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This paper describes clinical findings and case characteristics of children who are victims of severe and multiple forms of abuse; and proposes clinical criteria that indicate child abuse by torture. Medical records, investigation records, and transcripts of testimony regarding a nonconsecutive case series of 28 children with evidence of physical abuse, neglect, and psychological maltreatment, such as terrorizing and isolation, were reviewed for types of injuries, duration of maltreatment, medical and physical neglect, social and family history, and history of prior Child Protective Services (CPS) involvement. The median age was 7.5 years (9 months to 14.3 years). Thirty-six percent died. Duration of abuse ranged from 3.5 months to 8 years (median 3 years).Ninety-three percent of children were beaten and exhibited cutaneous injury; 21 % had fractures. There were 25 victims of isolation (89 %), as well as 61 % who were physically restrained and 89 % who were restricted from food or water. All of the children were victims of psychological maltreatment; 75 % were terrorized through threats of harm or death to themselves or loved ones and 54 % were degraded and/or rejected by caregivers. Nearly all children were medically neglected. Half had a history of prior referrals to CPS. The children in this case series were physically abused, isolated, deprived of basic necessities, terrorized, and neglected. We define child torture as a longitudinal experience characterized by at least two physical assaults or one extended assault, two or more forms of psychological maltreatment, and neglect resulting in prolonged suffering, permanent disfigurement or dysfunction, or death.

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The authors thank Doctors Alexander and Pena for their comments regarding our manuscript BChild Torture as a Form of Child Abuse^. When we wrote about Torture as Form of Child Abuse, we attempted to develop a coherent medical definition for this under-appreciated form of abuse. Fundamentally, we observed that the torture of the children in our case series was a means of systematically demeaning, subjugating and controlling the victims. Various forms of poly-victimization were used by perpetrators of all of our cases including both physical and psychological abuse. Our definition reflects the predominant forms of poly-victimization documented in this case series.As noted by Alexander and Pena, we reported that sexual abuse was also used as a form of poly-victimization in the abusive torture of some of the children in this case series.As authors, we discussed the complexities of the sexual torture of children (both from a power/control and ritualistic aspect). We chose to exclude cases in which the primary motivation seemed to be sexual rather than control and subjugation. The authors noted that the sexual torture of children had this fundamentally different motivation than what we were addressing in our case series. Although isolation of the victim is common both in the torture we reported and sexual torture, in the latter case it is primarily used to avoid detection and to maintain sexual access. As Alexander and Pena noted, the literature has never adequately addressed this issue; some of the current authors plan to separately analyze and define this type of primary abuse. Internet and communication technology facilitated crime components are becoming a frequent tool for this type of torture maltreatment and will be further analyzed. Several of our article's authors have been involved in the medical treatment of victims of sexual torture in childhood. We do note, however, that often physical, psychological and sexual tortures co-occur in these cases.As authors, we analyzed the issue of whether a torture definition in child abuse required repeated events over a prolonged period or if an extended act would constituted the torture of a child. The authors clearly observed cases where the same issues arose in a single, somewhat extended period of severe abuse. In response to Alexander and Pena's second comment, the wording of Bpermanent bodily dysfunctionŵ as made because most of the children we studied had permanently disfiguring or impairing injuries. Having frequently worked with the court system, we realize that Bprolongedŵ ould also be open to wildly different legal interpretations. We proposed our definition as a starting point, hoping it would stimulate discussion, and possibly modification, to better deal with this problem. Should language which would be both legally explicit, but still flexible enough to encompass the range of these cases be proposed, we would consider modifying the definition.