Distinct age‐related differences among victims in cases of suspected child abuse

Evidence describing age‐related differences among children with suspected physical and sexual child abuse is lacking. We describe findings in severe cases of suspected abuse. Cases with 756 children <15 years old were included during 2001–2013 at the Department of Forensic Medicine, Aarhus University, using forensic evaluation documents, medical records, and court proceedings. Eight percent of children <4 years old died from child abuse, 36% through violence resulting in death, and 64% by manslaughter, whereas 1% > 4 years old died, solely by manslaughter. External injuries were mainly located to head and torso in children <4 years old, changing to the upper and lower extremities in older children. Child sexual abuse was suspected in 52% of cases with living children <4 years old, 83% of children 4–7 years of age, 88% of children 8–11 years of age, and 93% of children >12 years old. Anogenital findings were mainly caused by other medical conditions in children <4 years old, hymenal clefts in the superior half of the hymenal rim were almost exclusively found in children between 8 and 11 years of age, whereas both superficial and complete hymenal clefts in the inferior half of the hymenal rim were found in children >12 years old. The present study describes age‐related differences in victims of suspected child abuse. Fatal versus nonfatal child physical abuse and the significance of hymenal findings in child sexual abuse could be studied further.


| INTRODUC TI ON
Child abuse represents a severe childhood trauma and bears a risk of death [1] or adverse consequences throughout the lifetime, including adverse effects on self-worth [2].V. J. Felitti's seminal Adverse Childhood Experiences study (ACE) described adverse consequences of abuse, focused on the association between health risks and illness in adulthood and exposure to adverse childhood experiences [3].ACE studies have found that child abuse leads to adverse effects on externalizing and internalizing behavior among juveniles [4] and has a major impact on mental health in adulthood, including increased risk of severe depression, anxiety, suicidal thoughts and attempts, and alcohol and substance abuse [5,6].ACEs also negatively affect the risk of delinquency [7], partly mediated by a strengthening of psychopathic features [8].Recent evidence emphasizes this by showing a synergistic increase in adversity of outcomes among children exposed to multiple types of abuse [9].Accordingly, continuing research into child abuse is warranted as this could improve clinical detection and, in turn, early intervention.
Child physical abuse can be defined as any bodily injury inflicted on a child, which based on the severity of the assault will give rise to a variety of clinical manifestations.Child physical abuse is prevalent with a survey-based, self-reported international prevalence of 22.6% [10], and a Danish prevalence of 22% [11], with the Danish prevalence including corporal punishment, illegal under Danish law [12].A distinct discrepancy between the clinical findings and the mechanism of injury explained should always give rise to a serious medical suspicion of child abuse [13,14].Under extreme circumstances, physical abuse results in child abuse homicide.For children under the age of 3 years in particular, abusive head trauma occurring through battering or shaking has been found to be the most common cause of death, with inconsolable crying identified as the main trigger [15,16].Future severe or lethal incidents of physical child abuse may be prevented by early intervention, and this is facilitated by clinical knowledge of expected findings in different age groups.
Child sexual abuse can be broadly defined as any involvement of a child in sexual activity that the child does not fully comprehend, for which the child is not developmentally prepared, or which violates national laws.Child sexual abuse is also prevalent with a surveybased, self-reported international prevalence of 7.6% for males and 18.0% for females [17], and a Danish prevalence of child sexual abuse of 7% among males and 16% among females [18].
Many types of sexual contact do not cause apparent physical injury, and especially injuries to the anogenital tissue heal rapidly and often completely.Consequently, only 4%-5% of children undergoing a forensic medical examination on suspicion of child sexual abuse have abnormal findings [19].In this context, it is important to be able to differentiate between normal anatomical variations and residues of anogenital manipulation [20][21][22].To guide clinical attention, clinical knowledge of the expected findings in different age groups would be beneficial.
With attention to the age of the child, distinct differences have been noticed in the literature regarding child abuse.Most fatalities from abuse happen among young children [23], with the risk of lethal physical abuse peaking among children between 0 and 3 years [24].In child sexual abuse cases, abnormal findings with complete hymenal clefts are most often found in older children [25][26][27].
Knowledge of age-related differences in findings helps inform the clinical examination.Also, age differences are useful for targeting initiatives for the management of child abuse cases.However, to the best of our knowledge, studies describing age differences in findings among abuse cases are lacking.
This study aimed to describe age-related differences in findings among the cases of suspected child physical and sexual abuse examined in our Department of Forensic Medicine.

| Case procedure
For each case of suspected abuse reported to the police, as part of the subsequent criminal investigation, the police are obliged to decide whether they consider a forensic medical examination of the child necessary.The police base their decision on the relevance of the forensic opinion and law, stating that such an examination can only take place based on the consent of the victim [28].The children seen by a forensic medical examiner are thus a highly selected group within the area of child abuse.

| The forensic medical examination in Denmark
The forensic medical examination in Denmark is performed by a forensic medical examiner, supervised by a senior colleague.Interpretation, including pattern recognition, and documentation of injuries are included, along with detection, collection, and preservation of possible DNA evidence [29].
If the child is deceased, an autopsy will be performed, consisting of a thorough combined external as well as internal bodily examination.Attention will be directed to injuries or alterations to the body deemed to be the possible cause of death.Additional • Anogenital findings among children less than 4 years old were mainly caused by other medical conditions.
• Clefts in the superior half of the hymenal rim were found mainly among children 8-11 years old.
• Clefts in the inferior half of the hymenal rim were found in children older than 12 years of age.observation, and protection is also recommended, under which mandatory notification to social services must be made [30,31].
If suspicion of child sexual abuse has been presented by either the medical history, the police, or the forensic medical examiner, a supplementary anogenital examination will be performed.The suspicion of child sexual abuse may arise from the child's statements or behaviors, or from other findings.The anogenital examination varies according to the perceived sexual activity of the child.If the child has not yet had their first voluntary sexual experience, a colposcopy will be performed, whereas after the sexual debut a regular gynecological examination is preferred.
In 1992, a standardized classification system emerged to establish consensus about the assessment of anogenital colposcopic findings.The system, later known as the "Adams Classification System," was developed using published data on both abused and nonabused children.Since then, the system has been revised continuously [32].
Occasionally, the police will request a forensic opinion report rather than having the child forensically examined.It usually relates to cases involving children previously examined by a pediatrician, where a forensic assessment is deemed necessary.The assessment will then be based on medical records including the pediatrician's observations.Data from such opinions were also included here.

| The present study
The study cohort consists of all children under the age of 15 years, suspected of being a victim of child abuse, on whom the police requested a forensic medical examination during the period from November 1, 2001, to October 31, 2013, covering 12 years.All examinations were from the Department of Forensic Medicine in Aarhus, Denmark, which serves an area of Jutland with approximately 2.5 million inhabitants, of whom 0.5 million are children under the age of 15 years [33].
Data on each case were extracted solely by the first author of this article, using medical records, forensic evaluation documents, police reports with the inclusion of information on the interrogation of the child and the alleged perpetrator as well as other relevant witnesses, court documents containing expert opinion reports, forensic psychiatric evaluations, and information about the court proceedings including the judicial decisions.
In the present study, suspected abuse is classified according to the Danish Penal Code and categorized into child physical abuse, including child abuse homicide, here defined as all deaths resulting from intentional injuries, and child sexual abuse [34].
• Internal injuries, assorted into fractures, cerebral hemorrhages, retinal hemorrhages, trauma to the oral cavity, and internal organ injuries.
• Anogenital findings, pursuant to the "Adams Classification System" further arranged into normal variants, findings commonly caused by medical condition, indeterminate findings, findings diagnostic of trauma or sexual contact, findings indicative of blunt force penetrating trauma, and presence of infection confirming mucosal contact [35].
The cohort was divided into four age groups:

| Statistical analyses
The data were entered into the data entry system REDCap (Van- The results are mainly presented as numbers (n) and percentages (%) of children, as well as mean and median values with standard deviations (SD).Differences were tested for significance using the chi-squared test, where results with p-values <0.05 were considered to be statistically significant.For tables containing counts less than five, Fisher's exact test was used.

| Reproducibility
Although different forensic medical examiners have performed the forensic medical examinations, the same senior colleague, a coauthor of this article, has supervised all cases included in the study.

| Presentation of the study cohort and suspicions of abuse
A total of 739 children under the age of 15 years were included during the 12-year study period.Of these, one child was included three times and 15 children twice, totaling 756 case descriptions, the majority of which described females (78%).Mean and median age of the child at police notification was 8.9 (

| Autopsy cases
Nineteen of the 756 cases included in the study were deceased.The majority (74%) were less than 4 years old (p < 0.001, Fisher's exact test), with more than half of them (68%) being male children.Independent of age and gender, the preponderant manner of death was manslaughter (intended homicide), whereas violence resulting in death exclusively involved male children under the age of 4 years (in addition see Table 2).
In most cases, the autopsy was performed within 24-72 h from the latest known suspected abusive event.External injuries were detected in 18 of the 19 autopsies, largely comprised of bruises (53%) and abrasions (46%), predominantly localized to the head and neck area, as well as to the lower extremities.Overall, internal injuries were found in 16 of the 19 autopsies, 26% had bone fractures, mainly costal, 26% had cerebral hemorrhages, both subdural and subarachnoid, of which all were found to have retinal hemorrhages as well, 16% had lip frenulum tears, and 79% had internal organ injuries, primarily cerebral and thoracic.Cerebral and retinal hemorrhages, as well as cerebral and abdominal internal organ injuries, were found only to be present in autopsies of children under the age of 4 years.
The final cause of death was found to be either strangulation or drowning in the majority (86%) of cases with manslaughter as the manner of death, whereas cerebral incarceration was the preponderant (80%) cause of death in cases of violence resulting in death.

| Clinical forensic examination cases
Of the 737 case descriptions of living children in the study, 689 (93%) described a forensic medical examination.Half of the examinations were completed within the first 24 h (31%) or 24-72 h (16%) from latest known assault.Having the examination performed within the first 24 h was more frequent among children over the age of 12 years (p < 0.001, chi-squared test).
A substantial part of the children (72%) was found to have external injuries, predominantly in the form of bruises (43%) and abrasions (37%), regardless of age (Table 3).A minority of the children (4%) had internal injuries, primarily in the form of trauma to the oral cavity (26%), mainly lip frenulum tears, and bone fractures (24%), mainly in the skull or lower leg (Table 4).

Child abuse homicide
Violence resulting in death < 0.001 Other sexual activity ( Pornographic photo/movie recordings a Missing = 2 (in the age specification grouping).

| Forensic opinion report cases
In 48 (7%) of the 737 cases with living children, a forensic opinion report was requested.The majority (71%) were children under the age of 4 years, previously medically examined by a pediatrician (91%) or in the emergency department (9%).
Based on received medical records, 46% of the children had external injuries, mainly bruises (87%) located primarily to the head (33%) or torso (28%).Internal injuries were found in 21 (44%) of the cases, 20 of which were cases involving children under the age of 4 years; 33% had bone fractures, mainly costal, humerus, or femur, 10% had cerebral hemorrhages, primarily subdural, of which 60% had retinal hemorrhages as well, 2% had lip frenulum tears, and 15% had internal organ injuries, of which the majority were cerebral.
Upper extremities Lower extremities (32) Note: External injuries in the form of lacerations, sharp force trauma, gunshot trauma, and burns totaled merely 1% and will not be included here.a Missing = 2 (in the age specification grouping).
b Missing = 1 (in the age specification grouping).
by cerebral incarceration due to both subdural and subarachnoid hemorrhages, as well as cerebral organ injuries, whereas manslaughter mainly was conducted by strangulation or drowning.
The finding that younger children, especially males, are at higher risk of fatal child abuse, corresponds to a previous study by Douglas et al. 2014 [23].The discovery in the present study of manslaughter as the predominant manner of death regardless of age is, however, in contrast to the findings by Kajese et al. 2011, where two-thirds of the fatalities were considered to be the result of violence, resulting in death mainly caused by abusive head trauma, and one-third was identified as manslaughter [16].Even though the number of child abuse homicides in the present study is low, it cannot be excluded that fatalities due to violence resulting in death are being overlooked in the Danish judiciary.
Nonetheless, differences may also reflect the underlying incidence.In a previous German study by Bajanowski et al. 2005, it was found that 5% of children autopsied under suspicion of sudden infant death syndrome were determined to have died from unnatural causes, of which 41% was due to head injuries [36].Thus, the implementation of a death scene investigation could be considered, as explained by Rognum et al.
2010 [37].Making it a statutory obligation to review the death of every child under the age of 4 years would increase the chances of obtaining corroborating evidence, correctly determining the cause of death and, furthermore, provide just treatment for both child and family.Additionally, the bereaved families could be supported in coping with the unexpected death of a child, as explained by Heltne et al. 2016 [38].

| Child physical abuse
In the present study, child physical abuse was suspected in 40% of histopathological examinations, along with microbiological, biochemical, and toxicological analyses, are also performed.Prior to the autopsy, the body is CT-scanned, as well as x-ray photographed on clinical indication.If the child is alive, a detailed external bodily examination is performed.The focus is aimed at injuries or alterations to the body that could support or weaken the suspicion of child abuse.On clinical indication, additional microbiological, biochemical, and toxicological analyses are completed.During the evaluation of child physical abuse cases, pediatric specialists are consulted.Since 1985, Danish pediatric guidelines regarding cases of child abuse have existed, and today, these guidelines are national.The recommendations include color photographs of possible injuries, blood tests, eye examination including ophthalmoscopy, neuroimaging for all children under the age of 2 years as well as for older children on clinical indication, and a complete body x-ray for children under the age of 2 years.Getting the child hospitalized for diagnosis, 11 years, and • 12-15 years of age.
University, 1207 17th Avenue South, Suite 105, Nashville, Tennessee 37212, USA) by the first author of this article and analyzed using the statistical program STATA (version 13.1, StataCorp LLC, 4905 Lakeway Drive, College Station, Texas 77845-4512, USA).

TA B L E 2
Characteristics of the presumed abuse, based on information from the police report.

c
If the child and the alleged offender do not share the same residence.other medical conditions (29%) largely in the younger age groups (p < 0.001, Fisher's exact test).Clefts in the superior half of the hymenal rim were found in 12% of children 8-11 years old and were absent in other age groups except 1% of 12-to 15-year-olds.Superficial hymenal clefts in the inferior half of the hymenal rim were absent in children under the age of 4 years, while it was the dominant (55%) normal variant in children over the age of 12 years.Likewise, deep hymenal clefts in the inferior half of the hymenal rim, as well as acute partial or complete hymenal laceration, were only represented in children over the age of 8 years (Table In 10 cases (21%), suspicion of child sexual abuse prompted a supplementary anogenital examination in the form of a colposcopy, the majority (60%) being children under the age of 4 years.Anamnestic, all the children were Tanner Stage I, without either menarche or sexual debut.In 7 cases, anogenital findings were documented, TA B L E 3 External injuries, detected on living children attending a forensic medical examination.
cases with living children under the age of 4 years.For children over the age of 4 years, a significant decrease was discovered, with only 16% of children 4-7 years of age and 7% of children over the age of 12 years suspected of being exposed to physical assaults.External injuries, predominantly bruises, were found in 72% of the forensic medical examinations and described in 46% of the forensic opinion reports.Head and torso were the dominant location for bruises in children under the age of 4 years, whereas it changed to the upper and lower extremities in older children.Internal injuries were largely detected in children under the age of 4 years, most frequently bone fractures, cerebral hemorrhages, and cerebral organ injuries.In accordance with the findings depicted in the present study for child abuse homicide, younger children are more often exposed to physical abuse.As described in Glick et al. 2016, infants have the highest victimization rate, whereas children under the age of 3 years have the highest fatality rate.To recognize minor injuriesas possible antecedent sentinel injuries may prove to be lifesaving for children exposed to child physical abuse[39].According toChristian et al. 2015, bruises are the most common and readily visible injuries due to child physical abuse[40].This corresponds to the discovery in the present study, with bruises being the predominant type of external injuries in children exposed to child physical abuse.Unfortunately, bruises are missed as sentinel injuries in almost half of fatal and near-fatal abusive events[40].Accidental bruising tends to occur over bony prominences, whereas bruises due to child physical abuse are more often located to the face, head, neck, torso, flanks, buttocks, and thighs[39], which resembles the location of bruises found in children under the age of 4 years in the present study.