JRSM >
Volume 97, Number 5 >
Pp. 258
84 Brunswick Avenue, Toronto, Ontario, M5S 2L7 Canada
Dr Michael Craig (February 2004 JRSM1) should be congratulated on his excellent review. My only regret is his failure to consider the vital role played by ‘help seeking and warning behaviour’ as a means of preventing such tragedies.
Under the rubric of the battered child syndrome there is a substantial but largely neglected literature on prodromal events culminating in infant deaths due to violence. In the context of evaluating dangerousness, Bennie and Sclare2 reported that ‘... five of ten patients had seen a doctor immediately preceding the crime, in some cases to complain about the child's behaviour and to seek help in management.’ Scott,3, in his study of 29 fatal battered-baby cases, found that ‘... three quarters of the men gave unmistakable warnings of their subsequent actions....’
The importance of ‘open warnings’ was a major concern of Ounsted and Lynch.4 Lynch and Roberts5 provide a typical example:
‘Two weeks before a ten-week old girl arrived in hospital, moribund with bilateral subdural haematoma, her mother had caused a minor bruising to the baby's buttocks during a feeding battle. She had demonstrated the injury to the family doctor who, not realizing the significance of this "open warning", reassured the mother that she had done no serious damage and prescribed a tranquilizer to calm her down.’
It is also important to appreciate that some vulnerable children are able to signal their distress in the presence of danger. Ounsted's description of ‘frozen watchfulness’ is well known.4 Unusual aggressive or antisocial behaviour, as a prodromal sign, is also reported.5,6 Even with young infants these behaviours may have survival value. For example, in the first of several hospital admissions, a girl aged two months had a transverse fracture of the upper left humerus with displacement. The mother attributed this to a fall. Two months before her death, two social workers witnessed the child resting comfortably in the arms of her aunt. However, when her mother arrived to take her home, the child became exceedingly agitated and resisted her mother's attempts to feed her. The child's death, at the age of eighteen months, was caused by ‘sub-arachnoid and subdural haemorrhaging due to blows to the head’ and other findings included unexplained anal and genital injuries.7
Ounsted and Lynch's concept of a ‘critical path’ leading to the tragedy has been of inestimable value to my own studies of family violence.7,8 This work has convinced me that the urge to kill or to severely injure a family member or members is, almost invariably, accompanied by an equal but opposite urge to be restrained from maiming or killing. However, as this insight is dependent on an unholy alliance of anecdotal reports and 20-20 hindsight, it is virtually impossible to prove. Nevertheless, effective clinical practice demands that physicians, nurses, social workers, police and others dealing with children at risk, should be extremely sensitive to help-seeking and warning behaviours.
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