Intentional Burn Injuries

Introduction

Forensic medicine has made tremendous advancements in developing scientific measures to identify child maltreatment and intentional injuries. Despite these advancements, deliberate injury by burning is often unrecognized. According to the U.S. Department of Health and Human Services Administration for Children and Families, child abuse and neglect are defined as “any recent act or failure to act on the part of a parent or caretaker, which results in death, serious physical or emotional harm, sexual abuse or exploitation, or an act or failure to act which presents an imminent risk of serious harm.” In January 2016, The Children's Bureau published the National Child Maltreatment Data from 2014, which reported that 1580 children died as a result of abuse or neglect. Within the United States alone, 1.5 million children are abused or neglected each year, with 4–39% of these occurrences being reported as intentional burn injuries and less than half ever being substantiated. In 2015, children aged 0–4 who sustained small burn injuries (total body surface area [TBSA] 0–29%) had a mortality rate of 0.25%, medium burn injuries (30–59.9% TBSA) had a mortality rate of 9.6%, and large burn injuries (≥60% TBSA) had a mortality rate of 29.06%. These mortality rates are significantly higher than in children over the age of 4, indicating that children younger than 4 years of age are at greatest risk.

It is imperative that all clinicians be aware of the importance of recognizing signs and symptoms of intentional injury presentations because the opportunity for intervention is critical when taking into account that 50% of children experience recurrent abuse and 30% are ultimately fatally injured. Reporting suspicious injuries to child protective services (CPS) is mandated by law for all clinicians working with children. Some treating facilities identify specific treatment team members (i.e., psychologist or social workers) to be responsible for all reporting. In these situations, it may be necessary to follow the protocol of the hospital or treating facility first; however it is important to note that any physician, medical professional, or mental health professional who encounters a suspicious injury must ensure that the injury is reported to the appropriate authorities. At other times, the concern of reporting is more a result of ambiguity or vagueness in the information, which can cause hesitation to report the suspicious injury. In these incidents of doubt, the most salient point to remember is that the clinician is responsible for reporting suspicious injury, not proving or validating abuse. It is always better to report the suspicion than to ignore it. Most state agencies also have hotlines that are available to call 24 hours to ask specific questions regarding reporting suspicious injuries. Although it is overwhelming to imagine that so much abuse occurs, statistics show that it does occur, not only with children but also with adults and our elderly population.

Intentional injuries can occur in the form of neglect, physical abuse, sexual abuse, and emotional abuse. All of these injuries can occur independently, but they often occur simultaneously. Neglect is the most common form of intentional injury. Of the average 5.5 million referrals made to CPS each year, 64.5% of these children are neglected. Physical abuse occurs in 25% of intentional injury cases. More than 15% of victims of abuse suffer more than one type of abuse, and more than one-third of child fatalities are attributed to neglect ( Fig. 62.1 ). Burn injury is frequent in both neglect and physical abuse of children. Severe burns in children are between 10% and 12% of all intentional injuries.

Since the last edition of this book, intentional injuries to adults have increased. It is frequently debated within the literature as to whether the increase is a valid increase or if there is an increase in reporting. Violence specifically against women and young girls has now become a universal phenomenon. The World Health Organization reported that, of the women who were partnered at some point during their lifetime, 15–71% reported experiencing physical or sexual violence by their partner. Within this realm of violence against women and young girls, acid violence is the worst form of violence and violation of human rights. Although steps are being taken to control the widespread free sale of acids to the public, this act of violence is still on the rise and warrants discussion in the burn care literature and sensitivity to this overwhelming problem by all burn care professionals. Another vulnerable population of intentional burn injuries is the elderly. In the past 10 years, burns in the elderly have increased secondary to an increase in size of the aging population.

In this chapter, we have integrated our experience with current literature to classify risk factors in the total population and to propose validated therapeutic interventions to treat the burn wounds and the complex social and psychological familial concerns that both create injury and complicate the recovery and rehabilitation of the patient. It is essential that burn team clinicians understand their role and responsibility in assisting not only burn patients but the perpetrators as well because history and statistics have shown us that the outcome can be fatal if intervention and prevention methods are not implemented with sensitivity to maintain positive relationships with burn patients as well as with perpetrators.

The authors are well versed in clinical experience and research experience of child abuse and pediatric burn injuries; however our experience of intentional burn injuries within the adult population is limited. The literature and our extensive knowledge of information regarding intentional injuries against children are reflected in this chapter. We have included the most recent literature on adult injuries, but it is not exhaustive. It is important to note that the pediatric population is not the only target for intentional injuries.

Prevalence Rates of Intentional Burn Injuries

Despite the improvement and use of smoke detectors, investment in sprinkler systems, and improvement in building codes in developing countries, burns continue to cause significant intentional and unintentional injuries. Smoking remains the leading cause of death by fire. Cooking is the number one cause of residential fires. Annually fire-related injuries claim more than 300,000 deaths and 10 million disability-adjusted life years worldwide. Middle and low-income countries exceed 95% of fire-related burns. Approximately half of these countries are in southern parts of Asia. In the United States, burn injuries result in approximately 1 million emergency department visits and 50,000 hospital admissions, with a 5% mortality rate. Fire and burns represent 1% of the incidence of injuries. Fatal home injury burns and fire deaths rank fifth and third, respectively, in the United States. The incidences of the causes of burns are flame/fire 46%, scalds 32%, hot objects 8%, chemicals 3%, and other forms 6%. Fires/burns occur frequently in the home (43%), on the street/highway (17%), in occupational settings (8%), and in other settings (32%). Burn injuries inflicted in Pakistan occur mostly to adult women: approximately one-third are secondary to stove burns and 13% are acid burns. Husbands inflict more than 52% of these injuries and in-laws one-quarter of the injuries. Victims who are at highest risk of fire-related injuries and deaths are children aged 4 and younger, adults older than 65 years, African-Americans and Native Americans, and the poor or those living in rural areas. A literature review of hospital-based studies of the prevalence of burn injuries in China revealed similar results with the most vulnerable being children younger than 3 years, males more than females, those living in a rural setting, and the incidence occurring between the hours of 17:00 and 20:00.

Distinctive Characteristics of Perpetrators and Families

Perpetrators are frequently individuals responsible for the care and supervision of their victims. In 2007, one or both parents were responsible for 69.9% of child abuse or neglect fatalities. More than one-quarter (27.1%) of these fatalities were perpetrated by the mother acting alone. Child fatalities with unknown perpetrators accounted for 16.4% of the total. According to the National Child Abuse and Neglect data system, in 2008, 56.2% of perpetrators were women, 42.6 % were men, and 1.1% were unknown. Of the reported women perpetrators 45.3% were younger than 30 years of age compared to 35.2% of men younger than 30. These percentages have remained consistent for several years in a row. Some 61% of all perpetrators were neglected as children. Approximately 13.4% of all perpetrators were associated with multiple types of abuse. Ten percent of perpetrators experienced physical abuse as children, and 6.8% were sexually abused as children. Of the children who are abused, 80% were abused by their parents. Other relatives accounted for an additional 6.5%. Unmarried partners of parents were 4.4% of perpetrators. Of those parents who were perpetrators, more than 90% were biological parents, 4% were step-parents, and 0.7% were adopted parents.

Other characteristics of perpetrators commonly include being adolescent parents, being a single parent, often maintaining inconsistent expectations for a child's development, experiencing a lack of external supports, stressors such as substance abuse, poor education (no high school diploma), unemployment, poor housing, mental illness, and being reliant on children for emotional support ( Box 62.2 ). Most fatalities from physical abuse are caused by fathers or other male caregivers. Mothers are most often held responsible for deaths resulting from child neglect. In some situations, there are two “perpetrators,” the actor and the overtly passive observer who does not stop the abuse. Justice and Justice, in their work with families who mistreat children, identified several erroneous belief systems that are commonly held by perpetrators; these are listed in Box 62.3 . Since, as most authorities believe, violence is a multigenerational intrafamily pattern, then it is likely that the belief systems attributed to child perpetrators can be extrapolated to perpetrators of adult abuse as well.