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Intentional burning: A severe form of child abuse
Intentional Burning: A Severe Form of Child Abuse
Patricia S. Phillips, RN* Elaine Pickrell, MSW** Thomas S. Morse, MD*** Columbus, Ohio
I n t e n t i o n a l b u r n i n g is a s e v e r e f o r m o f c h i l d a b u s e . D u r i n g a t h r e e y e a r p e r i o d , 25 a b u s e d c h i l d r e n w e r e a d m i t t e d to the b u r n u n i t of t h e Child r e n ' s H o s p i t a l , C o l u m b u s , Ohio. T h e y r e p r e s e n t e d 8% o f all b u r n e d child r e n a d m i t t e d d u r i n g this p e r i o d . F o u r o f t h e 25 a r e d e a d . T h e h a l l m a r k s o f i n t e n t i o n a l b u r n i n g i n c l u d e a s t o r y w h i c h d o e s n o t e x p l a i n the w o u n d , p r e v i o u s or c o e x i s t a n t injuries, s p e c i f i c b u r n p a t t e r n s a n d c h a r a c t e r i s t i c b e h a v i o r of p a r e n t s a n d c h i l d r e n . S u s p e c t e d c a s e s m u s t b e r e p o r t e d , the child p r o t e c t e d a n d the p a r e n t s h e l p e d . Child a b u s e t e n d s to b e r e p e a t e d w i t h p r o g r e s s i v e l y s e v e r e a t t a c k s , o f t e n e n d i n g in d e a t h .
INTRODUCTION Child abuse tends to be repetitive, w i t h p r o g r e s s i v e l y severe a t t a c k s , often e n d i n g in death. I n t e n t i o n a l b u r n i n g is a severe form of child abuse. T h r e e h u n d r e d a n d t w e l v e children were admitted to the b u r n u n i t of Children's Hospital, Columbus, Ohio, d u r i n g the three year period, 1971 t h r o u g h 1973. Twenty-five, or 8%, were b u r n e d i n t e n t i o n a l l y , and of these 25, 4 are dead. As our b u r n t e a m b e c a m e more a w a r e of child abuse, it dealt more effectively with the i n t e n t i o n a l l y b u r n e d child. ~Department of Nursing and ~ '~Department of Social Services, Children's Hospital; ***Division of Pediatric Surgery, Department of Surgery, Ohio State University College of Medicine, Columbus, Ohio. Presented at the Fourth Annual UA/EMS Meeting in Dallas, Texas, May, 1974. Address for reprints: Thomas S. Morse, MD, Division of Pediatric Surgery, Chi]dren's Hospital, 561 S 17th Street, Columbus, Ohio 43205.
Page 388
The t e a m includes physicians, nurses, a social worker, physical and occupat i o n a l therapists, a c h a p l a i n and a teacher, all of whom are able to identify the indications of abuse or neglect. The f o l l o w i n g Case Reports describe typical examples of i n t e n tional b u r n i n g of children.
Case Report One A three-year-old girl was admitted with second and third degree b u r n s on her feet, buttocks and perineum. She also had a bruise on her left arm and a pinch m a r k on her neck. While the mother was at work, her boyfriend was b a t h i n g the child. Allegedly, he a n s w e r e d the phone a n d the child t u r n e d the hot water on herself. Because the story and the b u r n did not m a t c h , a n d b e c a u s e b r u i s e s were present, the proper authorities were notified. In the hospital, the child showed no fear of the staff and interacted well with her mother. She refused, however, to look at the boyfriend and be-
came wide-eyed and fearful when he entered the room. He, on the other hand, encouraged her to call him "Daddy" but she refused. When he left she told a nurse, "he burned me." When her real father arrived, she ira- . mediately smiled, wanted to be held, and asked him to take her home. The mother's reaction was one of anger and defensiveness with the staff. When she was told that her child had _ lost parts of eight toes, she shed no tears and said nothing.
Case Report Two A 15-month-old girl was admitted to the burn unit with a 30% scald burn on her buttocks, legs and feet. The distribution of the b u r n s was inconsist e n t with the mother's story. On the day after she was b u r n e d she had been taken, u n d e r an assumed name, to two physicians who instructed the mother to bring her to Children's Hospital. The mother was frightened because the child h a d b e e n discharged two weeks earlier with a broken arm. At that time, she had several scratches and bruises on her face and the possibility of child abuse had been mentioned. She took the child to a city 40 miles away where she was hospitalized under another assumed name and t h e n transferred to our burn unit. On the u n i t she rejected closeness to her mother and to the staff. Her muscles became rigid and she opened
Journal of the American College of Emergency Physicians
Nov/Dec 1974
her eyes in a fearful stare when anyone entered the room. She rarely,cried luring painful procedures. At first h e r tevelopment a p p e a r e d delayed, but after several weeks she began p l a y i n g with toys a p p r o p r i a t e for h e r age. The case was reported to the Children's Services Board which felt t h a t .!he m o t h e r would be responsible for :aring for t h e chl!d p r o v i d e d t h e y moved out of the home which t h e y shared with 13 other people, and a hew b a b y s i t t e r was found. The mother did move b u t continued to leave Lhe child with the b a b y s i t t e r who h a d been suspected of a b u s i n g her. A month after discharge, the child returned to t h e e m e r g e n c y d e p a r t ment dead on a r r i v a l . The cause of death w a s a r u p t u r e d l i v e r . T h e b a b y s i t t e r w a s c o n v i c t e d of m a n slaughter and was sent to the women's reformatory. The m o t h e r was acquitted on charges of neglect.
DISCUSSION ~dentification
History Of the specific historical factors t h a t suggest possible child abuse, the most easily recognizable is a discrepancy between the b u r n injury and the story. Either the original story m a y change or descriptions of the accident by different f a m i l y m e m b e r s m a y n o t match. There m a y be an inappropriate delay in s e e k i n g t r e a t m e n t , or a history of previous injuries. One child was a d m i t t e d twice for burns before she was nine months old.
Physical Findings Physical f i n d i n g s consistent w i t h intentional b u r n i n g include evidence of other injuries; characteristic b u r n distributions such as hands, feet, butrocks and perineum; "tub burns," and SUggestions of m a l n u t r i t i o n and neglect. B u r n s of the hands, feet or butt0eks a r e w o r t h y of special medical attention, since a very high percentage are inflicted i n t e n t i o n a l l y . Tub burns, especially deep scald burns with even !nargins on t h e b u t t o c k s , legs a n d Perineum, should arouse a high index of SUspicion.
NOV/Dec 1974
Emotional Responses
Documentation
A b u s e d c h i l d r e n have some emot i o n a l responses which are characteristic. Many are fearful of adults and often e x h i b i t a wide-eyed stare. This response has been observed by us in children as y o u n g as 11 months of age. They lie quietly d u r i n g the e x a m i n a tion a n d cry v e r y l i t t l e even when t r e a t m e n t is painful. Some refuse to look at t h e i r parents, or protest when p a r e n t s try to pick t h e m up, and look for comfort from s t a f f r a t h e r t h a n from the family. Some become e x t r e m e l y f e a r f u l a f t e r d o i n g s o m e t h i n g for which t h e y h a v e been p u n i s h e d at home, such as stoohng in t h e i r bed. Older children m a y say such things as, " M o m m y b u r n e d me because I was bad." Even children too young to t a l k are able to c o m m u n i c a t e t h e i r fears.
The i m p o r t a n c e of complete and acc u r a t e d o c u m e n t a t i o n c a n n o t be over-emphasized. Color photographs are invaluable and are routinely t a k e n of all b u r n e d children. It is not n e c e s s a r y to o b t a i n consent before t a k i n g pictures. C h a r t s showing the d i s t r i b u t i o n of the burn are e x t r e m e l y useful. X-rays of the skull and long bones are t a k e n of every child susp e c t e d of h a v i n g b e e n a b u s e d . A s u m m a r y of previous t r e a t m e n t for i n j u r i e s is a s s e m b l e d , i n c l u d i n g e m e r g e n c y d e p a r t m e n t records because before m a n y abused children require hospitalization, they have been t r e a t e d , sometimes repeatedly, for less severe injuries. Often the int e n t i o n a l n a t u r e of these lesser inj u r i e s become a p p a r e n t only in retrospect.
P a r e n t s , on the other hand, e i t h e r show false concern or no concern for the child's condition. Some expect the c h i l d to p e r f o r m i m p o s s i b l e t a s k s . P a r e n t s who were abused as children m a y r e p e a t the cycle by abusing t h e i r children. Immature, lonely, bored mothers with few outlets for the frust r a t m n s of p a r e n t h o o d are prime suspects as a b u s e r s , as are those who m a k e i n a p p r o p r i a t e ' b a b y s i t t i n g arrangements when they leave their children.
Procedure
Reporting E v e r y state h a s laws which require t h e r e p o r t i n g of suspected child abuse cases and protect those who do the rep o r t i n g from liability. In our facility, one social w o r k e r i n v e s t i g a t e d and reported all eases to the authorities. It is her r e s p o n s i b i l i t y to i n t e g r a t e t h e o b s e r v a t i o n s of t e a m m e m b e r s r e g a r d i n g the history, physical findings and behavior of the child and parents. She reports all suspicious cases to the J u v e n i l e B u r e a u of the Police D e p a r t m e n t a n d to t h e C h i l d r e n ' s Services Board. They perform t h e i r own i n v e s t i g a t i o n s and may i n s t i t u t e court action. It is necessary to develop a close w o r k i n g r e l a t i o n s h i p w i t h t h e s e a g e n c i e s in o r d e r to achieve p r o m p t and efficient protection of the children.
Counseling S i n c e o u r m a i n c o n c e r n is t h e child's safety, there is a need for the p a r e n t s to receive t h e r a p e u t i c counseling. The hospital social w o r k e r is the first to approach the family. Her approach should be n o n j u d g e m e n t a l a n d e m p a t h e t i c r a t h e r t h a n accusatory. She allows the parents to explore t h e i r feelings and helps t h e m define t h e i r problems. This p r e p a r e s t h e m for f u r t h e r counseling by herself, the C h i l d r e n ' s Services Board or m e n t a l h e a l t h f a c i l i t y . U n t i l a r e f e r r a l is m a d e to a n o t h e r agency, she r e m a i n s the p r i m a r y family worker.
Disposition The C h i l d r e n ' s Services Board or t h e Police D e p a r t m e n t i n i t i a t e d court action in 17 of our cases. A l t h o u g h occ a s i o n a l l y p h y s i c i a n s and others of t h e b u r n t e a m were called upon to testify, in most cases the entire burn t e a m was r e p r e s e n t e d m court by the social worker. Eleven children were r e m o v e d from the home. In each instance the court order called for ternp o r a r y removal, and eight c h i l d r e n have s u b s e q u e n t l y r e t u r n e d home. In three, the disposition m a y be p e r m a n e n t because the p a r e n t s a p p a r e n t l y are satisfied and do not w a n t the child r e n b a c k . Two c h i l d r e n w e r e ret u r n e d h o m e a f t e r the a b u s e r h a d
Journal of the American College of Emergency Physicians
Page 389
separated from the family unit. Four children are dead. In eight instances, no c o u r t a c t i o n w a s d e e m e d n e c e s sary.
BIBLIOGRAPHY Bowden ML, Feller I: Family reaction to a severe burn. A m J Nurs 73:317-319, 1973. D a n k e n b r i n g W: The growing tragedy of
Page 390
b a t t e r e d c h i l d r e n . The P l a i n T r u t h : p 37-40, July, 1971. Fontana VJ: Somewhere A Child Is Crying. New York, Macmillan Publishing Co., 1973. Helfer R, Kempe CH (eds)" Helpzng the Battered C h d d and His Famdy. Philadelphia, Lippincott Co., 1972. Hopkins J: The n u r s e and the abused child. N u r s Clan N o r t h A m 5:589-598,
1970. Morris MG, Gould RW, Matthews PJ: Toward prevention of child abuse. Children 11:55-59, 1964. O'Neill JA, Meacham WE, Griffin JP, et al: P a t t e r n s of injury in the battered child. J Trauma 13"332-339, 1973. Stone WH, Rinaldo L, H u m p h r e y CR, Brown RH: Child abuse by burning. Surg Clin North A m 50:1419-1424, 1970.
Journal of the American College of Emergency Physicians
Nov/Dec 1974
Patricia S. Phillips, RN* Elaine Pickrell, MSW** Thomas S. Morse, MD*** Columbus, Ohio
I n t e n t i o n a l b u r n i n g is a s e v e r e f o r m o f c h i l d a b u s e . D u r i n g a t h r e e y e a r p e r i o d , 25 a b u s e d c h i l d r e n w e r e a d m i t t e d to the b u r n u n i t of t h e Child r e n ' s H o s p i t a l , C o l u m b u s , Ohio. T h e y r e p r e s e n t e d 8% o f all b u r n e d child r e n a d m i t t e d d u r i n g this p e r i o d . F o u r o f t h e 25 a r e d e a d . T h e h a l l m a r k s o f i n t e n t i o n a l b u r n i n g i n c l u d e a s t o r y w h i c h d o e s n o t e x p l a i n the w o u n d , p r e v i o u s or c o e x i s t a n t injuries, s p e c i f i c b u r n p a t t e r n s a n d c h a r a c t e r i s t i c b e h a v i o r of p a r e n t s a n d c h i l d r e n . S u s p e c t e d c a s e s m u s t b e r e p o r t e d , the child p r o t e c t e d a n d the p a r e n t s h e l p e d . Child a b u s e t e n d s to b e r e p e a t e d w i t h p r o g r e s s i v e l y s e v e r e a t t a c k s , o f t e n e n d i n g in d e a t h .
INTRODUCTION Child abuse tends to be repetitive, w i t h p r o g r e s s i v e l y severe a t t a c k s , often e n d i n g in death. I n t e n t i o n a l b u r n i n g is a severe form of child abuse. T h r e e h u n d r e d a n d t w e l v e children were admitted to the b u r n u n i t of Children's Hospital, Columbus, Ohio, d u r i n g the three year period, 1971 t h r o u g h 1973. Twenty-five, or 8%, were b u r n e d i n t e n t i o n a l l y , and of these 25, 4 are dead. As our b u r n t e a m b e c a m e more a w a r e of child abuse, it dealt more effectively with the i n t e n t i o n a l l y b u r n e d child. ~Department of Nursing and ~ '~Department of Social Services, Children's Hospital; ***Division of Pediatric Surgery, Department of Surgery, Ohio State University College of Medicine, Columbus, Ohio. Presented at the Fourth Annual UA/EMS Meeting in Dallas, Texas, May, 1974. Address for reprints: Thomas S. Morse, MD, Division of Pediatric Surgery, Chi]dren's Hospital, 561 S 17th Street, Columbus, Ohio 43205.
Page 388
The t e a m includes physicians, nurses, a social worker, physical and occupat i o n a l therapists, a c h a p l a i n and a teacher, all of whom are able to identify the indications of abuse or neglect. The f o l l o w i n g Case Reports describe typical examples of i n t e n tional b u r n i n g of children.
Case Report One A three-year-old girl was admitted with second and third degree b u r n s on her feet, buttocks and perineum. She also had a bruise on her left arm and a pinch m a r k on her neck. While the mother was at work, her boyfriend was b a t h i n g the child. Allegedly, he a n s w e r e d the phone a n d the child t u r n e d the hot water on herself. Because the story and the b u r n did not m a t c h , a n d b e c a u s e b r u i s e s were present, the proper authorities were notified. In the hospital, the child showed no fear of the staff and interacted well with her mother. She refused, however, to look at the boyfriend and be-
came wide-eyed and fearful when he entered the room. He, on the other hand, encouraged her to call him "Daddy" but she refused. When he left she told a nurse, "he burned me." When her real father arrived, she ira- . mediately smiled, wanted to be held, and asked him to take her home. The mother's reaction was one of anger and defensiveness with the staff. When she was told that her child had _ lost parts of eight toes, she shed no tears and said nothing.
Case Report Two A 15-month-old girl was admitted to the burn unit with a 30% scald burn on her buttocks, legs and feet. The distribution of the b u r n s was inconsist e n t with the mother's story. On the day after she was b u r n e d she had been taken, u n d e r an assumed name, to two physicians who instructed the mother to bring her to Children's Hospital. The mother was frightened because the child h a d b e e n discharged two weeks earlier with a broken arm. At that time, she had several scratches and bruises on her face and the possibility of child abuse had been mentioned. She took the child to a city 40 miles away where she was hospitalized under another assumed name and t h e n transferred to our burn unit. On the u n i t she rejected closeness to her mother and to the staff. Her muscles became rigid and she opened
Journal of the American College of Emergency Physicians
Nov/Dec 1974
her eyes in a fearful stare when anyone entered the room. She rarely,cried luring painful procedures. At first h e r tevelopment a p p e a r e d delayed, but after several weeks she began p l a y i n g with toys a p p r o p r i a t e for h e r age. The case was reported to the Children's Services Board which felt t h a t .!he m o t h e r would be responsible for :aring for t h e chl!d p r o v i d e d t h e y moved out of the home which t h e y shared with 13 other people, and a hew b a b y s i t t e r was found. The mother did move b u t continued to leave Lhe child with the b a b y s i t t e r who h a d been suspected of a b u s i n g her. A month after discharge, the child returned to t h e e m e r g e n c y d e p a r t ment dead on a r r i v a l . The cause of death w a s a r u p t u r e d l i v e r . T h e b a b y s i t t e r w a s c o n v i c t e d of m a n slaughter and was sent to the women's reformatory. The m o t h e r was acquitted on charges of neglect.
DISCUSSION ~dentification
History Of the specific historical factors t h a t suggest possible child abuse, the most easily recognizable is a discrepancy between the b u r n injury and the story. Either the original story m a y change or descriptions of the accident by different f a m i l y m e m b e r s m a y n o t match. There m a y be an inappropriate delay in s e e k i n g t r e a t m e n t , or a history of previous injuries. One child was a d m i t t e d twice for burns before she was nine months old.
Physical Findings Physical f i n d i n g s consistent w i t h intentional b u r n i n g include evidence of other injuries; characteristic b u r n distributions such as hands, feet, butrocks and perineum; "tub burns," and SUggestions of m a l n u t r i t i o n and neglect. B u r n s of the hands, feet or butt0eks a r e w o r t h y of special medical attention, since a very high percentage are inflicted i n t e n t i o n a l l y . Tub burns, especially deep scald burns with even !nargins on t h e b u t t o c k s , legs a n d Perineum, should arouse a high index of SUspicion.
NOV/Dec 1974
Emotional Responses
Documentation
A b u s e d c h i l d r e n have some emot i o n a l responses which are characteristic. Many are fearful of adults and often e x h i b i t a wide-eyed stare. This response has been observed by us in children as y o u n g as 11 months of age. They lie quietly d u r i n g the e x a m i n a tion a n d cry v e r y l i t t l e even when t r e a t m e n t is painful. Some refuse to look at t h e i r parents, or protest when p a r e n t s try to pick t h e m up, and look for comfort from s t a f f r a t h e r t h a n from the family. Some become e x t r e m e l y f e a r f u l a f t e r d o i n g s o m e t h i n g for which t h e y h a v e been p u n i s h e d at home, such as stoohng in t h e i r bed. Older children m a y say such things as, " M o m m y b u r n e d me because I was bad." Even children too young to t a l k are able to c o m m u n i c a t e t h e i r fears.
The i m p o r t a n c e of complete and acc u r a t e d o c u m e n t a t i o n c a n n o t be over-emphasized. Color photographs are invaluable and are routinely t a k e n of all b u r n e d children. It is not n e c e s s a r y to o b t a i n consent before t a k i n g pictures. C h a r t s showing the d i s t r i b u t i o n of the burn are e x t r e m e l y useful. X-rays of the skull and long bones are t a k e n of every child susp e c t e d of h a v i n g b e e n a b u s e d . A s u m m a r y of previous t r e a t m e n t for i n j u r i e s is a s s e m b l e d , i n c l u d i n g e m e r g e n c y d e p a r t m e n t records because before m a n y abused children require hospitalization, they have been t r e a t e d , sometimes repeatedly, for less severe injuries. Often the int e n t i o n a l n a t u r e of these lesser inj u r i e s become a p p a r e n t only in retrospect.
P a r e n t s , on the other hand, e i t h e r show false concern or no concern for the child's condition. Some expect the c h i l d to p e r f o r m i m p o s s i b l e t a s k s . P a r e n t s who were abused as children m a y r e p e a t the cycle by abusing t h e i r children. Immature, lonely, bored mothers with few outlets for the frust r a t m n s of p a r e n t h o o d are prime suspects as a b u s e r s , as are those who m a k e i n a p p r o p r i a t e ' b a b y s i t t i n g arrangements when they leave their children.
Procedure
Reporting E v e r y state h a s laws which require t h e r e p o r t i n g of suspected child abuse cases and protect those who do the rep o r t i n g from liability. In our facility, one social w o r k e r i n v e s t i g a t e d and reported all eases to the authorities. It is her r e s p o n s i b i l i t y to i n t e g r a t e t h e o b s e r v a t i o n s of t e a m m e m b e r s r e g a r d i n g the history, physical findings and behavior of the child and parents. She reports all suspicious cases to the J u v e n i l e B u r e a u of the Police D e p a r t m e n t a n d to t h e C h i l d r e n ' s Services Board. They perform t h e i r own i n v e s t i g a t i o n s and may i n s t i t u t e court action. It is necessary to develop a close w o r k i n g r e l a t i o n s h i p w i t h t h e s e a g e n c i e s in o r d e r to achieve p r o m p t and efficient protection of the children.
Counseling S i n c e o u r m a i n c o n c e r n is t h e child's safety, there is a need for the p a r e n t s to receive t h e r a p e u t i c counseling. The hospital social w o r k e r is the first to approach the family. Her approach should be n o n j u d g e m e n t a l a n d e m p a t h e t i c r a t h e r t h a n accusatory. She allows the parents to explore t h e i r feelings and helps t h e m define t h e i r problems. This p r e p a r e s t h e m for f u r t h e r counseling by herself, the C h i l d r e n ' s Services Board or m e n t a l h e a l t h f a c i l i t y . U n t i l a r e f e r r a l is m a d e to a n o t h e r agency, she r e m a i n s the p r i m a r y family worker.
Disposition The C h i l d r e n ' s Services Board or t h e Police D e p a r t m e n t i n i t i a t e d court action in 17 of our cases. A l t h o u g h occ a s i o n a l l y p h y s i c i a n s and others of t h e b u r n t e a m were called upon to testify, in most cases the entire burn t e a m was r e p r e s e n t e d m court by the social worker. Eleven children were r e m o v e d from the home. In each instance the court order called for ternp o r a r y removal, and eight c h i l d r e n have s u b s e q u e n t l y r e t u r n e d home. In three, the disposition m a y be p e r m a n e n t because the p a r e n t s a p p a r e n t l y are satisfied and do not w a n t the child r e n b a c k . Two c h i l d r e n w e r e ret u r n e d h o m e a f t e r the a b u s e r h a d
Journal of the American College of Emergency Physicians
Page 389
separated from the family unit. Four children are dead. In eight instances, no c o u r t a c t i o n w a s d e e m e d n e c e s sary.
BIBLIOGRAPHY Bowden ML, Feller I: Family reaction to a severe burn. A m J Nurs 73:317-319, 1973. D a n k e n b r i n g W: The growing tragedy of
Page 390
b a t t e r e d c h i l d r e n . The P l a i n T r u t h : p 37-40, July, 1971. Fontana VJ: Somewhere A Child Is Crying. New York, Macmillan Publishing Co., 1973. Helfer R, Kempe CH (eds)" Helpzng the Battered C h d d and His Famdy. Philadelphia, Lippincott Co., 1972. Hopkins J: The n u r s e and the abused child. N u r s Clan N o r t h A m 5:589-598,
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Journal of the American College of Emergency Physicians
Nov/Dec 1974