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WI CAN Educational SeriesLynn K. Sheets, MD, FAAP
Medical Director - Child Advocacy and Protection Services - CHW
Professor – Medical College of Wisconsin
Lynn K. Sheets, MD
has documented
that she has no
relevant financial
relationships to
disclose or conflicts
of interest to resolve.
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Disclaimer:
This lecture is not intended as legal
advice and should not replace legal consultation within your
agency.
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Outline
• Scope of the problem
• Biases – Avoiding Cognitive Errors
• Improving understanding when health care providers report suspected CAN
• Forensic interviews of child witnesses
• Improving detection of injuries that should raise suspicion for abuse– Implausible histories – red flags
– Occult injury screening– Screening for other at risk children
• Death scene review/re-enactment and Autopsy
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Rationale
• 4 – 8 children die daily from CAN; it is under-reported and under-detected
• About 50% are < 12 months old and 75% are < 3 y/o
• Missed maltreatment is common; previous report predicted risk (5.8 times more likely to die from CAN)
• Costs our nation $124 billion/each year of confirmed CAN (lifetime costs) and societal costs
Commission to Eliminate Child Abuse and Neglect Fatalities. (2016).
Within our reach: A national strategy to eliminate child abuse and neglect fatalities.Washington, DC: Government Printing Office. 12/5/2017 Copyright 2017 LKSheets MD 5
AVOIDING COGNITIVE ERRORS
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Common Land Mines in
Accurate Identification of
Child Abuse• Human nature dictates that unintentional
injury is the most likely diagnosis. All of us have an inherent COI – our work is easier if it is not abuse.
• Even if aware of your own biases, it is challenging to resist their influence. (“Nice family”)
• The human mind has a tendency to fill in gaps in the history and make assumptions. (“I could see how that could happen”)
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Challenge: Biases
• Mistaken impressions - “nice” families
• Cognitive error: This leads to under-detection in groups perceived to be lower risk and over-screening/reportingin groups perceived to be at increased risk
• Poor more likely to be screened (81% vs 59%); AA more likely to be screened (Wood et al 2010)
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Common Land Mines in
Accurate Identification of
Child Abuse• Anchoring – once a diagnosis or
explanation is suggested, it may be hard to consider alternatives
• Confirmation bias – Some of the history is likely true. Confirming some of the history should not substitute for confirming all of the history
• Triage cueing – “to the hammer, the world is a nail”
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The Challenge – The Haystack
• Most people don’t abuse children
• Falls and unintentional events are very common
• A history of a fall is the most common true and false history in pediatric injury
• How do we avoid missing abuse?
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Strategies to Reduce
Cognitive Errors
• Use colleagues – provide just the facts
without impressions
• Play ‘devil’s advocate’ by asking what else
could plausibly explain the injury
• Avoid questions such as “is it possible that. .
.?” Instead – “Is the injury expected?”
• Use your peers and professionals from
other disciplines (MDT); medical uses peer
review
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Consider Abuse If:
• No explanation or vague explanation for
significant injury
– DO NOT try to “explain away” an injury that does not have an explanation
• Important historical detail changes – however
poor communication can create this
appearance
• Explanation is inconsistent with the injury
(because of severity, timing, biomechanics or
developmental abilities) *Modified from Kellogg, Pediatrics2007;119;1232-1241
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Unintentional vs. Inflicted Trauma:
Does the Story Match the Injuries?
• Multiple injuries
• Patterned injuries
• Location of injuries
• Severity of injuries
• Injuries of different ages
Does it fit with the unintentional injury history?
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Kirschner’s “Dirty Dozen”+ for
severely injured young children
• Incident happened
when alone with
mother’s boyfriend
• Help is first sought
from a relative or
neighbor
• History of a bruise or
mouth injury in infant
< 7 mo old
Dr. Robert Kirschner 1940 – 2002 Forensic Pathologist and human rights activist
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Avoiding Missed Abuse
• Is the injury expected given the history of how it happened? Ask!
• Are the injuries in unusual places, more severe, more numerous than usually seen?
• Is there a history of sentinel injury during early infancy?
• Were occult injuries considered and screened for if age appropriate?
• Were other children in the same environment of care interviewed and examined?
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Mandated Reports by
Health Care Professionals• Physicians receive little or no training on
mandated reporting
• The quality of the report is critical
• The health care professional should
educate about why maltreatment is
suspected in understandable language
• Health care providers should consider
dual reporting if injury is present – to both
CPS and police
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What is “Reasonable Suspicion”?
Mandated reporters interpret and apply the
responsibility of reporting inconsistently (Levi
2004) for many reasons including
• The perception that more harm than good will be done from reporting
• Disagreement about what constitutes maltreatment and what constitutes reasonable
suspicion
• Lack of clarity about how reasonable suspicion relates to the age of the child and the type of
injury
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So What is “Reasonable
Suspicion”?
• ‘Reasonable suspicion’ means that it is objectively reasonable for a person to entertain a suspicion, based upon facts that
could cause a reasonable person to suspect child abuse or
neglect.
• ‘Reasonable suspicion’ does not require certainty that child
abuse or neglect has occurred nor does it require a specific
medical indication of child abuse or neglect. State Laws:https://www.childwelfare.gov/topics/systemwide/laws-
policies/statutes/manda/?hasBeenRedirected=1
• The reasonable person threshold is a low threshold!! If in doubt,
report! The practical threshold for reporting by many medical
providers is quite high! Ask lots of questions if a report is received from a medical provider!
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FORENSIC INTERVIEWING
Child Advocacy Centers
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Child Advocacy Centers
• “One stop shop” for children suspected of being abused
• Child friendly place where investigation
(forensic interviewers), medical, mental
health and
advocacy services are
provided
• About 700
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Forensic Interviews
• Consider in:
– Suspected child neglect, child physical
abuse and child sexual abuse
– Witness to IPV and witness to homicide
– Unexplained death of another child in the
home
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SCREENING FOR OCCULT INJURY
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Advice for Clinicians
“Think Less, Test More, Test
Routinely” – Dan Lindberg, Kempe Center
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Value of Protocols
• Following protocol-based diagnostic tests help reduce cognitive errors
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Guide for Investigators
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Learn About Sentinel
Injuries!
• http://uwm.edu/mcwp/sentinel-injuries/
• 25-minute module developed in
collaboration between CHW,
Milwaukee Child Welfare Partnership,
WI DCF, CANPB, and UWM Helen Bader School of Social Welfare
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Medical Abuse Evaluation for
Children ≤ 2 y/o• Head CT (always if <6 mo, if abnormal neuro <12
months and as indicated for 12-24 months) and/or MRI brain and spine if suspicion of AHT
• Skeletal Survey and repeat in 2 - 3 weeks• Labs:
– Abdominal screening labs (AST, ALT, Amylase, Lipase, UA)
– Coagulation studies if bruising or bleeding • (CBC with manual diff, PT, PTT, Platelet Function Screen, vWF
screen)
– Bone labs if fractures- Ca, PO4, Alkaline phosphatase, magnesium, 25 Vitamin D, intact PTH
– Drug urine investigation
• Dilated ophtho if rib fractures, abnormal neuroexam or if head CT is abnormal
• Other tests as indicated12/5/2017 Copyright 2017 LKSheets MD 28
Coagulation Studies
Bruising Intracranial hemorrhage
PT PT
PTT PTT
vWF antigen Factor VIII
vWF activity Factor IX
Factor VIII CBC with platelet count
Factor IX DIC panel (d-dimer and fibrinogen)
CBC with platelet count
Anderst JD et al. Pediatrics. 2013;131:e1314-e132212/5/2017 Copyright 2017 LKSheets MD 29
Inexpensive bleeding study:
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In bruising cases, think about:• If the child is pre-
mobile – is there a sentinel injury on exam or in the child’s history?
• If child is mobile, ask provider if the child has more bruising than normal in typical locations!
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Importance of the FUSS
• Follow up skeletal survey almost always indicated 2-3 weeks after the first
• Skeletal survey should be repeated in 2 weeks per the AAP if an initial SS is performed even if the child is 12-24 months – “A follow-up skeletal survey approximately 2 weeks
after the initial study increases the diagnostic yield and should be performed when abnormal or equivocal findings are found on the initial study and when abuse is suspected on clinical grounds.”
• Even when the initial SS on a child ≤ 2 y/o is negative, a repeat SS is indicated as it yields forensically important information in 8.5% of cases
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Pediatrics 2009;123:1430-1435; Hansen KK and Campbell KA, Child Abuse & Neglect 2009;33:278-281; Bennett BL, et al. BMC Research Notes 2011;4:354 and Harper NS, et al Pediatrics 2013;131;e672
Ophtho Screening?
• If head imaging is negative, yield of dilated
ophthalmologic exam is generally low.
• However, consider Ophthalmology consult
if head CT is negative for intracranial injury
but patient has significant facial, orbital, or
periorbital injury, abnormal neurologic
exam, and/or other signs of abusive head
trauma (AHT) such as rib or metaphyseal
fractures.
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Thackeray JD et al. Yield of Retinal Examination in Suspected Physical Abuse with Normal Neuroimaging. Pediatrics. 2010;125:e1066-e1071
SIBLINGS AND HOUSEHOLD
CONTACTS OF ABUSED CHILDREN
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Siblings and contacts- How
much work-up?
• 2012 Lindberg et al. (Pediatrics.2012;130:1-9)- ExSTRA multisite research
study:
• Found ~12% of contacts under 2 y/o
had abusive fractures
• Twins at substantially increased risk of
fracture when the index child was the
other twin; odds ration 20x!!
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Screening for Intimate
Partner Violence
• Co-occurrence of IPV and child physical abuse is about 50%
• Standard screening tools are available
• Example – RADAR available at:
– http://www.opdv.ny.gov/professionals/he
alth/radar.html
– Routinely Ask Document Assess
Review/Refer
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Scene Investigations
• Scene Investigations are critical – see
– http://www.nij.gov/topics/law-
enforcement/investigations/crime-scene/guides/death-investigation/pages/document-body.aspx
• Scene re-enactments can be very helpful
– Never use a living child to re-enact
– Conduct separate re-enactments if more than 1 adult was at the scene
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When a Child Dies or is Hurt
• Injury – Injury scene such as burn scene investigation can be pivotal in understanding how injury occurred
• Death– Routinely perform high quality death scene
investigations
– Always request an autopsy in cases of unexpected or unexplained death of a child
– Autopsy should be performed by the most qualified person
– Support Child Death Reviews
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Key Points• Be aware and safeguard against your human
tendencies to make cognitive errors• Use best practice in mandated reporting• Use Child Advocacy Centers and Forensic
Interviews when available• Recognize sentinel Injuries – bruises and mouth
injuries in children not yet cruising• Screening for occult injuries – brain, skeletal,
abdomen, chemical/drug exposure• Sibling exams when there is an index case of abuse
• Screen and intervene for Intimate Partner Violence (IPV)
• Injury and Death scene review/re-enactment and Autopsy
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References
Christian CW and the AAP, Clinical Report: The Evaluation of Suspected Child Physical Abuse. Pediatrics. 2015:135(5):e1337.
Jenny, C., Hymel, K. P., Ritzen, A., Reinert, S. E., & Hay, T. C. Analysis of missed cases of abusive head trauma. JAMA.1999:282(7); 621–626.
Petska HW, Sheets, LK, & Knox BL. Facial bruising as a precursor to abusive head trauma. Clinical Pediatrics. 2012:52(1);86–88.
Petska HW and Sheets LK. Sentinel Injuries: Subtle Findings of Physical Abuse. Pediatr Clin N Am. 2014:61:923-935.
Laskey AL. Cognitive Errors: Thinking Clearly When It Could Be Child Maltreatment. Pediatr Clin N Am. 2014;61:997-1005.
Sugar NF, Taylor, JA, & Feldman, KW. Bruises in infants and toddlers: Those who don’t cruise rarely bruise. Archives of Pediatrics & Adolescent Medicine. 1999:153(4);399-403.
Labbe J, & Caouette G. Recent skin injuries in normal children. Pediatrics.2001:108(2);271-276.
Thackeray JD. Frena tears and abusive head injury: A cautionary tale. Pediatric Emergency Care. 2007:23(10);735-737.
Sheets LK, Leach ME, Koszewski IJ, Lessmeier AM, Nugent M, Simpson P. Sentinel Injuries in Infants Evaluated for Child Physical Abuse. Pediatrics. 2013:131:701-707.
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Questions?
Contact Information:
Lynn K. Sheets, MD, FAAP
(414) 266-2090
[email protected] 2017 LKSheets MD12/5/2017 40
1.12.17 LK Sheets, HW Petska & J Yates 414-266-2090 [email protected]
Physical Abuse Concerns in Infants Birth to 2 years of Age: Taking a Closer Look
Sentinel Injuries:
What are they? Visible, poorly explained small injuries such as a bruise or mouth injury in pre-cruising infants are often from abuse and can precede more serious abuse. Cruising means the baby is able to pull to a stand and take a few steps holding onto something which babies learn to do between 7 and 12 months of age.
What do they mean? Babies who are not yet cruising should not be bruising! Any bruise or mouth injury in a pre-cruising infant should raise concerns for abuse or a bleeding disorder (Sugar, N et al., Arch Pediatr Adolesc Med. 1999;153:399-403 and Sheets, LK et al., Pediatrics. 2013; 131:701–707).
A baby with a small bruise from abuse may have severe internal injuries, so additional medical screening is necessary. Medical screening is performed to detect additional injuries and to rule out conditions that can cause easy bruising such as a bleeding disorder. In a recent study, 50% of babies with just a bruise who were evaluated for abuse had other serious injuries (Harper NS et al. J Pediatr 2014;165(2):383-388)
Who should evaluate an infant with a sentinel injury? Ideally the infant should be evaluated by the most experienced medical provider available. If unsure about where to seek care or another opinion, consult with your Child Advocacy Center for further guidance.
What if the further injury surveillance (see Medical Evaluation below) is negative? Even if no other injuries are present, the sentinel injury should be carefully considered as suspicious for abuse. Remember that a bruise or mouth injury may be the first injury from abuse! Injury surveillance is not complete until both parts of the skeletal survey are performed (initial and repeat in 3 weeks).
Other considerations:
Fractures can be the first sign of physical abuse and 55% to 70% of abusive fractures occur in children under 1 year of age. Consider child physical abuse in any child with a fracture that is unexplained, poorly explained or in an infant < 12 months old.
Sibling or household contacts of abused children should be evaluated for abuse. Researchers found that siblings or household contacts under 2 years of age had abusive fractures in almost 12% of cases! (Lindberg, DM et al., Pediatrics. 2012;130:1-9)
Guidelines (depends upon clinical judgment) when physical abuse is suspected in a child < 2 years of age:
Obtain Photographs. Photos, while important, often cannot replace evaluation by a medical provider. Include photos of the face, knees and shins in every suspected case.
Medical evaluation: Dilated ophthalmology exam if there is a high suspicion for abusive head trauma (AHT) Head CT routinely < 6 months and if AHT is suspected in a child > 6 months. MRI of head and neck if there is a high suspicion for AHT Full skeletal survey including oblique ribs and a repeat skeletal survey in 3 weeks. So-called “baby grams”
are inadequate. Blood and Urine Laboratory testing
Abdominal labs to screen for abdominal trauma – Urinalysis and blood for AST, ALT, Lipase and Amylase. Obtain an abdominal CT for abused children with GCS less than 10 and/or abnormal abdominal laboratory screen (AST or ALT greater than 80)
Coagulation screen ONLY if there is concerning bruising or bleeding – CBC with differential and platelets, PT, PTT, Platelet function assay, von Willebrand activity and antigen. Strongly consider adding fibrinogen, d-dimer, Factor VIII, Factor IX, and Factor XIII if severe bruising or extensive bruising.
Bone labs ONLY if there are fractures concerning for abuse – calcium, magnesium, phosphate, alkaline phosphatase, intact parathyroid hormone, and 25-OH-Vitamin D.
Consider comprehensive urine drug investigation testing with lab confirmation of any positive results
Consider referring the child to the nearest Child Advocacy Center for follow-up
1.12.17 LK Sheets, HW Petska & J Yates 414-266-2090 [email protected]