Physicians are sometimes called upon to provide critically important guidance and expertise for legal decisions regarding potential child abuse, and the significance of these decisions means physicians and all specialists need to base their testimony on solid evidence and scientific fact.1 But what happens when the evidence is unsupported?
In an opinion piece published in JAMA, John M. Leventhal, MD, of the Yale School of Medicine in New Haven, Connecticut, and George A. Edwards, MD, of the Dell Children’s Medical Center in Austin, Texas, emphasized that over the last 2 decades, a number of pediatricians, specialists, lawyers, and journalists have wrongfully advanced scientifically unfounded theories to provide an alternative diagnosis for symptoms presented as physical abuse of children, both in the courtroom and in the press.
Drs Leventhal and Edwards claim that “flawed explanations of child abuse” are usually presented under 3 categories:
- “Legitimate diagnoses that should be considered in the differential diagnosis of a child with injuries.” These conditions can sometimes appear as child abuse, for example, a household fall that results in a life-threatening injury or osteogenesis imperfecta, a genetic disease that predisposes to fractures and may be confused with abuse.
- “Legitimate diagnoses that lack scientific support as explanations of injuries.” An example of this is Ehlers-Danlos syndrome, which is often used in the courtroom as an alternative explanation for multiple fractures in infants, even though evidence is lacking, so any association remains a speculative hypothesis.
- “Fabricated diagnoses.” Examples include “dysphagic choking” and “temporary brittle bone disease,” which have been used to explain fatal abusive head trauma and multiple abusive fractures, respectively. However, both are speculative diagnoses without any scientific support.
Advocates of these flawed explanations argue that the alternative diagnosis can often appear as child abuse, and because the diagnosis is possible, it’s impossible to conclude any abuse occurred. Some advocates have published articles about abuse and alternative diagnoses, but the articles often include unproven hypothesis, case reports with omitted facts, and fallacious descriptions of conditions. The problem, then, is that attorneys cite these articles in court.
Alternative diagnoses have serious consequences, including the failure to hold guilty parties responsible and protect abused children who are at risk of returning to their abusive environment.
Drs Leventhal and Edwards argue that there is no controversy surrounding the diagnosis of abusive head trauma in clinical medicine. In 2009, the American Academy of Pediatrics released a statement recommending pediatricians use “abusive head trauma rather than a term that implies a single injury mechanism, such as shaken baby syndrome, in their diagnosis and medical communications.” The statement confirmed that abusive head trauma was a valid diagnosis, and the only controversy surrounding the term exists solely in the courtroom.2
“Physicians, researchers, academic medical centers, journalists, and legal scholars have a responsibility to repudiate scientifically unsupported theories that falsely purport to explain child abuse and abusive head trauma,” the investigators concluded.
- Leventhal JM, Edwards GA. Flawed theories to explain child physical abuse: what are the medical-legal consequences? [published online September 18, 2017]. JAMA. doi: 10.1001/jama.2017.11703
- Christian CW, Block R; Committee on Child Abuse and Neglect; American Academy of Pediatrics. Abusive head trauma in infants and children. Pediatrics. 2009;123:1409-1411.