An analysis of physicians' diagnostic reasoning regarding pediatric abusive head trauma

the Pediatric Brain Injury Research Network (PediBIRN) Investigators

Research output: Contribution to journalArticlepeer-review

Abstract

Background: Physician diagnoses of abusive head trauma (AHT) have been criticized for circular reasoning and over-reliance on a “triad” of findings. Absent a gold standard, analyses that apply restrictive reference standards for AHT and non-AHT could serve to confirm or refute these criticisms. Objectives: To compare clinical presentations and injuries in patients with witnessed/admitted AHT vs. witnessed non-AHT, and with witnessed/admitted AHT vs. physician diagnosed AHT not witnessed/admitted. To measure the triad's AHT test performance in patients with witnessed/admitted AHT vs. witnessed non-AHT. Participants and setting: Acutely head injured patients <3 years hospitalized for intensive care across 18 sites between 2010 and 2021. Methods: Secondary analyses of existing, combined, cross-sectional datasets. Probability values and odds ratios were used to identify and characterize differences. Test performance measures included sensitivity, specificity, and predictive values. Results: Compared to patients with witnessed non-AHT (n = 100), patients with witnessed/admitted AHT (n = 58) presented more frequently with respiratory compromise (OR 2.94, 95% CI: 1.50–5.75); prolonged encephalopathy (OR 5.23, 95% CI: 2.51–10.89); torso, ear, or neck bruising (OR 11.87, 95% CI: 4.48–31.48); bilateral subdural hemorrhages (OR 8.21, 95% CI: 3.94–17.13); diffuse brain hypoxia, ischemia, or swelling (OR 6.51, 95% CI: 3.06–13.02); and dense, extensive retinal hemorrhages (OR 7.59, 95% CI: 2.85–20.25). All differences were statistically significant (p ≤ .001). No significant differences were observed in patients with witnessed/admitted AHT (n = 58) vs. patients diagnosed with AHT not witnessed/admitted (n = 438). The triad demonstrated AHT specificity and positive predictive value ≥0.96. Conclusions: The observed differences in patients with witnessed/admitted AHT vs. witnessed non-AHT substantiate prior reports. The complete absence of differences in patients with witnessed/admitted AHT vs. physician diagnosed AHT not witnessed/admitted supports an impression that physicians apply diagnostic reasoning informed by knowledge of previously reported injury patterns. Concern for abuse is justified in patients who present with “the triad.”

Original languageEnglish (US)
Article number105666
JournalChild Abuse and Neglect
Volume129
DOIs
StatePublished - Jul 2022

Keywords

  • Abusive head trauma
  • Diagnosis

ASJC Scopus subject areas

  • Pediatrics, Perinatology, and Child Health
  • Developmental and Educational Psychology
  • Psychiatry and Mental health

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