12/5/2017€¦ · 12/5/2017 13 When a Child Dies or is Hurt •Injury –Injury scene such as burn...

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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.

12/5/2017 Copyright 2017 LKSheets MD 2

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


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”)


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)


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?


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


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?


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


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


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


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!


https://www.childwelfare.gov/topics/systemwide/laws-policies/statutes/manda/?hasBeenRedirected=1

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FORENSIC INTERVIEWING

Child Advocacy Centers


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

nationwide12/5/2017 Copyright 2017 LKSheets MD 20

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


Advice for Clinicians

“Think Less, Test More, Test

Routinely” – Dan Lindberg, Kempe Center


Value of Protocols

• Following protocol-based diagnostic tests help reduce cognitive errors


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Guide for Investigators

Copyright 2017 LKSheets MD 2512/5/2017

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



Suspected Physical Abuse Guidelines 2.11.15.pdf

http://uwm.edu/mcwp/sentinel-injuries/

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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


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.


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!!


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


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


http://www.opdv.ny.gov/professionals/health/radar.html

http://www.nij.gov/topics/law-enforcement/investigations/crime-scene/guides/death-investigation/pages/document-body.aspx

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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


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


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]

12/5/2017€¦ · 12/5/2017 13 When a Child Dies or is Hurt •Injury –Injury scene such as burn...

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