Division of Population Medicine, School of Medicine, Cardiff University, Wales, United Kingdom.
Child Abuse Negl. 2018 Aug;82:178-191. doi: 10.1016/j.chiabu.2018.06.009. Epub 2018 Jun 16.
Clinicians face unique challenges when assessing suspected child abuse cases. The majority of the literature exploring diagnostic decision-making in this field is anecdotal or survey-based and there is a lack of studies exploring decision-making around suspected abusive head trauma (AHT). We aimed to determine factors influencing decision-making and multidisciplinary collaboration in suspected AHT cases, amongst 56 child protection professionals. Semi-structured interviews were conducted with clinicians (25), child protection social workers (10), legal practitioners (9, including 4 judges), police officers (8), and pathologists (4), purposively sampled across southwest United Kingdom. Interviews were recorded, transcribed and imported into NVivo for thematic analysis (38% double-coded). We identified six themes influencing decision-making: 'professional', 'medical', 'circumstantial', 'family', 'psychological' and 'legal' factors. Participants diagnose AHT based on clinical features, the history, and the social history, after excluding potential differential diagnoses. Participants find these cases emotionally challenging but are aware of potential biases in their evaluations and strive to overcome these. Barriers to decision-making include lack of experience, uncertainty, the impact on the family, the pressure of making the correct diagnosis, and disagreements between professionals. Legal barriers include alternative theories of causation proposed in court. Facilitators include support from colleagues and knowledge of the evidence-base. Participants' experiences with multidisciplinary collaboration are generally positive, however child protection social workers and police officers are heavily reliant on clinicians to guide their decision-making, suggesting the need for training on the medical aspects of physical abuse for these professionals and multidisciplinary training that provides knowledge about the roles of each agency.
临床医生在评估疑似儿童虐待案件时面临独特的挑战。探索该领域诊断决策的大多数文献都是轶事或基于调查的，缺乏研究探索疑似虐待性头部创伤（AHT）的决策。我们旨在确定影响疑似 AHT 病例决策和多学科合作的因素，涉及 56 名儿童保护专业人员。对来自英国西南部的临床医生（25 名）、儿童保护社会工作者（10 名）、法律从业者（包括 4 名法官在内的 9 名）、警察（8 名）和病理学家（4 名）进行了半结构式访谈。采访进行了录音、转录并导入 NVivo 进行主题分析（38%进行了双重编码）。我们确定了影响决策的六个主题：“专业”、“医疗”、“环境”、“家庭”、“心理”和“法律”因素。参与者根据临床表现、病史和社会史排除潜在的鉴别诊断后诊断 AHT。参与者发现这些案例具有情感挑战性，但意识到他们的评估中存在潜在的偏见，并努力克服这些偏见。决策的障碍包括缺乏经验、不确定性、对家庭的影响、正确诊断的压力以及专业人员之间的分歧。法律障碍包括法庭上提出的替代因果理论。促进因素包括同事的支持和对证据基础的了解。参与者对多学科合作的经验总体上是积极的，但儿童保护社会工作者和警察严重依赖临床医生来指导他们的决策，这表明需要对这些专业人员进行有关身体虐待的医学方面的培训，并进行多学科培训，使他们了解每个机构的角色。
