medical aid was needed and
that no physical problems were expected to occur after re-
covery. The criteria for very seriously injured were that the
injuries were potentially life-threatening or at risk for giv-
ing permanent harm. Reports filed by physicians and other
health-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 less
well off economically and was less well educated than the
population in general. Those born outside of Sweden were
overrepresented in relation to the proportion of foreign born
in 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 made
to the police (2,10). The most serious cases of child abuse
ought to be discovered first and foremost in childrens sec-
tions of hospitals and clinics. This is especially true for the
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Annerb ack et al. Severe child abuse
youngest children who cannot speak. The identification of
violence committed against these youngest children depends
on the diagnostic skills of childrens health-care personnel
(1113) and also on their willingness to report cases to social
services.
Aim
The aim of this study was to investigate the occurrence of
severe child abuse among cases reported to the police. To
what extent and in what ways do cases of severe child abuse
differ fromless severe kinds of abuse? An additional goal was
to determine who calls attention to the childrens situation
by reporting to the police or to social services and what was
already known about these children and their families prior
to the event in question. Finally, we wanted to determine the
extent to which reports to the police lead to prosecution and
to court judgments.
MATERIALS AND METHODS
All reports made to the police about suspected violence to-
wards children in a Swedish police district between 1986
and 1996 have been collected (14) and further analyzed in
this study. The police district consists of four municipalities
including a relatively large city, other smaller well-populated
areas and a rural area. The total population was 144817 in
1986 and 159027 in 1996. The total number of reports of vi-
olence directed towards children reported to the police was
363; in 142 of these reports, the children were physically
abused 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 (which
was 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 had
suffered severe child abuse constitute the study group. The
reference group consists of all the remaining children (n =
102) (Fig. S1).
The study is based largely on the information found in the
police reports. In addition to these reports, we have studied
the records of court cases and 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 psychological
problems were collected both from the police reports and
from 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 the
parent, had the responsibility at the time of the abuse.
The definition of children in this study is a person younger
than 18 years.
The definition of severe child abuse is based on the fol-
lowing criteria (15,16):
- Demonstrable bodily injury is present and is documented
in the medical examiners report or other certification by
a physician.
- The injury is clearly serious either because it indicates a
serious physical threat or appears to have been caused
by an object or indicates repeated violence, e.g. from the
presence of bruises of varying age.
- The incident itself constitutes a serious danger such as an
attempt to kill, even if the bodily injuries cannot be said
to be serious.
Parental drug or alcohol abuse and psychological prob-
lems is designated when the police reports or the files from
social 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 the
Ethical 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, the
Chi-square test has been used.
RESULTS
Children
In both the groups there were somewhat more boys among
the children subjected to abuse. The mean age of the chil-
dren was 7 years and 1 month in the study group and 7 years
and 6 months in the reference group. There were no signif-
icant differences between groups with respect to gender by
age (Table S1). In the study group 12 (60%) of the children
were living with both their biological parents and 8 with
separated 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 the
total number of reports of suspected abuse by a parent or a
caretaker reported to the police and in 16% of the children.
Injuries to the children in the study group were docu-
mented by the medical examiners office in 13 cases, by pae-
diatricians in five cases, and by other physicians in two cases.
(Table S2). In two of the cases, the incidents were extremely
serious, even though the children only had relatively minor
injuries. Two of the children who had suffered ear injuries
had received these in an effort to produce symptoms of ill-
ness, a form of child abuse called Munchausens Syndrome
by Proxy (18). These two children were siblings.
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Severe child abuse Annerb ack et al.
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 les.
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 agencies
in 16 cases (80%), and in the reference group in 53 cases
(52%). The difference is significant (p 0.025). Only one
case (5%) in the study group had been reported to the police
by a biological parent, compared to 29% of the reports in
the reference group (p 0,025).
Suspected perpetrators
There were a total of 25 suspected perpetrators in the study
group (in five cases there were two suspects). There were
118 suspected perpetrators in the reference group (Table 1).
Parental drug or alcohol abuse and psychological
problems
In both groups the records indicated some form of drug or
alcohol abuse in about one-third of the parents. Psychologi-
cal problems were noted in 11 cases (55%) in the study group
and 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 were
not 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 that
finally led to conviction (n = 10) had admitted that they had
abused the child. Eighty-seven percent of the suspected per-
petrators in the reference group had been interviewed. All
except one of these denied having abused the child, even
if one-fourth of them did admit to having employed minor
violence as part of bringing up the child. Of the total of 18
reports (13% of the total of 142 and 15% of the 122 children)
that led to conviction (10 in the study group and 8 in the
reference group), the charge was abuse in 15 cases, severe
abuse 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 children
were already known to social services prior to the event in
question. In all, 21 previous reports had been filed from dif-
ferent actors within the Child care area, e.g. child health-care
centre, preschools and schools (13 reports), private individ-
uals (5 reports) and the parents themselves who had pointed
out 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 were
persons other than those named in the most recently re-
ported cases. The remaining reports pointed to the need for
supportive action in cases of known neglect, incidents in the
home and spousal abuse and finally the need for child care
and help in the home was pointed out in connection with
stressful family situations.
In the reference group 52 (51%) were previously known
to social services. In half of these cases the parents them-
selves had reported the need for support. In 13 cases the
reports had been made by agencies. In 10 cases the other
parent or other private individuals had made reports, and
in three cases there was no information describing how so-
cial services had learned about the family. Six (6%) of the
prior 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 the
suspected perpetrators were primarily the biological parents,
who were themselves overrepresented in groups facing diffi-
culties as concerned employment, socioeconomic status and
ethnicity, confirms previous reports. Children who had been
subjected to severe child abuse in most cases lived with both
of their biological parents, a situation that differs from that
reported by the study made by BR (6) of all types of cases
reported to the police for children 06 years of age. The BR

A
study found that the majority of the children lived in families
where the parents were separated.
Reports to the police had been made by agencies in the
majority of the severe cases. The source of reporting of cases
differs 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 in
general already known to social services, and reports of child
abuse had frequently been made, which indicates that these
cases earlier had been presented as minor abuse.
Preliminary investigations by the police concerning seri-
ous child abuse have led to prosecution and convictions in
half of the cases of severe child abuse and in 8% of the
remaining cases. The frequency of prosecutions and con-
victions was not correlated with whether or not the child
confirmed abuse during the interview. Prosecution and
conviction seems instead to depend on the admission
of abuse by the perpetrator and on other evidence like
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Annerb ack et al. Severe child abuse
documentation of the injuries or in some cases if there were
testimony by a witness.
The reference group displayed many similarities with the
group that had been subjected to severe child abuse and the
results in our study do not show the differences between
groups that have been found in studies from other coun-
tries, studies that have led to the assumption that less severe
and 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 status
and parents psychological problems.
Reservations/Limitations
The conclusions that may be drawn from the results of this
study are limited to the extent that they apply only to cases
of child abuse reported to the police. It is possible that the
number of unreported abuse fromfamilies that are economi-
cally and socially better off is even larger. Those families that
are not well off are the subject of agency attention by the
police as well as the social services to a greater extent than
other 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, but
still the severe cases represent the total number of cases re-
ported to the police during 11 years in the designated police
district. Much remains to be learned by developing a more
systematic body of knowledge concerning these cases.
Interpretation
One noteworthy finding is the significant difference in the
pattern of reporting between the two groups. Agencies and
childrens clinics and schools observe and act upon the most
serious cases, whereas in the less severe cases there are no
injuries to be seen so actions are not taken. The children
do not tell or are not able to tell anyone about problems
in the home to a great extent. The less severe cases were
often reported by a parent in a separated relationship. That
parents who are not living together do report each other
when there is a problem for the children may provide these
children with a kind of protection not available to children
in intact families with two biological parents. Parents who
are living together may find that it is decidedly more difficult
and even threatening to report the other parent to agencies
such as the police and social services, when the children are
having difficulty. Another common hypothesis proposed to
explain why separated parents more commonly report one
another is that this action is one factor in a conflict over
separation.
The difference between the study group and the reference
group may depend on the stage in the process at which a
report is filed, so that the less severe cases were reported
at an earlier stage than the severe cases. The supposition
that children with severe injuries have previously been pre-
sented with less severe injuries was not supported by the
findings but by other research (20). This indicates that all
reports 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 decreased
drastically 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 as
serious.
That less than 10%of all cases reported to the police led to
prosecution and conviction shows that the judicial process
alone is not a solution, but rather that society at large needs
additional 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 independent
evaluations concerning the possible need to give the child
protection and to identify risks associated with the childs
situation. What is needed is a practice where other agencies
make their own assessments and determine the childs situ-
ation and the familys need for help without relying on the
question 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.
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Supplementary material
The following supplementary material is available for this
article:
Table S1 Distribution of age and gender of children in the
study 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 from
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2227.2007.00519.x
(This link will take you to the article abstract).
Please note: Blackwell Publishing is not responsible for the
content or functionality of any supplementary materials sup-
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1764 C 2007 The Author(s)/Journal Compilation C 2007 Foundation Acta Pdiatrica/Acta Pdiatrica 2007 96, pp. 17601764