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doi:10.1111/jpc.12813
REVIEW ARTICLE
Child protection: A 50-year perspective Catherine Yvette Skellern Child Protection and Forensic Medicine, Lady Cilento Childrens Hospital, Brisbane, Queensland, Australia
Abstract: It has been 50 years since Kempe et al. published ‘The Battered Child Syndrome’, describing harm from inflicted injury mechanisms derived from parents and care givers. Since then, there has emerged a rapidly expanding literature on paediatric forensic medicine and child protection, which has offered new insights into injury mechanisms, informed us of the sequelae of abuse and neglect, aided diagnosis and guided clinical practice in the treatment and management of children who become involved in the child protection system. Through the scrutiny of government inquiries and at times uncomfortable media exposure, there have been improvements in child protection and forensic practices resulting in recognition of need for specialised forensic training, improved funding, development of resources and development of professional standards that support accountable, objective, safe and robust practice. From the perspective of an Australian child protection paediatrician, this paper chronicles some of the most significant and at times controversial research in the last 50 years in child protection that have played a key role in shaping our current understanding of child abuse and neglect. Key words:
abuse; child protection; neglect; paediatric forensic medicine.
It has been 50 years since Kempe et al. published their landmark paper ‘The Battered Child Syndrome’, describing harm from inflicted injuries.1 While others before them had drawn attention to the plight of neglect and exploited children, Kempe et al. drew to the attention of medical professionals’ suspicion of physical harm from care givers within the differential diagnosis of clinical practice. Since that time, a rapidly expanding literature has evolved in the field of child abuse, spanning many medical and scientific disciplines that underpin clinical practice, support legal decision-making and the management of children.
Key Points 1 Over the last 50 years the literature on child abuse and neglect has rapidly expanded. 2 There are now improvements in knowledge of injury mechanisms, diagnosis and treatments stemming from abuse and neglect. 3 Paediatricians have been at the forefront of advocacy for children in the prevention of avoidable harm through abuse and neglect. Correspondence: Dr Catherine Yvette Skellern, Child Protection and Forensic Medicine, Lady Cilento Childrens Hospital, 501 Stanley St, Sth Brisbane, QLD 4101, Australia. Fax: (07) 3068 2659; email: [email protected] Conflict of interest: None declared. Accepted for publication 24 August 2014.
From Shaken Baby Syndrome to Abusive Head Trauma In the 1960s and 1970s, researchers funded by the motor vehicle industry investigated the biomechanics of head injury from whiplash after vehicle deceleration/impact.2 Around the same time, Caffey published a paper he titled ‘On the theory and practice of shaking injuries. Its potential residual effects of permanent brain damage and mental retardation’, coining the term ‘whiplash shaken baby syndrome’ due to the similarities ofinjuries found in infants to those of primates in whiplash experiments.3 A British neurosurgeon Guthkelch wrote of ‘the relatively large head and puny neck muscles of the infant which must render it particularly vulnerable to whiplash injury’.4 Interestingly, many years later, Guthkelch expressed concern about how his original research has been applied to individual cases to support a legal opinion of inflicted abusive head trauma.5 In the late 1980s, neurosurgeon Ann-Christine Duhaime and colleagues developed an anthropomorphic model to measure angular and linear acceleration/deceleration force in shaking and impact injury scenarios, then compared these findings with injury thresholds from the original primate studies.6 Alongside evidence from post-mortems, Duhaime et al.’s research recognised the critical role of impact in presumed abusive head injury mechanisms. Since then, multiple scientific and medical disciplines continue to explore the complex pathophysiology of head injury, which causes what is now referred to by some as the ‘triad’ of suspicious abusive head trauma (subdural haemorrhage, retinal haemorrhages and encephalopathy).7 While some knowledge has been gained regarding force, injury mechanisms and timing of evolution of injury patterns, there remain critical gaps in our understanding. The
Journal of Paediatrics and Child Health 51 (2015) 87–90 © 2014 The Author Journal of Paediatrics and Child Health © 2014 Paediatrics and Child Health Division (Royal Australasian College of Physicians).
87
Child protection: 50-year perspective
CY Skellern
‘triad’ remains the most vigorously debated subject in child protection within legal, medical and scientific circles. Since Duhaime et al.’s original work, biomechanical research has developed improved biofidelic models that attempt to replicate tensile properties of various components of an infant’s head and the intracranial environment to assess stress/strain responses and define injury thresholds or ‘failure limits’ alongside a variety of animal models such as piglets and lambs, extending the original primate data. There has been some effort to find a common language to communicate medical findings such as a standardised classification system of retinal haemorrhages and other ocular findings in relation to pattern, distribution and type seen in complex injury events.8 The exact causative mechanisms of retinal haemorrhages remain subject to debate and in particular, understanding precisely why specific retinal haemorrhage patterns have strong associations with presumed inflicted injury remains unclear.9 Complex interactions of changes of intracranial pressure, flow and volume that are specific to injury mechanism may be critical.10 More recently, biomechanical research has refocused attention on the craniocervical junction in fatalities showing primary evidence of trauma arising in the context of suspicion of inflicted head injury.11 High-profile pathologists have raised controversies based on ‘novel’ hypotheses of non-traumatic causation for subdural haemorrhages, which have at times endured intense debate inside a courtroom.7 Identification of patterns of histopathological findings and biomarkers in head injury may prove to be helpful in differentiating force inflicted from accidental injury mechanisms or naturally occurring medical conditions, which may present with some of the ‘triad’ findings. The Cardiff Child Protection Systematic Reviews (Core Info) group has contributed much to our understanding of the epidemiology of injury patterns seen in abuse and childhood accidents by undertaking systematic reviews of clinically relevant research questions relating to burns, head injuries, oral injuries and fractures.12–14 These papers give valuable insight into patterns of injury observed in trauma scenarios to support or negate suspicion of harm.
Child Sexual Abuse Perhaps unexpectedly, paediatricians found themselves being asked to see children alleged to have suffered sexual abuse, reflecting a community expectation that sexual abuse could be ‘diagnosed’ from a genital examination. In the 1980s, it was realised that little was actually known about normal and abnormal genital anatomy, which led to studies of normal children using a colposcope as a light source and magnification with camera attachment to document genital findings.15 Empirical research soon led to the Adams classification system of normal and abnormal genital anatomical findings, which remains useful in interpretation of genital findings undertaken in this context.16 There has been broader recognition of the need to ensure appropriate forensic standards are applied to collection of evidence in the context of allegations of sexual abuse or assault including improved forensic interviewing protocols by police investigators 88
and collection of DNA and trace evidence from alleged victims. Specialist services have evolved to support child victims of sexual offences.
Diagnostic Advances in Medical Technologies The development of other technologies has been useful to document medicolegally relevant clinical examination findings. A retinal camera is routinely used in most tertiary centres to document the retinal examination through dilated pupils, allowing visualisation to the ora serrata. Improved neuroimaging technology, particularly magnetic resonance imaging, has improved the detection of intracranial haemorrhage and evolution of hypoxic-ischemic brain injury from head trauma. Improved computerised tomography has reduced radiation exposure and now allows 3D reconstructions of the skull, which differentiates skull fractures from anatomical variants of suture pattern or fissures. Improved imaging protocols have refined detection of skeletal injuries, particularly those strongly associated with inflicted injury such as rib and metaphyseal fractures. On the horizon is diffusion tensor imaging, currently under development, which will provide greater detail of the structure and integrity of white matter in the brain.
From Munchausen by Proxy to Medical Child Abuse In the 1970s, a newly recognised form of child abuse was published termed ‘Munchausen syndrome by proxy’ by Meadow.17 Since then, this topic has received much attention in the published literature as a potentially dangerous form of harm that can involve fabrication of physical symptoms and at times illness induction in children by their care givers as a means to seek secondary gain from the medical profession through deceit. The original term has since been replaced by other terms that focus more appropriately on the form of harm experienced by the child under the umbrella of ‘medical child abuse’ where the child receives unnecessary and harmful medical care at the instigation of a caretaker rather than focusing on the motivation of the offender. Child protection paediatricians play a key role in the assessment and case management of these complex cases in hospital settings once suspicion arises to ensure investigations are well co-ordinated, to achieve safety and protection for the child and to facilitate communication of medical information to statutory and criminal investigators involved in these complex child protection cases.18
The Evolution of Child Protection Systems Leading research has focused on understanding the neurobiological sequelae of abuse and neglect on brain development, which has been powerful in informing the development of effective child protection practices.19 Particularly in the last 20 years, there have been significant advances in abuse prevention and advocacy for children at risk, shaping clinical service delivery, raising awareness and keeping child protection on the political agenda. Paediatricians have been visible in this field internationally as respected professionals committed to
Journal of Paediatrics and Child Health 51 (2015) 87–90 © 2014 The Author Journal of Paediatrics and Child Health © 2014 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
CY Skellern
child safety and advocacy for children at risk. In the last 10 years, there has been a focus on defining the health needs for children who have been harmed or considered at risk of harm, which have informed development of health services for this targeted population.20 The results are clinical models of care for assessment and management of children at risk as a key function in many designated child protection services in hospitals and community settings for this population, led by paediatricians trained in the relatively new subspecialty of community paediatrics, applied to a child protection context. In response to recognition of the need for paediatric expertise in the field of child protection, in 2006, child abuse paediatrics became a US board-certified subspecialty.21 Across the United States, national ‘experts’ in child protection provide medical leadership in tertiary hospitals in child protection or child advocacy services. Although they are currently few in number and are restricted to regions with high density populations in the United States, the advent of telehealth has been used effectively in this context to provide valuable outreach to reach broader geographical regions. From the United States, The Child Abuse Quarterly remains an important source of published scientific information, led by Dr Robert Reece, a leading child abuse paediatrician in the United States. This publication brings together a diverse literature of relevance to the field of child protection, with reviews on selected papers by US experts in the field. Government inquiries around the world have examined systemic failures surrounding tragic, preventable child deaths or errors of medico-legal practice that eroded public confidence in institutions and professionals involved in paediatric forensic practices.22 In the United Kingdom, such events adversely affected the willingness of paediatricians to work in child protection. These inquiries, although painful to endure, often under intense media spotlight, have served nevertheless as important drivers of change in practice, allowing reform and restoration in confidence in professionals and systems involved in the child protection system. As a result, there has been broader recognition of the need for specialised forensic training, improved funding of forensic services and child protection, and development of professional standards that support accountable, objective, safe and robust forensic practices and institutions. In Australia, the development of postgraduate universityaffiliated training in forensic medicine has been undertaken by some child protection paediatricians seeking training in the interface of medical child protection and the law. In Australia and New Zealand, paediatricians in designated child protection positions work in regional hospitals and tertiary centres, often within multidisciplinary teams and as part of an interagency network with skilled statutory and criminal investigators who are involved in assessing allegations of harm. Within child protection units in hospitals, such services play key roles in training other health professionals, reminding them of their responsibilities in recognising and reporting suspicions of harm. They also play a key role in educating other key stakeholders in child protection, external to health services on medically related child protection issues. Paediatricians have been vocal in advocating on key issues through the Royal Australasian College of Physicians (RACP), raising awareness on issues such as children in
Child protection: 50-year perspective
detention,23 physical punishment24 and by reminding the fellowship of the college that child protection is ‘everyone’s business’. Forensic paediatricians are increasingly being asked to provide review opinions on complex legal cases involving allegations of inflicted injury, gaining experience in working in the adversarial legal environment to communicate information and medico-legal opinion of injury event causation.
The Future of Child Protection Over time, there will continue to be further refinement of forensic procedures and functions, standardisation of assessment and development of protocols, which may be endorsed by a regulatory professional body such as RACP. This will enhance the ability of a paediatrician to communicate effectively within a medico-legal environment to enhance safety and reduce risk of error.25 To achieve effective oversight and regulation, there is a pressing need for peer-review processes to be inserted into child protection practice, and conduct root cause analyses examining system errors when there are unexpected outcomes in cases involving child protection. There is still some work to be done in refining how medico-legal opinion is communicated to ensure that medical opinion is understood by other professionals who have a responsibility for legal decision-making. Developing a common language to communicate what it is we have to say would be a useful development to this field of practice. Over the last 50 years, much has been learned in what is in fact a relatively new area of paediatric medicine. Child protection paediatricians are charged with the challenge of keeping up with a rapidly expanding body of knowledge, yet remain aware of what is not yet understood in areas of scientific uncertainty then apply this knowledge to individual case assessments following identification of suspicion of harm. At that point, in a child protection and criminal investigation, child protection paediatricians are required to adopt rigorous cognitive problem-solving methods to determine whether what we ‘see’ (from clinical findings) is explained by what we are told (from parental report), rather than rely on heuristic decision-making methods that may increase risk of error. This field of knowledge is dynamic and while new research advances our understanding in some areas, in some key areas, we have moved from positions of certainty to less certainty with the passage of time. Child protection as a specialty has evolved significantly over the past 50 years with new insights emerging alongside new dilemmas and challenges. There is a clear need for greater collaboration between researchers in various fields to enable us to better understand injury patterns, specificity of mechanisms of injury and more closely define timing of trauma from physical findings. In each jurisdiction, there is a need for paediatricians to play a key role in improving how health services respond and recognise and report suspicion of harm to investigating authorities. Within hospitals, designated child protection services in hospitals will continue to evolve, define how they fit into existing service networks (within and external to the hospital) and strengthen referral pathways and supports for children at risk.
Journal of Paediatrics and Child Health 51 (2015) 87–90 © 2014 The Author Journal of Paediatrics and Child Health © 2014 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
89
Child protection: 50-year perspective
CY Skellern
References 1 Kempe C, Silverman F, Steele B, Droegmueller W, Silver H. The battered child syndrome. JAMA 1962; 181: 17–24. 2 Ommaya AK, Faas F, Yarnell P. Whiplash injury and brain damage: an experimental study. JAMA 1968; 204: 285–9. 3 Caffey J. On the theory and practice of shaking injuries. Its potential residual effects of permanent brain damage and mental retardation. Am. J. Dis. Child. 1972; 124: 161–9. 4 Guthkelch AN. Infantile subdural haematoma and its relationship to whiplash injuries. Br. Med. J. 1971; 2: 430–1. 5 Bazelon E. Shaken-Baby Syndrome Faces New Questions in Court. The New York Times 2011. Available from: www.nytimes.com/2011/02/06/ magazine/06baby-t.html?_r=2&pagewanted=all&# [accessed November 2013]. 6 Duhaime AC, Gennarelli TA, Thibeault LE et al. The shaken baby syndrome: a clinical, pathological and biomechanical study. J. Neurosurg. 1987; 66: 409–15. 7 Geddes JF, Tasker RC, Hackshaw A et al. Dural haemorrhage in non-traumatic infant deaths: does it explain the bleeding in ‘shaken baby syndrome’? Neuropathol. Appl. Neurobiol. 2003; 29: 14–22. 8 Vinchon M, De Foort-Dhellemmes S, Desurmont M et al. Confessed abuse versus witnessed accidents in infants: comparison of clinical, radiological and ophthalmological data in corroborated cases. Childs Nerv. Syst. 2010; 26: 637–45. 9 Watts P, Obi E. Retinal folds and retinoschisis in accidental and non-accidental head injury. Eye 2008; 22: 1514–16. 10 Piatt JH. A pitfall in the diagnosis of child abuse: external hydrocephalus, subdural hematoma and retinal haemorrhages. Neurosurg. Focus 1999; 7: e4. 11 Bandak FA. Shaken baby syndrome: a biomechanics analysis of injury mechanisms. Forensic Sci. Int. 2005; 151: 71–9. 12 Maguire S, Mann MK, Sibert J, Kemp A. Are there patterns of bruising in childhood which are diagnostic or suggestive of abuse? A systematic review. Arch. Dis. Child. 2005; 90: 182–6.
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13 Maguire S, Moynihan S, Mann M, Potokar T, Kemp AM. A systematic review of the features that indicate intentional scalds in children. Burns 2008; 34: 1072–81. 14 Maguire S, Hunter B, Hunter L, Sibert JR, Man M, Kemp AM. Diagnosing abuse: a systematic review of torn frenum and other intra-oral injuries. Arch. Dis. Child. 2007; 92: 1113–17. 15 Adams JA, Girardin B, Faugno D. Documentation of acute injuries using photocolposcopy. J. Pediatr. Adolesc. Gynaecol. 2001; 14: 175–80. 16 Adams J. Evolution of a classification scale: medical evaluation of suspected child sexual abuse. Child Maltreat. 2001; 6: 31–6. 17 Meadow R. Munchausen syndrome by proxy – the hinterland of child abuse. Lancet 1977; ii: 343–5. 18 Flaherty EG, MacMillan HL, Committee on Child Abuse and Neglect. Caregiver-fabricated illness in a child: a manifestation of child maltreatment. Pediatrics 2013; 132: 590–7. 19 Perry B. Examining child maltreatment through a neurodevelopmental lens: clinical applications of the neurosequential model of therapeutics. J. Loss Trauma 2009; 14: 240–55. 20 Crawford M. Health of children in out-of-home care: can we do better? (Editorial). J. Paediatr. Child Health 2006; 42: 77–8. 21 Block RW, Palusci VJ. Child abuse pediatrics: a new pediatric subspecialty. J. Pediatr. 2006; 148: 711–12. 22 Hall DMB. Child protection – lessons from Victoria Climbie. Editorial. BMJ 2003; 326: 293–4. 23 Royal Australasian College of Physicians. Statement on the Health of People Seeking Asylum. 2013. Available from: www.racp.edu.au/index .cfm?objectid=A88AC7C8-F73B-24A2-AD272DO4A3C57C7C [accessed November 2013]. 24 Royal Australasian College of Physicians. Consensus Statement on Bringing an End to Physical Punishment of Children. 2013. Available from: www.racp.edu.au/index.cfm?objectid=C27EE461-0D63–6E91 -A957F9F7547B74EE [accessed November 2013]. 25 Johnson S. Paediatric expert witness. J. Paediatr. Child Health 2013; 49: 611–13.
Journal of Paediatrics and Child Health 51 (2015) 87–90 © 2014 The Author Journal of Paediatrics and Child Health © 2014 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
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doi:10.1111/jpc.12813
REVIEW ARTICLE
Child protection: A 50-year perspective Catherine Yvette Skellern Child Protection and Forensic Medicine, Lady Cilento Childrens Hospital, Brisbane, Queensland, Australia
Abstract: It has been 50 years since Kempe et al. published ‘The Battered Child Syndrome’, describing harm from inflicted injury mechanisms derived from parents and care givers. Since then, there has emerged a rapidly expanding literature on paediatric forensic medicine and child protection, which has offered new insights into injury mechanisms, informed us of the sequelae of abuse and neglect, aided diagnosis and guided clinical practice in the treatment and management of children who become involved in the child protection system. Through the scrutiny of government inquiries and at times uncomfortable media exposure, there have been improvements in child protection and forensic practices resulting in recognition of need for specialised forensic training, improved funding, development of resources and development of professional standards that support accountable, objective, safe and robust practice. From the perspective of an Australian child protection paediatrician, this paper chronicles some of the most significant and at times controversial research in the last 50 years in child protection that have played a key role in shaping our current understanding of child abuse and neglect. Key words:
abuse; child protection; neglect; paediatric forensic medicine.
It has been 50 years since Kempe et al. published their landmark paper ‘The Battered Child Syndrome’, describing harm from inflicted injuries.1 While others before them had drawn attention to the plight of neglect and exploited children, Kempe et al. drew to the attention of medical professionals’ suspicion of physical harm from care givers within the differential diagnosis of clinical practice. Since that time, a rapidly expanding literature has evolved in the field of child abuse, spanning many medical and scientific disciplines that underpin clinical practice, support legal decision-making and the management of children.
Key Points 1 Over the last 50 years the literature on child abuse and neglect has rapidly expanded. 2 There are now improvements in knowledge of injury mechanisms, diagnosis and treatments stemming from abuse and neglect. 3 Paediatricians have been at the forefront of advocacy for children in the prevention of avoidable harm through abuse and neglect. Correspondence: Dr Catherine Yvette Skellern, Child Protection and Forensic Medicine, Lady Cilento Childrens Hospital, 501 Stanley St, Sth Brisbane, QLD 4101, Australia. Fax: (07) 3068 2659; email: [email protected] Conflict of interest: None declared. Accepted for publication 24 August 2014.
From Shaken Baby Syndrome to Abusive Head Trauma In the 1960s and 1970s, researchers funded by the motor vehicle industry investigated the biomechanics of head injury from whiplash after vehicle deceleration/impact.2 Around the same time, Caffey published a paper he titled ‘On the theory and practice of shaking injuries. Its potential residual effects of permanent brain damage and mental retardation’, coining the term ‘whiplash shaken baby syndrome’ due to the similarities ofinjuries found in infants to those of primates in whiplash experiments.3 A British neurosurgeon Guthkelch wrote of ‘the relatively large head and puny neck muscles of the infant which must render it particularly vulnerable to whiplash injury’.4 Interestingly, many years later, Guthkelch expressed concern about how his original research has been applied to individual cases to support a legal opinion of inflicted abusive head trauma.5 In the late 1980s, neurosurgeon Ann-Christine Duhaime and colleagues developed an anthropomorphic model to measure angular and linear acceleration/deceleration force in shaking and impact injury scenarios, then compared these findings with injury thresholds from the original primate studies.6 Alongside evidence from post-mortems, Duhaime et al.’s research recognised the critical role of impact in presumed abusive head injury mechanisms. Since then, multiple scientific and medical disciplines continue to explore the complex pathophysiology of head injury, which causes what is now referred to by some as the ‘triad’ of suspicious abusive head trauma (subdural haemorrhage, retinal haemorrhages and encephalopathy).7 While some knowledge has been gained regarding force, injury mechanisms and timing of evolution of injury patterns, there remain critical gaps in our understanding. The
Journal of Paediatrics and Child Health 51 (2015) 87–90 © 2014 The Author Journal of Paediatrics and Child Health © 2014 Paediatrics and Child Health Division (Royal Australasian College of Physicians).
87
Child protection: 50-year perspective
CY Skellern
‘triad’ remains the most vigorously debated subject in child protection within legal, medical and scientific circles. Since Duhaime et al.’s original work, biomechanical research has developed improved biofidelic models that attempt to replicate tensile properties of various components of an infant’s head and the intracranial environment to assess stress/strain responses and define injury thresholds or ‘failure limits’ alongside a variety of animal models such as piglets and lambs, extending the original primate data. There has been some effort to find a common language to communicate medical findings such as a standardised classification system of retinal haemorrhages and other ocular findings in relation to pattern, distribution and type seen in complex injury events.8 The exact causative mechanisms of retinal haemorrhages remain subject to debate and in particular, understanding precisely why specific retinal haemorrhage patterns have strong associations with presumed inflicted injury remains unclear.9 Complex interactions of changes of intracranial pressure, flow and volume that are specific to injury mechanism may be critical.10 More recently, biomechanical research has refocused attention on the craniocervical junction in fatalities showing primary evidence of trauma arising in the context of suspicion of inflicted head injury.11 High-profile pathologists have raised controversies based on ‘novel’ hypotheses of non-traumatic causation for subdural haemorrhages, which have at times endured intense debate inside a courtroom.7 Identification of patterns of histopathological findings and biomarkers in head injury may prove to be helpful in differentiating force inflicted from accidental injury mechanisms or naturally occurring medical conditions, which may present with some of the ‘triad’ findings. The Cardiff Child Protection Systematic Reviews (Core Info) group has contributed much to our understanding of the epidemiology of injury patterns seen in abuse and childhood accidents by undertaking systematic reviews of clinically relevant research questions relating to burns, head injuries, oral injuries and fractures.12–14 These papers give valuable insight into patterns of injury observed in trauma scenarios to support or negate suspicion of harm.
Child Sexual Abuse Perhaps unexpectedly, paediatricians found themselves being asked to see children alleged to have suffered sexual abuse, reflecting a community expectation that sexual abuse could be ‘diagnosed’ from a genital examination. In the 1980s, it was realised that little was actually known about normal and abnormal genital anatomy, which led to studies of normal children using a colposcope as a light source and magnification with camera attachment to document genital findings.15 Empirical research soon led to the Adams classification system of normal and abnormal genital anatomical findings, which remains useful in interpretation of genital findings undertaken in this context.16 There has been broader recognition of the need to ensure appropriate forensic standards are applied to collection of evidence in the context of allegations of sexual abuse or assault including improved forensic interviewing protocols by police investigators 88
and collection of DNA and trace evidence from alleged victims. Specialist services have evolved to support child victims of sexual offences.
Diagnostic Advances in Medical Technologies The development of other technologies has been useful to document medicolegally relevant clinical examination findings. A retinal camera is routinely used in most tertiary centres to document the retinal examination through dilated pupils, allowing visualisation to the ora serrata. Improved neuroimaging technology, particularly magnetic resonance imaging, has improved the detection of intracranial haemorrhage and evolution of hypoxic-ischemic brain injury from head trauma. Improved computerised tomography has reduced radiation exposure and now allows 3D reconstructions of the skull, which differentiates skull fractures from anatomical variants of suture pattern or fissures. Improved imaging protocols have refined detection of skeletal injuries, particularly those strongly associated with inflicted injury such as rib and metaphyseal fractures. On the horizon is diffusion tensor imaging, currently under development, which will provide greater detail of the structure and integrity of white matter in the brain.
From Munchausen by Proxy to Medical Child Abuse In the 1970s, a newly recognised form of child abuse was published termed ‘Munchausen syndrome by proxy’ by Meadow.17 Since then, this topic has received much attention in the published literature as a potentially dangerous form of harm that can involve fabrication of physical symptoms and at times illness induction in children by their care givers as a means to seek secondary gain from the medical profession through deceit. The original term has since been replaced by other terms that focus more appropriately on the form of harm experienced by the child under the umbrella of ‘medical child abuse’ where the child receives unnecessary and harmful medical care at the instigation of a caretaker rather than focusing on the motivation of the offender. Child protection paediatricians play a key role in the assessment and case management of these complex cases in hospital settings once suspicion arises to ensure investigations are well co-ordinated, to achieve safety and protection for the child and to facilitate communication of medical information to statutory and criminal investigators involved in these complex child protection cases.18
The Evolution of Child Protection Systems Leading research has focused on understanding the neurobiological sequelae of abuse and neglect on brain development, which has been powerful in informing the development of effective child protection practices.19 Particularly in the last 20 years, there have been significant advances in abuse prevention and advocacy for children at risk, shaping clinical service delivery, raising awareness and keeping child protection on the political agenda. Paediatricians have been visible in this field internationally as respected professionals committed to
Journal of Paediatrics and Child Health 51 (2015) 87–90 © 2014 The Author Journal of Paediatrics and Child Health © 2014 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
CY Skellern
child safety and advocacy for children at risk. In the last 10 years, there has been a focus on defining the health needs for children who have been harmed or considered at risk of harm, which have informed development of health services for this targeted population.20 The results are clinical models of care for assessment and management of children at risk as a key function in many designated child protection services in hospitals and community settings for this population, led by paediatricians trained in the relatively new subspecialty of community paediatrics, applied to a child protection context. In response to recognition of the need for paediatric expertise in the field of child protection, in 2006, child abuse paediatrics became a US board-certified subspecialty.21 Across the United States, national ‘experts’ in child protection provide medical leadership in tertiary hospitals in child protection or child advocacy services. Although they are currently few in number and are restricted to regions with high density populations in the United States, the advent of telehealth has been used effectively in this context to provide valuable outreach to reach broader geographical regions. From the United States, The Child Abuse Quarterly remains an important source of published scientific information, led by Dr Robert Reece, a leading child abuse paediatrician in the United States. This publication brings together a diverse literature of relevance to the field of child protection, with reviews on selected papers by US experts in the field. Government inquiries around the world have examined systemic failures surrounding tragic, preventable child deaths or errors of medico-legal practice that eroded public confidence in institutions and professionals involved in paediatric forensic practices.22 In the United Kingdom, such events adversely affected the willingness of paediatricians to work in child protection. These inquiries, although painful to endure, often under intense media spotlight, have served nevertheless as important drivers of change in practice, allowing reform and restoration in confidence in professionals and systems involved in the child protection system. As a result, there has been broader recognition of the need for specialised forensic training, improved funding of forensic services and child protection, and development of professional standards that support accountable, objective, safe and robust forensic practices and institutions. In Australia, the development of postgraduate universityaffiliated training in forensic medicine has been undertaken by some child protection paediatricians seeking training in the interface of medical child protection and the law. In Australia and New Zealand, paediatricians in designated child protection positions work in regional hospitals and tertiary centres, often within multidisciplinary teams and as part of an interagency network with skilled statutory and criminal investigators who are involved in assessing allegations of harm. Within child protection units in hospitals, such services play key roles in training other health professionals, reminding them of their responsibilities in recognising and reporting suspicions of harm. They also play a key role in educating other key stakeholders in child protection, external to health services on medically related child protection issues. Paediatricians have been vocal in advocating on key issues through the Royal Australasian College of Physicians (RACP), raising awareness on issues such as children in
Child protection: 50-year perspective
detention,23 physical punishment24 and by reminding the fellowship of the college that child protection is ‘everyone’s business’. Forensic paediatricians are increasingly being asked to provide review opinions on complex legal cases involving allegations of inflicted injury, gaining experience in working in the adversarial legal environment to communicate information and medico-legal opinion of injury event causation.
The Future of Child Protection Over time, there will continue to be further refinement of forensic procedures and functions, standardisation of assessment and development of protocols, which may be endorsed by a regulatory professional body such as RACP. This will enhance the ability of a paediatrician to communicate effectively within a medico-legal environment to enhance safety and reduce risk of error.25 To achieve effective oversight and regulation, there is a pressing need for peer-review processes to be inserted into child protection practice, and conduct root cause analyses examining system errors when there are unexpected outcomes in cases involving child protection. There is still some work to be done in refining how medico-legal opinion is communicated to ensure that medical opinion is understood by other professionals who have a responsibility for legal decision-making. Developing a common language to communicate what it is we have to say would be a useful development to this field of practice. Over the last 50 years, much has been learned in what is in fact a relatively new area of paediatric medicine. Child protection paediatricians are charged with the challenge of keeping up with a rapidly expanding body of knowledge, yet remain aware of what is not yet understood in areas of scientific uncertainty then apply this knowledge to individual case assessments following identification of suspicion of harm. At that point, in a child protection and criminal investigation, child protection paediatricians are required to adopt rigorous cognitive problem-solving methods to determine whether what we ‘see’ (from clinical findings) is explained by what we are told (from parental report), rather than rely on heuristic decision-making methods that may increase risk of error. This field of knowledge is dynamic and while new research advances our understanding in some areas, in some key areas, we have moved from positions of certainty to less certainty with the passage of time. Child protection as a specialty has evolved significantly over the past 50 years with new insights emerging alongside new dilemmas and challenges. There is a clear need for greater collaboration between researchers in various fields to enable us to better understand injury patterns, specificity of mechanisms of injury and more closely define timing of trauma from physical findings. In each jurisdiction, there is a need for paediatricians to play a key role in improving how health services respond and recognise and report suspicion of harm to investigating authorities. Within hospitals, designated child protection services in hospitals will continue to evolve, define how they fit into existing service networks (within and external to the hospital) and strengthen referral pathways and supports for children at risk.
Journal of Paediatrics and Child Health 51 (2015) 87–90 © 2014 The Author Journal of Paediatrics and Child Health © 2014 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
89
Child protection: 50-year perspective
CY Skellern
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Journal of Paediatrics and Child Health 51 (2015) 87–90 © 2014 The Author Journal of Paediatrics and Child Health © 2014 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
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