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”  . The other, the need to look for coagulopathies and
to explain them in cases of suspected inflicted head injury is well-
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 . 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  may be the principal cause of
his current difficulties with the GMC. MSBP can also be diagnosed by the
“separation test” . 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  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 . 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 .
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
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: No competing interests