Cognitive errors have been studied in a broad array of fields, including medicine. The more that is understood about how the human mind processes complex information, the more it becomes clear that certain situations are particularly susceptible to less than optimal outcomes because of these errors. This article explores how some of the known cognitive errors may influence the diagnosis of child abuse, resulting in both false-negative and false-positive diagnoses. Suggested remedies for these errors are offered.
Key points
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Cognitive errors occur in every profession. Dozens of cognitive errors have been demonstrated to happen in medicine, many leading to poor patient outcomes.
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The diagnosis of child maltreatment can be susceptible to cognitive errors because of conditions of high stress, limited or questionable quality of data, and the subtlety of some diagnoses.
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Errors may be avoided through deliberate efforts to consider alternative diagnoses, avoiding premature closure, seeking objective input without social cues, and multidisciplinary collaboration.
Medical decision making is an exercise in process management: health care providers must gather data from multiple data sources, sometimes simultaneously, interpret signs and symptoms, sometimes without adequate history to fully understand the information provided, and direct patient management including further diagnostics and treatment, often without complete data. Most of the time the process seems to work adequately, that is, the patient is appropriately diagnosed and treated. Yet there continue to be studies that demonstrate failures in diagnosis and treatment related to factors that seem to be unrelated to the medical condition and more related to the patient’s specific demographic characteristics.
It is important that the diagnosis of child maltreatment be made accurately. Failure to correctly diagnose an abused child as abused (a false negative) could result in that child being returned to a potentially dangerous environment. Conversely, the overdiagnosis of child abuse (a false positive) could result in a child being removed from an environment wherein no one has caused harm to the child. The potential for errors in decision making related to child abuse extend far beyond the health care arena and include law enforcement, social welfare systems, prosecutorial decisions, and judge or jury decisions. Understanding the potential pitfalls in decision making is especially important for process improvement. Social psychologists have spent considerable effort in understanding how humans think, but only relatively recently have physicians looked to the literature to understand what clinicians can do better.
Humans have evolved to process an astonishing amount of information, often dealing with large simultaneous sensory inputs assaulting all of their senses. How is it that we are able to take in information, filter out what is not immediately relevant, and arrive at a reasonable conclusion? Are there shortcuts we can use to improve our processing speed without sacrificing the quality of the decision making? Perhaps most importantly, is it possible to avoid cognitive errors that we make and are compounded when community professionals from other disciplines, such as law enforcement and child protection services, are involved in a decision process?
Cognitive processes: an overview
Humans routinely make decisions in an overwhelming, complex environment. There are also limited cognitive resources available at any given moment to process all of the information available. Given the inability to completely process all of the data, humans have adapted by using cognitive shortcuts, which can be both hardwired and derived. One easy-to-appreciate example of a hardwired shortcut is that of recognizing potential danger. It does not take a prior experience with a potential threat, such as an obviously hostile animal, to realize that care must be taken.
Derived shortcuts also are common occurrences that increase over the course of a lifetime. Driving represents a classic example of a derived shortcut. Memories of learning to drive often will conjure the stress associated with the myriad of data bombarding the novice driver. It is only after years of practice that the process becomes nearly fully automated. What was once a difficult, stressful, and complex effort changes into a background process that frees the mind to handle other tasks. However, this automation can be an impediment to rapid responses to the unexpected. Deviations from the norm will take longer to recognize and process when one is not fully engaged in the task at hand.
Just as driving or tying one’s shoes, or doing any number of complex learned tasks becomes less of an elaborate mental juggling act, so too does one’s ability to complete tasks associated with the work. In the early years of a person’s career, every part of the job requires thought and deliberation. As one gains experience and feedback on process and decision making, the process becomes more refined and automated. However, just as automation improves efficiency in tasks such as driving, it can also decrease the ability of an individual to recognize and respond to deviations from the norm.
Decision theory is the study of identifying what is known, what is unknown, and the other factors involved in arriving at an optimal (and therefore correct) decision. Social psychologists use multiple techniques to understand the processes involved in decisions. Decisions are very often reliant on heuristics, which are the shortcuts used to aid in decision making sometimes referred to as rules of thumb; new, incoming data are constantly incorporated and compared with previously gathered information. If they match previously acquired data, a shortcut in the thought process may be used to arrive at the answer. Heuristics can certainly be helpful in improving efficiency, but also may lead one astray if they compound biases in the thought process.
Biases may be either explicit or implicit. An implicit bias is one that an individual holds without being aware. Implicit biases can be difficult for an individual to acknowledge or control, given that they are happening without any real understanding or conscious effort. It has been clearly demonstrated that even people who profess to be egalitarian in their beliefs, and act outwardly in egalitarian ways, hold implicit biases that can influence decision making. It is especially important to draw a distinction between implicit and explicit biases. Explicit biases are very much part of a person’s conscious awareness and can be considered less socially desirable. Examples of explicit biases include overt racism, sexism, or ageism.
Much is now known about how humans process complex information. Research has shown that it is possible to improve thinking and reduce errors in judgment. Multiple studies have demonstrated that cognitive errors may lead to incorrect medical diagnoses. It is therefore important that professionals engaged in these high-stakes decisions, such as the diagnosis of child abuse, make efforts to understand how and when these errors might occur and how best to mitigate their effects.
Cognitive processes: an overview
Humans routinely make decisions in an overwhelming, complex environment. There are also limited cognitive resources available at any given moment to process all of the information available. Given the inability to completely process all of the data, humans have adapted by using cognitive shortcuts, which can be both hardwired and derived. One easy-to-appreciate example of a hardwired shortcut is that of recognizing potential danger. It does not take a prior experience with a potential threat, such as an obviously hostile animal, to realize that care must be taken.
Derived shortcuts also are common occurrences that increase over the course of a lifetime. Driving represents a classic example of a derived shortcut. Memories of learning to drive often will conjure the stress associated with the myriad of data bombarding the novice driver. It is only after years of practice that the process becomes nearly fully automated. What was once a difficult, stressful, and complex effort changes into a background process that frees the mind to handle other tasks. However, this automation can be an impediment to rapid responses to the unexpected. Deviations from the norm will take longer to recognize and process when one is not fully engaged in the task at hand.
Just as driving or tying one’s shoes, or doing any number of complex learned tasks becomes less of an elaborate mental juggling act, so too does one’s ability to complete tasks associated with the work. In the early years of a person’s career, every part of the job requires thought and deliberation. As one gains experience and feedback on process and decision making, the process becomes more refined and automated. However, just as automation improves efficiency in tasks such as driving, it can also decrease the ability of an individual to recognize and respond to deviations from the norm.
Decision theory is the study of identifying what is known, what is unknown, and the other factors involved in arriving at an optimal (and therefore correct) decision. Social psychologists use multiple techniques to understand the processes involved in decisions. Decisions are very often reliant on heuristics, which are the shortcuts used to aid in decision making sometimes referred to as rules of thumb; new, incoming data are constantly incorporated and compared with previously gathered information. If they match previously acquired data, a shortcut in the thought process may be used to arrive at the answer. Heuristics can certainly be helpful in improving efficiency, but also may lead one astray if they compound biases in the thought process.
Biases may be either explicit or implicit. An implicit bias is one that an individual holds without being aware. Implicit biases can be difficult for an individual to acknowledge or control, given that they are happening without any real understanding or conscious effort. It has been clearly demonstrated that even people who profess to be egalitarian in their beliefs, and act outwardly in egalitarian ways, hold implicit biases that can influence decision making. It is especially important to draw a distinction between implicit and explicit biases. Explicit biases are very much part of a person’s conscious awareness and can be considered less socially desirable. Examples of explicit biases include overt racism, sexism, or ageism.
Much is now known about how humans process complex information. Research has shown that it is possible to improve thinking and reduce errors in judgment. Multiple studies have demonstrated that cognitive errors may lead to incorrect medical diagnoses. It is therefore important that professionals engaged in these high-stakes decisions, such as the diagnosis of child abuse, make efforts to understand how and when these errors might occur and how best to mitigate their effects.
Cognitive errors and child maltreatment
There are many common assumptions made by professionals that might not apply when the case involves child abuse. First, health care professionals assume that parents will be open and honest when seeking medical care for their child. However, if the perpetrator is a parent, he or she may not share the relevant information leading up to the symptoms that brought the child to medical attention, or worse, this person may lie and obfuscate. Second, there is a generally held belief that health care professionals use science and logic alone to reach a correct diagnosis, yet there is evidence to the contrary that “the art of medicine” is actually antithetical to science in some cases. There are situations wherein a better, more scientifically sound approach to medical care is available to clinicians who resist implementation of the new protocol because they “know what is best.” Third, primary care providers often feel they know their patients’ families and can judge who is at risk and who is not. Finally, primary care providers often feel that they would be able to detect problems in parent-child relationships by how a child interacts with their parent (eg, the child seems well bonded to the mother so there is no reason to think the mother could be abusing him). None of these factors is meant as an indictment of a profession or group of individuals; rather, it is an acknowledgment of the complexities of the human thought process in light of difficult decisions.
The problems inherent in the human thought process are abundant. Many cases of potential child maltreatment are subtle and there are few “a-ha” moments that bring absolute clarity. Sometimes, despite best efforts, professionals are not fully engaged in the work of the day and rely more readily on derived shortcuts without realizing this is occurring. Often, parents and caregivers do not know what information is relevant or most important to share when talking to medical personnel or investigators, causing them to offer information that could be construed as misinformation or attempts at deception. Moreover, in other circumstances parents or caregivers may lie deliberately.
A closer look at common cognitive errors can help illustrate how they can confound arrival at an optimal answer. An in-depth exploration of all possible cognitive errors is beyond the scope of this article ( Table 1 ).
