Child Abuse Experts Research Articles

Initial development of tools to identify child abuse and neglect in pediatric primary care

BackgroundChild abuse and neglect (CAN) is prevalent, associated with long-term adversities, and often undetected. Primary care settings offer a unique opportunity to identify CAN and facilitate referrals, when warranted. Electronic health records (EHR) contain extensive information to support healthcare decisions, yet time constraints preclude most providers from thorough EHR reviews that could indicate CAN. Strategies that summarize EHR data to identify CAN and convey this to providers has potential to mitigate CAN-related sequelae. This study used expert review/consensus and Natural Language Processing (NLP) to develop and test a lexicon to characterize children who have experienced or are at risk for CAN and compared machine learning methods to the lexicon + NLP approach to determine the algorithm’s performance for identifying CAN.MethodsStudy investigators identified 90 CAN terms and invited an interdisciplinary group of child abuse experts for review and validation. We then used NLP to develop pipelines to finalize the CAN lexicon. Data for pipeline development and refinement were drawn from a randomly selected sample of EHR from patients seen at pediatric primary care clinics within a U.S. academic health center. To explore a machine learning approach for CAN identification, we used Support Vector Machine algorithms.ResultsThe investigator-generated list of 90 CAN terms were reviewed and validated by 25 invited experts, resulting in a final pool of 133 terms. NLP utilized a randomly selected sample of 14,393 clinical notes from 153 patients to test the lexicon, and .03% of notes were identified as CAN positive. CAN identification varied by clinical note type, with few differences found by provider type (physicians versus nurses, social workers, etc.). An evaluation of the final NLP pipelines indicated 93.8% positive CAN rate for the training set and 71.4% for the test set, with decreased precision attributed primarily to false positives. For the machine learning approach, SVM pipeline performance was 92% for CAN + and 100% for non-CAN, indicating higher sensitivity than specificity.ConclusionsThe NLP algorithm’s development and refinement suggest that innovative tools can identify youth at risk for CAN. The next key step is to refine the NLP algorithm to eventually funnel this information to care providers to guide clinical decision making.

A validated Screening instrument for Child Abuse and Neglect (SCAN) at the emergency department

The objective of this study is to develop and validate a screening instrument for the recognition of child maltreatment in the emergency department (ED). Existing data on screening questions and outcomes (diagnosis of child maltreatment) from three large observational screening studies at eight different EDs in the Netherlands were harmonized. A multivariate logistic regression was performed to develop the Screening instrument for Child Abuse and Neglect (SCAN). The SCAN was validated by performing a cross-validation and calculating the discriminative ability. A total of 24,963 patients were included. Out of the potential screening questions the following questions were included in the final instrument: is the injury compatible with the history, and does it correspond to the child’s developmental level? (aOR 10.40, 95% CI 5.69–19.02), was there an unnecessary delay in seeking medical help? (aOR 3.45, 95% CI 1.73–6.88) and is the behaviour/interaction of the child and parents (carers) appropriate? (aOR 14.67, 95% CI 7.93–27.13). The SCAN had a pooled AUC of 0.75 (95% CI 0.63–0.87) in the cross-validation. The question “Are there other signals that make you doubt the safety of the child and/or family?” (available in only one of the original datasets, OR 182.9; 95% CI 102.3–327.4) was by consensus added to the final SCAN.Conclusion: This validated and brief Screening instrument for Child Abuse and Neglect (SCAN) is designed to improve early recognition of child maltreatment in the ED. A positive screening result of the SCAN warrants a thorough work-up for child maltreatment, including a top-toe examination, if necessary additional diagnostics and adequate safety measures.What is Known:• Screening instruments increase the detection of possible cases of child maltreatment in the emergency department and support health care professionals to identify these cases.• The application of different screening instruments led to the need for one brief validated instrument.What is New:• This study presents a validated and brief Screening instrument for Child Abuse and Neglect (SCAN), consisting of four questions.• The SCAN supports professionals in detecting signals of child maltreatment, and a positive screening result should lead to a thorough work-up, including a top-toe examination, complete history, additional diagnostic tests and consultation of a child abuse expert.

A changing history: When is it a red flag for child abuse?

Background and objectiveWhile a changing history is frequently cited as a red flag for child abuse, no data support which changes are significant, nor the degree to which concern should be increased. We sought to measure the impact of changing caregiver histories on expert assessments of abuse likelihood. MethodsWe used a vignette survey to measure the impact of a changing history on child abuse expert assessments of abuse likelihood and willingness to undertake testing and protective interventions. By randomly varying the presence and magnitude of history changes, we determined their impact on perceived abuse likelihood. ResultsOf 494 invited participants, 267 (54 %) completed the survey. The presence of historical changes significantly affected experts’ level of concern for abuse and willingness to test or report abuse, though to variable degrees. For example, while a minor change in the timing of an injury did not significantly increase willingness to perform a skeletal survey (OR: 1.5, 95 % CI: 0.8−2.9), a major change in the timing of an injury did (OR: 2.0, 95 % CI: 1.1−3.6). In addition, a change from having no initial history of trauma to then giving a history of accidental trauma significantly lowered the mean estimate of abuse likelihood and triggered significantly less reports to child protective services (OR: 0.02, 95 % CI: 0.003−0.2). ConclusionFor abuse experts, some history changes are more concerning than others, with major changes in history, and an initial denial of trauma having the largest impact. Future research regarding changing histories should consider details of the change, rather than treating all changes equally.

An Unusual Case of Thiamine Deficiency in a Total Parenteral Nutrition-Dependent Child Secondary to Munchausen by Proxy

An Unusual Case of Thiamine Deficiency in a Total Parenteral Nutrition-Dependent Child Secondary to Munchausen by Proxy

Child Protection Team Consultation for Injuries Potentially Due to Child Abuse in Community Emergency Departments.

Emergency care for children is provided predominantly in community emergency departments (CEDs), where abusive injuries frequently go unrecognized. Increasing access to regional child abuse experts may improve detection of abuse in CEDs. In three CEDs, we intervened to increase involvement of a regional hospital child protection team (CPT) for injuries associated with abuse in children<12 months old. We aimed to increase CPT consultations about these infants from the 3% baseline to an average of 50% over 12months. We interviewed CED providers to identify barriers and facilitators to recognizing and reporting abuse. Providers described difficulties differentiating abusive from nonabusive injuries and felt that a second opinion would help. Using a plan-do-study-act approach, beginning in April 2018, we tested, refined, and implemented interventions to increase the frequency of CPT consultation, including leadership and champion engagement, provider training, clinical pathway implementation, and an audit and feedback process. Data were collected for 15 months before and 17 months after initiation of interventions. We used a statistical process control chart to track CPT consultations about children<1 year old with high-risk injuries, use of skeletal surveys (SSs), and reports to child protective services (CPS). Evidence of special cause was identified beginningin June 2018, with a shift of 8 points to one side of the center line. For the subsequent 8-month period, the CPT was consulted for a mean of 47.5% of children with high-risk injuries; this was sustained for an additional 7months. The average percentage of infants with high-risk injuries who received a SS increased from 6.7% to 18.9% and who were reported to CPS increased from 10.7% to 32.6%. Targeted interventions in CEDs increased the frequency of CPT consultation, SS use, and reports to CPS for infants with high-risk injuries. Such interventions may improve recognition of physical abuse.

A national educational campaign to raise awareness of child physical abuse among health care professionals.

Education is necessary to improve child physical abuse detection and management. A few studies have described national child abuse training programs, but none has measured changes in knowledge among participants. A collaboration of child abuse experts from the USA, an academic pediatric department, and a non-governmental organization in child protection aimed at (a) training hospital physicians in a train-the-trainer course for the detection and management of child physical abuse and (b) conducting workshops and measuring attendance and gain of knowledge of participants. A train-the-trainer and a national curriculum were created. A 78-item and a 20-item knowledge questionnaire were used pre and post the train-the-trainer course and all workshops, respectively. Nineteen physicians from all pediatric departments of the seven medical schools in Greece attended the course. Eight workshops in seven cities took place with a total attendance of 1220 health care professionals. Gain of knowledge was demonstrated for participants in the train-the-trainer course (p = 0.0015) and local workshops (p < 0.001).Conclusion: We successfully engaged physicians from all medical schools in Greece and conducted a train-the-trainer module and eight workshops in major cities that improved the participants' knowledge in child physical abuse. This approach may help address physician deficiencies in emerging areas of child abuse clinical practice. What is Known: • Education is necessary to improve child physical abuse detection and management. • Although national training programs have been described, none has measured participants' changes in knowledge. What is New: • A collaboration of child abuse experts, all medical schools in Greece, and a non-governmental organization resulted in a national educational campaign in child physical abuse and gains in knowledge for participants. • This approach may help address deficiencies in emerging areas of clinical practice.

Interdisciplinary collaboration needed in obtaining high-quality medical information in child abuse investigations.

Despite reporting legislation, healthcare providers (HCPs) do not always report and collaborate in cases of suspected child abuse. Recognizing this leaves children at risk, the Wisconsin Child Abuse Network (WI CAN) sought to understand barriers to mandated reporting and collaboration with child abuse investigators. The purpose of the study was to investigate barriers for professionals in providing and obtaining high-quality medical information in child abuse investigations. Participants included five discipline-specific focus groups: HCPs, child protective services (CPS), law enforcement, lawyers, and judges. All professionals had been directly involved in Wisconsin child abuse cases. This qualitative study consisted of discipline-specific focus groups, directed by open-ended interview questions. Data analysis was completed through the narrative inquiry methodology. Barriers to providing and obtaining high-quality medical information in child abuse investigations were both discipline-specific and universal amongst all groups. Discipline-specific barriers included: HCPs' discomfort with uncertainty; CPS' perception of disrespect and mistrust by HCPs; law enforcement's concerns with HCPs' overstepping professional boundaries; lawyers' concern of HCPs' discomfort with court proceedings; and judges' perception of a lack of understanding between all disciplines. Universal barriers included: value of high-quality medical information in child abuse investigations, burden of time and money; unequal resources between counties; a need for protocols, and a need for interdisciplinary collaboration. Findings from this study suggest several ways to address identified barriers. Possible interventions include equalizing resources between urban and rural counties (specifically financial resources and access to child abuse experts); protocolizing reporting and investigations; and, increasing interprofessional education.

LO81: Bridging the GAP: A deliberate practice method for learning Genital Abnormalities in Prepubescent girls

Introduction: Correctly identifying pathology in pre-pubertal females is a high-stakes physical examination skill. Currently, learning this skill relies heavily on case-by-case exposure, which is variable, limited and often results in suboptimal skill. Thus, there is a need to develop and evaluate learning platforms that simulate the presentation and diagnosis of this important clinical task. We developed an on-line learning and assessment platform that allowed the deliberate practice of 158 pre-pubertal female genital image interpretations . We examined the quantity of skill acquisition by deriving performance metrics and learning curves. Methods: This was a prospective cross-sectional study administered via an on-line learning and assessment platform. Colposcopic images were acquired from a child abuse clinic. Two child abuse experts interpreted images to determine case solutions and 40% of cases had medical or traumatic pathology. Further, to validate image interpretations, a unique set of five child abuse and pediatric gynaecology experts reviewed the cases. Study participants were recruited from the USA and Canada and were required to complete all 158 cases. For each image, learners designated cases as normal or abnormal and if abnormal indicated the abnormal area on the image. The primary outcome was the change in accuracy, sensitivity and specificity. Results: We enrolled 107 participants, 26 medical students, 31 pediatric residents, 24 pediatric emergency fellows, and 26 pediatric emergency attendings. For all participants, the change in accuracy was +9.6% for accuracy (&lt;0.001), +1.4% for sensitivity (p=0.6) and +15.7% (p&lt;0.001) for specificity. The final score for accuracy, sensitivity and specificity was 79.5%, 66.1%, and 87.8%, respectively. There was no difference between learner types with respect to summary performance metrics (accuracy, p=0.15; sensitivity, p=0.44; specificity, p=0.54). Learning curves show maximal learning gains (inflection point) up until 100 cases. Conclusion: Deliberate practice of pre-pubertal female image interpretation was effective for ensuring predictable skill improvement for normal cases but was less effective for abnormal cases. Future research could examine how to refine the education tool to better serve diagnostic skill of abnormal cases.

Child abuse and neglect experts\u2019 determination of when a child being left home alone constitutes child neglect

BackgroundOnly 14 states have laws or guidelines regarding the minimum age a child may be left home alone. These ages range from 6 to 14 years. Our objective was to identify factors that influence child neglect determination by experts with regards to parents leaving children home alone.MethodsAmerican Academy of Pediatrics Section on Child Abuse and Neglect members (N = 523) were surveyed from July–August, 2015. Respondents were asked whether scenarios involving a child of varying age knowingly left home alone for 4 h were neglect in the presence or absence of injury to the child and the legality of the situation. Comparisons were performed using the chi-square test.ResultsOne hundred ninety-three members responded (36.9%). In the scenario where there were no relevant laws and the child was uninjured, nearly 100% of the child experts determined this as being child neglect when the child was 6 years old. For 8, 10, 12, and 14 year olds, this was 88, 48, 4, and 1%, respectively. However, a significantly higher percentage of experts considered it child neglect for most ages when there was a law making the scenario illegal as compared when there was no law, and when the child was injured versus when they were not. The only demographic variable that showed a difference in child neglect determination was that females were more likely to consider higher aged children as having been neglected when there were no laws but the child was injured. The vast majority of experts (85%) stated that leaving a child home alone for 4 h should be illegal if the child is < 9 years old, and nearly one-half (44%) said it should be illegal for children < 11 years old.ConclusionsA number of factors affect how experts view children being left home alone as potential child neglect. Our data suggests that such cases may be evaluated differently due to variations in state laws, even though the risk to the child is the same. These results call for child safety law reform to provide greater uniformity in the evaluation of potential child neglect cases and better protect the safety of children.

Encouraging Bystanders to Promote Positive Parenting and Prevent Child Maltreatment in Retail Settings: Results of an Exploratory Qualitative Study

ABSTRACTCommunity-level bystander approaches with media campaigns have successfully reduced sexual violence, but these programs have not been developed for child maltreatment prevention. This study informs the development of such programs in retail settings. Data were collected using focus groups with parents (n = 29) and surveys with child abuse experts (n = 10). Participants were asked how retail environments and employees could support parents during shopping excursions and what employees should do if they witnessed a concerning interaction. Participants highlighted (a) the need for in-depth training of employees to engage with parents and children to promote positive interactions and intervene in concerning situations; (b) the importance of the built environment (i.e., physical design and layout) to reduce stress and establish positive social norms through store-wide messaging; and (c) the role of parents in establishing expectations and actively including children in shopping. Future research should test approaches to training and engaging retail employees as supportive bystanders.

Characteristics of cases submitted to a statewide system of child abuse experts

BackgroundThe Texas Department of Family and Protective Services (DFPS) created a statewide network of child abuse pediatricians working at 6 academic centers in 2006. MethodsCase data for the period 9/1/2012–8/31/2014 were reviewed for child demographics, risk factors, physician determinations, injury descriptors, and information made available to the physician. Results8061 of 410,315 DFPS cases (2%) were referred during the period. Network utilization rates ranged from 7.5% in counties served by San Antonio to 1.4% in Austin-served counties. Cases from outlying counties were less likely to involve older children. African American children were over-represented in referrals, and Caucasian and Asian children were underrepresented. Prevalent risk factors included prior DFPS history, single parent-household, mental illness, substance abuse, and domestic violence. Network providers found no or only nonspecific evidence for maltreatment in 45% of cases. Determinations were hindered by poor quality photographs in 188 cases and inadequate skeletal surveys in 121. Insufficient information precluded case completion for 65 cases of children <2years. ConclusionsOur data indicate that child abuse centers in Texas are underutilized, and there are practice differences with respect to medical referrals across different regions. Our findings concerning ethnic differences and risk factors are consistent with national trends. The problems of inadequate photographs and case information may improve with better training of workers; the issue of poor quality skeletal surveys requires further study. Standard DFPS criteria for referrals to child abuse pediatricians should mitigate some of the problems identified by this study.

Value of systematic detection of physical child abuse at emergency rooms: a cross-sectional diagnostic accuracy study

ObjectivesThe aim of our diagnostic accuracy study Child Abuse Inventory at Emergency Rooms (CHAIN-ER) was to establish whether a widely used checklist accurately detects or excludes physical abuse among children...

Using simulation to identify sources of medical diagnostic error in child physical abuse

Little is known regarding sources of diagnostic error at the provider level in cases of possible child physical abuse. This study examines medical diagnosis as part of medical management and not as part of legal investigation. Simulation offers the opportunity to evaluate diagnostic accuracy and identify error sources. We aimed to identify sources of medical diagnostic error in cases of possible abuse by assessing diagnostic accuracy, identifying gaps in evaluation, and characterizing information used by medical providers to reach their diagnoses. Eight femur fracture simulation cases, half of which were abuse and half accident, were created. Providers from a tertiary pediatric emergency department participated in a simulation exercise involving 1 of the 8 cases. Performance was evaluated using structured scoring tools and debriefing, and qualitative analysis characterized participants’ rationales for their diagnoses. Overall, 39% of the 43 participants made an incorrect diagnosis regarding abuse. An incorrect diagnosis was over 8 times more likely to occur in accident than in abuse cases (OR=8.8; 95% CI 2 to 39). Only 58% of participants correctly identified the fracture morphology, 60% correctly identified the mechanics necessary to generate the morphology, and 30% of ordered all appropriate tests for occult injury. In misdiagnoses, participants frequently falsely believed the injury did not match the proposed mechanism and the history provided by the caregiver had changed. Education programs targeting the identified error sources may result in fewer diagnostic errors and improve outcomes. The findings also support the need for referral to child abuse experts in many cases.

Defining ‘reasonable medical certainty’ in court: What does it mean to medical experts in child abuse cases?

Physicians and others who provide expert testimony in court cases involving alleged child abuse may be instructed to state their conclusions within a ‘reasonable medical certainty’ (RMC). However, neither judges nor jurors knows what degree of probability constitutes RMC for a given expert, nor whether different experts use different standards to formulate their opinions. We sought to better understand how experts define RMC in the context of court cases. An email survey was sent to members of six list-serves, representing four specialties, whose members testify in child abuse cases. Respondents were asked to define how RMC corresponded to (1) the numerical probability that abuse occurred, (2) the ordinal probability, and (3) how their determinations relate to common legal standards (‘preponderance of the evidence’, ‘clear and convincing’, and ‘beyond a reasonable doubt’). Participants were also asked how comfortable they were in defining RMC; whether their definition changed according to the charges or type of proceeding; and how they would apply RMC to several hypothetical cases. The 294 list-serve participants who responded included child abuse pediatricians (46%), forensic pathologists (21%), pediatric neurosurgeons (15%), pediatric ophthalmologists (12%), and others (6%). Though 95% of respondents had testified in court, only 45% had received training in the definition of RMC. Only 37% were comfortable defining RMC. Although many responses were highly clustered and paired comparisons showed that 95% of participants’ responses were internally consistent, there was variability in respondents’ definitions of RMC. There is some variability in how child abuse expert witnesses define and use the term RMC; we provide suggestions about how to more accurately and transparently define RMC to ensure justice in these cases.

Preliminary Development of a Rapid Assessment of Supervision Scale for Young Children

Standardized evaluation tools have been shown to reduce variability in care. The objective of this study was to develop a clinically oriented evaluation tool for the rapid assessment of the adequacy of supervision of a young child. The Rapid Assessment of Supervision Scale (RASS) was developed via a 3-step process: (1) a modified Delphi survey of child abuse experts identified the most important characteristics for use in the assessment of adequacy of supervision; (2) the RASS was designed by using standardized definitions and the results of the Delphi survey; and (3) a total of 4 medical professionals evaluated 139 real case scenarios by using the RASS. Reliability and feasibility were assessed. Sixty-seven child abuse experts participated in round 2 of the Delphi process and 50 participated in round 3. The RASS included 9 supervision characteristics identified from the Delphi process, standardized definitions, and a scoring system. The interclass correlation coefficients for interrater reliability of the mean RASS scores and overall supervision classification were 0.63 (95% confidence interval: 0.56-0.70; P = .000) and 0.59 (95% confidence interval: 0.51-0.67; P = .000), respectively, indicating moderate to strong agreement. For intrarater reliability, correlation coefficients for mean RASS scores indicated moderate to high correlation (0.50-0.83). Correlation for overall classification of supervision ranged from low to high (0.27-0.80). The RASS scale has been shown to be efficient and, in a small sample, to have moderate to substantial interrater agreement. Further development could result in a tool that aids clinicians and researchers in the evaluation of supervision.

Child Abuse Experts Disagree About the Threshold for Mandated Reporting

Child Abuse Experts Disagree About the Threshold for Mandated Reporting

To Report or Not to Report: Examination of the Initial Primary Care Management of Suspicious Childhood Injuries

Objective This study examined the validity of primary health care providers’ (PHCPs) assessment of suspicion that an injury was caused by child abuse and their decision to report suspected child abuse to child protective services (CPS). Methods By using a subsample of injuries drawn from the 15,003 childhood injuries evaluated in the Child Abuse Recognition and Evaluation Study, PHCPs completed telephone interviews concerning a stratified sample (no suspicion of abuse; suspicious but not reported; and suspicious of abuse and reported) of 111 injury visits. Two techniques were used to validate the PHCPs’ initial decision: expert review and provider retrospective self-assessment. Five child abuse experts reviewed clinical vignettes created by using data prospectively collected by PHCPs about the patient encounter. The PHCPs’ opinions 6 weeks and 6 months after the injury-related visits were elicited and analyzed. Results PHCPs and experts agreed about the suspicion of abuse in 81% of the cases of physical injury. PHCPs did not report 21% of injuries that experts would have reported. Compared with expert reviewers, PHCPs had a 68% sensitivity and 96% specificity in reporting child abuse. A PHCP’s decision to report suspected child abuse to CPS did not reduce the frequency of primary care follow-up in the 6 months after the index visit. PCHPs received information from their state CPS in 70% of the reported cases. Conclusions Child abuse experts and PHCPs are in general agreement concerning the assessment of suspected child physical abuse, although experts would have reported suspected abuse to CPS more frequently than the PHCPs. Future training should focus on clear guidance for better recognition of injuries that are suspicious for child abuse and state laws that mandate reporting.

Child Abuse Consultations Initiated by Child Protective Services: The Role of Expert Opinions

Objective To describe consultations provided by child abuse pediatricians for cases referred by child protective services (CPS); compare the opinions of the likelihood of child maltreatment of the initial physician, CPS, and the child abuse pediatrician; and examine predictors of the experts’ opinions. Methods Cases were referred by CPS for consultations between March 1, 1998, and June 30, 2005, to 2 child abuse pediatricians at Yale–New Haven Children’s Hospital. We abstracted demographic and clinical information and the opinions of the initial physician, CPS, and the child abuse expert, each coded using a 5-point scale from definite maltreatment to definite benign cause (eg, accident). Results Of 187 cases, 50.3% occurred in children younger than 1 year of age. Children’s most serious injuries were fractures (50.8%), burns (16.6%), and bruises/abrasions (15.0%). The child abuse experts’ opinions were 47.6% definite or probable maltreatment, 8.6% uncertain, and 43.9% definite or probable benign. Of the 119 cases with opinions from all 3 assessors, the expert agreed with the physician in 57.1% of cases (κ = 0.34) and with CPS in 64.7% (κ = 0.42). The best predictor of the expert’s opinion that the injury was due to maltreatment was agreement between the physician and CPS that maltreatment had occurred. Conclusions Levels of agreement were fair to poor between the child abuse expert and either the physician or CPS. Child abuse experts’ opinions have important value in selected cases to confirm previous assessments by the physician and/or CPS, or to change the opinion of the case.

Response to Vinchon

Dear Editor: Vinchon maintains that alleged abusers’ “confessions” and/ or judicial decisions can confirm violent shaking as a cause of subdural hemorrhages in infants [1]. We suggest that it is time for physicians, especially medical journal reviewers, to disabuse themselves from accepting “alleged” perpetrator confessions and judicial outcomes as per se scientific confirmation of child abuse. Certainly, some perpetrator confessions do accurately explain abusive acts causing subdural hemorrhage. However, it is common knowledge that there are “confessions” of those who maintain their innocence made to obtain a plea bargain to avoid the vagaries of a trial. In some cases, one parent will make a false admission in order to try and save his/her mate. Some, for multiple reasons, will confess to an act they did not commit. In reading and viewing interviews of alleged perpetrators, we find statements of resuscitative shaking or playful bouncing, or other playing similar to this being construed as the cause of a subdural hemorrhage [2]. This certainly should not be considered “violent” shaking”. Whether shaking alone can cause subdural hemorrhage is still a zealously debated hypothesis [3, 4]. As medicine has proven through the ages, experience alone is not a substitute for the scientific method and does not prove a hypothesis [4]. We agree with Turkheimer that it is untenable to suggest that this particular scientific dispute should be decided in courts. In our adversarial system, the presentation of scientific evidence is dependent on the constrictions imposed by the court, on the legal competency of the attorney, on the knowledge and communication skills of the expert, if they can afford one, and on the educational background and the capacity of the triers of fact to evaluate science. While judges, many of whom are learned legal minds, make decisions of cases brought before them, they do not have the scholarly standing in the biomedical community to determine the scientific validity of competing medical evidence [5, 6]. Sadly, we have encountered judges who have abrogated judicial impartiality by failing to consider the possibilities of competing medical science and advocating for the omniscience of the state’s child abuse experts. The natural course of scientific evolution has resolved many medical conflicts separating scientifically valid arguments from opinion and speculation. Until that time, confessional data and judicial decision must be considered with caution and cannot be taken as per se determinants of child abuse.

Child Abuse Experts Disagree About the Threshold for Mandated Reporting

Though reasonable suspicion serves as the standard threshold for when to report suspected child abuse, there is little guidance how to interpret the term. To examine how experts on child abuse interpret reasonable suspicion using 2 probability frameworks. Anonymous survey of clinical and research experts on child abuse. Responses on ordinal and visual analog scales quantifying the probability needed for "suspicion of child abuse" to rise to reasonable suspicion. A total of 81 of 117 experts completed the survey (69% response rate, mean age 47 years, 69% female). On both the ordinal probability scale (rank order on a differential diagnosis) and the estimated probability scale (1% to 99% likelihood), experts demonstrated wide variability in defining reasonable suspicion, with no statistically significant differences found for age, race, gender, professional training, seniority, or prior education on reasonable suspicion. This study found no consensus in how experts on child abuse interpret reasonable suspicion.