Study looks at traumatic brain injury - leading cause of abusive death in children

Confronted with the same hypothetical scenarios of traumatic brain injuries to children, pediatricians and pathologists were unable to agree half the time whether the deaths should be investigated as potential child abuse, researchers at Indiana University School of Medicine found.

The study demonstrates the need for improved, uniform definitions if research is to prevent such abuse, said Antoinette Laskey, M.D., M.P.H., a forensic pediatrician and assistant professor of pediatrics at the Indiana University School of Medicine, and her colleagues. They reported on their efforts to develop a framework to help researchers compare cases in the April issue of the journal Child Abuse and Neglect.

Traumatic brain injury is the leading cause of abusive death in children and is especially common in abused children under the age of 4. Fifteen hundred children a year in U.S. are killed because of traumatic brain injury and those who survive are often devastated.

It is impossible to do randomized controlled studies of abusive head trauma but researchers need to develop improved tools to correctly identify and ultimately prevent this abuse according to Dr. Laskey.

"We have to understand abusive head trauma. Research in the field is in its infancy compared to what we know about other pediatric conditions. We need to increase both the volume and the quality of what we know. We need to know more and we can't until we have pediatricians and pathologists, the doctors who see these children, speaking the same language," said Dr. Laskey.

In their groundbreaking study, Dr. Laskey, a Regenstrief Institute, Inc. affiliated scientist and a member of the Riley Hospital Child Protective Program, and her colleagues showed 16 hypothetical scenarios of traumatic brain injury to 570 pediatricians and pathologists, who were asked to classify them as inflicted, unintentional, or undetermined. To reflect actual experience, some of the scenarios contained incomplete or potentially conflicting information.

There was an overwhelming agreement among the pediatricians and pathologists when the case involved a confession, traumatic birth history, or a witness to abuse or accident.

But the pediatricians and pathologists surveyed were unable to agree on 50 percent of the hypothetical cases. Pathologists were less likely than the pediatricians to view these scenarios as inflicted traumatic brain injury.

"We were surprised to find that pathologists were more in the gray zone for cases that didn't fall into these categories , they weren't ready to say whether they were accidental or inflicted traumatic brain injury. We think this is due in part to their different perspectives , pediatricians look at injured children and pathologists are conduct autopsies. They are considering different details," Dr. Laskey said.

"Our study results will help facilitate the development of more uniform research definitions for future comparative studies of unintentional vs. inflicted pediatric traumatic brain injury," said Dr. Laskey, of the section of Children's Health Services Research of the IU School of Medicine and of Riley Hospital for Children of Clarian Health.

"Our [pediatricians] role as mandatory reporters of child abuse cause pediatricians to err on the side of caution, reporting our suspicions, and then letting the medical and legal systems make the final determination of abuse or accident," she said.

Dr. Laskey and colleagues are working on a follow-up evaluation of the free text comments from the pediatricians and pathologists surveyed comparing the two groups.

"This field [child abuse detection] is new enough that the science is exploding exponentially. As any field takes off, questions arise. As we learn more about what doctors want to know we are seeing holes in our knowledge and beginning to look for ways to address those holes," Dr. Laskey said.