J R Soc Med 2005;98:229-231
doi:10.1258/jrsm.98.5.229
© 2005 Royal Society of Medicine
Child abuse and paediatrics
Timothy J David
Timothy J David, PhD FRCPCH, Professor of Child Health and
Paediatrics, University of Manchester, is also Proceedings Editor of the
JRSM.
Booth Hall Children's Hospital, Charlestown Road, Blackley, Manchester M9 7AA,
UK
E-mail:
t.david{at}netcomuk.co.uk
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INTRODUCTION
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There have been many success stories in paediatrics, but finding
a good way
to deal with child abuse is not yet one of them;
indeed, for this reason
paediatricians in the UK are under fierce
attack. From your superior knowledge
of fifty years hence, dear
reader in 2055, you may wonder how the specialty
came to be
in such a predicament. However, you should bear in mind that,
as I
write, hardly more than forty years have passed since child
abuse entered the
medical consciousness.
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The troubled present and recent past
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Paediatricians at present stand accused of both overdiagnosis
and
underdiagnosis of child abuse, and media coverage has taken
inaccuracy to new
extremes. Newspaper readers must have become
bewildered recently by reading
almost simultaneously of fatal
cases of Munchausen syndrome by proxy and the
‘fact’
that no such form of abuse exists. One bizarre accusation
is
that, according to the rules of evidence-based medicine, child
abuse itself
may not exist. It is true that randomized controlled
trials are lacking, but
this is about as relevant as the failure
of aviation medicine to perform
randomized controlled trials
on the life-saving efficacy of
parachutes.
1
Public confidence in the ability of British paediatricians to distinguish
abuse from accident or natural disease took its first serious hits with the
overdiagnosis of abuse in
Cleveland2 and the
false evidence from a paediatrician who claimed that sudden and unexpected
death of infants could be prevented by the use of respiration
monitoring.3 The use
of covert video surveillance of mothers and babies in hospital, in order to
prove intentional suffocation, caused great controversy and
disquiet.4,5
Recent cases given immense publicity include Climbié (fatal
abuse),6 Clark and
Cannings (mothers jailed for murdering multiple infants but subsequently freed
on appeal)7 and
Patel (acquitted of murdering three infants). The selective nature of the
media coverage is reflected by the massive publicity concerning paediatricians
who allegedly overdiagnose abuse compared with the negligible attention given
to a specialist (now off the Medical Register) who was in the habit of
diagnosing brittle bone disease despite clear evidence of physical abuse.
As a result of widespread alarm regarding the Clark, Cannings and Patel
cases, the Attorney General reviewed all cases in which a parent or carer had
been convicted in the past 10 years of killing a child under 2 years of age.
The review was published in December
2004.8 Of the 297
cases of past convictions that were reviewed, the Attorney General considered
there was cause for concern that the conviction had been unsafe in 28 (9%),
and his doubts were relayed to the Criminal Cases Review Commission, the Court
of Appeal and the defence solicitors. Of these 28 cases, 3 were sudden infant
death and the rest showed detectable injuries. This was a serious attempt to
identify miscarriages of justice, and an error rate potentially as large as 9%
is clearly unsatisfactory.
One consequence of the public consternation is that many paediatricians are
now reluctant to engage in child protection work. In 2004 the Royal College of
Paediatrics and Child Health reported that, of 3879 paediatricians involved in
child protection, 536 had been subject to complaints (of whom 71 had been
reported to the General Medical Council). The College found that 20-30% of
posts for child-protection-designated doctors were vacant and 10-15% of
hospitals had no named doctor for child protection.
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The future
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Over the next half-century we can confidently expect improvements
in the
expertise of community health workers, social workers,
lawyers and judges.
Within paediatrics itself, the challenge
is to do better in recognizing and
responding to child abuse.
One of the most positive developments in paediatrics in the UK has been the
emergence of nurse specialists. In diabetes, cystic fibrosis, asthma and
gastrointestinal disorders, the introduction of nurse specialists has
transformed the care of ill children; and soon to come are nurse practitioners
(who can diagnose and treat) and nurse consultants. In the hospital where I
work, an important and promising innovation is the provision of a child
protection nurse specialist service, which offers a focal point for contacts
and information. In the USA, another type of nurse specialist is the sexual
assault nurse examiner (SANE), who conducts forensic medical examinations in
women but also children suspected of having been sexually abused; though SANE
programmes have experienced teething troubles, they do indicate that these
nurses can provide a skilled input into assessment and treatment.
It is in the assessment and reporting of suspected abuse that room for
improvement is greatest. Some simple practical
suggestions9
are:
- Before providing a report, ensure that all the child's medical records have
been studied. Resist requests to prepare reports without access to the child's
medical records
- Even if the injury has healed or resolved, consider the need to examine the
patient, to find evidence of an underlying medical condition that has been
overlooked
- This type of work demands great care; there is no place for short cuts.
Consider taking a fresh history from the parent or carer. Previously taken
histories may be incomplete, or taken by an inexperienced junior doctor.
‘Paperwork exercises’ in which the paediatric expert sees neither
the child nor the parents have been described as ‘hearsay
squared’. The main pitfall in history-taking, in cases of suspected
abuse, is that the history provided may be deliberately misleading
- When looking at colour photographs of injuries, do not accept laser colour
photocopies or prints but insist on good-quality large glossy prints of
original photographs
- Attempts to gauge the age of bruises from their colour are fraught with
difficulties. The time course of the appearances may vary with the location,
depth, extent and nature of a bruise. The only established fact is that the
presence of a yellow colour within a bruise indicates that it is at least 18
hours
old10,11
- A normal blood ‘clotting screen’ excludes only the commonest
conditions that may cause spontaneous bleeding or serious bleeding following
trauma. If there are pointers to a coagulation disorder (such as a history of
a bruising or bleeding tendency in the patient or the family), referral to a
haematologist is required
- In view of the importance of the diagnosis, radiographs (original films not
copies) should be seen by a paediatric radiologist
- In the absence of controlled studies to study the effects of injuries on
children, it is wise to exercise caution and avoid firm statements about the
extent of the force required. The terra firma is that, in an infant
with healthy bones, normal handling and normal activities do not produce
fractures, and domestic accidents (such as short falls) seldom produce serious
injury
- Assumptions about the likely severity of ongoing pain occurring after a
fracture based on the reports of adults with complete fractures (e.g. of a
rib) may not apply to infants with stable and incomplete fractures, in whom
ongoing pain may be undetectable
- Try to avoid bias. A mother may have failed to bring a child to three
hospital appointments, but if so it is only fair to also record details of the
(say) fifteen appointments that were kept
- If involved in research, one should be conscious of (and avoid) the natural
tendency to promote one's own findings
- When coming to a conclusion in a report, it is essential to include
existing material that does not support one's conclusion
- In cases of suspected Munchausen syndrome by proxy (also known as
fabricated and induced illness), it is helpful to focus on the actual evidence
of harm. Was the history of epilepsy true or false; were the child's symptoms
caused by the administration of medication (e.g. drowsiness caused by
phenobarbitone); did the blood in the urine come from the child's kidneys or
had it been added to the urine sample? Profiling of a parent to see if the
profile fits a described pattern is no substitute for direct evidence of harm
(e.g. poisoning or suffocation) or potential harm (false reporting).
At present, paediatricians dealing with suspected abuse are handicapped by
a dearth of paediatric pathologists, forensic pathologists, paediatric
neuropathologists, ophthalmic pathologists and paediatric radiologists. In due
course, most of these deficiencies can be put right. Let me close with an
anecdote.
Having diagnosed a non-accidental injury, I was required to attend court to
give evidence. The case concerned a young infant who had been healthy until a
parent left the child in the care of another adult. A few hours later the
child collapsed and died. A post-mortem demonstrated fresh subdural
haemorrhage, massive brain injury, particularly extensive retinal and optic
nerve sheath haemorrhages accompanied by traumatic retinal folds, multiple rib
fractures and bruising to the chest wall and abdomen. On my way out of the
court I was taken aside by one of the lawyers and thanked for my
‘bravery’ in being willing to make a diagnosis of child abuse.
Will we see bravery awards for paediatricians? I think not. Dealing with
suspected child abuse has never been popular, but child protection is emerging
as a specialty in its own right. An encouraging development is systematic
review of existing
knowledge.12,13
Things can only get better.
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REFERENCES
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- Smith GCS, Pell JP. Parachute use to prevent death and major trauma
related to gravitational challenge: systematic review of randomised controlled
trials. BMJ2003; 327:1459
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- Report of the Inquiry into Child Abuse in Cleveland
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- Foreman DM, Farsides C. Ethical use of covert videoing techniques
in detecting Munchausen syndrome by proxy. BMJ1993; 307:611
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- Anonymous. Spying on mothers. Lancet1994; 343:1373
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- The Victoria Climbié Inquiry. Report of an
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- Batt J. Stolen Innocence. A Mother's Fight for Justice.
The Story of Sally Clark. London: Ebury Press,2004
- Lord Goldsmith. The Review of Infant Death
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- Langlois NEI, Gresham GA. The ageing of bruises: a review and study
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- Stephenson T, Bialas Y. Estimation of the age of bruising.
Arch Dis Child1996; 74:53
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INTRODUCTION
The troubled present and...
