The sixtieth anniversary of the “Battered Child Syndrome”

Howard Fischer
Uppsala, Sweden

 

child abuse head trauma x-ray
An intraparenchymal bleed with overlying skull fracture from abusive head trauma. May 29, 2016. James Heilman, MD, via Wikimedia. CC BY-SA 4.0.

“The more original a discovery, the more obvious it seems afterward.”
— Arthur Koestler, novelist and journalist

 

In 1962, Dr. C. Henry Kempe and colleagues at the University of Colorado School of Medicine in Denver published their groundbreaking article, “The Battered Child Syndrome,” in the Journal of the American Medical Association.1 The article alerted American physicians to the prevalence of the problem of child abuse and eventually produced a change in physician attitudes and practices.

Born Karl Heinz Kempe, he was fifteen years old in 1937 when he fled his native Germany. He studied medicine at the University of California School of Medicine at San Francisco. His pediatric residency was interrupted when he was recruited to serve as an assistant in virology at the US Army Medical Research and Graduate School in Washington, D.C. for two years. He then completed his residency. In 1956, at the age of thirty-four, Kempe became the youngest chief of the department of pediatrics at the University of Colorado School of Medicine.2 His interests were viral diseases and antiviral vaccines.

The history of medical interest in child abuse may have started in 1860, when Dr. Ambroise Tardieu, a French forensic physician, published a report on the physical maltreatment of children.3 This article produced little interest and did not stimulate further research or reports. After a dormant century, interest in childhood injuries started again in the second half of the twentieth century. Reports of infants with subdural hematomas (bleeding under the meninges covering the brain) and long bone fractures appeared in 1946 and 1950. The cause of the bleeding and the fractures was “not known.” Silverman4 in 1953 wrote that these fractures were “manifestations of unrecognized skeletal trauma.”

In 1955, Paul V. Woolley Jr. (who was one of my teachers), and William Evans5 suggested that the long bone fractures in infants were the result of the “indifference, immaturity, and irresponsibility of parents.” They did not speculate any further, nor did they clearly state that these were inflicted injuries. John Caffey in 1957 stated that these were deliberately inflicted injuries.6 Between 1956 and 1962, at least ten medical reports were published stating that children were being seen with inflicted injuries. Many of these articles were in radiology journals.

In 1962, 100 years after Tardieu’s publication, C. Henry Kempe, along with a pediatric radiologist, a psychiatrist, and an obstetrician-gynecologist published “The Battered Child Syndrome.” This paper “medicalized” the physical abuse of children. The condition had physical and radiological findings, and possibilities for treatment. It became a “condition,” like others treated by physicians. The article was endorsed by the editorial board of the Journal.7

Kempe defined the battered child syndrome as a “clinical condition in young children who have received serious physical abuse and is a frequent cause of permanent injury or death.” The syndrome should be considered in a child with a bone fracture, subdural bleeding, failure-to-thrive (meaning lower than expected weight gain), swelling, bruising, sudden death, or where the history and the physical findings are discordant.

“Physicians have a duty and responsibility to the child to require a full evaluation of the problem and to guarantee that no repetition of trauma will be permitted to occur,” wrote Kempe.8 The article discusses a survey of seventy-one hospitals. During one year, 302 cases of child abuse were suspected, with thirty-three deaths and eighty-five children left with permanent brain injuries. Most of the children were younger than three years of age. There was frequently a discrepancy between the history given for the injury and the physical examination. The authors stated that physicians had not learned about child abuse during residency training, that they have “emotional unwillingness to consider child abuse,” and that they do not want to be “policemen or district attorneys.”

Child maltreatment, the article pointed out, occurs in all socioeconomic groups and in families with differing educational attainments. Physicians are encouraged to ask the parents about their own childhoods, to try and be helpful to parents, and to be nonjudgmental. The ten-page article has five pages of X-ray images and their explanations, as well as differential diagnoses. Physicians are required to report suspicions to the police or child protective services, if such an entity exists in the community.

Dr. Kempe and his wife, psychiatrist Dr. Ruth Kempe, in 1972 started the National Center for Treatment and Prevention of Child Abuse and Neglect as part of the department of pediatrics at the University of Colorado School of Medicine. This later became the Kempe Center.9 The mission of the Kempe Center10 is to:

  1. Evaluate and diagnose suspected victims of child abuse and neglect.
  2. Provide treatment for these children and their parents.
  3. Develop and test new programs to help children.
  4. Teach professionals to protect and heal abused children and support parenting skills.
  5. Conduct studies that assist in public policy.

Since the 1962 article, physicians and other professionals who deal with children have become obligatory (“mandated”) reporters of suspected child abuse or neglect. Residency programs include education about the condition. National and international organizations and journals have been created to stimulate research and disseminate knowledge about child abuse. Conferences are held worldwide on child abuse and neglect, and the American Board of Pediatrics has recognized child protection pediatrics as a pediatric subspeciality. In 1979, Sweden made it a crime to physically punish children. Thirty-three countries have followed Sweden’s lead.11

In the US, 4.3 million children are referred yearly for suspected child abuse or neglect. Confirmed victims in 2019 numbered 656,000 with 1,840 deaths, the majority in children younger than three years.12 Still, “Millions of children…are benefiting and shall benefit from Dr. Kempe’s admirable foresight…and powerful leadership. Henry Kempe succeeded in being what he wanted to be: a true benefactor of mankind.”13

 

References

  1. Charles Kempe, Frederic Silverman, Brandt Steele et al. “The Battered Child Syndrome,” JAMA, 181, 1962.
  2. Pierre Ferrier. “C. Henry Kempe Remembered,” Child Abuse Negl, 9, 1985.
  3. Ambroise Tardieu. “Etude médico-légale sur les sévices et mauvais traitements exercés sur des enfants,” Annales Hyg Publ et Méd Légale,13, 1860.
  4. Frederic Silverman. “Roentgen manifestations of unrecognized skeletal trauma in infants,” Am J Roentg, 69, 1953.
  5. Paul Woolley Jr. and William Evans. “Significance of skeletal lesions in infants resembling those of traumatic origin,”JAMA, 158, 1955.
  6. John Caffey. “Some traumatic lesions in growing bones other than fractures and dislocations,” Br J Radiol, 30, 1957.
  7. Stephen Pfohl. “The ‘discovery’ of child abuse,” Soc Prob, 24(3), 1977.
  8. Kempe. “Battered Child.”
  9. Andrew Rowland. “Our children’s future and the world’s future are one (Henry Kempe 1922-1984,” Dr. Andrew Rowland: Churchill fellow of the Winston Churchill Memorial Trust, 2014.
  10. Rowland. “Our children’s.”
  11. Larry Wolf. “The Battered Child Syndrome: 50 years later,” HuffPostLife, 2013. huffpost.com
  12. NA. “Child Abuse Statistics,” childhelp, ND.
  13. Ferrier. “Remembered.”

 


 

HOWARD FISCHER, M.D., was a professor of pediatrics at Wayne State University School of Medicine, Detroit, Michigan. He was medical director of the Child Protection Team at Children’s Hospital of Michigan in Detroit for fourteen years. He is the co-editor of a textbook on child abuse and neglect.

 

Winter 2022  |  Sections  |  Doctors, Patients, & Diseases