Jim Holler, Jr. Holler Training Chief of Police, Liberty Township Police Department (Retired) (717)752-4219 Email: [email protected] www.hollertraining.com

Child Homicide/Death Investigations

Course Outline

Four Types of Child Fatalities ✓ Natural Deaths ✓ Accidental/Unintentional Deaths ✓ Suicides ✓ Homicides

Natural Deaths ✓ Two thirds of natural deaths occur within the first 28 days of life ✓ Pre-maturity ✓ SIDS – Most occur between 2 and 4 months of age ✓ Maternal complications ✓ Diseases ✓ Congenital anomalies

Sudden Unexplained Infant Death (SUID) ✓ “Sudden and unexpected death of an infant due to natural or unnatural causes.” ✓ “Sudden death of an infant under one year of age which remains unexplained after a thorough case investigation, including performance of a complete forensic autopsy, examination of the death scene, and review of the clinical history.” ✓ SIDS is the leading cause of death among infants who are 1 month to 1 year old, and claims the lives of about 2,500 infants each year in the United States ✓ Sudden Unexplained Infant Death claimed the lives of 4,600 infants each year ✓ Accidental suffocation & strangulation has doubled in the last decade ✓ Most SIDS deaths are associated with sleep (hence the common reference to "crib death"), and infants who die of SIDS show no signs of suffering ✓ While most conditions or diseases usually are diagnosed by the presence of specific symptoms, most SIDS diagnoses come only after all other possible causes of death have been ruled out through a review of the infant's medical history and environment

Importance of Investigating Sudden Unexplained Infant Death

✓ Without a complete death scene investigation ✓ It is difficult to determine cause and manner-of-death ✓ Disadvantage for pathologist conducting autopsy ✓ Disadvantage for those trying court cases ✓ Hinders prevention efforts

Types of Sudden Unexplained Infant Death

✓ SIDS ✓ Suffocation ✓ Metabolic Error ✓ Injury or Trauma ✓ Unknown or Unclassified ✓ Several studies show that SIDS and other SUID are more accurately diagnosed when information from a death scene investigation is used to make the diagnosis

The Importance of SUID Data Collection ✓ A form developed by workgroup comprised of medical examiners, coroners, death scene investigators, law enforcement, infant death researchers, and SIDS parents organizations. ✓ Body design ✓ EMS interview ✓ Hospital interview ✓ Immunization record ✓ Infant exposure history ✓ Informant contacts ✓ Law enforcement interview ✓ Materials collection log ✓ Non-professional responder interview ✓ Parental information ✓ Primary residence information ✓ Scene diagram

Accidental /Unintentional Deaths ✓ Ranked number 1 in children 1 to 4 ✓ Crashes, drowning, poisoning, firearms, fires, window covering cords & cribs ✓ A study released by the American Academy of Pediatrics shows that black and American Indian children were more likely than others to die in accidents involving fire, suffocation, poisoning, falls, vehicle collisions and firearms. ✓ The data show 13.7 per 100,000 children up to age 4 died in accidents in 2003. ✓ For American Indian children, the rate was 28 per 100,000. For blacks, it was 20.6. The rate was 13 for Latinos, 11.1 for whites and 5.9 for Asians.

Re-Breathing ✓ The inhalation of expired CO2 and other gases recovered from porous sleeping surfaces. ✓ Covering or other object caused a buildup of carbon dioxide around their head ✓ The inspired CO2 inhibits CO2 receptors in the brainstem. ✓ It truly appears that they either peacefully fall asleep or continue peacefully sleeping through this life-threatening event.

Suffocation ✓ The impedance of oxygen supply by obstruction of nose or mouth. ✓ Difficult diagnosis ✓ Requires investigation and corroboration by witness/perpetrator statements ✓ Minimal or no external or internal trauma ✓ Petechiae may or may not be present ✓ If petechiae are present, they are suggestive but not diagnostic of suffocation or smothering

Strangulation - Suicidal, Homicidal or Accidental

Hanging is the most common type of committing suicide

✓ Ligature mark around the neck ✓ Presence of abrasion, ecchymoses (bruising) and redness around the ligature mark ✓ Trickling of saliva from the mouth ✓ When found in a case of suspect hanging, the presence of petechial hemorrhages strongly suggests the victim was hung when still alive. This helps distinguish hangings staged to make a murder look like a suicidal act.

Post-mortem Hanging ✓ A person may be murdered, and the body suspended to simulate suicide ✓ Look for signs of dragging to the place of suspension ✓ When a dead body is suspended, the rope is usually tied first around the neck and then around the beam, branch of a tree etc.

Homicidal Strangulation ✓ Most common form of murder ✓ Many victims are adult women and is often associated with sexual interference ✓ Strangulation by ligature ✓ Manual strangulation, or throttling ✓ In ligature strangulation, in contrast to hangings, the ligature mark usually encircles the neck ✓ Abrasions are usually seen due to movement of the ligature across the neck. ✓ Fingernail marks may be seen either from the victim attempting to remove the ligature of the from the assailant tying to secure the ligature ✓ The victims clothing may sometimes be caught in the ligature during a struggle and produce marks ✓ The mark may completely encircle the neck or may be seen only at the front, when the ligature is pulled tightly from behind

Suicidal “Throttling” ✓ Suicide by throttling is not possible, because the compression of the windpipe produces rapid unconsciousness and the fingers relax

Homicidal Strangulation ✓ Sudden and violent compression of the windpipe causes almost IMMEDIATE unconsciousness insensibility and death ✓ If the windpipe is partially closed, buzzing in the ears, congestion, vertigo, tingling, muscle weakness, bleeding from the mouth, nose and ears, clinching of the hands and convulsions occurs before death ✓ Evidences of a struggle is usually found but if the victim is taken unawares, and the ligature is suddenly placed around the neck and pulled tightly, the person loses consciousness quickly and is unable to offer much resistance. ✓ Signs of strangulation include bruises, marks on the neck, bleeding in the throat, and fracture of the hyoid bone, a U-shaped bone at the base of the tongue ✓ Signs of strangulation include bruises, marks on the neck, bleeding in the throat, and fracture of the hyoid bone, a U-shaped bone at the base of the tongue

Post-mortem Appearances ✓ Composition of ligature: the pattern and texture is produced in the skin ✓ Width of ligature: when the ligature is narrow a deep grove is made because much more force is being used

Accidental Strangulation ✓ Children may get entangled in ropes during play, or the neck may get caught in widow cords. ✓ Belts, ropes or parts of clothing may get caught in rollers of machinery and causes accidental strangulation

Positional Asphyxia ✓ Positional asphyxia happens when a person can't get enough air to breathe due to the positioning of his/her body. ✓ This happens most often in infants, when an infant dies and is found in a position where his/her mouth and nose is blocked, or where his/her chest may be unable to fully expand. ✓ There may be markings of congestion, cyanosis, and petechiae ✓ Examples include an infant found wedged between a mattress and the wall, an infant sleeping on a couch with an adult who is found with his face pushed against the cushions of the couch.

“Gentle” Homicides ✓ Victims tend to be very young, very old, debilitated, or incapacitated by restraints ✓ When a pillow is used, it is placed over the face and pushed down ✓ This causes the obstruction to the nose and mouth, asphyxia, and death ✓ There are usually NO MARKS on the face ✓ The face is not congested and there is no petechiae indicated

Suicidal Deaths ✓ Third leading cause of death in children from ages 10-19 o Autoerotic Asphyxiation – Suicide or Accidental? ▪ A sexual partner may or may not be involved in the act, however, if one is excluded the practice can be referred to as autoerotic asphyxiation, ▪ Various methods are used to achieve the level of oxygen depletion needed such as a plastic bag over the head or self-strangulation, typically by the use of a ligature (scarfing). ▪ The increased pleasure results from the body producing more endorphins as it approaches the state of asphyxia. ▪ Pleasurable or not, it is an extremely dangerous practice that results in many accidental deaths each year. ▪ In most cases, people strangulate themselves by using a ligature such as a rope with which they have made a noose or slip-knot around the neck. Most people have built-in safety or rescue methods. In nearly all fatal cases, people did indeed have safety mechanisms, but these had failed. ▪ The Choking Game achieves a brief high or euphoric state by stopping the flow of oxygen containing blood to the brain ▪ Sometimes children choke each other until the person being choked passes out. The pressure on the arteries is then released and blood flow to the brain resumes causing a "rush" as consciousness returns ▪ There are variations of this activity which involve hyper- ventilating until the participant loses consciousness ▪ The danger becomes even greater when a ligature is used and the activity is performed by a lone child. If the child loses consciousness and there is no one there to IMMEDIATELY release the pressure, he is unable to help himself. The child will suffer brain damage and death certainly after three minutes. Some of those who have died were alone for as little as 15 minutes before someone found them and it was already too late.

Drowning Homicides

✓ First responders' observations and incident reports into them may be critical in initiating an investigation ✓ Holding a child's head underwater in a tub takes little effort, and the little water splashed from the tub is easily wiped away. ✓ A non-swimmer pushed into deeper water may not even have subcutaneous bruising. ✓ Pure-drowning homicides can be medically undetectable, are effortless to perform ✓ Requires no perpetrator skill ✓ Little or no clean up ✓ The body does not need to be disposed of ✓ The perpetrator often receives much sympathetic attention and possibly accidental death life insurance money. ✓ Actively look around and make mental notes. ✓ If it is a child, was a wet diaper laying on the floor? ✓ Are there any wet towels on the floor? ✓ How many people are on the immediate scene? ✓ Is there any smell you can distinguish such as alcohol or vomit? ✓ Are the witnesses wet? You might be able to touch a witness on the arm in a gesture of support to feel if an arm or sleeve is damp. ✓ Where exactly did you first see the patient and what was the body posture? ✓ Was there any vomit, feces or other substance found in the water or on the scene that looked like it could have come from the victim? ✓ If someone from your crew has access to the water where the victim supposedly was found in, touch both the water and body to get an idea of the temperature. ✓ If the deceased has been in water for more than 1-2 hours a washerwoman appearance may be evident ✓ Note skin color and temperature — and document what parts of the body you touched and examined. • Make a note of any mark you notice on the body such as a scratch or a bruise. • Suicide by drowning is not impossible, although it is not the easiest method. • Most of the people who do choose very deep water, and are very determined to succeed. • If they can hold their breath long enough to pass out, the next thing that happens is that the body breathes automatically.

Homicides ✓ Ranked number 4 in children 1 to 14 years ✓ The National Child Abuse and Neglect Data System (NCANDS) reported an estimated 1,490 child fatalities in 2009. ✓ This translates to a rate of 2.03 children per 100,000 children in the general population. ✓ "child fatality" as the death of a child caused by an injury resulting from abuse or neglect, or where abuse or neglect was a contributing factor. ✓ Perpetrators are, by definition, individuals responsible for the care and supervision of their victims. ✓ In 2009, one or both parents were involved in 78.9 percent of child abuse or neglect fatalities. ✓ Of the other 21.1 percent of fatalities, 10.7 percent were the result of maltreatment by nonparent caretakers, and 10.4 percent represent unknown or missing information. ✓ There is no single profile of a perpetrator of fatal child abuse, although certain characteristics reappear in many studies. ✓ Frequently, the perpetrator is a young adult in his or her mid-20s, without a high school diploma, living at or below the poverty level, depressed, and who may have difficulty coping with stressful situations. ✓ In many instances, the perpetrator has experienced violence first-hand. ✓ Most fatalities from physical abuse are caused by fathers and other male caretakers. ✓ Mothers are most often responsible for deaths resulting from child neglect.

Faulty Statistics ✓ Child’s disappearance my not be known ✓ Missing child’s body never found ✓ Parents may fabricate a story of a child’s abduction ✓ Improper death investigations ✓ No autopsy ✓ Timeliness of the investigation ✓ Crime scene investigation ✓ Witness and caretaker information ✓ Background of the child and family

What is a Child Death Review Team? • The death of a child is a community responsibility. • A child’s death is a sentinel event that should urge communities to identify other children at risk for illness or injury. • A death review requires multidisciplinary participation from the community.

Operating Principles of Child Death Review • A review of case information should be comprehensive and broad. • A review should lead to an understanding of risk factors. • A review should focus on prevention and should lead to effective recommendations and actions to prevent deaths and to keep children healthy, safe and protected. • Results of these reviews may be used to improve services, advocate for change, and conduct public awareness activities, ultimately for the purpose of preventing future child maltreatment deaths

Looking beyond the risk factors……Using the team to help determine the cause of death 10 Objectives of Child Death Review

1) Ensure the accurate identification and uniform, consistent reporting of the cause and manner of every child Reviews ensure team members are informed of all deaths and thus they are more likely to take actions for investigation, services and prevention ✓ More complete information may help to identify cause and manner ✓ Reviews can lead to modifications of death certificates death

2) Improve communication and linkages among local and state agencies and enhance coordination of efforts ✓ Meeting regularly can improve interagency cooperation and coordination ✓ The benefits of sharing information and clearly understanding agency responsibilities can make the CDR process worthwhile in and of itself ✓ Reviews facilitate valuable cross discipline learning and strategizing ✓ Reviews improve interagency coordination beyond the review meetings

3) Improve agency responses in the investigation of child deaths ✓ Reviews promote early and more efficient notification of child deaths, facilitating more timely investigations ✓ Sharing information on the type of investigation conducted leads to improved investigation standards ✓ Reviews can identify ways to better conduct and coordinate investigations and resources

4) Improve agency response to protect siblings and other children in the homes of deceased children ✓ Reviews can often alert other agencies, such as social services, that other children may be at risk of harm; and they identify gaps in policies that may have prevented the earlier notification to these agencies

5) Improve criminal investigations and the prosecution of child homicides ✓ Reviews can provide new case information to aid in better identifying intentional acts of violence against children ✓ Reviews may bring a multidisciplinary approach to assist in building a case for adjudication ✓ Reviews can provide a forum for professional education on current findings and trends related to child homicides

6) Improve delivery of services to children, families, providers and community members ✓ Reviews can identify the need for delivery of services to families and others in a community following a child death ✓ Reviews can facilitate interagency referral protocols to ensure service delivery

7) Identify specific barriers and system issues involved in the deaths of children ✓ Team members can help agencies identify improvements to policies and practices that may better protect children from harm

8) Identify significant risk factors and trends in child deaths ✓ Reviews bring a broad ecological perspective to the deaths, thus medical, social, behavioral and environmental risks are identified and more easily addressed 9) Identify and advocate for needed changes in legislation, policy and practices and expanded efforts in child health and safety to prevent child deaths ✓ Every review should conclude with a discussion of how to prevent a similar death in the future ✓ Reviews are intended to be a catalyst for community action ✓ Teams are not expected to always take the lead, but should identify where and to whom to direct recommendations, then follow-up to ensure they are being implemented.

10) Increase public awareness and advocacy for the issues that affect the health and safety of children ✓ When review findings on the risks involved in the deaths of children are presented to the public, opportunities can be identified for education and advocacy

The Child Abuse Problem ✓ Three million reports of child abuse are made every year in the United States, experts estimate that the actual number of incidents of abuse and neglect is 3 times greater than reported ✓ More than 2,000 children die of child abuse each year in the US ✓ Most child deaths result from physical abuse, head injuries in particular ✓ The next most common cause of physical abuse deaths is punches or kicks to the abdomen ✓ Other forms of fatal physical abuse include immersion into hot water, drowning and smothering ✓ Many times these injuries occur when a child’s head is slammed against a surface, is severely struck or when a child is violently shaken

Repeated Abuse ✓ Children are rarely severely abused or killed in a single incident where there is no evidence of a pattern of prior conduct, often evidenced by preexisting injuries, such as rib fractures, skull fractures, older bleeding within the skull, bruises, or simply changes in the baby's behavior with no apparent cause.

Triggering Event ✓ What was the triggering event or motive of the defendant to harm the child? ✓ Classic triggering events include soiling, vomiting, feeding difficulties, and inconsolable crying.

Common Perpetrator's Lies: The Dirty Dozen 1. Child fell from a low height (less than 4 feet), such as couch, crib, bed or chair. 2. Child fell and struck head on floor or furniture, or hard object fell on child. 3. Unexpectedly found dead (age and/or circumstances not appropriate for sudden infant death syndrome). 4. Child choked while eating and was therefore shaken or struck on the chest or back. 5. Child suddenly turned blue or stopped breathing, and was then shaken. 6. Sudden seizure activity. 7. Aggressive or inexperienced resuscitation efforts to a child who suddenly stopped breathing. 8. Alleged traumatic event 1 day or more before death. 9. Caretaker tripped or slipped while carrying child. 10. Injury inflicted by sibling. 11. Child left alone in dangerous situation (e.g., bathtub) for just a few minutes 12. Child fell down the stairs

The Scene ✓ One of the cornerstones of a successful investigation is recording the scene and the lawful seizure of evidence. ✓ Can I reconstruct and present this scene in a court of law? ✓ The thorough scene investigation maximizes the collection of data and evidence; helps to reconstruct the most accurate account of what really happened; minimizes defense options; and presents a more clear and understandable picture of those cases ultimately decided by a jury ✓ You usually have only ONE opportunity to view the scene and surrounding areas ✓ The search warrant should be broad enough to include items that might not be considered sexual, but which a child may have mentioned in the statement as used by the offender to entice the child, help consummate the crime, or record the crime. ✓ Since many children are unable to testify, convictions can be obtained with a combination of circumstantial and corroborating evidence whether the child testifies or not. ✓ Work from scene back – When discovered to before death ✓ Listening to the caregivers story

The Important 911 Call ✓ ALWAYS OBTAIN A COPY OF 911 TAPE ✓ The care giver’s statements on the 911 call should be compared to subsequent care giver statements ✓ Are there other voices or other background noises in the tape? ✓ Does this information differ from the care givers original account?

What Rescue and/or Resuscitation Efforts Were Made? ✓ Document resuscitative efforts ✓ Did anyone attempt to resuscitate the infant ? ✓ If yes, were they trained in pediatric CPR? ✓ If family replies positively; ask if they have ever resuscitated a child before????? OR has a child ever died in their care?????

Retinal Hemorrhages after CPR ✓ 6 out of 54 children had retinal hemorrhages after CPR (55% <2y/o) ✓ 4 children with head injury from abuse ✓ 1 child with head injury following MVA ✓ 1 child with severe hypertension ✓ Very unusual after accidental head injury ✓ CPR may RARELY cause small punctuate hemorrhages ✓ Other conditions may cause RH but ABUSE is most likely if head injury is also present

Case Information ✓ Demographics o Infant o Mother o Caretaker (if not mom) o Household residents ✓ Diet ✓ Recent hospitalization ✓ Previous medical diagnosis ✓ History of medical care without diagnosis ✓ Recent fall or other injury ✓ Use of religious remedies

Arriving on the Scene ✓ The Importance of Law Enforcement Responding as FIRST RESPONDERS ✓ Preserve life is first priority ✓ Call EMS if needed ✓ Survey the crime scene ✓ TALK to first responders ✓ TALK to first officer on the scene ✓ WHAT did they see, hear, and smell? ✓ What was the scene temperature? ✓ Establish scene boundaries ✓ What did EMS move to get to the body? ✓ Conditions upon arrival? ✓ What did family members/witnesses say or do? ✓ Don’t be blinded about “where” the house is located and the neighborhood that you are in ✓ The IMPORTANCE of DEATH SCENE PACKETS or CHECK LISTS ✓ You usually have only ONE opportunity to view the scene and surrounding areas

The Importance of Preliminary Questioning ✓ You want to LOCK the caretaker into a story as soon as possible! ✓ Should be done in a non-intrusive and non-threatening manner ✓ Initiate questioning of caregiver by asking him or her “how it happened” ✓ Do not make threats or accusations ✓ A lack of detail and/or any contradictory or unconvincing explanations may provide important clues about whether an injury was accidental or a result of abuse ✓ Acceptable to take notes throughout ✓ Usually not a custodial situation ✓ Subject may give a preview for their alibi or information for themes ✓ Miranda not required ✓ Subject may or may not be the suspect ✓ Subject should be locked into their side of the story ✓ Statements should be documented

Search Warrants ✓ Always LAWFULLY conduct the search of the crime scene ✓ This includes consent searches, search warrants, and exigent circumstances searches ✓ The investigator should not cue the care giver by inserting words and phrases that clearly specify possible child abuse/homicide ✓ The investigator should list generic terms such as: searching for “items” regarding the “incident”, “occurrence”, “accident”, etc ✓ If you do not have sufficient probable cause to support a search warrant, ask the suspect to sign a “consent to search” form

Crime Scene Evidence ✓ Every crime scene is three dimensional. Always look in every direction including up. ✓ Take detailed notes. ✓ Never assume cause of death ✓ Collect everything in the immediate vicinity of the reported trauma, such as, crib, bedding, sheets, toys ✓ Items impractical to seize should be measured along with the manufacture name and model being recorded (living room sofa, kitchen table, wall to wall carpet etc) Looking for evidence such as: o Last meal o Baby bottle o Diaper for last movement o Trash cans o Dumpster o Wash machine for soiled clothes o Refrigerator/cabinet for foods o Medicines ✓ Examination should include trash containers, laundry chutes and bins and areas outside widow wells (places where a suspect could hastily discard items in a location that he or she hopes will be overlooked ✓ Look for any possible stressors such as a job layoff notice, bank statement listing NSF checks, all of which coupled with a crying infant may culminate in a shaking episode ✓ Knowledge of the possible stressors in the care giver's life provides themes during subsequent interviews ✓ Bite marks/other bruises ✓ Color of injury may indicate time table of events ✓ Animal vs child/adult bites ✓ Foot, shoe, tire impressions ✓ An emphasis should be made on seizing trace evidence (hair, blood, fibers, body fluids, paint chips, fragments, etc.), as these items may directly affirm or negate the presenting history. ✓ If the investigator suspects a staged scene, latent fingerprint examinations may be helpful. ✓ The investigator at the scene should collect everything in the immediate vicinity of the reported trauma, e.g. crib, bedding, sheets, toys, etc. ✓ Look for any possible stressors such as a job layoff notice, bank statement listing NSF checks, all of which coupled with a crying infant may culminate in a shaking episode ✓ Knowledge of the possible stressors in the care giver's life provides themes during subsequent interviews

Child Abuse Photography ✓ Photograph, document, sketch using appropriate measuring device in your photos and on your sketches ✓ Room Photos • Overall – The entire scene from a distance • Medium – Move in on subject matter • Close up – Photograph the specific area of concern • Size standard – After the taking the above shots, use a measuring device and take the photos over again ✓ Make sure you are taking the whole area in ✓ Literally get low for crawling babies ✓ Think like a kid! ✓ Beware of “assumptions” ✓ Utilize a system to keep track of the patient's name and date of the photographs, such as a name card with date and name written in black marker. ✓ Use one roll of film, one media card(if possible) per patient. ✓ Take full body photographs for identification purposes. ✓ When photographing the person's back, have the child/adolescent turn his/her face toward the camera for identification purposes. ✓ Take photographs head on so that the surface that is to be photographed is parallel to the camera and at the same level. ✓ Compose the picture the way you normally look at the area. ✓ Use an uncluttered, neutral-colored background. Skin is best photographed against a blue background. ✓ Lighting is crucial to accurate color reproduction. In the absence of proper lighting, it is very important to document in writing in the medical chart the color and description of the lesion. ✓ Duplicated slides will likely have distorted color. Take two or three shots of the same view instead. ✓ Document a finding with several shots taken from different distances and angles. Take some photographs of a lesion that include landmarks such as an elbow or a knee so that the lesion is seen in its proper location. ✓ Use the rule of three. Take at least two shots of three orientations: full body, medium range of the finding, and close up. ✓ Document the size of the injury by using an inch scale. Be sure that there is at least one other close-up of the injury without the scale to demonstrate the scale was not covering evidence. • Document pattern or circumferential injuries, such as burns and bite marks, using photographs showing antero-posterior and lateral views. • Photograph transfer evidence that may be present on the body or clothing, such as dirt, gravel, or vegetation. • Ultraviolet light may be helpful for photographing bite wounds months later even when the overlying skin appears totally normal. • It may be useful to take serial photos of injuries over a period of time to show progression of healing. ✓ Photographing Bite Marks - Forensic odontologists required you to use a “ABFO” Ruler when photographing bite marks

Scene Assessments – Perimeters and Boundaries ✓ Where are the boundaries? ✓ Set clear boundaries so they can be controlled ✓ Start large and reduce if needed ✓ May not have a good understanding of witnesses and family members ✓ Who is suspect and what is their relationship to the child ✓ Be cautious of curious neighbors being too helpful

Scene Assessments – Outside Areas ✓ Open fields ✓ Wooded areas ✓ Parking lots ✓ Playgrounds ✓ Closest house? ✓ Type of neighborhood? ✓ Containment of area?

Scene Assessments – Night Scenes ✓ Lighting ✓ Determining crime scene ✓ Weather conditions ✓ Public view ✓ Traffic areas ✓ Should always be conducted during daylight if possible ✓ Fragile evidence will be found more often

Scene Assessments ✓ Watch out for tunnel vision , keep an open mind ✓ Make mental notes of key evidence and write down or relay to others

Scene Preservation ✓ Note conditions of crime (scene, clean, cluttered) ✓ Note dust patterns ✓ Don’t use or flush the commode ✓ Don’t turn on the water in the sink ✓ Don’t open widows until photographed

Photography Documentation ✓ Take pictures of the crowd, EMS, scene and vehicles

Scene Control

✓ Careful consideration must be given to scene control, which necessitates several officers. ✓ There may be multiple scenes (e.g., the dwelling and an outdoor swing set); multiple care givers; visits from family and significant others; siblings and other children; and media presence. ✓ Maximum scene control means minimal scene contamination. ✓ The scene is very likely to have been altered prior to the arrival of the investigator. ✓ Care givers may have attempted resuscitation efforts, moved items, or in the worse case scenario, attempted to stage the scene. ✓ EMT personnel, other investigators, or the coroner/medical examiner may have had contact with the victim and/or moved items. ✓ Careful interviewing will assist in the best possible reconstruction of the scene.

Who are the Witnesses? ✓ Relatives/Babysitter/Boyfriend/Girlfriend/ Families/Neighbor? ✓ Three most important witnesses (in dealing with a dead infant) o Placer – Person who placed the infant down last o Last Known Alive (LKA) – Person who saw or heard the infant last o Finder – Person who found the infant dead or unresponsive

Other Potential Witnesses ✓ School teachers ✓ Daycare providers ✓ Child Protective Services Workers (CPS) ✓ Police Officers ✓ Other victims ✓ Forensic interviewer ✓ Friends of the Alleged Perpetrator ✓ Physicians ✓ Registered nurses

Conducting Doll Reenactments ✓ Have the caregiver walk you through the events leading up to the injury event ✓ Have the caregiver demonstrate with a doll the child’s position, describing the event ✓ Handle the doll with respect while not attempting to treat the doll as a living infant ✓ Explain the doll’s use and purpose (prop) ✓ Demonstrate the articulation of the doll’s body, head, arms and legs (this allows for the positioning of the doll to recreate the exact positioning of the doll ✓ Provide a brief explanation of the step-by-step procedure ✓ Highlight the placer/finders role (this helps ensure cooperation throughout the reenactment) ✓ Encourage them to ask questions ✓ Give step-by-step instruction, explaining manipulation of doll for exact placed/found position ✓ Emphasize importance of ensuring accurate recreation • Body position • Bed-sharing scenario • Bedding/blankets • Toys/stuffed animals • Positional supports (wedges)

Three most important witnesses for doll reenactments ✓ Placer – Person who placed the infant down last ✓ Last Known Alive (LKA) – Person who saw or heard the infant last ✓ Finder – Person who found the infant dead or unresponsive

Remember that it m y be three DIFFERENT people!

What is “Normal” for this Infant? ✓ Have the witness explain the infant’s daily routine ✓ Is the child easy-going – or cranky? ✓ Is the child sickly – or robust? ✓ Does the child have medical problems? ✓ Is the child a good eater – or finicky? ✓ Does the child sleep soundly – or is often wakeful at night?

Crash Course in Child Physical Development Birth to 3 months - Most infants begin to: ✓ Raise head slightly when lying on stomach ✓ Hold head up for a few seconds, when supported ✓ Hold hand in a fist ✓ Lift head and chest, while lying on stomach ✓ Use sucking, grasping, and rooting (holding tongue to the roof of the mouth) reflexes ✓ Touch, pull, and tug own hands with fascination ✓ Repeat body movements, and enjoy doing so

3 to 6 months - Babies are quickly becoming stronger and more agile. Most begin to: ✓ Roll over ✓ Push body forward and pull body up by grabbing the edge of a crib ✓ Reach for and touch objects ✓ Reach, grasp, and put objects in mouth ✓ Make discoveries with objects (for example, a rattle makes noise when it is moved)

6 to 9 months - "Child-proofing" becomes important as babies get more mobile. During this time most begin to: ✓ Crawl ✓ Grasp and pull things toward self ✓ Transfer objects between hands

9 to 12 months - By this time, most babies can: ✓ Sit without support ✓ Stand unaided ✓ Walk with aid ✓ Roll a ball ✓ Throw objects ✓ Pick things up with thumb and one finger ✓ Drop and pick up toys

1 to 2 years - Walking and self-initiated movement become easier. Most children can: ✓ Walk alone ✓ Walk backwards ✓ Pick up toys from a standing position ✓ Push and pull objects ✓ Seat self in a child's chair ✓ Walk up and down stairs with aid ✓ Move to music ✓ Paint with whole arm movement

2 to 3 years - Children become more comfortable with motion, increasing speed, and coordination. Most begin to: ✓ Run forward ✓ Jump in place with both feet together ✓ Stand on one foot, with aid ✓ Walk on tiptoe ✓ Kick ball forward

Finding the Body ✓ DO NOT MOVE UNLESS RESCUE EFFORTS WARRANT MOVING ✓ Contact the coroner ✓ Photograph the body in place ✓ Photograph everything around the body ✓ What you first see may not tell you the real story ✓ Bite marks/other bruises ✓ Color of injury may indicate time table of events ✓ Animal vs child/adult bites ✓ Foot, shoe, tire impressions ✓ Special emphasis should be placed on areas/items involved in impacts. If the accidental fall explanation is provided ✓ Measure the distance between the surfaces from which the child fell to the floor. Note any carpet, carpet padding, etc. where the child was alleged to have fallen and obtain samples of same ✓ What you first see may or may not tell you the real story

Children are rarely severely abused or killed in a single incident where there is no evidence of a pattern of prior conduct, often evidenced by pre-existing injuries, such as rib fractures, skull fractures, older bleeding within the skull, bruises, or simply changes in the baby's behavior with no apparent cause.

The Body Lividity – State of Decay ✓ Postmortem Changes - Livor Mortis/Rigor Mortis

✓ Livor Mortis o Blanchable or Fixed o Push against the skin – if blanchable, there will be a mark – if fixed, there will not be a mark left o Generally fixed at 8-12 hours; may take longer o Difficult to see in dark skinned individuals o Difficult to see in massive blood loss o Difficult to see in chronic anemia

✓ Rigor Mortis o The body muscles will normally be in a relaxed state for the first 3 hours after death o Muscles will stiffen between 3 hours and 36 hours and then becoming relaxed again o There is some uncertainty in estimates derived from rigor mortis because the time of onset is highly dependant on the amount of work the muscles had done immediately before death

If body is warm, Not dead more than a but not stiff couple of hours

Dead between a couple If body is warm hours and half of day. and stiff

If body is cold Dead between a half day and stiff and two days

If body is cold, Dead more than but not stiff two days

Accidental versus Inflicted Injuries ✓ Injuries to the buttocks, genitalia, abdomen, back, and lateral area of the body, especially the sides of the face, frequently indicate abuse ✓ Contusions: A bruise caused when skin tissue is crushed ✓ Hematoma: A lump that develops when a pool of blood collects ✓ Petechiae: Very small bruises caused by broken blood capillaries ✓ Purpura: Small bruises occurring in groups ✓ Ecchymosis: A large bruise

Bruising ✓ Bruises my be difficult to see if they were made immediately before death ✓ Bruises take a while to develop even in a living person ✓ Many internal injuries do not show at all on the skin, especially before death ✓ These are not discovered until an autopsy is performed

Suffocation ✓ Difficult diagnosis ✓ Requires investigation and corroboration by witness/perpetrator statements ✓ Minimal or no external or internal trauma

Petechiae ✓ Tiny broken capillary broken blood vessels ✓ Everyone has them ✓ A hard bout of coughing or vomiting can cause facial petechiae, especially around the eyes ✓ Petechiae may or may not be present ✓ If petechiae are present, they are suggestive but not diagnostic of suffocation or smothering

Head Injuries

• Concussion • The Jostling of the brain’s soft matter. Often leaves a patient dazed or unconscious. Recovery will be complete, leaving only a cut or bruise on the scalp or head • Contusion • A more serious bruising of the brain. Often involves unconsciousness for days or weeks

• Laceration • Involves a tear in the brain substance, bruising, and torn blood vessels. Often leads to subdural hematoma

Subdural Hematoma ✓ The collection of blood within the outer covering of the brain. A subdural is often produced by a blow to the head or violent shaking. ✓ Low pressure bleed venous bleed o Venous bleeding occurs in a steady flow, and the blood is dark-red, almost maroon, in color. Since capillaries are so small, capillary bleeding is a slow, oozing flow that carries with it a higher risk of infection than either arterial or venous bleeding. ✓ Subdural hematomas are most often caused by head injury, when fast changing velocities within the skull may stretch and tear small bridging veins. ✓ Subdural hematomas due to head injury are described as traumatic. ✓ In infants and children, subdural hematoma is often seen in physical child abuse . ✓ Infants rarely fall until they start learning to walk, so falls account for only a small number of subdural hematomas in infants. ✓ Many subdural hematomas in toddlers result from accidental falls, as they learn to walk and climb. In older children, a fall in which they hit their head is a common cause of subdural hematoma. ✓ All age groups are susceptible to developing subdural hematomas from vehicle accidents. ✓ In young children, even if the head does not contact a solid surface, the shaking, whiplash movement from some vehicle crashes causes blood vessels to burst in the brain.

Epidural Hematoma ✓ When the blood accumulates between the dura and skull, swelling of the brain occurs. There is no extra room within the skull to allow for the brain to swell and for the blood to accumulate. ✓ High pressure arterial bleed o Arterial bleeding is characterized by spurts of bright-red blood; spurting each time the heart beats. ✓ The main cause of epidural hematoma is usually traumatic ✓ Epidural hematoma commonly results from a blow to the side of the head. ✓ Epidural hematoma is usually found on the same side of the brain that was impacted by the blow, but on very rare occasions it can be due to a contrecoup injury. ✓ Accidental Injuries UNLIKELY in infants

Fatal Falls ✓ In most cases, a trivial injury occurs when a child has a routine fall ✓ When a child is reported to have had a routine fall and presents with a skull fracture, cerebral edema, retinal hemorrhages, subdural hematomas, abuse should be indicated ✓ Suspect child abuse whenever the child presents with serious head injury, with or without skull fracture, as a result of a reported fall from a bed, sofa, or crib ✓ Injury pattern that results with this mechanism is dependent upon three factors: o distance of the fall o body part that impacts first o type of landing surface ✓ Falling from greater heights increases the incidence of trauma because velocity increases as they fall ✓ Falls are considered severe if greater than three times the height of the victim ✓ If the landing surface is more resilient, thereby increasing the stopping distance, the kinetic energy will be absorbed by the surface instead of the victim's body ✓ Associated with head injury, since their head is the heaviest part of their body and usually impacts first

Shaken Baby Syndrome – ABUSIVE HEAD TRAUMA ✓ SBS results from violent shaking of an infant or toddler ✓ Every shaken baby investigation should focus on two major issues: ✓ What was the nature of the injuries to the child and, to a reasonable medical certainty, what can be said about when the injuries were afflicted? ✓ Who committed the acts which resulted in those injuries? ✓ Inconsolable crying is the most frequently reported reason by caretakers for losing control with a child ✓ Other reasons include frustrations related to toilet training, fussy eating, and adults having unreal expectations for a child's behavior ✓ A one-time violent shaking episode, of even two to three seconds, can cause partial or complete loss of vision, hearing impairment, a fractured skull, broken bones, seizure disorders and learning disabilities. ✓ One of the cornerstones of a successful investigation is recording the scene and the lawful seizure of evidence. A disciplined investigator should ask him/herself:

Shaking - Immediate Consequences ✓ Breathing may stop or be compromised ✓ Extreme irritability ✓ Seizures ✓ Limp arms and legs or rigidity/posturing ✓ Decreased level of consciousness ✓ Vomiting; poor feeding ✓ Inability to suck or swallow ✓ Heart may stop ✓ Death

Shaking - Long-Term Consequences ✓ Learning disabilities ✓ Physical disabilities ✓ Visual disabilities or blindness ✓ Hearing impairment ✓ Speech disabilities ✓ Cerebral Palsy ✓ Seizures ✓ Behavior disorders ✓ Cognitive impairment ✓ Death

Why? ✓ Babies' heads are relatively large and heavy, making up about 25% of their total body weight. Their neck muscles are too weak to support such a disproportionately large head. ✓ Babies' brains are immature and more easily injured by shaking. ✓ Babies' blood vessels around the brain are more susceptible to tearing than older children or adults.

Common Symptoms ✓ Lethargy / decreased muscle tone ✓ Extreme irritability ✓ Decreased appetite, poor feeding or vomiting for no apparent reason ✓ Grab-type bruises on arms or chest are rare ✓ No smiling or vocalization ✓ Poor sucking or swallowing ✓ Rigidity or posturing ✓ Difficulty breathing ✓ Seizures ✓ Head or forehead appears larger than usual or soft-spot on head appears to be bulging ✓ Inability to lift head ✓ Inability of eyes to focus or track movement or unequal size of pupils

In a study of 151 cases of head trauma related to SBS ✓ The age range of victims was three weeks to 24 months, with a median range of five months ✓ 60% of victims were male. ✓ 23% of the victims died. ✓ Biological mothers were responsible for 12% of injuries. ✓ Female babysitters, a previously unrecognized group of offenders, caused 17% of the injuries. Male babysitters accounted for 3% of the injuries. ✓ Male perpetrators (usually the biological father or the mother's boyfriend) outnumbered females 22:1.

How much force is necessary to cause injuries in shaken baby syndrome? How many times do you have to shake an infant or young child to cause damage? ✓ No firm answer exists ✓ Shaking probably lasts a maximum of 20 seconds or less. ✓ In most cases the period of shaking is 5 to 10 seconds. ✓ To cause brain damage sufficient to allow clinical detection of the syndrome, severe forces must be used. ✓ On mechanical/physiologic grounds and by experience with perpetrators who have been convicted or confessed to the shaking, it is clear that to lift an infant and shake requires an adult or an adult-sized person. ✓ A common misconception regarding non-accidental head injuries is that severe brain injury only develops if the victim is shaken "50 to 100 times". ✓ However, a single forceful impact is sufficient to produce very high deceleration forces in the infant's brain. It is these forces which result in bleeding to the eyes and brain. ✓ The injury is often the result of a single loss of control where the baby may be shaken but is also thrown down because the caretaker is still angry

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