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J Fam Viol (2010) 25:165
172
DOI 10.1007/s10896-009-9280-1
–
ORIGINAL ARTICLE
Characteristic Features of Severe Child Physical Abuse
—
A
Multi-informant Approach
Eva -Maria Annerbäck
&
Carl -Göran Svedin
&
Per A. Gustafsson
Published online: 10 November 2009
#
Springer Science + Business Media, LLC 2009
Abstract Minor child physical abuse has decreased in
Sweden since 1979, when a law banning corporal punish-
ment of children was passed, but more serious forms have
not decreased. The aim of this study was to examine risk
and background factors in cases of severe child abuse
reported to the police. Files from different agencies (e.g.,
Social services, Adult and Child psychiatry and Pediatric
clinic) for 20 children and 34 caretakers were studied. An
accumulation of risk factors was found. It is concluded that
when the following four factors are present, there is a risk
for severe child abuse: 1) a person with a tendency to use
violence in conflict situations; 2) a strong level of stress on
the perpetrator and the family; 3) an insufficient social
network that does not manage to protect the child; 4) a
child that does not manage to protect him or herself. Thus,
multiple sources of information must be used when
investigating child abuse.
violence in bringing up children have changed markedly
since the law was passed. (Allmänna barnhuset
2007
;
Statens offentliga utredningar [SOU]
2001
:18; SOU
2001
:72). Studies show that there has been a significant
decrease in minor abuse and corporal punishment, however
there has been no corresponding decrease in the more
serious forms of child abuse that result in bodily injury
(Gelles and Edfeldt
1986
; SOU
2001
:18; SOU
2001
:72). A
national Swedish study documented that the percentage of
children who have at some time been subjected to severe
abuse has remained stable at about 3
4% since the 1980s
(Allmänna barnhuset
2007
). Severe abuse and minor abuse
seem in this respect to be completely different phenomena
controlled by different factors. In an investigation of all
cases of child abuse reported to the police in a single police
district, severe abuse cases constituted 14% of the total
(Annerbäck et al.
2007
). The most obvious difference
between the cases of severe respectively minor abuse in the
study was the occurrence of documented injuries in the
severe cases. The severe cases had a significantly higher
proportion of lowest socio-economic status and a tendency
to higher levels of unemployment and foreign born parents.
The children who had 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 have been presented as minor abuse.
Cases of the more severe types of abuse apparently occur in
a context where efforts to prevent abuse that follow a
standard model apparently have no effect. Therefore, one
must have better knowledge of the underlying factors in
order to be able to design preventive measures created for,
and aimed at, specific risk groups (Hornor
2005
). It is a
paradox that the number of cases of suspected child abuse
reported to the police has increased by a factor of four
during the period 1980
–
Keywords Child physical abuse
.
Severe
.
Social services
.
Reports
.
Sweden
In 1979, Sweden passed a new law banning corporal
punishment of children, the first country in the world to do
so. Attitudes toward physical punishment and the use of
:
C. -G. Svedin
:
P. A. Gustafsson
Child & Adolescent Psychiatry, Department of Clinical
and Experimental Medicine, Faculty of Health Sciences,
Linköping University,
Linköping, Sweden
E. -M. Annerbäck
E. -M. Annerbäck (
)
Child & Adolescent Psychiatry, Department of Clinical
and Experimental Medicine, Linköping University,
S-581 85 Linköping, Sweden
e-mail: eva-maria.annerback@dll.se
*
–
2000. One possible explanation is
 166
J Fam Viol (2010) 25:165
–
172
an increase in the level of awareness and a decrease in the
tolerance of abuse of children.
was taken on another 25%, and the rest received services
from the Child and Family Agency, such as provision of a
contact person, contact family, home counseling, or referral
to Child and Adolescent Psychiatric Services (Lindell and
Svedin
2001
).
Risk Factors
Previous studies from other countries have found many
different risk factors linked to child abuse. Social isolation,
unemployment, low socio-economic status, economic diffi-
culties, parental substance or alcohol abuse, the occurrence
of violence between the parents, the experience the parents
themselves have of abuse, psychiatric symptoms/illness,
and medical problems are all conditions that have been
reported (Hornor
2005
). In Sweden, parents born abroad
have been shown to constitute a risk group (Annerbäck et
al.
2007
; Lindell and Svedin
2001
). Children with
functional disabilities are also a risk group (Sullivan and
Knutson
2000
). However, as has been shown in a Spanish
study, even this, the presence of disabilities, is not an
isolated factor but instead is related to other factors. Other
factors related to abuse of these children are age (younger
children are more subject to abuse), illness, behavioural
problems, and premature birth (Olivián-Gonzalvo
2002
).
Parents who subject children to serious abuse are often
known to Social Services before the actual event; and these
children have frequently been seen earlier bearing less
serious injuries (Hornor
2005
).
Research on Child Abuse in Sweden
—
Methodological
Aspects
Research on child abuse in Sweden has been, and continues
to be, limited (Larzelere and Johnsson
1999
). Many studies
are available from other countries, but in many respects
there is reason to believe that there are cultural as well as
legislative differences making comparisons difficult. Na-
tional mapping of the occurrence of violence directed
toward children has been carried out through questionnaire
surveys studies (Allmänna Barnhuset
2007
; SOU
2001
:18;
SOU
2001
:72); however research is lacking to a large
degree about the underlying conditions. This makes it
difficult for the professionals who are charged with taking
responsibility for child-abuse cases to decide how to act.
It is difficult to systematize knowledge about child
maltreatment in Sweden because sources of knowledge are
few. The only database for child abuse that is accessible is
the police register of reported crimes. There is no national
register concerning reports of child abuse or of children
who are in trouble and no child protection register
concerning evaluated cases of severe abuse (Cocozza et
al.
2007
). The alternative source that was chosen in the
present study was information obtained by examining the
files of a number of known cases reported to the police. An
attempt was also made to extend knowledge of the families
by studying the files available in many different contexts
that concerned several different individuals in the affected
families. Different actors have different perspectives on the
people in question and thereby can provide various kinds of
information about the families. No single factor suffices to
explain why people hit and hurt their children; the
phenomenon can only be understood on the basis of
multifactorial models that integrate social, sociological,
and psychological explanations. Child abuse must, there-
fore, be studied from a starting point that recognizes that a
variety of interacting and interdependent factors are present
and could strengthen one another. Explanations must be
sought at different levels with the goal of developing
knowledge of background and risk factors (Bardi and
Borgognini-Tarli
2001
; Browne and Herbert
1997
; Browne
et al.
1988
).
The aim of the current study was to examine and
describe the background and risk factors in cases of severe
child physical abuse through a multi-informant approach.
The actions taken by agencies when they had been
Interventions from Authorities
The judicial system plays a primary role in the way the
Swedish system handles child abuse. Violence directed
against children is always a crime and can serve as the basis
for indictment. Because of difficulties in the investigation
of children and in obtaining evidence, reports to the police
often lead only to a preliminary investigation and only a
few cases go further to court and eventually conviction
(Annerbäck et al.
2007
).
The Swedish social system of child care and child
protection is based on a duality that combines mandatory
reporting of child maltreatment to Social Services with a
family-service organization designed to cooperate with the
family rather than to control it. As a result, preventive
measures are given first priority after a report, and the rights
of the parents may be given priority over the rights of the
children (Cocozza et al.
2007
; Gilbert
1997
). This leads to
interventions that provide compensation for the family
s
weaknesses rather than to interventions to protect the child
(Wiklund
2007
). In one Swedish study of suspected cases
of child physical abuse that were investigated by Social
Services, it was shown that only 26% of all cases led to
protection of the child in the form of foster care. No action
’
 J Fam Viol (2010) 25:165
–
172
167
confronted with indications of child maltreatment were also
studied and finally a follow up was carried out to determine
what had happened to the children and to their contacts at
agencies during the first 5 years after the initial report of
child abuse.
The definition of severe child abuse is based on the
following criteria (Dale et al.
2002
; SFS
1962
:700): (1)
demonstrable bodily injury is present and is documented in
the medical examiner
s report or other certification by a
physician, (2) 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 or (3) the
incident itself constitutes a serious danger such as an
attempt to kill, even if the bodily injuries cannot be said to
be serious.
The socioeconomic status (SES) of the families has been
determined according to the Statistics Sweden, SEI (Statis-
tiska centralbyrån
1982
).
Economic problems are indicated by information that
social assistance had been provided to the family or that the
family had substantial debts and/or low income.
Unemployment was recorded if one or both of
’
Methods
All of the child physical abuse reports made between 1986
and 1996 to the police in a designated police district were
studied (N=142). Those that met the criteria for the
definition of severe child abuse (see below) were selected
and these constitute the total number of cases of severe
child abuse in this population (Annerbäck et al.
2007
).
The group studied consisted of 20 children and 34
caretakers of whom 18 were mothers (including one
stepmother) and 16 fathers (including two stepfathers). In
addition to the police reports, files from Social Services on
children and caretakers, journals from Child and Adoles-
cent Psychiatry and the Pediatric Clinic concerning the
children, and journals from Adult Psychiatry concerning the
caretakers were studied. The relevant agencies and units
were questioned by letter if they had any files on the people
in question (Table
1
). Data was collected at least 5 years
post the 10 year period in which the police reports
occurred; this made it possible also to make a follow-up
of the cases.
The journals/files have been read at each unit where they
were kept or,
the
parents were unemployed.
Ethical Considerations
Permission to make use of the files has been granted by the
different authorities. The study was approved by the Ethical
Committee at the University Hospital in Linköping (DNR
03-182)
Results
in some of the cases concerning Social
Services
files, at the City Archives. Data have been
recorded, partly according to a reading guide
’
Children
“
factors to
observe
(
Appendix 1
), and partly in a chronological report
from each journal. The files were read by the first author
(E-M.A), a trained social worker and psychotherapist, who
has worked for several years in different sectors of social
work and medical services and is familiar with these kind
of files. It was also possible to consult one of the co-
authors, who are medically trained, to get a second opinion.
Analyses have mainly been carried out with quantitative
methods and data are presented as frequencies and
percentages. Since the study consists of reading written
material and in some respects interpreting this material, a
qualitative approach has also been used, the purpose of
which was to find patterns and generate theory.
”
There were 12 boys (60%) and eight girls (40%).The
median age was 6 years and 6 months (range Two months
to 17 years). A majority of the children lived with both their
biological parents (n=12); five children lived with single
parents and two with one biological parent and one
stepparent.
Suspected Perpetrator
There were a total of 25 suspected perpetrators (in five
cases there were two suspects). Their median age was
32 years and 6 months (range 23 to 52 years). There were
somewhat more men than women (56% men, 44% women);
and most of the perpetrators were biological parents (85%)
and the rest stepparents (15%).
Definitions
Child abuse is physical violence against a child executed by
a parent or a caretaker.
Caretaker means parent or the person who, instead of the
parent, had responsibility for the child at the time of the
abuse.
The Legal System
The preliminary investigations led to charges being filed in
11 cases and 10 of the perpetrators were found guilty. In the
other 9 cases the preliminary investigations were closed.
 168
J Fam Viol (2010) 25:165
–
172
Table 1 Available sources of data
Case nr
1 2345678901234567890
Σ
Police
X XXXXXXXXXXXXXXXXXXX0
SS, children
X XXXXXXXXXXXXXXXXX8
SS, mothers
X XXXXXXXXXX XXXXXXX8
SS, fathers
X
X
X
X
X
X
X
7
SS, stepparents
X
1
CAPS
X XXXXX
X XXX XXX3
Pediatric clinic
X XXXXXX XXX X XXX4
AP., mother
XXXX
XX
XX
X
X
10
AP., father
X
XX 3
3456665566353
7
6
5
5
6
7
5
Σ
SS = Social Services
CAPS = Child and Adolescent Psychiatry Services
AP = Adult psychiatry
Risk Factors in the Families
Parental Conflicts Parental conflicts were reported, partly in
the form of quarrels or disagreements within the marriage and
partly concerning unresolved consequences of separations.
Eleven different variables representing economic, social,
psychological or medical risk factors were the most
frequently reported (Table
2
).
Domestic Violence In half of all the cases there was
information concerning violence between parents. Ordinar-
ily, these were reports of violence directed against the
woman, but in one case there was information about
violence directed against the man by the woman.
Social Network Problems Some of the families had no
contact with the children
s grandparents or other relatives
because they were living far away. Eight of these families
were immigrants from other countries, which helps to
explain their isolation. Another reason was conflicts
between the parents and their families of origin. In addition,
some families lived isolated from neighbours out in the
countryside.
’
Psychiatric Symptoms Thirteen of the caretakers had
contact with Adult Psychiatry and diagnoses were found
for four individuals, one of whom had been convicted of
child abuse of two children. Diagnoses included slight or
Table 2 Risk and Load factors most frequently reported
Case nr
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Σ
Lowest SES group
X X X X X
X
X X X
X
X
X
X
X
X
X
X
X
X
19
Economic problems
X X X X X
X
X X X X
X
X
X
X
X
X
X
17
Parental conflicts
X X X
X
X
X X
X
X
X
X
X
X
X
X
15
Social network problems X
X
X
X
X X X X
X
X
X
X
X
13
Psychiatric symptoms
X X X X X
X
X
X X
X
X
X
X
13
Unemployment
X X
X X
X
X
X X
X
X
X
X
12
Child
’
s.behavior
X X
X
X X
X
X
X
X
X
X
X
12
Family health problems
X
X X X X
X
X
X
X
X
X
11
Domestic violence
X X X
X
X
X
X
X
X
X
10
Foreign born
X X X
X
X
X
X
X
X
X
10
Addiction
X
X
X
X
X X
X
7
Σ
M=6,95
8
8
8
5
10
10
7
6
8
8
5
5
4
9
9
3
10
5
7
4
139
 J Fam Viol (2010) 25:165
–
172
169
moderate developmental disabilities, schizophrenia, crisis
reactions, personality disorder, Asperger´s syndrome, and
bipolar disorder.
In the other cases, individuals had sought psychiatric
help for symptoms, such as suicidal thoughts, crisis
reactions, and problems in relationships. Two convicted
perpetrators had sought help afterwards, because they
experienced problems with aggression or with the parent-
hood as well as difficulties with sleeping and with
concentration.
Social Services In 14 cases, reports had been previously
made to Social Services about maltreatment of the children;
one or more interventions had been carried out. These
interventions were intended primarily to compensate for
deficiencies in the home environment. However a secondary
effect was that they made it possible for Social Services to
indirectly control the family by following up on them. In two
cases, Social Services had only made telephone contact with
the parents who rejected the offer of help and support. Direct
protective measures such as placing the child outside of the
family had not been taken, but in two of the cases the child
s
living situation had been modified by moving the child to the
other biological parent. After additional reports of suspected
child abuse had been filed in these, cases decisions were made
to provide supervised contact with the suspected parent.
’
Family Health Problems In more than half of the cases
somatic health problems were identified. These concerned
the mothers in five cases, the fathers in three, and siblings
in three and represented chronic conditions that can have
represented an extra burden on the family situation.
Psychiatry, Adults In three cases, no conversation about
parenthood took place in the Adult Psychiatry contact, but
Adult Psychiatry (AP) had made an expert statement about
the mother
Children
s Behavior Concentration problems were noted in
four cases with reports coming partially from the family
’
’
s
side but also from school, Pediatric Clinic, and Child and
Adolescent Psychiatry. Relationship problems in school
were noted in two cases. In the other cases problems were
identified in reports from parents, and/or from school.
s mental health at the request of Social Services
in one of these. Two of the perpetrators had sought contact
with AP just before the abuse event but their requests had
been rejected. In two cases, there was a process of
cooperation between Social Services and AP and in one
case AP reported to Social Services that the mother was in
need of support as concerned her role as parent.
’
Foreign Born In half of the cases one or both parents were
born outside of Sweden. In seven cases, both parents were
of foreign background and came from countries outside of
Europe. They had arrived in Sweden rather recently before
the report (M=2.4 years) and five of these families were
political refugees. In three cases, one of the parents had
come from another country in Europe a long time ago and
the other parent was born in Sweden.
Psychiatry, Children In the three cases, in which the child
and the family had prior contact, it was a matter of limited
intervention (contact on 1
–
3 occasions). In one case, Child
and Adolescent Psychiatry reported suspected child abuse
to Social Services. In another case, where corporal
punishment as a method for bringing up the child had been
revealed, no report had been filed to Social Services.
Addiction In five cases, there was an alcohol dependency
problem and in two others a dependence on psychophar-
maca and narcotics.
Pediatric Clinic In three cases where the pediatric clinic
suspected child abuse, a report was made to Social Services.
Prior knowledge of the families and of interventions prior
to the report
Follow-up Five Years after the Report
Most of the families had one or more contacts with
agencies before the current report of child abuse (Table
3
).
Social Services After reports were filed with the police,
Social Services initiated an investigation in all the cases.
Table 3 Prior knowledge of the families
Case nr
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Σ
Social services
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
16
Psychiatry, adults
X
X
X
X
X
X
6
Pediatric clinic.
X
X
X
X
X
X
6
Psychiatry, children
X
X
X
3
Σ
M=1,55
2
–
2321112111
–
2
3
2
–
2
2
3
31
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