Child Abuse & Neglect 111 (2021) 104792

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Child Abuse & Neglect

journal homepage: www.elsevier.com/locate/chiabuneg

Consultation for child physical abuse: Beyond the history and

physical examination
Andrea G. Asnes *, Lisa Pavlovic, Beth Moller, Paula Schaeffer, John M. Leventhal
Department of Pediatrics, Yale School of Medicine, 333 Cedar Street, New Haven, CT 06520, United States

A R T I C L E I N F O A B S T R A C T

Keywords: Objective: To describe the components of an approach to the consultation for suspected child
Child maltreatment physical abuse beyond the history, physical findings, and laboratory and radiographic data.
Physical abuse Method: Description of both a baseline organizational structure and recommended behaviors.
Child protection team
Results: We describe four domains of the approach to the consultation for suspected child physical
abuse by child abuse clinicians: (1)components to have in place before a consultation, (2) com­
ponents of a quality consultation, (3) sharing a final opinion, and (4) inevitable pitfalls.
Conclusion: In proposing this approach, we aim both to make transparent and spark discussion
about the way we work and to answer questions about the role of child abuse clinicians raised by
recent interest in this subject by the mass media.

1. Introduction

A critical aspect of the clinical care of injured children is the decision about the likelihood that the injured child had been abused.
Previous articles have highlighted the importance of making an accurate assessment because of the substantial risks of an incorrect
diagnosis: if a child with an accidental injury is labeled as abused, that child and siblings may be needlessly removed from the care of
their parents, and someone may end up erroneously in prison. Alternatively, if an abused child is labeled as an accident, that child
returns to an abusive home and may suffer continued abuse and even death (Leventhal, Asnes, Pavlovic, & Moles, 2014). Guidelines for
history taking, the physical examination, and diagnostic testing have been issued (Christian, 2015), and advice has been provided
about interviewing caregivers when abuse is suspected (Snyder, Currie, & Stockhammer, 2011). Although previous studies have
examined how child abuse clinicians assess the likelihood of abuse as well as the structure and details of consultation notes (Campbell,
Olson, & Keenan, 2015; Keenan, Cook, Olson, Bardsley, & Campbell, 2017; Skellern & Donald, 2011), there is a paucity of literature
clarifying how this work is optimally done (Leventhal, 2000). In addition, recent publications in the mass media on the role of the child
abuse consultant have challenged both the evidence in support of and the value of the consultative process itself. More specifically,
child abuse clinicians have been portrayed as biased toward the diagnosis of abuse in the absence of evidence to support this diagnosis
(Clifford, 2020; Hixenbaugh, 2019a, 2019b, 2019c, 2019d, 2019e).
In this article, we describe our process of a child abuse consultation, from the request for a consultation to the formulation of a
diagnosis, and focus on critical components, common pitfalls, and how to avoid these pitfalls. We undertook this project to make
transparent aspects of our work beyond the historical questions we ask and the findings we elicit on physical examination. We set out
with two goals. First, we aim to initiate a discussion among our colleagues in the field of child abuse pediatrics and others in the field of

* Corresponding author.
E-mail address: andrea.asnes@yale.edu (A.G. Asnes).

https://doi.org/10.1016/j.chiabu.2020.104792
Received 3 September 2020; Received in revised form 17 October 2020; Accepted 20 October 2020
Available online 4 November 2020
0145-2134/© 2020 Elsevier Ltd. All rights reserved.
A.G. Asnes et al. Child Abuse & Neglect 111 (2021) 104792

child abuse about the way we work. While our approach has been thoughtfully developed over time and with considerable experience,
we recognize that input from others will be valuable. Second, we wish to clarify questions raised about the work of child abuse cli­
nicians by the media. Journalists have tried to understand how child abuse consultants think, function, and make decisions as outsiders
looking in; this article reflects our effort to step back and carefully consider these questions.

1.1. Goals of a consultation

When asked to offer an expert opinion as child abuse consultants, our overarching goal is to get it right. Knowing that the
consultation will be used to craft safety plans for children, the consultant’s aim is to gather the optimal data to help reach an accurate
conclusion. Using the best available medical evidence and avoiding bias are important goals, as is remaining nuanced in the under­
standing of each case and avoiding premature closure when making an assessment (Skellern, 2015). Once a conclusion is reached, the
consultant must endeavor to communicate not only the final opinion but also the basis for that opinion, in language that is clearly
understood by medical and nonmedical persons alike, including the family of the evaluated child. The components of a quality
consultation can be broken down into the following practices and approaches shown in Table 1.

2. Before the phone rings: components to have in place before a consultation

We believe that at least three key components of a successful child abuse consultation should be well established. These include a
Child Protection Team (CPT), a peer review process, and respectful relationships with colleagues in other medical services involved in
caring for injured children as well as with outside medical providers and community agencies.

2.1. The Child Protection Team: harnessing the value of the multidisciplinary view

Teamwork, including input from different disciplines, is critical to integrating the evidence when evaluating possible abuse and
reaching accurate conclusions and is a vital component of a high reliability organization. Effective teams are responsible for multiple
functions including, for example, regular provision of feedback to one another, helping one another, and periodic evaluation of team
effectiveness (Baker, Day, & Salas, 2006). In keeping with this approach, the establishment of a multidisciplinary team of professionals
who meet regularly to discuss cases of suspected child abuse can be a critical component of the provision of expert child abuse
consultations. Child protection teams (CPTs) have been in existence in various forms for over fifty years and their impact has been
studied (Bross, Schmitt, Krugman, Rosenberg, & Lenherr, 1988; Kistin, Tien, Bauchner, Parker, & Leventhal, 2010; Rowe, Leonard,
Seashore, Lewiston, & Anderson, 1970; Wallace, Makoroff, Malott, & Shapiro, 2007). We suggest that team membership be
thoughtfully considered for diversity of professional disciplines. Social workers, both those who work directly with the child abuse
consultants, as well as those who work in emergency, outpatient, and inpatient settings, contribute to comprehensive, biopsychosocial
perspectives. Medical professionals who provide frontline care and who are often the first to recognize and suspect possible abuse, such

Table 1
Components of an approach to the consultation for suspected child physical abuse.
Components to have in place before a consultation

• Child protection team

• Formal peer review
• Relationships with other medical services
Components of a quality consultation

• Data review before meeting the family

• Introduction to the family
• Listening carefully to the history
• An observer
• A consistent approach
• Real time discussions with other medical providers
• An early meeting with Child Protective Services
• On demand/informal peer review (phone a friend)
Sharing a final opinion

• Framing
• Avoiding undue certainty
• Clarity about the data used to derive an opinion
• Showing one’s work
Inevitable pitfalls

• When others disagree with the child abuse clinician’s opinion

• Errors in judgment

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as those in the emergency department, ground case discussions in the daily realities of busy patient care settings. Radiologists can
review imaging studies for the benefit of the team.
The composition of CPTs varies with respect to the inclusion of both child protective services (CPS) and law enforcement. While the
National Children’s Alliance mandates the participation of representatives of both CPS and law enforcement in multidisciplinary teams
for accreditation, hospital based CPTs have discretion in the identification of team members ("National Children’s Alliance, "). In our
institution, CPS workers, supervisors, and hotline workers attend every CPT meeting as standing members. In addition to participating
in all case discussion, CPS team members can educate the team about the legal limits of CPS’ authority, the boundaries of the law with
respect to, for example, parental rights, and what is needed from the medical evaluation in order to plan for children’s safety. We
choose to invite investigating police officers and occasionally prosecutors to our CPT on an ad hoc basis to discuss specific cases rather
than assign them standing membership. Our choice reflects our team’s focus on making a correct assessment that can in turn be used by
CPS to plan for a child’s safety.
Once identified, CPT members should prioritize regular attendance. Other medical specialists (e.g., hospitalist, pediatric neuro­
surgery) and hospital lawyers might attend ad hoc. Meeting notes that include attendance rosters and a list of the cases discussed at
each meeting can be used to track cases that are presented and can be reviewed if a child returns with another injury or concern. Such
notes are legally discoverable. Rather than a detailed recording, our notes provide a summary of our discussions.
The schedule of meetings should balance realistic expectations for attendance of members as well as case volume. Cases for dis­
cussion are best identified from consistent sources, such as the cases referred for child abuse consultation or evaluated for possible
maltreatment in the emergency department.
Intentional development and nurturance of the culture of the CPT are critical. The team leader and members with natural authority
due to seniority can help to encourage every member to share thoughts and opinions. Junior team members and nonmedical members
may be invited to speak regularly. A safe space for honest and direct communication should be maintained. This means that
disagreement is welcomed; it is a good marker of a healthy team. When disagreements occur, explicit appreciation of a variety of
opinions is useful to encourage team members to be forthright. A diversity of team members, with respect both to personal attributes
such as age, race/ethnicity, and gender, as well as to role and years of experience, adds value to team discussions. It should be noted
that the team is often most helpful in the understanding of and planning for challenging and uncertain cases.

2.2. Formal peer review

Peer review, a form of focused professional practice evaluation, is a tool to advance the Institute of Medicine’s “Six Aims for
Changing the Healthcare System” (Deyo-Svendsen, Phillips, Albright, Schilling, & Palmer, 2016; Institute of Medicine Committee on
Quality of Health Care in, 2001). Whether as a component of the CPT’s regular meetings or as a separate activity, peer review achieves
several goals. First, peer review can foster standardization of practice and consistent application of available evidence across cases.
Second, peer review helps safeguard against implicit bias (Hymel et al., 2018; Jenny, Hymel, Ritzen, Reinert, & Hay, 1999; Lane,
Rubin, Monteith, & Christian, 2002; Wood et al., 2010). Peer review allows for recognition of the instances in which a caregiver’s
appearance or attitude, for example, obscure the facts of the case, such as when a health care professional’s infant has a suspicious
injury or when a teen mother’s toddler has an accidental injury. Third, peer review protects against well-known cognitive errors in
medical decision making, such as premature closure and anchoring errors (Croskerry, 2003). Finally, peer review fosters continuous
teaching and learning, both of which lead to improved practice.
In our institution, we formally peer review every case. In addition to our weekly CPT meeting, we hold a weekly clinician’s meeting
during which we present, sometimes briefly, the cases not discussed in the CPT. We do this in order to safeguard against any effort,
conscious or unconscious, to select those cases for review about which we are most confident in our conclusions. We recognize that we
benefit from a group practice and the ability to devote the resource of time to this activity. Recognizing that not all providers have
similar resources, we suggest that cases chosen for selective peer review be identified by a means other than self-selection. A review of
all consultations from a particular day of the week, or a random selection of cases, can serve to avoid unwanted selectivity.
The culture of the peer review process should be actively tended: safety is a priority for peers who challenge the conclusions of the
child abuse consultant, as is sensitivity to the feelings of the consultant who is challenged. This culture is best established by regular
reminders to participants of the goals of peer review. As has been stated, the consistency and quality of case consultation is best
maintained by systematic review of every case; reliance on the consultant to choose which cases she or he will present may result in
biased selection and a reluctance, whether recognized or unrecognized, to avoid presentation of those cases that may most benefit from
peer review. In addition, child abuse consultants may seek out opportunities to participate in peer and case review activities conducted
by other medical services, such as morbidity and mortality rounds and case review of the pediatric trauma team or intensive care unit.
When written reports are prepared, or even for routine documentation when such documentation is shared with non-medical
professionals, review by a peer not only identifies mistakes, such as typographical errors, but also assures clarity of the writing and
conclusions; this is especially valuable for documentation that may be used in court proceedings.

2.3. Relationships with other medical services

Child abuse clinicians often depend upon the expertise of other medical services for opinions when consulted about the likelihood
of abuse. The child abuse consultant not only requires the expertise of others to reach a diagnosis, but also must synthesize the opinions
of other medical providers to develop a sound conclusion. Occasionally, the child abuse consultant may need to help other medical
professionals recognize that abuse is the etiology of a child’s findings. Similarly, the consultant may need to explain to colleagues that

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an offered explanation for an accidental injury is plausible and that the injury is not due to abuse. Consensus among all providers
involved in an individual case is always the goal; the disagreement of one professional about the likelihood of abuse may undermine
the impact of the child abuse consultant’s opinion in the family’s understanding of the cause of the child’s injuries and in legal settings.
In our experience, these disagreements take two forms. The first is when one medical provider either disagrees with the diagnosis of
abuse or is generally hard pressed to accept the possibility of abuse. The second is when a medical provider is uncomfortable rendering
an opinion as to the likelihood of abuse. Disagreements and differences of opinion naturally occur, but efforts should be made to
resolve them. We believe that such resolutions are more likely to occur when high-quality relationships between the child abuse service
and other medical services exist.
These high-quality relationships can be fostered in multiple ways. Regular education about child abuse for attendings and trainees
not only improves recognition and understanding of abuse, it also provides a forum for personal interactions with the child abuse
consultants. Participation by the child abuse consultants in shared enterprises, such as trauma teams that bring multiple services
together, also offers an opportunity for direct interactions with other specialists and the opportunity to establish positive working
relationships. A low threshold to speak personally with, for example, the pediatric hematologist ruling out a bleeding diathesis or the
neurosurgeon who evacuated a subdural hematoma, not only enhances communication, it also builds shared trust and respect between
professionals. Large children’s hospitals may make the establishment of personal relationships difficult. At a minimum, the leaders of
each service, such as division chiefs, can maintain regular communication so that disagreements can be optimally addressed.

3. At the bedside and in the hospital: components of a quality consultation

3.1. Data review before meeting the family

Prior to meeting the family, the child abuse provider should have a firm understanding of the concerns that prompted the
consultation. Speaking with the medical team allows the consultant to ascertain the question being asked and may help the primary
provider or team to clarify this question. Next, a thorough review of the patient’s medical record is needed as it may reveal useful
information. If an injury has been identified, the child abuse provider can meet with the pediatric radiologist or neuroradiologist to
review the imaging. This important step provides an opportunity to clarify the findings and discuss possible mechanisms of injury. It
also allows for discussion of possible causes of bony abnormalities and general bone health or intracranial anatomy. This review guides
further evaluation and possible imaging and other testing, such as a genetics evaluation. At our institution, a pediatric radiologist
regularly attends the weekly CPT meetings, allowing for further review and education.

3.2. Introduction to the family

After reviewing the chart, it is time to introduce oneself to the family. Our introductions include that we are medical professionals
on the child abuse team and that we are consulted anytime there is an injury in a child under the age of twelve months or there is a
worry about an injury to a child. We then describe how we work in conjunction with the hospital team, such as by recommending
diagnostic testing to help determine if there is a medical explanation or other causes of a child’s physical findings while ruling out an
abusive injury. We make clear our belief that a consistent approach to all injured children helps us to protect all children and to
decrease the risk that an abused child will go unrecognized. Consistency in this regard achieves dual goals. First, it has the capacity to
diffuse tension on the part of the family. When we explain that as consultants, we are always consulted and asked to assess for possible
physical abuse under certain circumstances, such as when a child under twelve months of age is injured, many families express un­
derstanding. Second, this consistency also serves to center and steady us as consultants. When we practice consistently, we develop
rhythms and routines that not only ground us but also may protect us from errors in judgment and bias. We strive to introduce
ourselves the same way, even when an injury appears to be consistent with the mechanism of injury.
When a case has been reported to Child Protective Services (CPS), we explain that our role as child abuse clinicians is separate from
CPS, but that we share medical findings and our final expert opinion with the investigators. We also let parents know that we will
personally notify them about test results and our opinion as these become available.

3.3. Listening carefully while taking a history

The components of a comprehensive interview of caregivers in the setting of suspected physical abuse have been well described and
include a past medical history and careful social history, family history, as well as a detailed history of the events leading up to the
admission or presentation to the hospital (Snyder et al., 2011). An understanding of any risk factors or stresses within a family not only
informs our assessment but also allows for the development of a plan to provide family support. A skilled interpreter must be used if
caregivers are not fluent English speakers. If there are two parents present, taking a separate history from each parent is most desirable,
enabling comparison of important details. We aim to find a quiet space nearby to speak to one parent while allowing the other parent to
remain with the child. This history taking is an opportunity to obtain a detailed description of the event beginning with the last time the
child was in his/her usual state of health up until the child’s entrance into medical care. Asking open-ended questions allows parents to
tell their story about what happened. It is important to give the parent one’s full attention and not interrupt the recollection of the
story. Allowing the parent to finish the full story prior to asking clarifying or additional questions may lead to a fuller understanding of
what occurred.
A review of any previously obtained histories of a child’s injury by caregivers also is important. Possible changes in and

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discrepancies between offered histories may suggest that caregivers have been misleading or untruthful. We have found, however, that
documented histories must be verified when a discrepancy or change is identified. Differences may be due to a carelessly documented
statement or repetition of mistaken documentation, and care should be taken not to place undue value in an unverified discrepancy.

3.4. The value of an observer

An observer of the interview with a caregiver can be highly valuable. An additional health care professional, such as a social
worker, nurse, or a resident present in the room can be helpful in several ways. An observer can note parental behaviors and body
language during history taking. The observer also can take notes so that the child abuse provider can listen to the parent without
interruption. Observers may recognize unconscious bias on the part of the child abuse consultant, and the observer should be
encouraged to bring this concern forward. If a caregiver complains about the behavior of the consultant during the interview, or
reports to others that certain information was not conveyed, an observer can provide an independent account of what occurred.
Finally, the observer can help to ensure the accuracy of the recollection of the interview’s details.

3.5. Using a consistent approach (same questions, every time)

When consulting on a case of suspected child abuse, a consistent approach may both prevent errors in medical decision making,
such as premature closure, and help to mitigate bias (Croskerry, 2003). We suggest that the same questions be asked, irrespective of the
injury and regardless of what any initial impression of the family may be. We routinely ask questions regarding social risk factors, such
as about the presence of intimate partner violence, mental health diagnoses, substance abuse, prior CPS involvement, history of
caregiver mistreatment in childhood, and criminal history for each case. It is helpful to normalize such questions, stating that they are
part of routine practice with everyone. We also identify sources of support and family strength. While a comprehensive social history
serves both to foster an understanding of family strengths and weaknesses as well as to dictate possible needs for services, care should
be taken to avoid using social data to understand a child’s injury. Child abuse consultants have been found to emphasize social risk
factors when evaluating injuries, even when these risk factors were not necessarily germane to the assessment of the injury (Olson,
Campbell, Cook, & Keenan, 2018; Keenan et al., 2017).

3.6. Real time discussions with other medical providers

Discussions with the other involved medical providers are an important aspect in working collaboratively toward a shared un­
derstanding of the case. For each subspecialty service that may be involved in a case, an understanding of that service’s evaluation and
opinions has impact upon the child abuse consultant’s final assessment. Some subspecialists are uncomfortable relating their findings
and opinions to a diagnosis of child abuse. For a pediatric hematologist to state that there is no medical evidence to support a diagnosis
of a bleeding diathesis is a highly useful opinion in an infant with multiple bruises, and the specialist need not make a diagnosis of
abuse for this to be true. When a diagnosis of abuse is made by the child abuse provider, however, it is ideal that the medical providers
involved be in agreement with the message given to the parents and that disagreements among providers are reviewed prior to dis­
cussions with parents. In our experience, primary and subspecialty teams often prefer that the child abuse consultant informs the
parents of the final assessment, especially in cases of abuse. Problems arise if one provider avoids a discussion about the diagnosis of
abuse as this may be interpreted by parents as a lack of confidence in the accuracy of the diagnosis.
For those child abuse clinicians who practice in teaching hospitals, paying attention to residents and students is important. In
addition to providing education regarding the management of these cases, the child abuse consultant also can be mindful of the
emotional toll these cases may have, especially for trainees, and be available to offer support and guidance. We believe that trainees
and students ought not be tasked with sharing a diagnosis of abuse. In our experience, frequent discussions with trainees will ensure
that there is consistency of messaging to the family about the diagnosis and that less experienced team members are not asked to
perform tasks for which they do not have the experience to handle expertly. Trainees should be included as observers in these tasks in
order to learn how to have difficult conversations, as well as to appreciate that abusive caregivers require compassionate and sup­
portive care.

3.7. An early meeting with Child Protective Services (CPS)

When a case is reported to CPS, an important early step in the evaluation is a discussion with the assigned CPS investigator. This
allows for information sharing between both parties, including if there has been prior CPS involvement and the nature and degree of
past services that have been provided to the family. Discussing the history provided by the caregivers may help reveal discrepancies.
The CPS investigator can conduct a home visit and possible scene investigation, providing invaluable details elucidating the possible
mechanism of injury. CPS may also have additional history regarding social risk factors. In cases in which there are siblings, CPS can
assist with having those children evaluated in a timely manner as needed. Providing the CPS investigator and supervisor with the
timeline for the medical evaluation and keeping them abreast of the results allows them to effectively plan for the disposition of the
patient.

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3.8. On-demand/ informal peer review (phone a friend)

In addition to frequent and regularly scheduled formal peer review sessions, we rely on the opportunity to speak to each other as
child abuse providers in real time, known colloquially in our group as “phoning a friend.” The calls or texts that we receive from one
another when we are not the primary provider on-call are welcomed because we know that we may be making such calls and sending
those texts when we are next on service. The opportunity for honest feedback while we are making decisions about a case helps us to
avoid bias. Whether we are feeling that a family is too “lovely” to have abused a child, or when we assess a family that has multiple
social concerns that, while real, are not relevant to the decision-making about whether an injury is due to abuse or accident, we rely
upon each other to remain consistent in our approach when we are tempted to deviate from it for any number of reasons and to receive
invaluable support from a trusted colleague. On-demand or informal peer review also may spark an expanded differential diagnosis
and consideration of additional medical explanations for a child’s findings. We have learned to appreciate the advice and possible
dissent when these are provided and recognize that the ability to safely disagree with one another is a byproduct of strong and trusting
relationships. Even the most seasoned among us rely upon this function, and we consider it one of the core attributes of our successful
team.

4. Sharing a final opinion: more than it is or is not abuse

4.1. Framing

Once the child abuse clinician has completed the evaluation and formulated an opinion, that opinion must be shared effectively. A
critical first step in this process is to be clear about the boundaries of the opinion. In most cases, we answer the following questions:
what is the likelihood of abuse? Is another explanation possible, or have these been adequately ruled out? When we make a diagnosis of
abuse, we also are asked about the likely mechanism of injury and who may have injured the child, and sometimes we can talk about
timing of the injuries and that timing can be linked to a specific caretaker. The clear identification of one caregiver as a perpetrator of
abuse can allow another non-offending caregiver to maintain custody of an abused child.
When answering the first question about the likelihood of abuse, sometimes, the answer is definite abuse. Our certainty in this
setting stems either from the fact that we have carefully ruled out other possible explanations for a child’s findings or that a caregiver
confessed to harming the child. Rarely, an abusive event is witnessed. Sometimes we can make a definitive assessment of non-abuse,
usually because an accident was witnessed and can be well explained or when we diagnose a medical explanation for a child’s findings.
At other times, there is less certainty, and our task is to convey this level of certainty to the child’s caregivers and to investigating
authorities, such as CPS and law enforcement.

4.2. Avoiding undue certainty

When the level of certainty put forth in an evaluation is well supported by the data gathered in the consultation and the medical
literature, these conclusions should be expressed clearly. When, however, as is sometimes the case, one is stuck in the proverbial gray
zone, this uncertainty must similarly be made clear. In the parlance of our team, these “gray cases” hold special challenges about which
we have written previously. In our team’s experience, approximately 15 %–20 % of our consultations fall into this “gray” category
(Chaiyachati, Asnes, Moles, Schaeffer, & Leventhal, 2016; Moles & Asnes, 2014).

4.3. Clarity about the data used to derive a final conclusion

All sources of information used in the evaluation should be documented. We document, even perhaps self-evident steps, such as an
interview with a parent or a physical examination of the child, as well as a list of people with whom we discussed a case, such as the
primary care pediatrician or a pediatric radiologist. Documenting the information that we had in hand at the time of the assessment
serves several purposes. First, for those reading the summary of the evaluation, knowing the data used to draw conclusions may inform
an opinion about the quality of the evaluation. Second, because new information may be forthcoming, a careful list of what was
available at the time the consultation was completed may clarify what was known and unknown at the time the child abuse con­
sultant’s conclusions were made. Finally, it is valuable for those who will use the child abuse provider’s conclusions to know, for
example, that she or he spoke personally to a parent or reviewed the radiographic studies of a child directly with the radiologist.

4.4. Showing one’s work

It is useful to carefully delineate the basis for one’s conclusions. This includes the evidence ruling out alternative explanations for
an injury. Accomplishing this task makes use of “positive” findings such as a skeletal survey that showed occult fractures, as well as
“negative” findings, such as a workup for a metabolic bone disorder that ruled out such a bone disorder. When reports are needed for
CPS or for court, the importance of clear, lay language cannot be overstated.

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5. Inevitable pitfalls: learning to anticipate and manage challenges

5.1. When others disagree with the child abuse consultant’s opinion

At the end of the evaluation, it is the child abuse consultant’s opinion regarding the likelihood of abuse that must be conveyed
clearly to the family and in writing in the medical record and, if necessary, to CPS and others. As noted previously, there may be
disagreement about the opinion with other clinicians. Recognizing that these disagreements exist and understanding their sources are
important aspects of the consultation. Ideally, sufficient discussion occurs prior to the conclusion of the child abuse consultation in
order to clarify the basis for the different interpretations and ensure that all parties have similar understanding of the medical eval­
uation completed and likelihood of alternative diagnoses. On some occasions, the disagreements may reflect biases about minority
families or those from impoverished communities, while in other cases, these disagreements may reflect difficulties in believing that
“these parents” could have hurt their child. Such disagreements may be more difficult to resolve if rooted in stereotypic beliefs about
what child abusers look like and how they may interact with medical providers. In these cases, it may be best to work with another
senior clinician from the same specialty to serve as a mediator and help to discuss these biases. Since a team goal is the establishment of
mutually respectful relationships with other medical services involved in abuse cases, when such disagreements arise, they can be
addressed in the context of such established relationships, making the possibility of resolution more likely.
Another challenge occurs when CPS or the police pursue actions that seem in conflict with the final opinion rendered by the child
abuse provider. We have made a diagnosis of abuse that CPS has discredited and opted not to pursue a safety plan for the child
involved. We have made a diagnosis of an accidental injury only to see police arrest a suspected perpetrator of abuse. These dis­
agreements may occur because of different interpretations or understandings of the facts of the case, an unwillingness to believe that a
particular parent could hurt a child, or implicit bias or even overt racism. These disagreements are best managed by a case review/
discussion, preferably in person. If the disagreement is with CPS, it helps to meet with the investigator, supervisor, and manager. If the
disagreement is with the police, it helps to meet with the detective and supervising officer and a prosecutor. The child abuse consultant
might include other clinicians who have evaluated the child, such as the physician from the emergency department or the pediatric
intensive care unit. These reviews are important to ensure that all parties have the same understanding of the medical evaluation and
opinion. Review of the details of the case may clarify the language being used by the clinicians versus the language understood by CPS
or law enforcement. In addition, at times, CPS and law enforcement may have information that is useful to the child abuse clinician but
has not been shared.

5.2. Errors in judgment

Mistakes in medical judgment can occur as well. The two most serious mistakes can have tragic consequences for the child and
family. Deciding that a child was abused when, in fact, abuse did not occur (a false positive judgment) can result in the child being
placed in CPS custody and removed from his or her family. These mistakes are difficult for the child abuse consultant or the child
protection team to learn about because the child and family get caught up in the CPS system, the family may have limited legal
representation and may not have a medical expert in court, and the judge in the child protection court may assume that the previous
decisions that resulted in the child’s placement were the correct ones. Furthermore, that racial and ethnic minority families are
overrepresented with respect to involvement with CPS speaks to a structural racism that must be consciously addressed in every case
(Hymel et al., 2018; Jenny et al., 1999; Lane et al., 2002; Wood et al., 2010). In contrast, deciding that the child was not abused when,
in fact, abuse did occur (a false negative judgment) can result in the child suffering from additional abuse and even dying. These
mistakes are obvious when the child returns to the hospital with another abusive injury or a fatal one, and all clinicians who provided
care to the child at the first encounter feel terrible about the mistake in judgment, even if they did not make the final decision.
As difficult as facing mistakes may be for the child abuse provider who erred and for the entire team, these cases must be closely
examined in a morbidity and mortality review format. In our experience, these are the cases that have led to the most important and
successful shifts in our collective practice. In fact, some of the practice approaches we describe in this article were born of cases in
which mistakes were made.
Equally important is the creation and nurturance of an environment in which clinicians are not blamed or vilified for errors. When
mistakes in judgment occur, they most often, in our experience, fall into two categories. The first relates to bias and, specifically, a
reluctance to recognize abuse due to other assigned positive attributes to a family. The second often occurs in the aftermath of the first:
when we have misunderstood a serious case of abuse to be due to an accident and see a child return with more serious injuries or even
death. When this happens, worry about missing another case can lead to an overcalling of abuse. We believe these pitfalls to be
inherent to us as people, and, therefore, inherent to our system. The standardized processes and systems deeply rooted in careful,
systematic team and peer review described in this article are designed to mitigate these errors. When errors occur, therefore, we see
them as system failures rather than personal ones, and, therefore, efforts are made to shore up system-level protections against them.

6. Discussion

In this article, we have aimed to make transparent the comprehensive approach we take as child abuse clinicians when asked to
determine if physical abuse has occurred. We recognize that we speak as one team and that we do not speak for all child abuse cli­
nicians. In sharing our own approach, we do not intend to be prescriptive in informing what other teams should do. Rather, we aim to
initiate a dialogue about the work done by child abuse clinicians both in response to questions raised in the mass media and in hopes

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that we can spark shared best practice between child abuse clinicians. We recognize that much of what we put forth in this article
assumes that child abuse pediatrics is practiced within a team, but that many child abuse clinicians work as solo providers. It is our
belief that core practices, such as formal peer review, can be pursued for solo providers by forming virtual communities (Tiyyagura
et al., 2019). We also recognize that solo practice is not the only barrier to the adoption of the practices we propose. Workload, time,
and staffing pressures make the addition of these practices a challenge. It is our hope that the practices for which we advocate herein
may serve as a jumping off point for child abuse clinicians advocating for the resources and time required to engage in these efforts.
We also recognize that working as a child abuse clinician can be difficult. While sometimes the decisions about the likelihood of
abuse are straightforward, they often can be complex and challenging. Ongoing research is needed to expand and improve the evidence
base upon which medical decisions are made (Lindberg et al., 2017) and examine how child abuse clinicians make decisions (Campbell
et al., 2015). Although the findings in these clinical domains will be helpful to clinicians in the field, it is our belief that the work of
child abuse clinicians benefits greatly from the teamwork of the CPT and the peer review process, which will continue to be most
helpful in uncertain and challenging cases. It takes time to learn to trust one’s colleagues and be willing to take another look at a
decision about whether abuse has occurred or not and one’s level of certainty. In these complex cases, disagreements with other
specialists pose a particular challenge. Principled, strong leadership of the abuse team that is rooted in building and nurturing
collaboration with the other providers can allow for clear and collegial discussion that, when differences arise, can lead to timely
resolution. And finally, while the goal is to get every case right, that is not possible. By focusing on the components of a consultation
laid out here, we hope to get closer to that goal.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declaration of Competing Interest

The Department of Pediatrics at the Yale School of Medicine receives grants from the State of Connecticut to support its child abuse
programs and bills for the expert child abuse consultation and testimony in court of Dr. Asnes, Dr. Pavlovic, Ms. Moller, and Dr.
Leventhal.

Acknowledgments

The authors wish to thank the following trusted colleagues for their critical review of this manuscript: Barbara Chaiyachati, MD,
PhD, Howard Dubowitz, MD, George Edwards, MD, and Sundes Kazmir, MD

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