Child Abuse Neglect Case Study

Fatma Yucel Beyaztas MD*, Halis Dokgoz MD**, Resmiye Oral MD***,
Yeltekin DEMIREL****

* Assoc.Prof.Dr., Cumhuriyet University, Faculty of Medicine, Department of Forensic Medicine 58140 Sivas/Turkey.
** Assoc.Prof.Dr., Mersin University, Faculty of Medicine, Department of Forensic Medicine Mersin/Turkey.
*** Assist.Prof.Dr., Iowa University, Department of Pediatrics, Director of Child Protection Program 200 Hawkins Drive Iowa City, IA 52242.
**** Assoc.Prof.Dr., Cumhuriyet University, Faculty of Medicine, Department of Family Medicine 58140 Sivas/Turkey.

Assoc. Prof. Dr. Fatma Yucel Beyaztas
Cumhuriyet University Faculty of Medicine
Department of Forensic Medicine 58140 Sivas/Turkey


Child abuse and neglect has been recognized as an important public health problem in the west since 1960s (1). Child abuse and neglect is defined in different ways in various cultures. In general, any commission or omission of acts by adult caretakers that imposes a negative impact on physical, psychological, and social wellbeing of a child is considered child abuse and neglect (2,3).

Child abuse has existed throughout the history of mankind, but studies in this field have emerged since the last century. For the first time in 1962, a pediatrician, Henry Kempe, set forth a diagnostic category and coined the term "Battered Child Syndrome". After a 12 year contentious period, all 50 states in the USA passed child protection laws for the prevention of child abuse and neglect (1,4). Child abuse and neglect may take many forms from inflicted injuries to failure to thrive due to inadequate feeding, from sexual abuse to emotional abuse, all of which limit the child's physical and mental development (2,3).

The risk factors setting up the stage for child abuse and/or neglect may be extra-familial or intra-familial. Economic, social, environmental, and cultural risk factors including poverty, low educational level, unemployment, violence, and substance abuse may lead to child abuse and neglect. Intra-familial risk factors include parental physical or mental health problems, certain characteristics of the child, parent deprivation, and unrealistic expectations of the family about the child's capabilities (5).
Child abuse and neglect was recognised in developed countries during the latter part of the last century and prevention programs were established (2,4). Developing countries have joined the western countries in recognising this issue as a socio-medico-legal public health problem within the last couple of decades (6-8).

In Turkey, Turkish Society for the Prevention of Child Abuse and Neglect has led the way to increased professional awareness of this important entity. The medical field, however, has not been involved in these efforts to a desirable extent, until 1990s. As the medical field began to get more involved in the recognition of child abuse and neglect, physicians have started publishing on child abuse and neglect, as well (6). In this paper, we present five cases diagnosed with child abuse and neglect, two of which had a fatal course. We hope these cases will guide physicians in Turkey and in other developing countries to be more diligent about the signs of child abuse and neglect.

Case 1

Two and a half year-old male, youngest child of a family with four children was brought to the emergency room of a University Medical School Hospital because of bleeding from the right ear and projectile vomiting after falling from a top bunk bed. Physical examination revealed no abnormalities except for bleeding from the right ear. He was observed for 24 hours after his vital signs were stabilised and was discharged to his parents with a diagnosis of head injury. Six days later, he returned to the same hospital complaining of right facial asymmetry while talking. Physical examination revealed superior posterior tympanic hematoma in the right ear. Computerised tomography (CT) of the head verified the tympanic hematoma and revealed right temporal linear fracture. Treatment for right peripheral facial paralysis was prescribed and he was again discharged to his parents.

Four months later, he returned to the hospital for a third visit because of falling from a balcony, a distance of 3-4 meters. Physical examination revealed, left peri-orbital edema and red fresh bruising, superficial abrasions over the right temple and cheek, and deformity and pain on palpation of the left forearm, all of which indicated acute trauma. X-ray of the left forearm revealed acute spiral fracture of the ulna and the radius. His abrasions were dressed, and his forearm was cast in the emergency room. Since the attending physician suspected inflicted trauma, hospitalisation was suggested. The father refused hospitalisation and discharged his son against medical advice, which prompted a forensic report to the police department. The father was tried for abusing his son and sentenced to one year, six months of jail time. There was no report filed with the Child Protective Services. There was no recommendation to assess the other children in the family, either. No expert witness was invited to trial.

Case 2

Six year-old girl, the second of four children in her family, was brought to the University Medical School Hospital by her stepmother with loss of consciousness and a story of falling from a sofa. Physical examination revealed absence of pupillary light reflex with fixed, dilated pupils, and absence of breathing and pulse. She was intubated but did not respond to cardiopulmonary resuscitation. She was pronounced dead after thirty minutes of resuscitation. Postmortem examination of the child was performed one day after death, which revealed numerous different colored old and new bruising between 0.5-1 cm on her neck, chest, back, and lower extremities, a red-purple old bruise of 1 cm over her right eyebrow, another red-purple old bruise of 0.5 cm on the right side of her forehead, and an old wound with dried scabbing of 6 cm at the back of her left shoulder. In internal examination, there was a widespread red new ecchymosis on the internal surface of her occipital scalp and over the vertex, and a linear occipital fracture. There were also occipital subdural hemorrhage, subarachnoidal hemorrhage at the left temporal lobe, and brain edema. The cross sections of her lungs were edematous, and there was a laceration at the right renal capsule. The cause of death was brain damage due to blunt head trauma. The eyes were not removed for retinal examination. Forensic report was filed with the police department.

At the end of the forensic investigation, her stepmother confessed that she slammed the child against a wall because of bedwetting. After the stepmother hit the child's head against the wall, she also kicked her until the child became unconscious. To resuscitate her, stepmother took her to the bathroom, shook her by the shoulders and wetted her head by the use of a hose. The girl slipped from her hand and hit her head against the wall again, which started wheezy breathing but she did not gain consciousness. The stepmother was convicted with involuntary manslaughter in Criminal Court. On appeal, seven months later, she was acquitted. There was no report filed with Child Protective Services. None of the other siblings was assessed for possible abuse. No expert witness was invited to trial.

Case 3

Three month-old male infant, the only child of his family, was referred to the University Medical School Hospital from a local hospital. On admission, physical examination revealed confusion, bilateral peri-orbital red fresh bruise, 2 x 3 cm size blue-purple old bruise on his cheeks bilaterally, 1 x 2 cm size red, new bruise on his forehead, edematous swelling of his upper lip, 2.5 x 4 cm size collapsed vesicle on the big toe of his right foot, and 5x2 cm size scabbing old lesion with peripheral hyperemia on his left foot. The latter two lesions appeared to be healing burn lesions. At the university hospital, head CT revealed subarachnoid hemorrhage. One day later, repeat head CT revealed bilateral fronto-temporo-parietal subdural hematoma, right occipital subdural hematoma, and right temporal parenchymal hemorrhage. Abdominal CT revealed linear laceration of the spleen and minimal perisplenic fluid accumulation. Full skeletal survey and eye examination were not done. In two days, his respiratory status deteriorated and he was intubated.

His mother reported his father beat the child up. After his treatment in the intensive care unit was completed, he was discharged to his mother. The child was neurologically stable on discharge. Forensic report was filed with law enforcement. His father was arrested. There was no report filed with Child Protective Services.
His mother testified in court that his father physically abused the child on many occasions causing umbilical hemorrhage from a beating at two weeks of age, left subcostal and periorbital ecchymosis from a beating at two months of age, and inflicted burns by pressing his feet against a hot stove at 2.5 months of age. She denied any medical visits for any of these inflicted injuries. The father was convicted with intentional child endangerment and sentenced to two years, two months, and twenty days of jail time. No expert witness was invited to trial.

Case 4

A four year-old female child of a single mother with no other children who works as a prostitute was brought to the emergency room of a University Medical School Hospital five hours after she fell from a chair. On physical examination her vital signs were unstable, she was unconscious with a Glasgow coma scale of three and had low blood pressure (60/30 mmHg). She was immediately intubated. Head CT revealed 1.5 cm wide subacute subdural hematoma around the right fronto-temporo-parietal convexity, which caused left midline shift. She was taken to the operating room for evacuation of the hematoma pressing on the right hemisphere. During the operation she had cardio-respiratory arrest. Despite extensive resuscitation, she was unresponsive and was pronounced dead.

Postmortem examination and autopsy were performed within 24 hours. External examination revealed 10 x 10 cm red fresh bruise on the left side of her upper abdomen, four blue-purple old bruising of 1 to 1.5 cm size on the front of the right thigh, knee, and shin, and left shin. Internal examination revealed multiple ecchymotic lesions of different colors under the scalp, a sutured fronto-temporal wound, and 0.6 cm defect on the underlying bone tissue, due to the operation procedure. Cerebral and cerebellar examination revealed acute edema, subdural hematoma, and enlargement of the third ventricle. Abdominal examination revealed petechial bleeding on the anterior surface of the liver and a hematoma of 5x8 cm on the left side of omentum major. The eyes were not removed for retinal examination. Due to suspect physical abuse, a forensic report was filed with the law enforcement. There was no report filed with Child Protective Services. The mother was tried for negligence after which she was acquitted. No expert witness was called to trial.

Case 5

Four year-old male child of a family with three children was brought to the University Medical School Hospital by his father complaining of vomiting after he woke up following a fall six hours prior to coming to the hospital. His mother and father provided a different fall history. His father reported the child fell down while walking but his mother reported he fell from a sofa. The assessment at the emergency room revealed a child in coma with Glascow coma scale of four, irregular breathing, left midriatic pupil (4 mm), left deviation of the eyes, and hemiparesis on the right side. The cranial CT revealed 3.5 cm size left-temporo-parietal epidural hematoma. He was taken to the operating room. Epidural hematoma was drained via left temporal craniectomy. Skeletal survey and retinal examination were not done. Inconsistent history of trauma prompted a forensic report to law enforcement. On discharge to his parents, he had residual right upper extremity paresis and limited medial vision on his left eye.

His father was tried criminally for physically abusing his son. Criminal investigation revealed that he got annoyed with being interrupted by the child playing near him while he was praying. He pushed the child toward the wall. The child lost his consciousness subsequent to impact from the wall. After the father was tried for involuntary child endangerment, he was acquitted. No expert witness was invited to trial. There was no report filed with Child Protective Services, nor was there an abuse assessment of the other children of the family.

Click here to view Table 1

Five cases of physical abuse were reported to the police department in compliance with the code in Turkey when physicians suspected child maltreatment. Two of these cases had a fatal outcome, one had residual neurological handicaps, and two were lost to follow up. Thus, it is appropriate to think that this series consists of most severely and overtly abused cases and represents the tip of the iceberg of physically abused children in the region. The strength of this study is to bring up the weaknesses of the child protection system in the region to the attention of the medical and child protection communities.

Cases display certain characteristics that are typical of societies at the crawling stage of developing a contemporary and humane response to child abuse and neglect (9). All children presented with head trauma that accounts for the high morbidity and mortality in this series (Table I). All but one presented with a past medical history of physical findings indicating recurrent abuse. All but one was an older child, possibly indicating delayed diagnosis of abuse. Two of three surviving children were discharged to the suspected perpetrator. Two of the acquitted perpetrators had inflicted fatal abuse on their children.

Literature on child abuse and neglect from the 1960s indicates that the medical field has led the way to establishing proper child protection in developed countries (9). Suspicion for abuse is heightened most commonly in health care settings when children present with unusual injuries. Because of that, the pioneers of recognition of child abuse and neglect have traditionally been medical professionals including Ambrois Tardieu (1860), S. West (1888), John Cafey (1946), and Henry Kempe (1962) (10-13). In Turkey, the medical field has become involved in the management of child abuse and neglect within the last decade (6,14,15). These efforts led to the establishment of increasing numbers of hospital based multidisciplinary teams in major cities. These teams initiated collaborations with community agencies such as Child Protection Services, prosecutors, law enforcement officers, and school staff attempting to establish regional organization of child protection services (14).

Despite these grass root activities Turkey still lacks a distinct child protection law with clear, culturally competent definitions of various categories of child abuse and neglect and structured social and legal intervention strategies. Due to these factors, the socio-legal management of child abuse and neglect is vague in Turkish code. Reporting of suspected abuse is still mandated through law enforcement rather than child protective services. Lastly, there is no provision in the code regarding professional mandatory education on response to child abuse and neglect.

Based on these nation-wide problems in the field, Sivas has lacked an awareness of child abuse and neglect as a public health problem. Thus, regional collaboration among agencies to address this issue properly has been non-existent. Even within the university medical school, there has been no curriculum on child abuse and neglect to increase the medical community's awareness of this issue. Thus, the fact that there have been five reports of suspect child abuse within the last six years is an improvement for Sivas region, indicating a positive trend to increased awareness of the at least most severe forms of abuse.

In none of the trials, an expert witness was called for testimony. Only in two of the cases, was there any conviction. Ironically there was no conviction in the two fatal cases. The court system in Turkey is the agency that is least interested in getting involved in multidisciplinary collaborations related to child abuse cases. Because of that, the outcome of the prosecution of these cases is poor even in severe incidents (16).

None of the cases in this series was reported to Child Protective Services. In none of the three children with siblings, were the siblings assessed for possible abuse. This is in clear contrast with the global contemporary and humane approach to child abuse and neglect. Since the target agency for mandatory reporting in Turkey is law enforcement, the prosecutor decides whether to prosecute these cases or not. When the decision is not to prosecute, there is no opportunity for social services for these needy families. When the decision is to prosecute, only occasionally judges will be broad-minded enough to establish court-ordered social services. Since child abuse and neglect is a social problem, approaching cases from a social services perspective would be much more cost effective and humane.

Suspicion for recurrent abuse was considered at least in all but one of the cases. Professional and public awareness of intra-familial physical abuse is very low in Turkey and Sivas due to lack of structured professional education on and management of child abuse and neglect. These children may have been observed being abused by many lay and professional individuals without any report to any agency before presenting to the University Medical School Hospital. Physical abuse is a spectrum, which many present with various clinical pictures. The lesions range from minimal bruising and abrasions caused by inflicted trauma to lesions, which can cause death such as inflicted head trauma and internal organ injuries (17,18). In every society, as awareness and professional education are heightened, the recognition gradually moves from the most apparent, severe cases to less apparent, mildly injured cases (6,19).

Skeletal survey has proven to be very helpful in establishing diagnosis inflicted trauma especially in subtle cases (20,21). When done properly skeletal survey can improve diagnosis at least in 20% of the cases (22). If not done when the child was alive, forensic pathologist may and should order a post-mortem skeletal survey. However, again due to the lack of professional structured response to child abuse and neglect, skeletal survey was not done in any of these cases.

These cases display a typical distribution of risk factors for child abuse. Single parenthood, low socio-economical status, anger management problem, step parent, parental psychopathology, staircase children, and multiparity were all risk factors observed in this case series. Other risk factors including isolated living conditions, teenage parenthood, low educational status, and parental substance abuse should also be considered in assessing suspect abuse cases (23,24).

Perpetrators of physical abuse are usually the parents or baby-sitters (17). In severe battering involving head trauma, fathers and stepfather figures have been reported 70% of the time (19). In our series, perpetrator in three cases was the father, all of which survived. In the two fatal cases on the other hand, perpetrator was the mother and the stepmother. Especially with the fourth case, there is a possibility that the male involved in the prostituting mother's life may have actually perpetrated and the mother may have taken the responsibility out of fear.

In conclusion; neurological deterioration, fractures, burns, and other soft tissue injuries unexplained by the history of trauma and lesions at various stages of healing without proper explanation must lead to suspicion of child abuse. Detailed history must be taken from the members of the family and relatives to clarify the circumstances surrounding observed injury. When suspicious, full skeletal survey should be ordered. Ophthalmology consultation is of paramount importance in cases presenting with head or facial trauma. Physicians are mandated to file a report with law enforcement when suspicious of abuse. Although not required by law, physicians should also report such cases to Child Protective Services with a recommendation of having other children under the care of caretakers in question, assessed. In fatal cases autopsy and postmortem skeletal survey may provide invaluable information (25-27). Determining whether bruises occurred before death or are due to rigor mortis, palpating especially the ribs, removing all bones that raise suspicion for fracture, removing the eye globes to assess for retinal hemorrhage, removing the cervical spine posteriorly to assess for axonal injuries are some of the key steps of the autopsy when inflicted head trauma is in question (25-28). The next step for each university hospital should be to establish a hospital based multidisciplinary team to develop structured clinical guidelines for institutionalised response to child abuse and neglect. These teams should also lead their communities in developing regional collaborations among the medical facilities, child protective services, prosecutor's office, and law enforcement. Primary prevention efforts by public education are also a very important task.

Physically abused children may present with findings ranging from minimal soft tissue lesions to intracranial injury leading to death. Child abuse is an important public health problem most prevalent in children under five years of age. Timely medical diagnosis of child abuse through detailed history and physical examination is of paramount importance to prevent further abuse and establish supportive services to the families.

We present five cases in this paper, two of which had a fatal outcome. We hope the presentation of these cases and apparent previous chronic abuse in their past medical history will help the medical community revisit their responsibility in preventing child abuse. These cases also indicate that there is great need for education to increase public and multidisciplinary professional awareness of child abuse. Interdisciplinary community collaboration is also very important in recognition, proper management, and prevention of child abuse.

Key words: Child abuse, physical abuse, neglect.

The story of Lisa, whose given name was Elizabeth, has also provoked widespread concern over the problems of identifying and preventing brutality against children. But Tamika, Keiko, Julian and Jose represent the other victims of fatal child abuse, the ones whose stories are often quickly forgotten by all but the protagonists.

In all, about 1,300 children nationwide are reported to have died from abuse or neglect in 1986, according to the National Committee for the Prevention of Child Abuse. In New York State alone, 162 children died last year of abuse and neglect; more than 100 of those deaths were in New York City, about 1 every 4 days. In New Jersey, there were 12 deaths, according to state officials. No figures were available for Connecticut.

Most of these deaths, the authorities say, are the result of negligence rather than intentional brutality by parents or guardians.

While precise figures are unavailable, according to prosecutors, only a handful of abuse cases result in criminal charges for murder or a lesser count, such as manslaughter.

Among them are the cases of Tamika, Keiko, Julian and Jose, and of Lisa Steinberg. They were children from different backgrounds and different places who are linked by violent death. According to the authorities, they reflect a common pattern: most often, experts say, it is a father or stepfather who is the killer.

From a review of court records and interviews with investigators and lawyers, here are four case studies. Keiko: Autopsy Clues

Leslie Aylor left her 5-week-old daughter, Keiko, alone with her husband, Aaron, while she was out shopping. When she returned to her condominium apartment in East Windsor, N.J., on Sept. 30, 1984, Mr. Aylor was asleep.

She peeked at the baby's crib and shrieked because Keiko was not breathing. Resuscitation efforts by a medical team failed. The infant was dead.

There were no apparent bruises on the baby's body and physicians at the Princeton Medical Center attributed the death to Sudden Infant Death Syndrome.

Before the body was removed for burial, however, a pathologist at the hospital, Dr. William Lowery, performed an autopsy to gather possible clues about the mysterious syndrome. To his surprise, Dr. Lowery discovered hemorrhaging in the skull.

A more comprehensive autopsy and forensic tests revealed that Keiko's death had been caused by a trauma, or a blow, to the head. The back of her skull had been fractured.

Detectives from the East Windsor Police Department became suspicious of Mr. Aylor, who was then 19, after he gave them inconsistent statements. At one point, he admitted clapping the infant on both sides of her head with his hands because she would not stop crying, but he later recanted that admission.

Testifying at his trial in March, Mr. Aylor, a slight, bespectacled man, wept as he denied striking Keiko.

Mr. Aylor, who had worked as a truck dispatcher for a pharmaceutical company, was convicted of reckless manslaughter and sentenced to a prison term of up to seven years.

East Windsor police Lieut. Pat L. Delre said investigators believe that Mr. Aylor may have committed the crime because he felt threatened by the birth of his daughter. ''He sensed a loss of feeling from his wife after the baby was born,'' Lieutenant Delre said. Tamika: Insurance Money

The short life and violent death of Tamika Greene unfolded last summer at the trial of her father, James Greene, in State Supreme Court in Manhattan. At the same trial, Mr. Greene, 3l, also was convicted of smothering the infant son of a woman companion.

Tamika's mother, Connie Robinson Greene, testified that she had left Mr. Greene shortly after Tamika was born in 1980. She said her husband had often beat her. Mrs. Greene, who was 19, said she had permitted Tamika to live with Mr. Greene's mother in the Bronx because the grandmother could take better care of Tamika.

In 1983, Mr. Greene proposed marriage to 17-year-old Wanda Pruitt. Miss Pruitt testified that he did not tell her he was married or that he had legally changed the name on the birth certificate of her son from Levalle Pruitt to James William Greene.

Mr. Greene obtained life insurance policies for Tamika and for Miss Pruitt's son in March 1984. He listed himself as the father of both children and the principal beneficiary of the two $10,000 policies.

On April 2, 1984, Miss Pruitt and her son, 10 months, were staying with Mr. Greene in his apartment at 17 West 125th Street in Harlem. Miss Pruitt testified that Mr. Greene had volunteered to give the boy his bottle of milk and put him to sleep in their bedroom.

Mr. Greene, she testified, told her: '' 'Stay out of the room or he'll never get to sleep.' '' About an hour after Mr. Greene left the bedroom, Miss Pruitt found the child dead, a plastic dry-cleaning bag over his face.

Mr. Greene told detectives that the bag had been left nearby on the bed and the boy must have become entangled in it. The death was listed by the police as ''accidental suffocation.''

A month later, Mr. Greene collected the infant's $10,000 life insurance and stopped seeing Miss Pruitt.

In June 1985, about a month before Tamika's fifth birthday, Mr. Greene took her from her grandmother. A 13-year-old girl who had been living with Mr. Greene testified that during the last month of Tamika's life, Mr. Greene had frequently locked Tamika in the bedroom, lashed her with an electrical cord and forced her to keep eating until she threw up.

Tamika's mother said she had visited the apartment a few days before Tamika died and had seen bruises and lacerations on the girl. But, she testified, her husband had prevented her from removing Tamika.

Mrs. Greene was not questioned at the trial about why she had failed to notify the authorities about her daughter's mistreatment.

Esther Bishop, who lived next door to Mr. Greene, said that on the night of July 29, 1985, she had heard Tamika crying and screaming. The woman testified that Mr. Greene could be heard saying, '' 'Take it, take it,' '' and the girl replying, '' 'No daddy, I don't want to.' ''

Mrs. Bishop said she had wanted to call the police but a neighbor dissuaded her saying, '' 'Mind your own business.' ''

Later that evening, Tamika's body was found by the 13-year-old companion of Mr. Greene when she returned to the apartment. Tamika had been in the same bed where Miss Pruitt's son had suffocated 15 months earlier.

An autopsy disclosed that the girl had died of a lethal dose of antihistamine capsules.

A month after Tamika's death, Mr. Greene, who was unemployed, had applied for her $10,000 life insurance. This time he was not paid. Instead, he was indicted for the murders of Tamika and Miss Pruitt's son.

''There is no lower form of human being than the one sitting here,'' a prosecutor, Consuelo Fernandez, said pointing to Mr. Greene during his trial in August.

Convicted of the murders of Tamika and Miss Pruitt's son, and of welfare fraud, Mr. Greene was sentenced to a prison term of 59 years to life. Julian: Emotional Stress?

Julian Shamoon was 4 years old and in a coma when he died. Later, investigators and prosecutors in the office of the Queens District Attorney, John J. Santucci, pieced together this account of the boy's final hours.

Shortly before the murder, Julian's mother, Krystal, had separated from his father, Harry, and was living in Germany, her native country. The father, who was unemployed, was caring for Julian and an older brother, Simone, 6, in their apartment at 139-27 88th Avenue in Jamaica.

Detectives say that Mr. Shamoon told them that on the night of Jan. 6, 1986, he had been playing chess with Simone when Julian repeatedly interrupted the game and refused to obey his father.

Mr. Shamoon admitted, according to police reports, that in trying to to discipline Julian he had ordered the boy to kneel on the floor and had struck him with his hands and with a broom.

A report by the medical examiner's office said the boy had suffered internal bleeding and multiple abrasions of the body and the head.

A defense lawyer, Stephen J. Singer, said Mr. Shamoon had been under emotional stress because his wife, who had been the family's main financial support, had left him and he had to care for his two young sons.

According to Mr. Singer, the 42-year-old Mr. Shamoon, who was born in Iran, ''was a brilliant, gifted guy'' who had suffered a mental breakdown before the death of Julian.

Mr. Shamoon has pleaded not guilty to a murder charge. Mr. Singer said he expected to offer a defense of insanity or extreme emotional disturbance when a trial date is set. Jose: First Offense

The first time Jose DeJesus was brought to the Montefiore Medical Center in the Bronx, physicians were immediately suspicious. It was December 1983 and the 15-month-old boy was unconscious, his body lacerated and covered with huge bruises. There were also contusions around his mouth, indicating that he had been gagged.

His mother, Maria Cadelario Collado, who was 26, denied that the child had been mistreated. He had been listless for weeks and throwing up, she told doctors. His stepfather, Ramon Collado, 26, corroborated her story.

Jose remained at the hospital for a month while the city's Human Resources Administration examined the case for possible child abuse. Jose's mother had been married for several months to Mr. Collado, an unemployed immigrant from the Dominican Republic. The couple had lived with Jose and another son of Mrs. Collado's, Moses, 4, in an apartment at 2146 Vyse Avenue in the South Bronx.

A Family Court judge in January 1984 ordered that while the case was under review, the child be kept with Mrs. Collado's parents in the Bronx while the case was reviewed.

On March 25, 1984 - less than two months after he had been released from Montefiore - Jose was carried into the hosital's emergency room by his mother and stepfather. The boy, 17 months, was pronounced dead. An autopsy disclosed that Jose had died from ruptured intestines.

According to detectives, Mrs. Collado, her parents, and Mr. Collado gave conflicting stories about how the child had been injured. But they eventually acknowledged, detectives testified, that Jose had been living with the Collados and not with his grandparents as directed by a judge.

Mr. Collado said the boy had suffered a fatal injury when he fell from a tricycle in the apartment. Mr. Collado was indicted for murder. No charges of wrongdoing were brought against Mrs. Collado, who said she had not been at home when the boy was injured.

At the trial, the prosecution presented evidence from pathologists who said Jose's injuries were inconsistent with a tumble from a tricycle and that the boy had been struck with a fist or a blunt object.

The jury convicted Mr. Collado in October 1984 of criminally negligent homicide after finding him not guilty of murder or manslaughter. He was sentenced to a prison term of 5 to 15 years.

The prosecutor, Diana Farrell, said she was disappointed by the verdict because it carried a minimum sentence of five years instead of the mininum 15 years Mr. Collado would have had received if he had been convicted of murder.

''On the witness stand he showed no remorse and a very quick temper,'' Ms. Farrell, a Bronx assistant district attorney, said referring to Mr. Collado. ''But after the trial some of the jurors said they convicted him of the lesser charge because it was his first offense and he looked and dressed like a decent man.''

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