Minimising bias in the forensic evaluation of suspicious paediatric injury

Complex Decision-Making in Paediatric Intensive Care: A Discussion Paper and Suggested Model

Paediatric Intensive Care Units (PICU) are complex interdisciplinary environments where challenging, high stakes decisions are frequently encountered. We assert that appropriate decisions are more likely to be made if the decision-making process is comprehensive, reasoned, and grounded in thoughtful deliberation. Strategies to overcome barriers to high quality decision-making including, cognitive and implicit bias, group think, inadequate information gathering, and poor quality deliberation should be incorporated. Several general frameworks for decision-making exist, but specific guidance is scarce. In this paper, we provide specific guidance on collaborative complex decision-making for PICUs. The proposed approach is on principles of procedural justice and pragmatic hermeneutics. The process encompasses set-up/planning, information gathering, question formulation, analysis (perspectives, values, and principles), action plan development, decision documentation, and a review and appeal mechanism. The process can be adapted to suit other clinical contexts. Research evaluating the process, exploring how best to develop education for clinicians, and how to build a culture that values high quality deliberation, is worthwhile.

Practices and perspectives regarding medico-legal reports in day-to-day cases in tertiary Australian child protection units

AIM

This study aimed to (i) summarise the workforce and (ii) identify how medico-legal opinion is communicated to the child protection and criminal courts within the day-to-day work of child protection paediatricians in tertiary child protection services.

METHODS

A survey of medical directors and child protection paediatricians working within tertiary child protection units within Australasia was conducted.

RESULTS

Directors from 5 out of 11 centres, and 18 paediatricians who work in these units responded. Most were female (89%) and experience varied, including many (62%) who had studied forensic medicine (Monash University). Just over half (56%) usually/always provided an interim report to the child protection system before a child is discharged and 59% had those reports peer-reviewed. Two-thirds (61%) had varied reports for the child protection agency initially with reports finalised later for the criminal jurisdiction.

CONCLUSION

Considerable variation in how opinion is communicated to the child protection system and later to police was identified. There were significant differences in staffing ratios between tertiary units which likely influences how this work is done in day-to-day cases evaluated by child protection paediatricians within their hospital due to volume of cases and demand. Peer review of opinion communicated to the child protection agency is not always undertaken and reports for the criminal jurisdiction do not always include review of evidence which may be identified after a child has been discharged from hospital. This survey captures how forensic practices and principles are embedded into child protection and exposes some challenges in being responsive to both the child protection and criminal justice systems.

Consultation for child physical abuse: Beyond the history and physical examination

OBJECTIVE

To describe the components of an approach to the consultation for suspected child physical abuse beyond the history, physical findings, and laboratory and radiographic data.

METHOD

Description of both a baseline organizational structure and recommended behaviors.

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) components 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.

Thinking fast and slow in the evaluation of injury plausibility in child protection

In evaluating injury in children, child protection paediatricians are tasked with determining whether the history given by parents or caregivers is valid with respect to explaining injury causation. This paper summarises metacognition and in particular the dual processing theory of 'fast and slow thinking' to explain how complex information in contexts of uncertainty is processed to produce decisions and responses, applied to a child protection context. An example is used that resembles abusive head trauma which focuses on understanding the difference between likelihood and plausibility in forensic interpretations of injury causation.

The developing significance of context and function: Neuroscience and law

Neuroscience has already changed the understanding of how intent forms and is acted upon, how an individual's cognitive processes shape behavior, and how bio-psychosocial history and neurodevelopmental approaches provide information that has been largely missing from the assessment of intent. In this paper, we first review the state of forensic assessment of mental condition and intent, focused primarily on the weaknesses of the current approach. In Section 2, we discuss neurobehavioral forensic assessment, which is a neuroscience-based approach. Section 3 focuses on the changing understanding of mental illness and how neuroscience is pushing law towards a functional capacity-and-ability model and away from a diagnostic cut-off model. Finally, in Sections 4 and 5, we turn to the role of social and environmental context in shaping behavior and propose a model of behavioral intent in line with the scientific evidence.

[Medicolegal aspects of child abuse]

CLINICAL ISSUE

The prevention and clinical diagnostics of maltreatment of children and adolescents represents a great challenge to all medical disciplines concerned; therefore, an interdisciplinary collaboration is indispensable.

DIAGNOSTICS

Medicolegal experts require specific radiological examination methods for the differentiation between accidental and non-accidental injuries, depending on the corresponding point in question. In addition, a clear and structured radiological appraisal of the findings is necessary. On the other hand, radiologists require an appropriate succinctly phrased question from the medicolegal expert.

PRACTICAL RECOMMENDATIONS

A close collaboration between radiologists and medicolegal experts is mandatory for a better recognition of cases of child abuse; therefore, the joint establishment of diagnostic standards and a comprehensive implementation is necessary.