Experts Identify Critical Elements to Spot Child Abuse

Yael Waknine

June 24, 2015

A panel of child abuse experts has defined critical elements for medically evaluating three common presentations of suspected physical abuse among infants and young children.

The findings, published online June 22 in Pediatrics, are intended to serve as a starting point for developing child abuse assessment protocols.

Diagnosing child abuse is often a matter of excluding alternative diagnoses, a process with no clearly defined end point. This uncertainty is reflected in the overly broad nature of previously published recommendations, write Kristine A. Campbell, MD, from the Department of Pediatrics at the University of Utah in Salt Lake City, and colleagues.

Lack of guidance may lead clinicians to "pick and choose" among the options, contributing to bias and reducing diagnostic reliability, the authors suggest.

Researchers therefore convened a panel of 28 child abuse pediatricians (CAPs) to participate in a Delphi Process, with the goal of defining key elements for evaluating the potential role of abuse in cases of intracranial hemorrhage, long bone fracture, and skull fracture among children aged 0 to 60 months.

Consultation notes were used to identify an initial set of 96 elements for CAP evaluation on a 9-point Likert scale. Those elements given a score of 9 or 8 by more than 75% of participants after 3 rounds of survey, summary, and feedback were classified as "required" and "highly recommended," respectively.

The resulting diagnostic model was, for the most part, consistent with published guidelines suggesting the need for an extended medical history that includes the source of said history, the caregiver present at the time of injury and their response to symptoms, and any changes or discrepancy in the history provided.

Notable Exclusions

"In contrast to traditional pediatric practice, CAPs recognize the potential misalignment of caregiver and physician goals in reaching the 'correct' diagnosis for a child. Broad inclusion of elements from the medical, developmental, and family history reflect the wide differential diagnosis entertained in cases of suspected abuse," the authors write.

Required historical elements included past injuries and/or fractures, estimated gestational age and birth complications (age < 6 months), developmental stage, and parental concerns for development. Some were specifically related to the nature of the injury, such as a history of easy bleeding or seizures (intracranial hemorrhage) or potential dietary insufficiencies (long bone fracture).

Laboratory elements focused on screening for coagulation disorders and occult abdominal trauma in children with intracranial hemorrhage, and for bone health in those with long bone fracture. Head computed tomography and skeletal survey were recommended radiologic procedures in all three settings.

The nature of psychosocial elements required in the evaluation constituted the greatest divergence from published guidelines. Although a description of the child-care setting (intracranial hemorrhage or skull fracture) and a prior history of abuse (skull fracture) were deemed "required," most "highly recommended" elements were directly related to violence in the home as a risk factor for abuse and mechanism for injury.

Notably excluded were any descriptions of caregiver mental health, substance abuse, pregnancy planning, and parent perceptions of child temperament or behavior.

"Experts worried about narrowing a medical evaluation to exclude elements that might help to reduce future adversities for the child and family, yet acknowledged the potential for bias introduced by the psychosocial history. The final consensus guideline reflects uncertainty regarding the reliability of these psychosocial factors in shaping early diagnostic decisions," the authors comment.

The authors acknowledge that the findings may not reflect the opinions of the wider CAP community, and that opinion may change as scientific truths emerge over time.

"Additional research is required to determine whether these consensus guidelines can reduce previously described variability, decrease potential bias, and/or improve reliability in the evaluation and diagnosis of child physical abuse," the authors conclude.

The study was supported by a grant from the Eunice Kennedy Shriver Institute of Child Health and Human Development of the National Institutes of Health. Study data were collected and managed using Research Electronic Data Capture, hosted through a grant from the Center for Clinical and Translational Science at the University of Utah. Dr Campbell's institution receives financial compensation for expert witness testimony provided in cases of suspected child abuse for which she is subpoenaed to testify. The other authors have disclosed no relevant financial relationships.

Pediatrics. Published online June 22, 2015. Abstract


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