The Emergence of Child Abuse Pediatricians in the Misdiagnosis of Child Abuse

by Jason L. Nohr[1] 

Child abuse is a serious problem that often goes unrecognized. The worthy desire to uncover mistreatment and protect kids from it, however, has led to a related and increasingly common dilemma: the overdiagnosis and misdiagnosis of child abuse. False or mistaken accusations of child abuse cause distinct and serious injuries, including the destruction of families, parent-child separation, unwarranted legal and medical investigations, and even the conviction and incarceration of innocent parents and caregivers. Preventing child abuse is certainly important, but misdiagnosing it can also traumatize children and their families. Because of the trauma an abuse misdiagnosis visits on innocent families, it is important to examine why they happen and may be on the rise.

Our legal and medical systems have long struggled to differentiate accidental injuries from abuse, particularly since children are often too young to describe what happened. Child protective services and law enforcement are increasingly seeking help in answering these questions from Child Abuse Pediatricians (CAPs), a pediatric subspecialty first recognized by the American Board of Pediatrics in 2009. Today, there are approximately 350 CAPs practicing in most major metropolitan areas in this country. The CAP accreditation process involves additional medical training in areas that include mechanisms of pediatric injury, radiology, and orthopedics. CAPs also receive forensic training, including instruction in testifying as expert witnesses in criminal cases and juvenile court deprivation proceedings. According to a recent multi-part series by NBC News and the Houston Chronicle chronicling misdiagnosis of child abuse cases, the salaries for many CAPs are funded by the state agencies that oversee child protective services and often lead teams investigating abuse that are funded by state Medicaid programs.

The rise in frequency and severity of misdiagnosis cases may be linked to the emergence of CAPs and the disproportionate weight and significance their opinions are afforded in medical and legal investigations of child abuse. Often, law enforcement, child protection agencies, prosecutors, judges, and even defense attorneys accept CAP conclusions about abusive causes as dispositive without question, scrutiny, or further investigation. This is problematic because CAPs are not infallible and, sometimes, guided by presumptions that impact their objectivity. CAPs are also not experts in many rare diseases and conditions that mimic the signs of physical abuse. To fully consider and investigate non-abusive explanations in matters of such grave importance, prudent CAPs have to consult with their colleagues in other medical specialties.

There are a variety of conditions and genetic disorders whose signs and symptoms are often mistaken for physical abuse. Coagulation disorders (such as von Willebrand Disease and Idiopathic Thrombocytopenic Purpura) and Vitamin K Deficiency cause bruising and bleeding are often mistaken for physical abuse, as are broken bones caused by Osteogenesis imperfecta. “Coagulopathies can mimic child abuse not only by producing easy bruising, but also by allowing small bleeding episodes to become large ones, suggesting to a treating physician that massive force was applied to create the bleeding.”[2] Indeed, the National Organization for Rare Disorders publishes resources for families who may face mistaken allegations of child abuse.

Unfortunately, CAPs sometimes confuse suspicion with certainty, rely upon flawed medical assumptions, and fail to investigate and exclude alternative causes or conditions inconsistent with abuse or consult with medical specialists. According to former Harvard Medical School professor, Eli Newberger, M.D., who founded the child protection team at Boston Children’s Hospital in 1970, some CAPs are “too quick to label a child’s injuries as abusive” and ignore benign, non-abusive explanations for the child’s presentation “far too often.” Because of the potential for misdiagnosis, it is “important that physicians approach these cases with humility. Otherwise, they risk making a mistake,” according to Dr. Newberger.

One area where humility is lacking and mistakes commonplace is with the diagnosis of so-called “Shaken Baby Syndrome.” Despite a lack of medical consensus, CAPs regularly presume that a child who presents with subdural hematomas (SDH) and retinal hemorrhages (RH) is the victim of physical abuse by shaking. This diagnostic presumption, however, has been widely discredited because there are so many non-abusive causes and conditions that cause both SDH and RH, including central nervous system infections, birth-related complications, and clotting disorders. In fact, an increase in intracranial pressure from a variety of underlying conditions can cause RH in children without any impact, shaking, or trauma. Biomedical studies also show that the severity of physical force necessary to cause SDH and RH would also injure a child’s neck, a finding that is typically absent from Shaken Baby Syndrome diagnoses. Nevertheless, CAPs often reflexively assume SDH and RH are caused by abuse without considering innocent alternative etiologies or consulting with specialists.

The author has represented innocent parents falsely accused of child abuse due to these faulty medical assumptions and the failure to consider alternative explanations. In each of these cases, the parents were ultimately exonerated at trial when the allegations of abuse were refuted through cross-examination of the CAP involved and/or an accurate medical diagnosis was presented through independent medical experts. Understanding the structural reasons behind misdiagnosed child abuse is essential for parents facing these challenges.

[1] I have had the privilege of representing parents falsely accused of child abuse and clearing them in trial and administrative proceedings. In each case, the CAPs involved either rejected or never considered non-abusive causes for the child’s condition. Using cross-examination skills developed during decades of litigating medical malpractice cases, the courts ultimately cleared my clients and dismissed these allegations of abuse.

[2] Laposta, MD, PhD, “Children With Signs of Abuse,” American Journal of Clinical Pathology; S119-125, S123, (2005).