Child abuse pediatrics is an evolving field. Prior to Dr. C. Henry Kempe and colleagues analyzing and defining Battered Child Syndrome in 1962 as physically abusive injuries to one or more body systems culminating in serious injury or death (Kempe et al. 1962) these cases were not recognized or, if diagnosed, mishandled by the physician. Kempe’s legacy has been to reshape our understanding of child maltreatment. Due in part to this seminal article, physical abuse of children is now diagnosed by clinicians, investigated by social services, and prosecuted in courts. The description of Battered Child Syndrome addressed system-wide failures to recognize child maltreatment.

As the years progressed, other subcategories of child abuse emerged including sexual abuse (Kempe 1978), neglect (Cantwell 1980), emotional abuse (Hart et al. 2011; Hibbard et al. 2012), abusive head trauma (Christian et al. 2009), medical child abuse (Roesler and Jenny 2009; Rosenberg 1987; Stirling and American Academy of Pediatrics Committee on Child Abuse and Neglect 2007), and intentional child starvation (Kellogg and Lukefahr 2005). Each identified subcategory of child maltreatment included unique clinical features which required specific child assessment, diagnostic, and treatment approaches.

Torture is different from other forms of child abuse, but it currently lacks medical definitional criteria. As opposed to torture, the majority of commonly recognized physically abusive acts result from a caregiver’s episodic unchecked anger or loss of self-control. Torture is usually prolonged or repeated and includes acts designed to establish the perpetrator’s domination and control over the child’s psyche, actions and access to the necessities of life. It employed elements of both physical abuse and psychological cruelty. According to Knox and Starling (2012), 1 to 2 % of children being evaluated for abuse present with such a unique constellation of physical and psychological injuries which appears to represent torture.

Recognition and management of these cases is problematic at multiple levels, including medical care, interventions by Child Protective Services (CPS), and prosecution by the legal system. A recent literature review and commentary notes the lack of a formal medical definition of torture in the context of child abuse (den Otter et al. 2013); this lack of a definition may have reduced the ability of medical and legal authorities to effectively recognize and address this problem. Although torture has been described in the context of politically motivated abuse, the torture of children within a familial context has received little attention. Review of the medical literature yielded only two isolated case reports of torture that were not politically motivated (Allasio and Fischer 1998; Tournel et al. 2006).

Definitions of Torture

Historically, torture in the context of politically or militarily motivated conduct, often by state actors, is a means of extracting information or controlling populations through intimidation and repression (Stover and Nightingale 1985). Definitions of torture have been proposed by Amnesty International (1975), the World Medical Association (1975), and the United Nations Convention Against Torture and Other Cruel, Inhuman, or Degrading Treatment or Punishment (Burgers and Danelius 1988) to address politically motivated conduct and the medical community’s response to torture. These definitions include two key components: (1) intentional infliction of severe pain and suffering without regard to the extent of injury, and (2) for the purpose of obtaining submission or dehumanization. Definitions of political torture generally require that perpetrators have physical control over the victim (Stover and Nightingale 1985), inflict severe pain and suffering, to behave systematically and with purpose, and continue or repeat the behaviors over time (Allasio and Fischer 1998). Stover and Nightingale (1985) state:

The purpose of torture is to break the will of the victim and ultimately to break his or her humanity…through infliction of severe or acute physical pain and mental suffering…and requires that the torturer exert physical control over his or her victim. (p. 4–5)

Campbell (2007) adds: “The act of torture is carried out for the purpose of physically and psychologically ‘breaking’ an individual” (p. 633). Children also have been documented victims of political torture (Cohn et al. 1981; den Otter et al. 2013; Green 2007; Welsh 2000). However, descriptions of manifestations and definitions specific to intra-familial torture, without political purpose, have not been described (Allasio and Fischer 1998; Tournel et al. 2006).

Exemplary Case Series of Child Abuse Torture

The goal of this case series is to exemplify and thus define child torture within the context of physical and psychological maltreatment inflicted on children by their caretakers. We sought to identify medical criteria distinguishing these cases from other forms of child abuse and present reasons for creating a new subcategory of child maltreatment. This case series also examines perpetrator characteristics and their implications.

Methods

Child abuse pediatricians from five U.S. medical centers selected cases they considered to represent child torture. The sites spanned the country, including Virginia, Texas, Wisconsin, Utah, and Washington State. These cases included a combination of severe physical and psychological maltreatment that occurred repeatedly and caused severe physical and psychological injury. This non-consecutive series included children between ages 9 months and 15-years-old evaluated between January 1, 1995 and August 31, 2012. They did not represent all potential cases from any institution. The medical records were abstracted for age, sex, relationship to perpetrator, details of the child’s physical and psychological injuries, reported methods of abuse, the child’s abuse disclosures, the duration of abuse, and outcomes of the case. Six major types of psychological maltreatment identified for abstraction included spurning (the emotional rejection/denigration of a child), terrorizing, isolating, exploiting/corrupting, denying emotional responsiveness, and mental health/medical/educational neglect (Hart et al. 2011; Hibbard et al. 2012). Cases involving primarily sexual torture were excluded from this study based on the authors’ experience that the perpetrator(s) motivation and relationship to the child were qualitatively different.

The Institutional Review Boards (IRB) of the University of Wisconsin School of Medicine and Public Health and Eastern Virginia Medical School approved this study prior to data collection. The University of Wisconsin Health Sciences IRB served as the IRB of record for Seattle Children’s Hospital and the National Center for the Prosecution of Child Abuse. The remainder of the institutions participating in this study exempted the research.

Results

Twenty-eight cases of extreme child abuse were identified. The children’s median age was 7.5 years (range = 9 months-14.5 years). Abuse duration ranged from 3.5 months to 8 years (median = 3 years). Eleven (39 %) children were male and 17 (61 %) female. Twelve children were Caucasian (43 %), 10 (36 %) African American, and six (21 %) were Hispanic. Forty-five percent of the victims’ siblings had been coerced into participation in the torture and 65 % of siblings were abuse victims themselves. Ages, physical injuries/outcomes, reported methods of torture, and perpetrator(s) for each case are presented in Table 1. Figures 1 and 2, and their individual case data in Table 1 document the abuse of two children and their injury environments.

Table 1 Physical injuries/outcomes, reported methods of torture, and perpetrator(s)
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Fig. 1
figure 1

A 4 6/12 year-old female was found dead in the bathroom. She had 50 % TBSA acute immersion burns and an acute subdural hemorrhage. She had been suspended from a closet rod at night by a bent coat hanger (distant and close up images a and b) to prevent her scratching her old scalp burn. That burn, a grid-like cheek contact burn and multiple sub-acute facial injuries are seen in her lateral face view (c). The back of her legs shows the immersion burns with popliteal sparing. They overlie pressure ulcerations over her heel cords from prior binding with ligatures (d)

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Fig. 2
figure 2

Law enforcement scene investigation confirmed the 11-year-old child victim’s disclosures that he was forcibly confined in a cubbyhole underneath the stairs (a) and in closets. A child alarm was placed on the house door to detect his movement and prevent escape (b). Scalp pressure injury from chronic confinement, eroded to the bone (c); burned and mummified toes, later spontaneously disarticulated (d); scalded fingers with mummified tips (e)

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All study children in this case series were subjected to more than one form of egregious physical abuse and neglect, and most children were deprived of basic necessities of life (Table 2). Ninety-three percent of children had cutaneous evidence of physical abuse at the time of medical intervention or death. Sixty-one percent had been physically restrained by binding. Ninety-three percent of children had been beaten and 21 % had fractures. They received no medical care for their physical injuries. The fatality rate was high at 36 % (10/28).

Table 2 Physical injuries (n = 28)
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Table 3 lists types of psychological abuse(s) and neglect of child victims. Eighty-nine percent experienced food deprivation and 79 % were fluid restricted. Sixty-four percent were restricted in the performance of normal bodily functions, including toilet access for urination and defecation. The majority of children (89 %) were isolated from people outside the immediate family; 75 % experienced solitary confinement. For over half, few individuals outside the abuser(s) knew of the child’s existence. This social isolation typically involved preventing the child from attending school or daycare. Twenty-nine percent of school-age children were not allowed to attend school; two children, though previous enrolled, were dis-enrolled by their caregiver and received no further schooling. An additional 47 % who had been enrolled in school were removed under the auspice of “homeschooling.” This “homeschooling” appears to have been designed to further isolate the child and typically occurred after closure of a previously opened CPS case. Review of these cases found no true educational efforts were provided to the homeschooled children. Their isolation was accompanied by an escalation of physically abusive events.

Table 3 Psychological maltreatment
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Every child included in the study was victim of several of the six major types of psychological maltreatment (as listed in the methodology section). Most of the children were denied emotional responsiveness, in which the caregiver ignored the child’s attempts and need for social interaction (den Otter et al. 2013). Threats of death were made to 32 % of the children. Of known mental health outcomes for the surviving children, post-traumatic stress disorder (PTSD) was the most common mental health condition.

Half of all cases reviewed had a prior history of 1 to 15 referrals and/or investigations by CPS. These prior CPS referrals had been investigated for intentional food/fluid restriction, lack of supervision, physical abuse, and neglect. CPS workers often accepted the caretaker(s) attribution that the child was emotionally/behaviorally disturbed or had an eating disorder. If the CPS worker recognized the child to be malnourished, he/she accepted the caretaker’s agreement to feed the child and closed the case without follow-up.

A clear timeline of abuse could not be established in all cases. However, for cases in which the timeline was known, the shortest period of time between onset of torture and recognition and intervention was 3.5 months, while the longest period was 8 years. Twenty of 51 perpetrators were either biologic mother or father (39.2 %). Females (31 total) were among the perpetrators in every case. Twelve female perpetrators were biologic mothers (38.7 %). Stepmothers or girlfriends constituted 19.4 %, as did adoptive mothers. Other female relatives (12.9 %, 4) and unrelated females (9.7 %, 3) were also perpetrators. Among the 20 male perpetrators, eight (40 %) were the biologic father, five (25 %) were stepfather or mother’s boyfriend, four (20 %) were adoptive fathers, one (5 %) was another relative, and two (10 %) were unrelated males. For all cases, all adults in the home knew of this extreme abuse and participated to some extent in abusive acts. Unlike other forms of abuse, most perpetrators of torture partially confessed to their crimes; however, they significantly minimized or rationalized their individual involvement.

Individual Detailed Case Report

A 14-year-old girl came to the attention of a county social worker who was notified that the child and her siblings had not been attending school. The social worker asked to see the children and was told by their father that they were sleeping. The worker was eventually allowed into the bedroom where she found the girl and her 8 and 5-year-old siblings hiding in the closet. The girl was lying in the fetal position in the back of the closet; she had a scalp laceration, bald patches, and dried blood on her head. The social worker called law enforcement, and the child was transported to an academic medical center. At the hospital, the child was emaciated and had multiple varying age lacerations and contusions on her body, a bite mark on her anterior shin, and numerous healed scars on her face, back, and abdomen. X-rays revealed an acute transverse fracture of the right patella, acute fracture of the left 5th metacarpal bone, and a healing fracture of the left 3rd metacarpal bone. It was later determined that the child had pubertal arrest and regression of breast development. On initial history, the child had stated her multiple injuries were self-inflicted, caused by fighting with other teens. However, during the course of her hospitalization, she reported ongoing severe physical and psychological abuse. She reported being forced to eat roaches, spiders, and other insects as a form of punishment and that her family attempted to force feed her a dead mouse. She stated that her father bound her hands behind her back, taped plastic bags over her head and torso, and threatened to drown her in the lake. Her younger sister participated in her abuse by encouraging their father to place more duct tape on her mouth and also encouraged their mother to force the girl’s face into soiled toilet water. She reported digital penetration of her vagina by her father who also repeatedly made her stand naked in front of the mirror while fondling her breasts. Her mother struck her with metal pipes, a skillet, baseball bats, and a glass candle. She also disclosed being stabbed in the abdomen and forearm with a kitchen knife, exposing the bone. No medical care was sought for her injuries. The girl reported she felt certain she would die. Her case had been reported to social services three prior times in the same year, one of which had not been accepted for investigation and the other two were unfounded for abuse. The most recent allegation was unfounded because the child attributed her bruises and lacerations to injuries sustained during a gang altercation.

Discussion

Defining Torture in the Context of Child Abuse

The children in this case series suffered a severe combined type of child abuse including extreme physical and psychological maltreatment (Table 4). Torture goes beyond simple polyvictimization in that it includes an increased severity of both physical and psychological maltreatment. It involves intense humiliation and terrorization (Finkelhor et al. 2011).

Table 4 Definition
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In our case series, common characteristics of child torture involved multiple abusive physical injuries, deprivation of essential needs, and denigration or dehumanizing the child. Torture was found to occur over a period of time, often with the knowledge and/or acquiescence of other caregivers and siblings. The role of female perpetrators in all cases is an atypical finding in most cases of child physical abuse. As the level of violence and control in the homes increased, perpetrators increased the isolation of the victims from everyone but their immediate caretakers. The child’s entire household either participated in or was aware of the child’s abuse. Nearly all children in this case series presented with cutaneous injury. A significant minority (21 %) had fractures. This is different from most forms of physical child abuse, in which fractures are common, but are typically limited to infants and toddlers (King et al. 1988). The children were denied medical intervention until fortuitously they were discovered or near fatal or fatal events occurred.

Based on the commonalities found among these infants and children, we propose defining child torture as a longitudinal period of abuse characterized by at least two physical assaults, and two or more forms of psychological maltreatment (e.g., terrorizing, isolating), resulting in prolonged suffering, permanent disfigurement/dysfunction, or death. Torture usually includes neglect of obvious medical needs that are often the result of their abusive injuries or starvation. Multiple episodes of physical and emotional abuse occur over time or during one prolonged period of abuse. In most cases, the caretaker(s) made concerted efforts to isolate the child from outside contact or observation. Table 4 outlines the definition and provides examples of common forms of assault experienced by child torture victims.

Caregiver Motivation and Dynamics

Definitions of political torture include analysis of the perpetrators’ intent to commit torture. Captor/perpetrators are politically motivated and are state actors, thus differ from a child’s caretaker in a caregiving setting.

For our subjects, caregiver statements to medical providers, CPS, and police were insufficient or incomplete. Thus, the motivation or intent of the abuser was not analyzed in this case series. The diagnosis of torture in an intra-familial setting is based on the severity, morbidity, and mortality of the physical and psychological maltreatment inflicted on the child. A similar focus on the harm the child has suffered, instead of the perpetrator’s intent, has been used in defining other types of child abuse, including Medical Child Abuse, a reframing of Munchausen Syndrome by Proxy (Stirling and American Academy of Pediatrics Committee on Child Abuse and Neglect 2007).

Household Dynamics

Several children came into the torturing households through informal family arrangements. We observed that 79 % of the primary abusers were not the child’s first degree relative; they included such caregivers as boyfriends, girlfriends, aunts, uncles, grandparents, adoptive parents, and stepparents. Most child victims appeared to be scapegoated within their family; this is another recognized form of abuse associated with sibling empathy deficits (Hollingsworth et al. 2007). Other siblings often were coerced to participate in or endorse the abuse of the index child. In this case series, many of the other children in the household were also abuse victims themselves, although generally suffering significantly less abuse than the index child.

Typically, abusers demonstrated little or no remorse for their actions. Many transferred blame for their actions onto others and most perpetrators blamed their victims for precipitating the abuse or causing abuse to be necessary. Perpetrators seemed to utilize a framework of necessary discipline and corporal punishment to justify their abusive acts. In these and other cases we have subsequently evaluated, some perpetrators saw it as a religious duty to discipline their children harshly.

Early identification of perpetrators and their child victims is critical as Steele (1987) finds it “extremely difficult, if not impossible, to rehabilitate perpetrators who torture their offspring” (p. 101). The nature of these crimes and the perpetrator’s self-justification argues against any reunification with caretakers and the rehabilitation potential of perpetrators is poor. Safety plans for victims of child torture should rarely, if ever, involve plans for family reunification. Identification of the correct diagnosis should facilitate a safe child protection disposition and appropriate long-term rehabilitative treatment for physical and psychological trauma endured by these victims.

The dynamic of psychological and physical cruelty used to control a child is similar to the dynamic often observed in intimate partner violence. Perpetrators of child torture exercised extreme control over their child victims, inflicting repetitive pain and suffering on these children and dehumanizing them. In some instances torturers may threaten or injure a child’s loved ones or objects such as a family pet or favored toy as a means of gaining control over the victim. Denial of necessities, including access to food, water, toilet, and sleep were frequently utilized as punishment by the perpetrators. Family members were coerced into participation in the child’s abuse, possibly out of their own fear or an inability to escape the situation.

Effects of Torture

The long-term effects of child torture as a form of child abuse are unknown. The medical literature clearly reflects that adult torture victims have significant physical and psychological sequelae (Goldfeld et al. 1988; Herman 1992). A psychological syndrome reported in adult torture survivors by Allodi and Cowgill (1982) includes findings of extreme anxiety, insomnia, nightmares, suspicious/fearfulness, as well as somatic symptoms of anxiety and phobias. PTSD is the most commonly diagnosed psychological disorder among adult torture victims (Allodi and Cowgill 1982; Herman 1992). In addition to torture, polyvictimization has been recognized to be associated with worse mental health outcomes in child abuse victims (Finkelhor et al. 2011). By definition, all of our children have suffered polyvictimization as defined by Finkelhor. Although mental health evaluations were not always done or accessible to us, the victims in our case series commonly were diagnosed with PTSD. Formal psychiatric evaluation is recommended for all victims.

Medical Evaluation

In some cases, health care providers had observed the child for caretaker complaints, but failed to recognize the child’s injuries or malnutrition or to accurately diagnose abuse as their cause. This subsequently resulted in a continuation of the abuse with severe physical and psychological injury to the child. For example, medical providers frequently based their evaluations solely on the history reported by the perpetrator and failed to consider alternate explanations for malnutrition, such as intentional starvation. The perpetrators’ explanations that their children were suffering from behavioral or psychiatric issues causing the starvation were initially accepted by health care practitioners. Many of these children had been bound, confined, or isolated to prevent acquisition of food or water; consequently, these children often attempted to steal or otherwise acquire food or water. They were severely punished if caught. A few children had been brought for medical evaluations with complaints of “excessive hunger and thirst.” Physicians evaluating these children did not recognize that the children’s behavior represented an appropriate response to their deprivation. As a result, victims suffered ongoing abuse or death.

The victims we saw share some of the characteristics of the child starvation cases described by Kellogg and Lukefahr (2005), including isolation of the child and hidden or missed malnutrition. They were usually kept at home, or if taken where others could observe them, were clothed to cover their degree of malnutrition and their physical injuries. Older children were removed from school under the guise of home schooling. Although home schooling is a valid form of education for many families, these children show no evidence of receiving any education. Their removal from school appears to have been motivated by the need to keep the children hidden. Several children had home visits from protective services or public health nurses or were seen by physicians, but their severe malnutrition was missed. Lack of regularly obtaining and charting growth data appeared contributory.

The evaluation requires a comprehensive, multidisciplinary approach, including scene investigation, careful questioning of the victim, siblings, potential witnesses, and the caregivers. Medical providers must collaborate with police and protective services who can evaluate the scene for evidence of confinement and past injuries. Photographs should be taken to document the availability of sufficient food in the household. Additionally, photographs should also be taken of any objects of value in the home (e.g., mobile technologies, gaming technologies, alcohol, expensive accessories) to document the availability of resources in the home that could have been used to purchase food for the children. Investigators should interview leaders of the perpetrator(s) faith community to determine whether their actions represent idiosyncratic religious beliefs. This could defend against claims that the perpetrator(s) abuses of the child fell within the range of acts sanctioned by doctrine of faith.

In cases involving starvation, it is important to obtain laboratory studies for dehydration and nutritional status as soon as possible after the child presents for care. If the case enters the court system, serial photographs of the victim from the time of presentation until nutritional recovery are compelling illustrations of the severity of nutritional deprivation, supplementing the growth curves. Likewise, these children’s voracious appetites and rapid weight gain after they are allowed food and fluids belie allegations that they suffer from eating disorders, unusual endocrine disorders, or metabolic disorders as a cause of starvation (Kellogg and Lukefahr 2005). Starved children risk re-feeding syndrome if their malnutrition has been prolonged.

The cases we observed reflect systematic attempts by the caregiver(s) to cause physical and psychological pain and suffering to the child. The dynamic of domination and control over the necessities of life is uniquely different from other forms of physical abuse, which usually result from caretaker anger and loss of control (Schmitt 1987). The extent to which these caregivers have created a system of rules, boundaries, and patterns for managing the targeted children is unique. Forced position holding, such as standing with arms stretched out holding phone books for hours, was a common form of discipline. Medical, child protection, or criminal justice professionals often failed to note these rules or rituals or understand their abusive significance. Thus the psychological maltreatment of these children often was overlooked.

When extreme discipline is accepted as the norm by a child, the child may not disclose to a medical provider the abuse they experienced unless specifically asked. Open-ended questions such as “tell me about meal time,” “tell me about going to the bathroom,” or “what are the rules about sleep or potty” can be very helpful in eliciting otherwise normalized punishments, such as food withholding or forced excrement ingestion. Often disclosures only gradually come forth after the child has been stabilized in a safe setting. Professionals involved in these cases may not be aware of the existence of or recognize the significance of extreme forms of discipline, including limited access to toilet, food, sleep, or other necessities which dehumanize or demean the child.

Fifty percent of the children in this case series had been previously reported to child protective services for maltreatment, including psychological maltreatment and starvation. However, there was poor coordination between the medical providers and the child protection system to identify and manage torture as an unique form of injury. Cases involving withholding of food were not recognized as a form of abuse. Cases of unusual punishment, such as prolonged forced exercise, also were dismissed and not further pursued. Ultimately a medical definition of child torture would provide the medical profession a framework to make an appropriate diagnosis of child victims, allowing earlier intervention by authorities. Medically defining child torture also would invite child protective services, law enforcement, and legal professionals to better recognize the full extent of the injuries suffered by these children, understand the possible outcomes, and allow them to more effectively protect victims and prosecute perpetrators.

We noted that siblings are also frequently recruited to assist in abusing the index child, but also are abuse victims to a lesser degree themselves. At the very least, they sustain the harms of witnesses of violence and abuse (Finkelhor et al. 2009). As such, both their safety and mental health needs also must be considered. Both victims and siblings will likely require therapeutic foster care placement and long-term mental health services (Anda et al. 2006).

The legal landscape for addressing torture varies widely by jurisdiction (Tiapula and Applebaum 2011). Statutes referencing torture reflect a range of legislative responses, including both criminal and civil statutes. Criminal laws prohibit and penalize both physical and sexual torture while civil statutes reference torture in matters of family law, employment law, and public health law. Both physical and sexual torture are explicitly addressed by some states in a range of criminal and child protection statutes and legal precedents, often these include specific provisions related to the extent of the injury or pain suffered by the victim (Tiapula and Applebaum 2011). Thus, medical providers should be careful to document the child’s pain and suffering in cases involving child torture. A medical definition of torture might stimulate other states to adopt explicit torture statutes and those with current statues to update them. Emerging recognition of torture as a distinct medical diagnosis would enable legislative responses that reflect the severity of injury. It would enable courts to focus on many of the factors that are often not addressed in existing statutes. For example, medical issues include restraint, isolation, and withholding of necessities and psychological maltreatment. Criminal prosecution and sentencing in cases of child torture reflect the uneven outcomes associated with institutional failures by law enforcement, prosecutors, and the courts to recognize and validate the emotional and psychological injuries linked to torture. Data not available to the current researchers included the prior criminal history of each defendant; a factor often weighed heavily in sentencing outcomes. Another significant factor in sentencing would be the relative culpability of each defendant in cases with multiple perpetrators torturing or participating in the torture of the child victim(s). The criminal sentences the perpetrators received ranged from probation to life in prison.

This series and paper is limited in that it is a select and by no means, inclusive series, of abuse cases. They have been chosen to be illustrative of the phenomenon of torture, but cannot be considered a consecutive case series for statistical analysis. Likewise, the information available to us was that primarily available through our consultations. In particular, detailed medical and psychiatric follow-up information was usually unavailable to us.

Conclusions

This case series identified specific components common to 28 children and infants who were considered victims of torture. These commonalities indicate that torture can be defined as at least two physical assaults (or a single extended incident) and two or more elements of psychological maltreatment. Neglect is often present, generally manifesting as failure to seek appropriate care for injuries and/or malnutrition. The combination of physical and psychological maltreatment results in severe child trauma, including prolonged emotional distress, pain and suffering, bodily injury/disfigurement, permanent bodily dysfunction, and/or death. Victims of torture were isolated, terrorized, neglected, deprived of basic necessities, as well as physically and psychologically maltreated. Their abuse appears to represent caretaker efforts to crush the child’s spirit and humanity. Recognizing early signs of torture, such as malnutrition, injuries suspicious for physical abuse, and lack of emotional responsiveness has significant potential to reduce the significant morbidity and mortality associated with this type of child abuse. The prevention of torture also depends on an effective child protection and criminal justice response requiring education and coordination among medical professionals, child protection workers, law enforcement, and the legal community.