Uncertainty in the diagnosis of abuse can have profound implications for the health and safety of the child, the emotional burden of a family, and investigative and criminal proceedings. A logical algorithm for addressing physical and sexual abuse cases that details aspects contributing to the uncertainty may aid the clinician in making a diagnosis and in communicating the crucial details to the relevant investigative agencies. This article defines and discusses uncertainty in the realms of physical and sexual abuse, and suggests an approach to managing uncertainty while still providing valuable information for the medical and child protective service systems.
Key points
- •
In cases of suspected child abuse, a clear understanding of the sources for potential uncertainty and a stepwise approach to managing uncertainty are of vital importance.
- •
Uncertainty in an evaluation for suspected physical abuse may stem from a question of whether a child’s presentation is secondary to injury or the result of a medical problem, about whether the cause of an injury is accidental or abusive, and about the timing of the injury.
- •
An evaluation for suspected sexual abuse can be confounded by uncertainties about the veracity and meaning of a child’s disclosure of abuse and the significance of any examination findings.
- •
In the setting of uncertainty, a consideration of family risk factors and potential strengths may aid the clinician in making a final determination and recommendations for the child’s safety.
Introduction
The practice of medicine has often been described as an art. Using the term “art” implies that medicine is somehow fluid, moldable, and influenced by the artist’s skill level, experiences, emotions, and tools. Medical schools teach raw skills, such as history taking and note writing, in addition to the pathophysiology of disease processes. The art in medical practice lies in the application of these skills and knowledge to a particular patient. Medicine may be viewed as art within which both the physician and the patient are the artists, working together toward the masterpiece of diagnosis and treatment. In very young or very old patients, the caretakers often become the artists on behalf of the patients.
A necessary and fundamental component of the practice of the art of medicine is uncertainty. Uncertainty is what drives research and new discoveries. If there were no uncertainty in diagnosis and treatment, there would be no need for a second opinion, and no need for clinical trials, case-control studies, or meta-analyses of data. Uncertainty, at its most basic level, is beneficial in medicine. At the level of an individual case, however, uncertainty is challenging, frustrating, and frightening, at times for both the patient and the physician. To admit uncertainty in a diagnosis or treatment plan may lead to a concern for malpractice by the treating physician.
Child abuse cases have unique complexities. A diagnosis of child abuse affects those with whom a child lives, may result in a parent’s incarceration, or may force a day-care provider to close her business. Incorrectly diagnosing child abuse as an accident may cause a child to be returned to an unsafe home and suffer additional injuries or death. Studies demonstrating lack of agreement on case etiology among child abuse pediatricians (CAPs) highlight the regular role uncertainty plays for a clinician faced with potential child abuse. Primary care medical providers may feel particularly uncertain about all aspects of a child abuse case, from when and if to report to child protective services (CPS), to what to say to parents about reporting, to what medical testing to order, to how to follow a child in the primary care office once CPS has become involved.
The purposes of this article are to define and discuss uncertainty in the case of physical and sexual abuse, and to suggest an approach to cases to assist with managing uncertainty while still providing valuable information to the medical and CPS systems to promote the health and safety of children.
Introduction
The practice of medicine has often been described as an art. Using the term “art” implies that medicine is somehow fluid, moldable, and influenced by the artist’s skill level, experiences, emotions, and tools. Medical schools teach raw skills, such as history taking and note writing, in addition to the pathophysiology of disease processes. The art in medical practice lies in the application of these skills and knowledge to a particular patient. Medicine may be viewed as art within which both the physician and the patient are the artists, working together toward the masterpiece of diagnosis and treatment. In very young or very old patients, the caretakers often become the artists on behalf of the patients.
A necessary and fundamental component of the practice of the art of medicine is uncertainty. Uncertainty is what drives research and new discoveries. If there were no uncertainty in diagnosis and treatment, there would be no need for a second opinion, and no need for clinical trials, case-control studies, or meta-analyses of data. Uncertainty, at its most basic level, is beneficial in medicine. At the level of an individual case, however, uncertainty is challenging, frustrating, and frightening, at times for both the patient and the physician. To admit uncertainty in a diagnosis or treatment plan may lead to a concern for malpractice by the treating physician.
Child abuse cases have unique complexities. A diagnosis of child abuse affects those with whom a child lives, may result in a parent’s incarceration, or may force a day-care provider to close her business. Incorrectly diagnosing child abuse as an accident may cause a child to be returned to an unsafe home and suffer additional injuries or death. Studies demonstrating lack of agreement on case etiology among child abuse pediatricians (CAPs) highlight the regular role uncertainty plays for a clinician faced with potential child abuse. Primary care medical providers may feel particularly uncertain about all aspects of a child abuse case, from when and if to report to child protective services (CPS), to what to say to parents about reporting, to what medical testing to order, to how to follow a child in the primary care office once CPS has become involved.
The purposes of this article are to define and discuss uncertainty in the case of physical and sexual abuse, and to suggest an approach to cases to assist with managing uncertainty while still providing valuable information to the medical and CPS systems to promote the health and safety of children.
Defining uncertainty
Medical providers frequently must make important decisions in the care of a patient in uncertain situations. There are countless patient care situations in which uncertainty plays a potent role. Beresford suggested that uncertainty falls into 3 main categories: (1) technical uncertainty, whereby inadequate scientific knowledge exists to predict disease processes or outcomes; (2) personal uncertainty, such as when the medical provider is unaware of the patient’s wishes or when personal connection to the patient may affect judgment; and (3) conceptual uncertainty, which occurs when a provider must choose between 2 or more options that are incomparable, such as determining which of 2 complex and seriously ill patients receives an urgent imaging appointment or when trying to predict outcomes of the same procedure in 2 vastly different patients. This article discusses each of these in the context of an evaluation of a child suspected of being a victim of physical abuse.
Technical Uncertainty
In cases of suspected child abuse, technical uncertainty plays a role in both the expertise of the individual medical provider and the body of knowledge that makes up the evidence base supporting or refuting a diagnosis of abuse. In cases of suspected physical abuse, a common question facing the clinician is whether the injury the child has sustained is adequately explained by the history provided by the caregiver. Primary care clinicians may be uncertain about how to answer this question because of a lack of training about and experience with injury mechanics in children of varying developmental abilities. CAPs may be faced with a lack of definitive, evidenced-based data toward which to turn. Both primary care providers and CAPs are likely to be challenged by incomplete information from caregivers about the circumstances of a child’s injury. In addition, primary care clinicians, who may be inexperienced in working with CPS, may be both uncertain about whether a child’s presentation meets the threshold for a CPS report and unused to providing information to CPS investigators. These uncertainties may cause primary care physicians to overreport or underreport concerns, and to inadvertently undermine the work of CPS.
Personal Uncertainty
Personal uncertainty, as defined as being unaware of the patient’s wishes or how personal involvement or connection to the patient may affect clinical decisions, is a nearly universal component of child abuse work. In cases of suspected child abuse, the parent or other caregiver of a child is, by definition, under suspicion for being the perpetrator of the abuse. The primary care provider may find that abuse does not enter the differential diagnosis of an explanation for an injury, owing to the provider’s previously established trust in the family. Similarly, the child abuse pediatrician or similar provider must guard against the possibility of the family or parents’ wishes interfering with objective assessment of the data. The facts pointing to abuse as the diagnosis can be blurred by the clinician’s emotional desire to please the family by pursuing some other cause for the presenting illness or injuries.
The role of personal connection is stronger and, potentially, more hazardous for the primary care physician. The provider may find it difficult or impossible to consider that a parent the provider trusts and with whom the provider has an established relationship may have harmed the child.
Conceptual Uncertainty
The last type of uncertainty in Beresford’s model is conceptual uncertainty, whereby the challenge lies in applying abstract information to a concrete scenario. One of the many skills taught in medical school is how to critically review the medical literature, asking questions such as “how can I apply this information to my particular patient?” Each case of child abuse is unique, and the art of medicine lies in applying a vast amount of experiential and literature-based knowledge to a particular patient. There is likely no case report in which the patient is identical to the one the clinician is evaluating. The provider must synthesize elements of experience, descriptive studies, clinical trials, and meta-analyses into the care of a particular patient, and specifically incorporate such data into a determination of whether the child was or was not abused. The determination of child abuse often relies on the opinions of other medical specialists in addition to investigative data from CPS and law enforcement. Each of these specialists has his or her set of technical, personal, and conceptual uncertainties. The degree of uncertainty in an individual case evaluation is the sum of that found in the clinician plus the uncertainties in each of the subspecialists and investigators who render opinions used by the clinician. The additive nature of uncertainty results in multiple opportunities for a correct diagnosis to be missed or clouded.
In the primary care setting, 2 possible sources of conceptual uncertainty may be present. First, the experiential base of the provider, that is, the number of child abuse evaluations managed by the specific provider, may be quite low. Second, familiarity with and depth of understanding of the literature are likely much lower than that of the child abuse expert with subspecialty training. The primary care provider may be more swayed by outlier cases in his or her past; for example, the child removed from a family for bruising found to have a bleeding disorder, or the subtle finding in an infant who was not followed up which became significant once the child died of abuse. In addition, primary care providers may be faced with children in their practice for whom a report to CPS has been made, but not substantiated. Limited but memorable past experience with potential abuse may leave the provider uncertain about what to watch for, when to be alarmed, and when and if another report to CPS is warranted.
Uncertainty Beyond the Medical Diagnosis
An additional complication in child abuse work is the level of certainty in the diagnosis required by each member of the multidisciplinary team responsible for the care and safety of the child. CPS must first determine the likelihood that abuse has occurred. Once this decision is made, CPS must derive and institute a safety plan for the abused child. Certainty about the timing of an injury can assist CPS is determining a perpetrator and in forming comprehensive safety plans. Strictly speaking, CPS need not be certain that the child was abused. If, however, CPS determines that a care plan that involves temporary or permanent placement of a child outside of the home is indicated, CPS must demonstrate that a “preponderance of the evidence” exists to show that abuse of the child is more likely than not likely.
Law enforcement and prosecution rely on the burden of proof of “beyond a reasonable doubt” and “within a reasonable degree of medical certainty.” To convict a caregiver of causing an abusive injury, the medical and investigative proof that the child was abused and that the person being charged is the perpetrator must be beyond a reasonable doubt. Child abuse cases often do rise to the certainty level at which CPS can intervene to protect a child, but a caregiver may not be criminally charged or face trial.
The classifications or subsets of uncertainty outlined can provide scaffolding around which to conceptualize uncertainty in child abuse cases. Understanding where uncertainty is likely to appear, added to the clinician’s personal recognition of the areas of uncertainty likely to be present during an evaluation, may assist the clinician in minimizing both doubt and the emotional burden that uncertainty brings to a case.
Reporting to Child Protective Services
The primary care provider faced with a child who may have been maltreated has one key question to answer: does the presentation warrant a report to CPS? Local statutes for mandated reporting share common language that should simplify decision making in this setting. Legally, mandated reporters must contact CPS immediately when they suspect that a child has been maltreated. Certainty is not required, and a delay may result in further injury or even death of a child. Despite the clarity of the law in this setting, however, providers have been shown to fail to report in the context of clear concern.
Approach to uncertainty in physical abuse cases
A framework within which to consider uncertainty in physical abuse can be useful in the setting of decision making, and is provided in Fig. 1 . Although each case is unique, this figure proposes a standardized thought process that may aid the clinician faced with a child suspected of being a victim of physical abuse. The depth of the case review may differ between a primary care provider and a child abuse consultant, but the process is similar.
Timing of Injury
Providers can diagnose an injury as having been caused by abuse, but the timing of the abuse is uncertain. In this setting, the question faced by medical providers “was this child abused?” has been answered affirmatively. The natural secondary question to address is, then, “when was the child abused?”, which is the frequently the same as asking, “by whom was the child abused?” In some cases, a child’s injuries can be determined to have certainly been caused by abuse, but determining when the injuries were inflicted, and by whom, often cannot be determined based on medical science. Why is timing so difficult to determine? One reason is that medical science is not as specific as investigators wish it to be. Bleeding on a computed tomography scan of the brain can be classified as “acute,” a term that covers hours to a few days. The child may have been in the care of several caregivers over the “acute” time period. In child abuse cases, the child often cannot provide a history because the child is nonverbal or minimally verbal, or too ill or scared to provide the details. Clinicians are reliant on the caregivers of the child to provide the history of symptoms that inform the determination of timing of the injury. The caregivers providing the history are often the same caregivers who are under suspicion for inflicting the injury. Details that may be important in determining the timing of the injury may be omitted by the caregiver in an effort to deflect blame.
Even when a child’s caregivers are not willfully distorting the history, accurately timing an injury may be very challenging. Some children are raised in such chaotic environments that obtaining a history of onset and progression of medical symptoms may be impossible even with truthful caregivers. In some cases, law enforcement or CPS workers may have removed the parents from the hospital. Medical providers are often then reliant on histories gathered from the parents/caregivers by nonmedical investigative staff without the benefit of a direct history. Additional complexity is added when a CAP or other clinician is reviewing the records of a child seen at another institution for the purpose of giving a second opinion for a medical or legal reason. The reviewing physician is then limited to the information provided and to the adequacy of the documentation completed by the treating physicians.
Uncertain Diagnosis of Abuse
Uncertainty arising from the possibility of accidental injury
When the diagnosis of abuse is itself uncertain, the reasons for uncertainty can be separated into 2 major categories: when the injuries may be accidental, or when the injuries/findings may be due to a medical process. Uncertainty about whether an injury is accidental is more likely when the suspected victim is ambulatory or there is a history of a fall or other trauma provided by the parent. The medical literature may offer validation for unusual histories, such as a femur fracture sustained by infants using Exersaucers. There will never be a study in which infants are shaken and their injuries studied, or one in which infants are dropped from the height of an adult and their injuries quantified and categorized. Clinicians must rely on a combination of professional experience, existing epidemiologic data, and details of the specific case at hand when determining whether an offered history is possible to explain the mechanism, severity, and timing of the injury. In child abuse work the terms possible, plausible, and probable are frequently encountered. Is an accidental femur fracture in a 4-month-old infant possible? Yes, in certain circumstances, such as in a fall with an adult, or in a baby device, or during a car accident. Is an accidental femur fracture in a 4-month-old plausible? Perhaps, if the history of the accident is clear and the injury mechanism described is of sufficient force to cause a fracture. Is an accidental femur fracture in a 4-month-old probable? Defining probable as “most likely,” the answer is no, when considering all femur fractures in 4-month-olds.
Uncertainty arising from the possibility of a medical condition
The cause of an injury or finding also may be uncertain when some or all of the findings may be due to, or are complicated by, a medical condition. An example of this scenario is a child with bruising. Bruising may be from normal childhood play or may signify a bleeding disorder in a child. Bruising may also be the first, and perhaps only, sign of physical abuse. Delaying an abuse evaluation or failure to ensure the safety of a child while the child awaits an evaluation by a hematologist may return the child to an unsafe situation and may allow additional injury, or death, to occur from abuse. The concepts of possible, plausible, and probable apply in cases where a medical diagnosis is suggested as an alternative diagnosis to abuse. It is possible that an infant with a bruise on the ear has a previously unrecognized bleeding disorder, but it is neither probable nor plausible. Even when a comorbid medical diagnosis is present, such as in a premature infant with multiple bruises, the presence of the comorbid condition does not preclude a diagnosis of abuse. Parents, lawyers, or clinicians may identify alternative but unlikely medical explanations for injuries attributable to abuse, such as a metabolic disease leading to multiple fractures. Although medical causes should certainly actively be pursued and managed, a search for an esoteric, extraordinarily rare disease cannot and should not interfere with the timely diagnosis of abuse, with protection of the child when such a diagnosis is warranted.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
