The creation of non-disease: an assault on the diagnosis of child abuse

Abstract

The triad of subdural hematoma, retinal hemorrhage and multiple fractures in a child has been extensively documented to strongly suggest non-accidental trauma. Based on confessional evidence, a medical workup excluding diseases that can present with some of these abnormalities, and almost 50 years of scientific medical supportive literature, the diagnosis of abuse is being made with increasing medical certainty [1–7]. The medical community and particularly child protection professionals take extraordinary care before making a diagnosis of intentional, non-accidental trauma and strongly consider alternative diagnoses. The foundations of medical diagnosis and treatment should be firmly rooted. While there will always remain instances in which the evidence is less than perfect and several diagnostic possibilities are acceptable, it is dishonest and fraudulent to advocate a diagnosis denied by reasonable medical certainty. In this ploy, the protagonist says “there is controversy” but as Oliver Wendell Holmes noted, “controversy equalizes fools and wise men—and the fools know it” [8]. This is what is occurring in the diagnosis of child abuse. A small group of individuals has, during depositions and court room testimony [9, 10], perverted cases by using incomplete statements of the facts and unproven hypotheses to obscure the straightforward historical and physical findings utilized to make the diagnosis of child abuse [11–18]. These individuals have utilized unethical methods to create controversy when there should be none. The role of the medical profession is to protect today’s child and future children. The question is not “who did it?” but rather “did the child suffer from non-accidental trauma?” A remarkably informative course titled “Imaging of Child Abuse: Fact, Fiction and Responsible Action” (4–5 February 2012) was sponsored by The Society for Pediatric Radiology and directed by Drs. Jeannette M. Perez-Rossello and Paul K. Kleinman [19]. Perhaps the most encouraging aspect of the weekend was the active participation of scientists, lawyers, and physicians of various clinical expertise. The course was preceded by a 1-day discussion between the speakers and other invited experts. The following day-anda-half seminar (Table 1, course outline) presented the scientifically accepted methodology for the diagnosis of nonaccidental trauma with emphasis on the pathophysiology of various injuries, and covered areas where new data have changed our understanding (e.g., subdural hematoma can occur from bleeding dural veins and not only bridging veins) [20–22]. The differential diagnosis of the various injuries was emphasized and appropriate workup of these childrenwas presented. There is no controversy that child abuse is real and deadly. In 2009, approximately 150,000 children were confirmed with physical abuse and 1,770 died [23]. As a T. L. Slovis (*) Department of Pediatric Imaging, Children’s Hospital of Michigan, Wayne State University School of Medicine, 3901 Beaubien Blvd., Detroit, MI 48201, USA e-mail: tslovis@med.wayne.edu