Classifying Injuries in Young Children As Abusive or Accidental: Reliability and Accuracy of an Expert Panel Approach

Overview

Journal J Pediatr

Specialty Pediatrics

Date 2018 Mar 19

PMID 29550228

Citations 6

Authors

Douglas J Lorenz

Mary Clyde Pierce

Kim Kaczor

Rachel P Berger

Gina Bertocci

Bruce E Herman

Sandra Herr

Kent P Hymel

Carole Jenny

John M Leventhal

Karen Sheehan

Noel Zuckerbraun

Affiliations

Soon will be listed here.

Abstract

Objective: To assess interrater reliability and accuracy of an expert panel in classifying injuries of patients as abusive or accidental based on comprehensive case information.

Study Design: Data came from a prospective, observational, multicenter study investigating bruising characteristics of children younger than 4 years. We enrolled 2166 patients with broad ranges of illnesses and injuries presenting to one of 5 pediatric emergency departments in whom bruises were identified during examination. We collected comprehensive data regarding current and past injuries and illnesses, and provided deidentified, standardized case information to a 9-member multidisciplinary panel of experts with extensive experience in pediatric injury. Each panelist classified cases using a 5-level ordinal scale ranging from definite abuse to definite accident. Panelists also assessed whether report to child protective services (CPS) was warranted. We calculated reliability coefficients for likelihood of abuse and decision to report to CPS.

Results: The interrater reliability of the panelists was high. The Kendall coefficient (95% CI) for the likelihood of abuse was 0.89 (0.87, 0.91) and the kappa coefficient for the decision to report to CPS was 0.91 (0.87, 0.94). Reliability of pairs and subgroups of panelists were similarly high. A panel composite classification was nearly perfectly accurate in a subset of cases having definitive, corroborated injury status.

Conclusions: A panel of experts with different backgrounds but common expertise in pediatric injury is a reliable and accurate criterion standard for classifying pediatric injuries as abusive or accidental in a sample of children presenting to a pediatric emergency department.

Citing Articles

Cohort analysis of child abuse and neglect cases treated during the initial 2 years of a programme to support hospital-based child protection work in Austria.

Mora-Theuer E, Klomfar S, Ramazanova D, Grylli C, Kletecka-Pulker M, Volkl-Kernstock S BMJ Open. 2023; 13(7):e071536.

PMID: 37451739 PMC: 10351272. DOI: 10.1136/bmjopen-2022-071536.

Prevalence of inflicted and neglectful femur shaft fractures in young children in national level I trauma centers.

Loos M, Bakx R, Allema J, Bloemers F, Ten Bosch J, Edwards M Pediatr Radiol. 2022; 52(12):2359-2367.

PMID: 35523968 PMC: 9616777. DOI: 10.1007/s00247-022-05378-8.

Validation of a Clinical Decision Rule to Predict Abuse in Young Children Based on Bruising Characteristics.

Pierce M, Kaczor K, Lorenz D, Bertocci G, Fingarson A, Makoroff K JAMA Netw Open. 2021; 4(4):e215832.

PMID: 33852003 PMC: 8047759. DOI: 10.1001/jamanetworkopen.2021.5832.

Who's Watching the Children? Caregiver Features Associated with Physical Child Abuse versus Accidental Injury.

Fingarson A, Pierce M, Lorenz D, Kaczor K, Bennett B, Berger R J Pediatr. 2019; 212:180-187.e1.

PMID: 31255388 PMC: 6707841. DOI: 10.1016/j.jpeds.2019.05.040.

Social history: A qualitative analysis of child abuse pediatricians' consultation notes.

Olson L, Campbell K, Cook L, Keenan H Child Abuse Negl. 2018; 86:267-277.

PMID: 30388710 PMC: 6342195. DOI: 10.1016/j.chiabu.2018.10.003.

References

Chu H, Chen S, Louis T . Random Effects Models in a Meta-Analysis of the Accuracy of Two Diagnostic Tests Without a Gold Standard. J Am Stat Assoc. 2009; 104(486):512-523. PMC: 2701906. DOI: 10.1198/jasa.2009.0017. View

Walter S, Irwig L, Glasziou P . Meta-analysis of diagnostic tests with imperfect reference standards. J Clin Epidemiol. 1999; 52(10):943-51. DOI: 10.1016/s0895-4356(99)00086-4. View

LEVENTHAL J, Thomas S, Rosenfield N, Markowitz R . Fractures in young children. Distinguishing child abuse from unintentional injuries. Am J Dis Child. 1993; 147(1):87-92. DOI: 10.1001/archpedi.1993.02160250089028. View

Keenan H, Cook L, Olson L, Bardsley T, Campbell K . Social Intuition and Social Information in Physical Child Abuse Evaluation and Diagnosis. Pediatrics. 2017; 140(5). PMC: 5654391. DOI: 10.1542/peds.2017-1188. View

Strait R, Siegel R, Shapiro R . Humeral fractures without obvious etiologies in children less than 3 years of age: when is it abuse?. Pediatrics. 1995; 96(4 Pt 1):667-71. View

Thomas S, Rosenfield N, LEVENTHAL J, Markowitz R . Long-bone fractures in young children: distinguishing accidental injuries from child abuse. Pediatrics. 1991; 88(3):471-6. View

Willinger M, James L, Catz C . Defining the sudden infant death syndrome (SIDS): deliberations of an expert panel convened by the National Institute of Child Health and Human Development. Pediatr Pathol. 1991; 11(5):677-84. DOI: 10.3109/15513819109065465. View

Lindberg D, Lindsell C, Shapiro R . Variability in expert assessments of child physical abuse likelihood. Pediatrics. 2008; 121(4):e945-53. DOI: 10.1542/peds.2007-2485. View

Pierce M, Magana J, Kaczor K, Lorenz D, Meyers G, Bennett B . The Prevalence of Bruising Among Infants in Pediatric Emergency Departments. Ann Emerg Med. 2015; 67(1):1-8. PMC: 4695295. DOI: 10.1016/j.annemergmed.2015.06.021. View

10.

Valley M, Heard K, Ginde A, Lezotte D, Lowenstein S . Observational studies of patients in the emergency department: a comparison of 4 sampling methods. Ann Emerg Med. 2012; 60(2):139-45.e1. PMC: 3387293. DOI: 10.1016/j.annemergmed.2012.01.016. View

11.

Sadatsafavi M, Shahidi N, Marra F, FitzGerald M, Elwood K, Guo N . A statistical method was used for the meta-analysis of tests for latent TB in the absence of a gold standard, combining random-effect and latent-class methods to estimate test accuracy. J Clin Epidemiol. 2009; 63(3):257-69. DOI: 10.1016/j.jclinepi.2009.04.008. View

12.

Buesser K, Leventhal J, Gaither J, Tate V, Cooperman D, Moles R . Inter-rater reliability of physical abuse determinations in young children with fractures. Child Abuse Negl. 2017; 72:140-146. DOI: 10.1016/j.chiabu.2017.08.001. View

13.

Laskey A, Sheridan M, Hymel K . Physicians' initial forensic impressions of hypothetical cases of pediatric traumatic brain injury. Child Abuse Negl. 2007; 31(4):329-42. DOI: 10.1016/j.chiabu.2006.02.017. View

14.

Vinchon M, de Foort-Dhellemmes S, Desurmont M, Delestret I . Confessed abuse versus witnessed accidents in infants: comparison of clinical, radiological, and ophthalmological data in corroborated cases. Childs Nerv Syst. 2009; 26(5):637-45. DOI: 10.1007/s00381-009-1048-7. View

15.

Louwers E, Korfage I, Affourtit M, Scheewe D, van de Merwe M, Vooijs-Moulaert A . Effects of systematic screening and detection of child abuse in emergency departments. Pediatrics. 2012; 130(3):457-64. DOI: 10.1542/peds.2011-3527. View

16.

Reitsma J, Glas A, Rutjes A, Scholten R, Bossuyt P, Zwinderman A . Bivariate analysis of sensitivity and specificity produces informative summary measures in diagnostic reviews. J Clin Epidemiol. 2005; 58(10):982-90. DOI: 10.1016/j.jclinepi.2005.02.022. View

17.

Jenny C, Hymel K, Ritzen A, Reinert S, Hay T . Analysis of missed cases of abusive head trauma. JAMA. 1999; 281(7):621-6. DOI: 10.1001/jama.281.7.621. View

18.

Lorenz D, Datta S, Harkema S . Marginal association measures for clustered data. Stat Med. 2011; 30(27):3181-91. PMC: 3430979. DOI: 10.1002/sim.4368. View

19.

Wood J, Fakeye O, Mondestin V, Rubin D, Localio R, Feudtner C . Development of hospital-based guidelines for skeletal survey in young children with bruises. Pediatrics. 2015; 135(2):e312-20. PMC: 4306798. DOI: 10.1542/peds.2014-2169. View

20.

Lorenz D, Levy S, Datta S . Inferring marginal association with paired and unpaired clustered data. Stat Methods Med Res. 2016; 27(6):1806-1817. PMC: 5524605. DOI: 10.1177/0962280216669184. View