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EDITORIALS: David L Chadwick The evidence base in child protection litigation BMJ 2006; 333: 160-161 [Full text]

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Child Abuse -Misdiagnosed

Michael D Innis   (24 July 2006)

and in the land of the free....

Oliver R Dearlove   (25 July 2006)

The General Public needs legal protection too

Elizabeth Marsh   (25 July 2006)

The evidence base in child abuse

Alison M Kemp, Jo Sibert, Sabine Maguire.   (31 July 2006)

Re: The evidence base in child abuse

Felicity A Goodyear-Smith   (1 August 2006)

Re: Child Abuse -Misdiagnosed

Joyce A Adams   (2 August 2006)

Child abuse evidence base is not robust

LC Blakemore-Brown   (5 August 2006)

Re: Goodyear-Smith's response to the evidence base in child abuse

Nancy D. Kellogg   (12 August 2006)

Response to reponses

David L. Chadwick   (14 August 2006)

Re: Response to reponses

Lisa C Blakemore-Brown   (15 August 2006)

Child Abuse -Misdiagnosed 24 July 2006
Michael D Innis, Director Medisets International Home 4575 Send response to journal: Re: Child Abuse -Misdiagnosed	Editor, Dr Chadwick suggests, “A well developed evidence base exists for child abuse medicine that is suitable for use in litigation for child protection …. Kempe and colleagues reiterated that doctors could and should infer abuse on the basis of certain medical findings of injury. The "battered child syndrome" that they defined is still a valid concept based on observational research.” In essence this so-called “evidence base” is characterized by acute encephalopathy with subdural and retinal haemorrhages, occurring in a context of inappropriate or inconsistent history and commonly accompanied by other apparently inflicted injuries(1). These other apparently inflicted injuries being bruises, and fractures often of various ages. What the proponents of this “evidence base” are forgetting, ignoring or are unaware of, is deficiencies of Vitamin C and/or K can and do produce identical signs and symptoms in vulnerable infants. Deficiencies of Vitamin D can result in fractures. Professor Alan Clemetson and Dr A. Kalokerinos have drawn the attention of the profession to the origin and consequences of Vitamin C deficiencies in Western Societies (2,3). Others have suggested the need to supplement the diet of children with Vitamin D Less well known are the origins and consequences of Vitamin K deficiency. Apart from Haemorrhagic Disease of the Newborn little or no thought has been given to the fact that it is a cofactor for the carboxylation of osteocalcin and is essential for the mineralization of bone(4). When reduced or absent fractures may occur. It is a lack of knowledge of the causation of these nutritional deficiencies and their effects, coupled with the injunction to “think dirty” that is responsible for the misdiagnoses of “child abuse” so common in the Western World. Unless Paediatricians take more care with the investigation of these children by becoming familiar with newer Laboratory tests such as PIVKA- II, Undercarboxylated Osteocalcin and Blood Histamine levels innocent people are bound to suffer. Michael Innis FRCPA;FRCPath References 1. Harding B, Risdon RA, Krous HF Shaken baby syndrome BMJ, Mar 2004; 328: 720 - 721 2.Clemetson CAB Is it “Shaken Baby,”or Barlow’s Disease Variant. A A P S 2004;Vol 9 No 3: 3. Kalokerinos A. Every Second Child. 1981 pp 3 –165 Thomas Nelson (Australia ) 4. Conway SP, Wolfe SP , Brownlee KG, White H, et al; Vitamin K Status Among Children With Cystic Fibrosis and Its Relationship to Bone Mineral Density and Bone Turnover PEDIATRICS Vol. 115 No. 5 May 2005, pp. 1325-1331 Competing interests: As previously declared
and in the land of the free.... 25 July 2006
Oliver R Dearlove, Consultant Anaesthetist Royal Manchester Children's Hospital M27 4HA Send response to journal: Re: and in the land of the free....	Chadwick conludes, “….doctors require the sort of protections generally provided by the laws on child abuse reporting and witness immunity that prevail in the US.” I think someone had better tell us what these protections available to doctors actually, are. I include an annotation from The New York Times 2004 which appeared in a paediatric journal, which clearly does not paint such a wonderful picture in the land of the free. Incidentally in England, libel proceedings are not possible on sworn evidence as such evidence is privileged, so what follows in the article below could not happen in England. If evidence is wrong, then perjury could be alleged. Indeed it is notable that untrue oral evidence had been a basis for a finding of serious professional misconduct at the GMC (1,2) I think the point Chadwick should be making loudly, is that it is not and never was, the function of the General Medical Council to do in child protection. No wonder it is getting reformed, it needs it. (BMJ this issue p. 163) DOCTOR’S TESTIMONY LEADS TO A COMPLEX LEGAL FIGHT “A San Francisco internist and an occasional expert witness in medical malpractice suits opened a letter from the Florida Medical Association not long ago. Inside, was a complaint from 3 doctors about expert testimony he had given for the patient in a malpractice case against them in Tampa last year. The doctors had won, and now they wanted the medical association to punish [the expert] for what they said were his ‘erroneous opinions.’ [The expert] filed his own lawsuit last month in Tallahassee, saying the doctors and the association had libelled him. Legal experts say the suit is the first to use a libel claim to challenge charges made in a medical disciplinary proceeding concerning expert testimony. The duelling disputes have a question in common: should medical groups have the power to discipline doctors for their expert testimony? Medical groups say they can help weed out incompetent and dishonest experts. Plaintiffs’ lawyers say the groups’ real goal is to silence doctors who testify for plaintiffs. And legal experts say the case in Florida shows that the entire malpractice system has gone off the rails. Several medical societies have created tribunals to consider complaints that expert testimony by their members was substandard.” Liptak A. New York Times. June 20, 2004 Noted by JFL, MD Submitted by Oliver R Dearlove References for the text, 1.Daily Telegraph. Surgeon lied under oath 2 December 2000 2.R v General medical Council ex parte Kypros Nicolaides Lloyds Law Reports Medical (2000) 525-529 Competing interests: Like many of his colleagues, the author steers well away from child protection work - an easy task as he is an anaesthetist
The General Public needs legal protection too 25 July 2006
Elizabeth Marsh, Writer DT4 9QU Send response to journal: Re: The General Public needs legal protection too	Dr Chadwick states that: "Medical expert witnesses need legal protection too, to use the evidence effectively". I would like to ask why do medical expert witnesses need legal protection? If they are testifying in a court of law why would legal protection be required? Does this mindset not leave itself open to criticism or ridicule if using evidence effectively is a criteria for conviction? Isn't one's responsibility to use medical evidence honestly, rather than effectively? An almost unassailable mountain of advice and contradiction, claim and counter-claim has arisen over the past decade or so, none moreso in the medical environment than in the area of child abuse and child protection. Too many involved in a professional response are caught up and swept along by what is topical, rather than having the ability or freedom to be able to think for themselves, in order to challenge that which may not be right - thereby causing an imbalance of the facts - significantly weighted against the individual; be they the victim of abuse, or the perpetrator. But what is child abuse? Is there a specific definition that people can identify with? As recently as a generation ago, most of what is now perceived as child-abuse would have been viewed as discipline. But successive liberal policies adopted predominantly by the incumbent government have eroded family values, undermining all that was once viewed a necessary part of growing up as to now be frowned upon. Parents have been emascualted of many of their former parental rights and in its place we have ASBOs ! Yet an army of child protection officanado have sprung up to pre-empt child abuse occurring, without realising or understanding that child abuse often cannot be prevented. This is the one fundamental difference between all the health professionals/social workers and the general public. The layman understands that child abuse happens as surely as night follows day - even knowing that sometimes it may be excessive. How can a parent discipline a child if doing so now potentially elicits a lablel of child abuse? Where is balance - and reason? A much greater wrong is done when innocent children die and those who set themselves up as experts fail to prevent it. Or when experts use their knowledge effectively, instead of honestly, which may lead to wrongful convictions of innocent people. Child abuse happens. It often cannot be prevented. To try to do so is like trying to pre-empt the direction of the wind. Understanding the direction of the wind is possible, preventing it is not. Competing interests: None declared
The evidence base in child abuse 31 July 2006
Alison M Kemp, Reader in Child Health Cardiff University CF64 2XX, Jo Sibert, Sabine Maguire. Send response to journal: Re: The evidence base in child abuse	The editorial entitled “The evidence base in child protection litigation” BMJ July 22 2006: places a welcome emphasis on the importance of scientific evidence and specialisation that is required in the clinical field of child protection. We have undertaken a series of systematic reviews of the evidence base that underpins the diagnosis of physical abuse and were surprised, however, that the author describes the evidence behind child abuse as robust. This broad statement is made on the basis of 16,000 citations for child abuse and historical reference to the formative work of Tardieu 1860 and Kempe 1962. We feel that this perception is misleading and fails to assess the quality of the published evidence base. When a standard systematic approach to the critical appraisal of this literature is adopted, the findings are very different and there are significant scientific limitations to many of the published studies. Child abuse is a generic term and includes physical, sexual, neglect and emotional abuse. Within each category there are a huge variety of types of abuse and clinical presentations that result. The multidisciplinary nature of child protection means that each agency involved comes with a different agenda and different questions that it requires the literature to resolve. As one of the few systematic review teams in this field we have interrogated the scientific literature around several key questions around the diagnosis of physical child abuse (www.core-info.cf.ac.uk) . In general, there was a paucity of literature. Most studies are performed in the United States and while these studies are invaluable, the difference in health systems, demographics, definitions and types of abuse and legal systems mean that the study findings are not necessarily directly transferable to UK. Studies are compromised by the differences in definition of abuse used in different countries over the 50 year time period of this research and the variation in diagnostic techniques. The security of diagnosis of abuse and reverse causality introduce significant bias. Case numbers included in studies are small and highly selective and most observational studies are of a case series design, inherently compromised by selection bias and lacking any comparative data. There are areas where the quality of evidence is good, examples include rib fractures in young children that have a high specificity for abuse and the profile of non accidental scalds where the literature defines clear differences between intentional and non intentional scalds. Our work demonstrates other areas that refute widely established dogma. A review of 50 years of international literature identified three studies that give good evidence that the age of bruises cannot be accurately judged on a visual interpretation of bruise colour . When we evaluated the evidence surrounding the dating of fractures we identified only three studies that addressed the topic . These studies included 56 children under the age of five. They evaluated fracture dating at different anatomical sites and used different radiological signs to inform their decision. Each came up with different time frames for these signs of healing. Radiologists use guidelines drawn together from an individual expert and published in a textbook: these have yet to be scientifically validated on a large scale. The overriding feeling is that fractures can only be aged in the broadest sense. A torn labial frenum has long been held as a strong indicator of physical abuse. The entire published evidence around this topic amounts to 28 case reports of torn frenum in abuse. Most cases are of severely abused children under the age of five. Although accidental torn frena are mentioned in the literature, there are no published comparative studies. The probability that a torn frenum is abusive is impossible to calculate from the literature and a prospective comparative study is called for. This same profound lack of published evidence applies to the recognition of adult bites and cigarette burns. These are a few examples of the strengths and weaknesses in the scientific literature which lead us to question the term “robust” in relation to the evidence base. Towards the end of the article the author reassuringly admits that there are shortcomings and that the evidence base is a long way from perfect or complete. He likens the situation to the evidence base for AIDS or Breast Cancer. There are however profound scientific differences between these three areas. Both of the latter topics are the subjects of systematic reviews with meta-analyses that evaluate the strength of evidence displayed in Randomised Control Trials. Research into the diagnosis of child abuse cannot avail itself of these trials for obvious reasons. Studies must rely upon good quality comparative observational studies. This field of research must be prioritised if we are to promote the interests of the abused child in the UK in the current climate of mistrust where clinicians are increasingly reluctant to participate in the specialty. This field of research is challenged in several areas. It is difficult to perform standard diagnostic studies in the absence of a gold standard test for abuse that is independent of the presenting injuries or symptoms of neglect. Consent issues for the inclusion of abused children and the relative rarity of abuse make it difficult to undertake cohort studies not to mention the challenges of defining ideal control cases. David Chadwick is correct that we must be creative in our study design and use several sources and study types to inform the evidence base that we draw upon in decision-making. The overriding priority must be to encourage optimal research in this field. There are many paediatricians and allied professionals who have worked in the child protection field for many years and continue to do so. Many have experience that could be translated into scientific published evidence if they were able to publish their data from often meticulously kept retrospective case series or better still use their experience to set hypothesise and under take well designed prospective comparative studies. This work urgently needs the support of research funding bodies. Expert witnesses appearing in court require a thorough understanding of the quality of the available scientific evidence and must be able to convey this to the Court in an understandable manner. Courts and clinicians need to appreciate that child abuse evidence base is a long way from being robust or complete and that “absence of evidence is not necessarily evidence of no effect or no association”. Where opinion is drawn from personal practice, this must be explicit. As Baroness Kennedy stated ‘A doctor can be convinced, based on his or her experience, that a defendant is guilty - but unless there is compelling evidence supported scientifically, he or she should not express that view in criminal proceedings’ , which sets the standard for an expert opinion in the British Courts. Although the clinical field of child protection is going through a difficult period in the UK, the current situation has the capacity to stimulate good quality scientific research. This is greatly needed to build the discipline up to the standards of evidence based clinical practice that is required throughout clinical practice. 1 Maguire S, Mann M, Sibert J, Kemp A. Can you age bruises accurately in children? A systematic review. Arch Dis Ch. 2005.90 182-6 2 I.Prosser, S. Maguire, S.K. Harrison, M. Mann, J.R. Sibert, A.M. Kemp.How old is this fracture? Radiological dating of fractures in children: A systematic review. AJR; 2005: 184(4) 3 Kennedy H. Sudden Unexpected Death in Infancy. 2004 The Royal College of Pathologists and The Royal College of Paediatrics and Child Health. Competing interests: None declared
Re: The evidence base in child abuse 1 August 2006
Felicity A Goodyear-Smith, Senior Lecturer and GP Department of General Practice & Primary Health Care, University of Auckland, PB 92019, Auckland NZ Send response to journal: Re: Re: The evidence base in child abuse	Chadwick writes that there is a robust evidence base in child protection litigation.1 Unfortunately large bodies of evidence may not be easily accessible to potential medical experts. For example, while it has always been recognised that Neisseria gonorrhoea is a sexually transmitted infection,9 there is loss of appreciation that pre-pubertal girls, beyond the perinatal period, are also susceptible to non-sexual transmission of gonorrhoea. American Academy of Paediatrics guidelines state ‘Physicians should assume that children with gonorrhoea have acquired it by sexual contact and that most such contacts are sexually abusive’.2 Kellogg claims a positive culture for N gonorrhoeae makes ‘the diagnosis of sexual abuse a near medical certainty’ and is diagnostic of sexual abuse ‘if not perinatally acquired and rare nonsexual vertical transmission is excluded’.3 Guidelines citing a working party of the Royal College of Physicians as an evidence source state ‘The bulk of evidence strongly suggests that gonorrhoea in young people over one year is sexually transmitted and the isolation of a gonococcal infection is highly suggestive of sexual abuse’.4 5 Child abuse authorities Sgroi and Adams write ‘Except in the neonate, gonorrhoea in a child signifies sexual abuse’’6 and ‘Positive confirmed culture for gonorrhea (from genital area, anus, throat) in a child outside the neonatal period’ is diagnostic of sexual contact.7 These various documents either provide no supportive primary data or refer to a 1985 paper cklaiming to have summarised ‘all studies of gonococcal infections in children since 1965’8 and concluding that ‘the bulk of evidence strongly suggests that gonorrhoea in children, as in adults, is sexually transmitted.’ However a literature search reveals that this review does not include all studies between 1965 to 1985. Furthermore there are numerous studies of non-sexual transmission both prior and subsequent to their review. Prior to the advent of antibiotics, N gonorrhoeae was endemic. Epidemics of vaginal gonococcal infection was a serious problem in children’s wards and orphanages, usually through some failure in nursing care.9 10 The source of infection for an index case might have been sexual transmission. However once an infected child was admitted, the infection spread rapidly among other girls within the institution. The literature records over 40 epidemics involving about 2000 children in Europe and the United States.9 11-21 Communal baths, towels, bedding and other cloth, rectal thermometers, enema nozzles, and caregivers’ hands22-2728 were all identified as agents of transmission. Prior to the advent of penicillin there was no adequate treatment. While generally causing vulvovaginitis, to which young girls are particularly susceptible, there were cases of conjunctivitis and more serious complications including arthritis, peritonitis and fatality. Epidemics often would continue until strategies to isolate infected children and identify the transmission source (nurses’ hands or fomites) were implemented. The pattern of spread was clearly due to contamination not sexual abuse of children within the institutions. Modern-day epidemics of non-sexually transmitted conjunctival N gonorrhoeae occur in parts of Africa and Australia where adequate facilities for diagnosis, treatment and epidemiological surveillance are lacking.29 In Ethiopia over 9,000 cases of gonococcal conjunctivitis, particularly affecting children under five years of age, were reported during eight months in one district.30 Epidemical, surveillance and clinical data showed no concurrent genital gonorrhoea outbreak - genital transmission could not explain the community-wide epidemic. Similar outbreaks occur in Aboriginal communities in rural Australia under conditions of substandard, overcrowded housing with insufficient water supply, poor sanitation and sewerage disposal and inadequate food hygiene.31-35 Children with unwashed faces and/or hands are more likely to be infected.36 Flies are possible vectors.30 32 37 Many other studies link clusters of family members and associates having conjunctival or vulvovaginal gonococcal infection with non-sexual transmission.38-47 48-52 Children may acquire gonococcal infections through contact with infected towels or bedding.29 48 53-56 Accidental transmission through freshly contaminated hands of mothers or other contacts is another mode of infection.49 46 57-59 In some cases it cannot be established whether transmission was sexual or non-sexual. Unusual accidental modes of infection include sharing a bed urinal bottle with an infected fellow-patient,8 ingestion of chocolate agar from a culture plate,60 being struck in the eye with an infected face mask strap,61 spraying the eyes with infected fluid62 or bathing them in contaminated urine.63 Infected toilet seats are an unlikely source of indirect transmission,64 although contact with contaminated toilet paper has greater potential to cause infection. 65 While N gonorrhoea is killed by drying or heating, it can survive for hours if kept warm and damp on towels, bedding and other objects27 39 66- 68 69-71 24 and has .been cultivated from infected bathwater after 24 hours.72 The prepubertal girl develops vulvovaginitis rather than cervicitis. She is susceptible to this for many reasons: the vulva lack the protection of adult labial fat pads and pubic hair and the labia minora tend to open when the child squats; the vulval skin is thin, delicate and sensitive, susceptible to irritation, infection, drying, chapping and blistering; the vagina is an excellent bacterial culture medium being warm, moist and of neutral pH with an atrophic anoestrogenic mucosa; antibodies that may be present in adolescents and adults are lacking and children may have poor local hygiene.73-77 With the advent of antibiotics, gonorrhoea is no longer endemic. Epidemics in institutions are an event of the past. Gonorrhoea in children is relatively rare. Knowledge of nonsexual transmission has largely been lost to modern literature. Medical experts rely on ‘guidelines’ from leading medical institutions3-5 9 78 rather than referring to primary sources. Unfortunately these documents are opinion not evidence-based. For example, Kelly assumes all paediatric cases of gonorrhoea due to sexual abuse ('the consensus in the Western literature is that genital gonorrhoea in a child, out of the neonatal period, is a sexually transmitted disease') with the child requiring urgent placement 'in a safe household'.79 While some cases may result from sexual abuse, non-sexual transmission is not considered a possibility. Babies and young children are taken in to custody and adults prosecuted solely on the finding of paediatric gonorrhoea. Expert witnesses testify that sexual abuse is a medical certainty, citing the leading authorities listed above. Clearly it is important to identify cases of sexual abuse and keep children safe. Paediatric gonorrhoea is a strong indicator that must be taken seriously. However denial of the possibility that children may be infected non-sexually has grave medicolegal implications and may result in harm and injustice. References 1. Chadwick D. The evidence base in child protection litigation. BMJ 2006;333(22 July):160-161. 2. American Academy of Pediatrics. Committee on early childhood aadc. Gonorrhea in prepubertal children. Pediatrics 1983;71(4):553. 3. Kellogg N, Committee on Child Abuse and Neglect. Clinical Report: the evaluation of sexual abuse in children. Pediatrics 2005;116(2):506-512. 4. Thomas A, Forster G, Robinson A, Rogstad K, Clinical Effectiveness Group Association of Genitourinary M, Medical Society for the Study of Venereal D. National guideline for the management of suspected sexually transmitted infections in children and young people. Archives of Disease in Childhood 2003;88(4):303-11. 5. Thomas A, Forster G, Robinson A, Rogstad K, Clinical Effectiveness G. National guideline for the management of suspected sexually transmitted infections in children and young people. Sexually Transmitted Infections 2002;78(5):324-31. 6. Sgroi SM. Pediatric gonorrhea and child sexual abuse: the venereal disease connection. Sexually Transmitted Diseases 1982;9(3):154-6. 7. Adams J. Approach to the Interpretation of Medical and Laboratory Findings in Suspected Child Sexual Abuse: a 2005 Revision. The APSAC Advisor, 2005:7-13. 8. Neinstein LS, Goldenring J, Carpenter S. Nonsexual transmission of sexually transmitted diseases: an infrequent occurrence. Pediatrics 1984;74(1):67-76. 9. Hamilton A. Gonorrheal vulvovaginitis in children with special reference to an epidemic occurring in scarlet fever wards. Journal of Infectious Diseases 1908;5:133-157. 10. King A, Nicol C. Veneral diseases. 3rd ed. London: Bailliere Tindall, 1975. 11. Gittings C, Mitchell G. Review of the literature of the past five years on gonovoccus vulvovaginitis in childhood. American Journal of Diseases in Children 1917;13:438-456. 12. Abt I. Gonorrhea in children. Journal of American Medical Association 1898;31(17 Dec):289-294. 13. Morse J. 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Lipsitt HJ, Parmet AJ. Nonsexual transmission of gonorrhea to a child. New England Journal of Medicine 1984;311(7):470. 61. Diena BB, Wallace R, Ashton FE, Johnson W, Platenaude B. Gonococcal conjunctivitis: accidental infection. Canadian Medical Association Journal 1976;115(7):609. 62. Bruins SC, Tight RR. Laboratory-acquired gonococcal conjunctivitis. JAMA 1979;241(3):274. 63. Valenton MJ, Abendanio R. Gonorrheal conjunctivitis. Complication after ocular contamination with urine. Canadian Journal of Ophthalmology 1973;8(3):421-7. 64. Gilbaugh JH, Jr., Fuchs PC. The gonococcus and the toilet seat. New England Journal of Medicine 1979;301(2):91-3. 65. Dayan L. Transmission of Neisseria gonorrhoeae from a toilet seat. Sexually Transmitted Infections 2004;80(4):327. 66. Cruickshank R, JP D, BP M, RHA S. Chapter 27: Neisseria. Medical Microbiology: the practice of medical micobiology. 12th ed. Edinburough: Churchill Livingstone, 1975:399-402. 67. Jordan E, Burrows W. Textbook of bacteriology. 13th ed. Philadelphia & London: WB Saunders Company, 1941. 68. Bigger J. Handbook of bacteriology. 6th ed. London: Bailliere Tindall & Cox, 1949. 69. Marshall C. Syphilology and venereal diseases. 3rd ed. London: Balliere, Tindall & Cox, 1914. 70. Elmros T, Larsson PA. Survival of gonococci outside the body. British Medical Journal 1972;2(810):403-4. 71. Alausa K, Sogbetun A, Montefiore D. Effect of drying on Neisseria gonorrhoae in realtion to nonvenereal infection in children. Nigerian Journal of Paediatrics 1977;4(1):14-18. 72. Leishman W, Keogh A, Melville C. A manual of venereal diseases. 2nd ed. London: Oxford University Press, 1916. 73. Altchek A. Pediatric vulvovaginitis. Journal of Reproductive Medicine 1984;29(6):359-75. 74. Altchek MA. Gonococcal vaginitis in children. Medical Aspects of Human Sexuality 1982;16(1):46-51. 75. Robinson AJ. Sexually transmitted organisms in children and child sexual abuse. International Journal of STD & AIDS 1998;9(9):501-10. 76. Woods CR. Gonococcal infections in neonates and young children. Seminars in Pediatric Infectious Diseases 2005;16(4):258-70. 77. Rein MF. Nonsexual acquisition of genital gonococcal infection. New England Journal of Medicine 1979;301(24):1347. 78. American Academy of Pediatrics. Committee on Child A, Neglect. Guidelines for the evaluation of sexual abuse of children: subject review. Pediatrics 1999;103(1):186-191. 79. Kelly P. Childhood gonorrhoea in Auckland. New Zealand Medical Journal 2002;115(1163). Competing interests: None declared
Re: Child Abuse -Misdiagnosed 2 August 2006
Joyce A Adams, Professor of Pediatrics University of California, San Diego, 200 Arbor Drive, San Diego California 92103-8449 Send response to journal: Re: Re: Child Abuse -Misdiagnosed	Regarding Goodyear-Smith's response to the article by Chadwick, I would like to submit a correction to one of the citations. The article I published in The APSAC (American Professional Society on the Abuse of Children)Advisor (1) contained a table: "Approach to Interpreting Physical and Laboratory Findings in Suspected Child Sexual Abuse: 2005 Revision". This table was developed through a process of consensus development and endorsed by group of physician experts in child sexual abuse medical evaluation. The wording our group agreed upon for interpreting the significance of infections caused by gonorrhea, syphilis, Trichomonas vaginalis, Chlamydia trachomitis and HIV, when perinatal transmission is ruled out, was: "Presence of Infection Confirms Mucosal Contact with Infected and Infective Bodily Secretions, Contact Most Likely to Have Been Sexual in Nature". If there is an explanation for how fresh infected secretions from an individual with gonococcal vaginitis, urethritis or conjuctivitis came to be directly deposited on the eye or genitals of a child in a non-sexual manner, then it may not be necessary to suspect sexual abuse. With common good hygiene practices, this should not happen, but in areas where people don't wash their hands between touching their own infected genitalia or eyes before touching a child's genitalia or eyes, then such non-sexual transmission probably does occur. The table in the Advisor article does note that for gonorrhea, syphilis, Chlamydia and HIV, the most recent guidelines from the American Academy of Pediatrics Committee on Child Abuse and Neglect (in the Clinical Report authored by Nancy Kellogg, MD)(2)consider these infections to be diagnostic of sexual transmission if neonatal transmission is ruled out, however the group of experts who reviewed the listing of findings did not want to use "diagnostic" or "clear evidence" terminology. Alternative modes of transmission, in cases where a child is too young to give a history of sexual abuse, or who denies such contact, should always be investigated. (1) Adams JA. Approach to the interpretation of medical and laboratory findings in suspected child sexual abuse: A 2005 revision. The APSAC 2005;17 (3):7-13. (2) American Academy of Pediatrics, Committee on Child Abuse and Neglect, & Kellogg NK.(2005). Clinical Report: The evaluation of sexual abuse of children. Pediatrics, 116 (2):506-512. Competing interests: None declared
Child abuse evidence base is not robust 5 August 2006
LC Blakemore-Brown, Psychologist UK Send response to journal: Re: Child abuse evidence base is not robust	Kemp, Sibert and Maguire write: "Expert witnesses appearing in court require a thorough understanding of the quality of the available scientific evidence and must be able to convey this to the Court in an understandable manner. Courts and clinicians need to appreciate that child abuse evidence base is a long way from being robust or complete..." I very much welcome the fact that these particular workers have done the research and come to the conclusion which I reached back in 1996 after being an Expert Witness in a court case in which Munchausen Syndrome by proxy was being alleged. My published article in The Psychologist (1) states: " I cannot estabish a robust scientific base .... I am of the opinion that we need to clarify the nature of MSBP with some urgency. That some disturbed women are known to have seriously harmed their children should not lead to distortions of thinking in which many are assumed to have done so. One swallow does not make a summer." Tragically, as John Stone writes, such assumptions based on such theories without robust research to back them up, have now coursed their way through the entire system. Training and guidance based on such theories - as Patricia Hamilton, President of the RCPCH confirms on bmj.com - has been and continues to be handed down to multiple thousands of workers with no qualifications in medicine/psychology or psychiatry. So the errors which have happened in Court are now spread far and wide through the system and have the potential to negatively affect untold numbers of children and families whose cases may never reach Court. The potential for a social disaster that I wrote about all those years ago has become a reality. 1. Blakemore-Brown LC Munchausen Syndrome by Proxy. Letters The Psychologist September 1997 Competing interests: Expert in Autism and related disorders frequently misinterpreted as child abuse
Re: Goodyear-Smith's response to the evidence base in child abuse 12 August 2006
Nancy D. Kellogg, Professor of Pediatrics University of Texas Health Science Center at San Antonio; 7703 Floyd Curl Drive San Antonio Texas 78 Send response to journal: Re: Re: Goodyear-Smith's response to the evidence base in child abuse	I agree with Dr. Goodyear-Smith’s last paragraph. However, she has not established that contemporary publications demonstrate “DENIAL (emphasis added) of the possibility that children may be infected non- sexually,” nor has she acknowledged that in most situations post-natal non -sexual acquisition of gonorrhea is uncommon. A more careful perusal of the American Academy of Pediatrics clinical report that was cited (1) will reveal that in Table 2, a positive test for gonorrhea should elicit a high level of concern about sexual abuse “if nonsexual transmission is unlikely or excluded.” “Think common, remember rare” is a lesson from residency days. It is also instructional to look critically at the references provided in Dr. Goodyear-Smith’s response; many are more than 50, and some are more than 100, years old. Many are textbook references or case reports, not case control studies. In these older studies, we do not know if Neisseria gonorrhoeae was appropriately diagnosed; even now, in some regions, laboratories fail to conduct the appropriate confirmatory tests to determine the correct Neisseria species. We do know that child abuse was not even fully acknowledged as a possibility until the 1960's (excepting Mary Ellen) and it is safe to say that sexual abuse of children was acknowledged later than physical abuse. It is possible that sexual transmission may not have been considered in many of these earlier reports. Prospective case-control studies are one of the best ways to address the question of transmission modes. Dr. Gardner did a prospective study comparing gonorrhea culture results in 209 sexually abused girls to 108 girls with no history or indicators of sexual abuse. No gonorrhea was found among the latter group (2). In an earlier retrospective study(3) that included children between 1 and 14 who were infected with gonorrhea, sexual contact was confirmed in 126, and 32 were said to be infected via “casual acquaintances” which was not further clarified. Of interesting note, one child with GC between 5 and 9 years of age was determined to have been infected through “boyfriend-girlfriend relationship”; this also was not further elucidated. Another retrospective chart review (4) describes 15 children with gonorrhea, 3 of whom had a history of sexual abuse and 5 of whom had unknown mechanisms of infection. The remaining 7 all co-slept with their parents and either one or both parents were noted to have GC. The gender of the infected parent was not given, but it is interesting that in the 5 of 7 cases where the child and one parent had GC, the other parent who was in the same bed did not have GC. Could it be that there was closer or more frequent "contact" between the child and the infected parent than between the infected and non-infected parent? More studies, as always, would be instructive. Currently, a confirmed gonorrhea infection in a child that is determined not to be infected through vertical transmission at birth deserves a referral for an investigation. While some of these children (few in my experience) will not initially have a history of sexual contact, many do disclose sexual abuse during the process of the investigation. Practitioners should, and many do, consider all possibilities in evaluating suspected child abuse. The key is not only to become familiar with – to quote Dr. Chadwick – the “well developed evidence base” - but also to read such studies with a careful, critical and discerning eye. Nancy D. Kellogg, M.D. 1. Kellogg ND, American Academy of Pediatrics Committee on Child Abuse. The evaluation of sexual abuse in children. Pediatrics 2005; 116: 506-512. 2. Gardner JJ. Comparison of the vaginal flora in sexually abused and nonabused girls. J Pediatrics 1992; 120: 872-7. 3. Branch GB and Paxton R. A study of gonococcal infections among infants and children. Public Health Reports 1965; 80: 347-352. 4. Shore WB and Winkelstein JA. Nonvenereal transmission of gonococcal infections to children. J Peds 1971; 79: 661-663. Competing interests: None
Response to reponses 14 August 2006
David L. Chadwick, Reitred pediatrician California 91941 Send response to journal: Re: Response to reponses	To the Editor, BMJ Rapid Responses August 13, 2006 Seven Rapid Responses have now appeared in response to my editorial on the state of the evidence base in child protection litigation. They include far more words and more specificity than was allowed in the original (800-word) contribution. I will attempt to answer each as briefly as possible. Michael Innis proposes two theories to explain the findings in Shaken Baby Syndrome. The one that attempts to connect subclinical Vitamin C deficiency is novel and so weakly supported as to constitute “unique causal theory” [1] . The other, the need to look for coagulopathies and to explain them in cases of suspected inflicted head injury is well- recognized [2]. Elizabeth Marsh raises many interesting questions, and the most relevant to the editorial is the question of the need to provide protection for persons who are required or expected to report child abuse when they perceive it. The writers of these reporting laws recognized that without such protections the laws would not be observed because to observe them would be too dangerous. This appears to be the case in the U.K. Further, without witness protection laws that cover court testimony there would be no witness testimony at all. Ms. Marsh’s comments about the prevention and the preventability of child abuse go beyond the scope of the editorial, but there is a robust and developing literature on this topic also. However, this issue is rarely the subject of litigation except in the occasional case in which a failure to report is followed by a catastrophic second injury. I appreciate Oliver Dearlove’s comment that I should have been more emphatic that: “that it is not and never was, the function of the General Medical Council to do in child protection.” I also agree that all is not entirely rosy in the land of the free. We still observe much irresponsible expert testimony [1, 3]. Some medical societies in the U.S. are doing their best to deal with this issue. The American Association of Neurological Surgeons took the lead a few years ago [4]. In the case of the neurosurgeons (who pay $100,000/yr for malpractice insurance) the resources to provide competent peer review of expert testimony may be available. The Florida State Medical Society experiment is unique in the U.S. and it’s too soon to evaluate it fairly. However, few, if any, of our state licensing boards (the U.S. equivalent of the GMC) have the resources to provide competent review of expert testimony and none have tried it on their own. Joyce Adams has already responded to the note by Felicity Goodyear- Smith about gonorrhea and Nancy Kellogg may soon do so also. I will leave this interesting discussion to these experts. The note by L.C. Blakemore-Brown (a psychologist) illustrates a serious but common error about the Munchausen Syndrome by Proxy (MSBP). This is the idea that the condition can be defined or excluded by psychological observations or criteria. It cannot be. In fact, it is defined as a form of child abuse in which a caretaker fakes illness in a child with resulting harm to the child. It can be conclusively diagnosed by covert video surveillance in a hospital and this has now been done in hundreds of cases in a number of countries. The condition is uncommon but not rare and the documentation of these behaviors is beyond dispute. Southall’s pioneer work on this issue [5] may be the principal cause of his current difficulties with the GMC. MSBP can also be diagnosed by the “separation test” [6]. Although this is less conclusive it is often certain enough to support a life-saving protective intervention. MSBP may be excluded by the firm diagnosis of a well-described medical condition in the child that provides a “natural” explanation for all signs and symptoms. The fact that not all suspected cases can be clearly placed in one category or another [7] does not diminish the validity of the basic concept and definition or the need to intervene when a child’s life or health is threatened by it. I have saved the comment by Kemp, Sibert and Maguire for last because these writers themselves are major contributors to the growing literature that can be referenced in child protection litigation. Their contributions are admirable. I agree with a number of the specific points in their note. We cannot read the age of bruises with our eyes as we might like to although everyone knows that they evolve. There is a “clock” in bruise resolution, and we still need to learn to read it. I differ with their views on the radiological dating of certain fractures. For example, it is clearly correct to say that a rib or long- bone fracture in an infant or young child that demonstrates subperiosteal new bone formation is more than 5 days old [8]. Often this fact is sufficient to invalidate a history provided with an injured child. To argue otherwise is simply nihilistic. An enormous clinical experience backs up this finding. The fact that the chief reference for this position is given in a book chapter does not invalidate it. Much that is true can be found in book chapters and much that is not can be found in peer- reviewed journal articles. The torn labial frenulum example is something of a straw man. In young infants is may certainly be an indicator of abuse, but what it really indicates is blunt facial or oral trauma that often occurs unintentionally in toddlers and preschool children. The comparison of the child abuse medical literature to that pertaining to cancer or AIDS is (of course) unfair. With 10% of the recent research funding for cancer and AIDS, child abuse researchers might be much more advanced than they are. It is no longer possible to argue that cancer is a more important medical problem than child abuse [9]. Kemp appears to agree that the subject is important. I am only surprised by Kemp’s surprise at my use of the term “robust” since their contributions to the literature have contributed so much. I stick with it. “Complete” is something else, of course. David L. Chadwick References 1. Brent, R.L., The irresponsible expert witness: a failure of biomedical graduate education and professional accountability. Pediatrics, 1982. 70(5): p. 754-62. 2. Hymel, K.P., et al., Coagulopathy in pediatric abusive head trauma. Pediatrics, 1997. 99(3): p. 371-5. 3. Chadwick, D.L. and H.F. Krous, Irresponsible expert testimony by medical experts in cases involving the physical abuse and neglect of children. Child Maltreatment, 1997. 2: p. 315-321. 4. AANS, Professional association's disciplinary action upheld. Austin v. American Association of Neurological Surgeons. Hosp Law Newsl, 2002. 19(6): p. 4-7. 5. Southall, D.P., et al., Covert video recordings of life-threatening child abuse: lessons for child protection [see comments]. Pediatrics, 1997. 100(5): p. 735-60. 6. Rosenberg, D.A., Munchausen syndrome by proxy: currency in counterfeit illness, in The Battered Child, M.E. Helfer, R.S. Kempe, and R.D. Krugman, Editors. 1997, University of Chicago Press: Chicago. p. 413-430. 7. Rosenberg, D.A., Munchausen Syndrome by Proxy: medical diagnostic criteria. Child Abuse Negl, 2003. 27(4): p. 421-30. 8. O'Connor, J.F. and J. Cohen, Dating Fractures, in Diagnostic Imaging of Child Abuse, P.K. Kleinman, Editor. 1998, Mosby: St. Louis. p. 168-177. 9. Felitti, V.J., et al., Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study [see comments]. Am J Prev Med, 1998. 14(4): p. 245-58. Competing interests: Unchanged
Re: Response to reponses 15 August 2006
Lisa C Blakemore-Brown, Psychologist UK Send response to journal: Re: Re: Response to reponses	Dr Chadwick. in reference to my Rapid Response, states " The note by LC Blakemore-Brown (a psychologist) illustrates a serious but common error about the Munchausen Syndrome by Proxy (MSBP). This is the idea that the condition can be defined or excluded by psychological observations or criteria". I am afraid it is Dr Chadwick who has made a serious but common error, and one regularly found at the very outset in false allegations of MSBP/SBS - he has made an early false assumption about my concerns and then built his case on that. Where in my response do I say what he has attributed to me? Nowhere. However, I do state that I am a Psychologist and it would seem that Dr Chadwick has therefore leapt to the conclusion he reached because of that. In actual fact, I am in total agreement with Dr Chadwick about psychological observations and criteria! I too do not consider that they help us to establish whether a parent has abused their child. Thinking that there is a psychological or psychiatric profile is simply not correct. I differ from Dr Chadwick in that he thinks that covert video surveillance can lead to conclusive diagnoses. To my certain knowledge great errors have been made in the interpretation of such videos and to my certain knowledge women have had children removed despite no evidence at all following covert surveillance, only to have them returned by a Court. Furthermore, by knowing, as I said in my response, that some women have harmed their children, this should not lead us to assume (assumption again) that many have. This means that because some people have genuinely been seen to cause harm to children under covert surveillance, for instance, cannot possibly allow us to make assumptions about the vast majority who have been accused when they have been nowhere near a camera. The fact that Professor Southall may have been able to capture some cases of disturbed women harming their children and that this may have also happened in some cases around the world, does not permit us to make assumptions about the vast majority who fall foul of this allegation without ever being filmed doing anything. The theorising and methodology is palpably not robust. To make it clear, my fundamental concern as a Psychologist is, in agreement with Dr Chadwick, that we are assuming psychological profiles can be used to accuse parents and this is simply wrong. Furthermore and clearly not in agreement with Dr Chadwick who has made the same sort of errors and shown the same sort of thinking in his response, we are using assumption and rumour and processes of suggestibility to guide and train thousands of medically unqualified staff to go on to accuse parents of causing real illnesses and disorders. It is my opinion that many of those illnesses and disorders could very well have been caused by iatrogenic processes. I want to see iatrogenic abuse becoming a routine part of the differential diagnosis in child abuse cases. I want to know why it NEVER is. Competing interests: Expert in Autim and related conditions often misdiagnosed as child abuse