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We identified three main categories of notes used in child abuse consultations: the base model, the investigative model, and the family-dynamic model. The base model conforms to the traditional medical approach of creating a differential diagnosis. CAPs who use this model ask why the child was brought for medical care, the signs, symptoms, and associated risk indicators just as they would for other medical diagnoses. The history concentrates primarily on mechanisms of injury and alternate medical diagnoses. Risk indicators are reviewed as present or absent similar to a cardiologist reporting cholesterol levels and blood pressure measurements as risk indicators for a patient presenting with chest pain.

The base model reflects a general pediatrics-based philosophy and is firmly situated in the tradition of pediatric training. The base model may be less accessible to the non-medical audience reading the consultation note than the investigative or family dynamic model.


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While nuances of medical content are easy for physicians to decipher, the language and neutrality of this model may make the note opaque for others. The impressions paragraph spells out the medical findings and thought process underlying the diagnosis in clear, non-medical terms. In the investigative model, the CAP methods of history-taking are quite distinct from a traditional medical approach and may reflect an underlying forensic philosophy. CAPs using this model interview parents separately and actively note inconsistencies, record suspicions voiced by other family members, and more aggressively interview parents about reasons for their actions or inactions.

Although all diagnostic processes carry an investigative element, this traditionally involves triangulation of history, exam, and laboratory and radiologic findings against medical knowledge in order to arrive at a diagnosis. When CAPs use the context of a medical evaluation to arrive at not only a medical diagnosis, but also a potential timeline and potential perpetrator of a crime, they have stepped outside of a traditional medical model. Whether the CAP should adopt the perspective of the non-medical audience in his or her consultation or maintain a more focused medical perspective is debated in the CAP community, with some arguing for a clear distinction between the diagnostic and investigative roles Richards et al.

Finally, the family-dynamic model includes observations of complex family relationships and interpretations of observed behaviors. This model may reflect a more secondary prevention-oriented philosophy.

These observations may inform whether secondary prevention therapies intended to change family perceptions of the child or improve parenting skills might mitigate future risk; however, they are not diagnostic of the current injury. The use of language is strikingly different among the three models and reflects how the CAP perceives his or her role in the diagnostic process.

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In contrast to the base model, the CAP plays a more active role in the investigative model, confronting parents to answer questions and relaying whether the CAP thought the answers were adequate. All CAPs included medical information in their notes suggesting a broad consensus among our participants that a primary role of the CAP is as the medical expert. Consensus does not exist among our participants for the investigative role or the role of evaluating family dynamics as reflected by the clear distinctions in the consultation notes.

Does documenting observations of the family in the hospital help CPS or the CAP provide resources for the family or do these observations bias the end users of the notes toward the family? These are as yet unanswered questions that need to be addressed by the CAP community before best practices in documentation can be addressed.

The experiences of other forensic subspecialists both inside and outside the U. Psychiatry, for example, has formally separated the forensic role from the diagnostic or treatment roles of the physician, noting that in a forensic evaluation there is no therapeutic relationship between the client and physician, that there are clear limits to confidentiality, and that the primary purpose of the forensic exam is to answer a legal question Kraus et al.

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The American Academy of Child and Adolescent Psychiatry AACAP places emphasis on role clarity between the forensic psychiatrist and the child and family being assessed, and suggests a purposeful lack of bias with an attempt to be neutral and objective Kraus et al. In Canada, best practices in forensic pathology as related to the justice system were addressed as the result of a public inquiry Goudge, In the UK, writing about forensic child abuse reports, David suggests that a major pitfall in writing medical reports that will be used in court proceedings are selective extraction of negative information bias and using a profile of a caregiver to make a diagnosis David, While psychiatry, pathology, and pediatrics have myriad differences, and Canada and the UK have different practice of law than the U.

CAP practice. The widely varying practice models identified in this study suggest that there is an opportunity for U. CAPs to develop a best practice model for performing and documenting child abuse consultations. This analysis of CAP notes has weaknesses and strengths.

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If the differing approaches noted in the model descriptions have no relationship to these outcomes, then the use of multiple practice styles may not be relevant. Another weakness is that while we ascribe philosophical styles to the model types, the CAPs using the model type may not have had that intent. It is possible that CAPs choose model types because they feel it gives the most complete documentation of the case, because they wish to sway CPS by providing a more full positive or negative picture of the family, or because they wish to identify malleable risk indicators that need to be addressed to insure child well-being.

The main strengths of the analysis are the use of notes from 32 experienced CAPs from programs across the United States, and the identification of models that incorporate elements of recommended approaches to child physical abuse evaluations. This increases the generalizability of the study and the chance that we have identified the main models of evaluation. CAPs use three different models to evaluate injuries that may have been caused by abuse and to inform the many audiences of the child abuse consultation.

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These models reflect the variety of roles that CAPs play in diagnosis, treatment, and prevention of child abuse and as the medical expert to outside agencies. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The funder had no involvement in the study design, collection, analysis or interpretation of the data, or the decision to submit the manuscript for publication.

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Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form.

Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. Heather T. Kristine A. National Center for Biotechnology Information , U. Child Abuse Negl. Author manuscript; available in PMC May 1. Campbell , MD, MSc a. Author information Copyright and License information Disclaimer.

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The publisher's final edited version of this article is available at Child Abuse Negl. See other articles in PMC that cite the published article. Introduction Medical diagnoses require physicians to select, assemble and document relevant facts from the large amount of information available from patients and families. Methods Study Context Data for the current study were collected in the first year of a three-year period of data collection for a larger mixed method study of risk perception in child physical abuse.

Study Design Participants were asked to cut and paste their de-identified consultation notes from completed consultations of injured children into a secure, web-based interface. Participants Study participants were 32 CAPs who were recruited from two national, professional physician child maltreatment groups: the Ray E. Qualitative analysis Thirty-seven consultation notes were selected for analysis from the consultation notes submitted in the first two 3-month data collection cycles using purposive sampling to include the full range of evaluation styles and at least one note by each participant.

The editors have designed a guide through the medical, surgical, radiographic, and laboratory terrain of child abuse and neglect. For the medical practitioner, there is advice about diagnostic tools and therapeutic approaches for child victims of abuse. Nonmedical professionals will find authoritative information about current medical knowledge and practices. Those who must present their findings and opinions in court will find the collective knowledge and experience of experts in the field of child maltreatment.

Class Publishing. BMC Pediatr. Categories : Anus Child sexual abuse Reflexes Sexual abuse.

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