Investigative Guidelines for Child Homicides

It is not always readily apparent that a child’s death was the result of homicide. In some cases, homicide is evident:

  • It is fairly obvious that the child’s death was caused by an abusive injury.

  • The person who had custody of the child at the time the abusive injury was inflicted is known. Most infant deaths occur when the baby is in the care of known individuals.

  • The injuries themselves are obviously the result of a deliberate intent to do harm—that is, there is really no debate that someone abused the child and that the abuse caused the child to die. Such cases include strangulation, beating, severe inflicted burns, such as scalding, and the use of a weapon.

Unfortunately, the more careful and planned out the killing is, the less likely it is that a medical explanation for the death will be found. Most fatal injuries resulting from abuse are much more subtle than poisoning, beating, bludgeoning, shooting, or strangulation. Suffocation, for example, often leaves absolutely no medical sign of the cause of death. Most infant deaths are related to head injuries, some of which leave no external sign of trauma.

In case after case of suspicious deaths of children, the caretakers’ explanation is: “She fell off the couch (chair, changing table, or bed, or down the stairs).” Investigators must be aware that children do not die of simple falls. When investigating whether a child’s death was a homicide, investigators must ask themselves the following questions:

  • How do we find out what actually did happen to the child?

  • How do we make sure we are talking to the right expert about what could have caused the child’s death?

  • How do we know we have talked to everyone who might be able to shed light on a difficult case?

When presented with a child who has died under suspicious circumstances in which there is no obvious sign of abuse, investigators should ask an experienced pediatrician to help locate a specialist whose medical expertise can help make sense of a confusing picture. However, everyone who handles child fatalities must have a basic understanding of the following conditions:

  • Shaken baby syndrome.

  • Munchausen syndrome by proxy.

  • Sudden infant death syndrome (SIDS).

Shaken Baby Syndrome

The classic medical symptoms associated with infant shaking are:

  • Retinal hemorrhage (bleeding in the back of the eyeball), often bilaterally (in both eyes).

  • Subdural or subarachnoid hematomas (intracranial bleeding, most often in the upper hemispheres of the brain, caused by the shearing of the blood vessels between the brain and the dura mater or the arachnoid membrane).

  • Absence of other external signs of abuse (e.g., bruises), although not always.

  • Symptoms including breathing difficulties, seizures, dilated pupils, lethargy, and unconsciousness.

According to all credible studies in the past several years, retinal hemorrhage in infants is, for all practical purposes, conclusive evidence of shaken baby syndrome in the absence of a good explanation. Good explanations for retinal hemorrhage include:

  • A severe auto accident in which the baby’s head either impacted something with severe force or was thrown about wildly without restraint during the crash.

  • A fall from several stories onto a hard surface, in which case there are usually other signs of trauma, such as skull fractures, swelling, intracranial collection of blood, and contusions.

Simple household falls, cardiopulmonary resuscitation (CPR), and tossing a baby in the air in play are not good explanations for retinal hemorrhage. There simply is not enough force involved in minor falls and play activities to cause retinal hemorrhage or the kinds of severe, life-threatening injuries seen in infants who have been shaken.

In most cases of shaken baby syndrome, there are no skull fractures and no external signs of trauma. The typical explanation given by the caretakers is that the baby was “fine” and then suddenly went into respiratory arrest or began having seizures. Both of these conditions are common symptoms of shaken baby syndrome.

The shaking necessary to cause death or severe intracranial injury is never an unintentional or nonabusive action. These injuries are caused by a violent, sustained action in which the infant’s head, which lacks muscular control, is violently whipped forward and backward, hitting the chest and shoulders. The action occurs right in front of the shaker’s eyes. Experts say that an observer watching the shaking would describe it as “as hard as the shaker was humanly capable of shaking the baby” or “hard enough that it appeared the baby’s head would come off.” In almost every case, the baby begins to show symptoms such as seizures or unconsciousness within minutes of the injury being inflicted. The baby may have difficulty in breathing, or breathing may stop completely. Often, but not always, when shaking causes death or severe injuries, it has been followed by sudden deceleration of the action caused by throwing the child down onto a surface that may be either soft or hard.

Shaken baby syndrome occurs primarily in children 18 months of age or younger. It is most often associated with infants less than a year old, because their necks lack muscle control and their heads are heavier than the rest of their bodies. An infant cannot resist the shaking, but a toddler can, to some extent. Although the collection of injuries associated with shaken baby syndrome is sometimes seen in toddlers, it is rare and is always a sign of extremely violent and severe action against the child.

Munchausen Syndrome by Proxy

Munchausen syndrome is a psychological disorder in which the patient fabricates the symptoms of disease or injury in order to undergo medical tests, hospitalization, or even medical or surgical treatment. To command medical attention, patients with Munchausen syndrome may intentionally injure themselves or induce illness in themselves. In cases of Munchausen syndrome by proxy, a parent or caretaker suffering from Munchausen syndrome attempts to bring medical attention to themselves by injuring or inducing illness in their children. The parent then may try to resuscitate the child or to have paramedics or hospital personnel save the child. The following scenarios are common occurrences in these cases:

  • The child’s caretaker repeatedly brings the child for medical care or calls paramedics for alleged problems that cannot be medically documented.

  • The child only experiences “seizures” or “respiratory arrest” when the caretaker is there—never in the presence of neutral third parties or in the hospital.

  • When the child is hospitalized, the caretaker turns off the lifesupport equipment, causing the child to stop breathing, and then turns everything back on and summons help.

  • The caretaker induces illness by introducing a mild irritant or poison into the child’s body.

Investigative guidelines in suspected cases of Munchausen syndrome by proxy

  • Consult with all experts possible, including psychologists.

  • Exhaust every possible explanation of the cause of the child’s illness or death.

  • Find out who had exclusive control over the child when the symptoms of the illness began or at the time of the child’s death.

  • Find out if there is a history of abusive conduct toward this child.

  • Find out if the nature of the child’s illness or injury allows medical professionals to express an opinion that the child’s illness or death was neither accidental nor the result of a natural cause or disease.

  • In cases of hospitalization, utilize covert video surveillance to monitor the suspect. Some cases have been solved in this way.

  • Determine whether the caretaker had any medical training or a history of seeking medical treatment needlessly. Munchausen syndrome by proxy is often a multigenerational condition.

Sudden Infant Death Syndrome

Sudden infant death syndrome (SIDS) is not a positive finding; rather, it is a diagnosis made when there is no other medical explanation for the abrupt death of an apparently healthy infant. When a baby dies from shaking, intracranial injury, peritonitis (inflammation of the peritoneum, that is, the membrane that lines the abdominal cavity), apparent suffocation, or any other identifiable cause, SIDS is not even considered a possibility. SIDS rarely occurs in infants older than 7 months and almost never is an appropriate finding for a child older than 12 months.

A SIDS death is not a homicide, and apparent SIDS cases must be approached with great sensitivity. However, before SIDS can be ruled the cause of death, the investigator must ensure that every other possible medical explanation has been explored and that there is no evidence of any other natural or accidental cause for the child’s death.

An investigator’s suspicions should be aroused when multiple alleged SIDS deaths have occurred under the custody of the same caretaker. Statistically, the occurrence of two or three alleged SIDS deaths in the care of the same person strongly suggests that some degree of child abuse is involved. Whenever there is evidence that the child who has died was abused, or that other children in the family have been abused, SIDS is not an appropriate finding.

Even when there is no affirmative medical finding of the cause of death, prosecution may still be possible. In some circumstances, experts can explain what occurs when a child is suffocated and can render a medical opinion that suffocation is one of the ways someone could cause the child’s death without leaving obvious medical signs.