Developing diagnostic tools for clinicians to improve diagnostic accuracy and identify patterns of bruising in physical
Lead Research Organisation:
CARDIFF UNIVERSITY
Department Name: School of Medicine
Abstract
The NSPCC states that one in ten children are seriously abused in the UK during their childhood and that one of these children dies every week. Doctors see injured children daily where physical abuse is suspected. They have to decide whether these injuries are accidental or whether they have been inflicted intentionally. This is particularly challenging when it involves infants who are unable to give their own explanations for their injuries and who are at the highest risk of dying from abuse or sustaining life long disability or psychological scaring.
There is little published scientific evidence to help Doctors with their diagnosis or medical evidence in Care Hearings or the Criminal Courts. We urgently need quality research to protect children and to prevent parents from being wrongly accused of abusing their children.
Bruising is the commonest injury in physical abuse. The doctor is asked to say whether the pattern of bruises is consistent with an accident or child abuse, how the bruise was caused, whether the child may have a blood clotting problem, how old the bruise is and who caused it.
We will study four groups of children who have bruises from abuse, accidents, every day activities and blood-clotting problems. We will provide a scientific comparison of these groups.
We will develop three diagnostic tools to improve diagnostic accuracy.
? A statistical calculation of the distribution, size and number of bruises. This will give a probability that bruising is abusive or not and will help health professionals to identify children where child abuse is likely or can be excluded.
? Standardised digital photography to record the size, colour and shape of a bruise. are needed to provide an accurate record of the bruise for future discussion in the child protection or court process. We will develop techniques to measures size, shape and colour by counting the pixels in each bruise and monitor how this changes with time. We will determine whether this method will give the age of a bruise or answer questions about the cause of a bruise.
? An analysis of DNA from skin swabs of children. We will investigate a group of children to identify the background distribution of DNA from carers and DNA overlying accidental bruises. This will determine background information for a future study that will identify whether an individual has caused a bruise and whether we can identify or eliminate a suspected abuser.
There is little published scientific evidence to help Doctors with their diagnosis or medical evidence in Care Hearings or the Criminal Courts. We urgently need quality research to protect children and to prevent parents from being wrongly accused of abusing their children.
Bruising is the commonest injury in physical abuse. The doctor is asked to say whether the pattern of bruises is consistent with an accident or child abuse, how the bruise was caused, whether the child may have a blood clotting problem, how old the bruise is and who caused it.
We will study four groups of children who have bruises from abuse, accidents, every day activities and blood-clotting problems. We will provide a scientific comparison of these groups.
We will develop three diagnostic tools to improve diagnostic accuracy.
? A statistical calculation of the distribution, size and number of bruises. This will give a probability that bruising is abusive or not and will help health professionals to identify children where child abuse is likely or can be excluded.
? Standardised digital photography to record the size, colour and shape of a bruise. are needed to provide an accurate record of the bruise for future discussion in the child protection or court process. We will develop techniques to measures size, shape and colour by counting the pixels in each bruise and monitor how this changes with time. We will determine whether this method will give the age of a bruise or answer questions about the cause of a bruise.
? An analysis of DNA from skin swabs of children. We will investigate a group of children to identify the background distribution of DNA from carers and DNA overlying accidental bruises. This will determine background information for a future study that will identify whether an individual has caused a bruise and whether we can identify or eliminate a suspected abuser.
Technical Summary
There is only one case-control study in the world literature that compares bruising in abused and non-abused children and no studies that evaluate bruising in bleeding disorders or after known mechanism of injury. Understanding the epidemiology of bruising will help clinicians to evaluate bruises in suspected child abuse and improve their diagnostic accuracy.
Study 1: We propose a prospective observational study to compare the pattern of bruising in 4 groups of children after: abuse, accidents, every day activity and coagulation disorders. We have previously developed a prototype mathematical tool of probability from Bayesian Principals using the number, sizes and distribution of bruises to calculate the likelihood that bruising is due to abuse. We will collect relevant data in the above comparison groups to further develop this scoring system and produce a diagnostic tool of probability that a bruise is abusive or not. The score will be applicable to infants and across the differential diagnosis of bruising. We will evaluate its use in clinical practice.
Study 2: There is no scientific evaluation of the changes in childhood bruises (size, shape, orientation or colour) over time or nationally accepted standard photographic techniques in this field. Ageing of bruises involves visual assessment of colour in a bruise or photograph. Studies show that both are inaccurate.
We will develop standardised digital photographic and colorimetric techniques to give an objective measure of colour, size and appearance of a bruise. We will conduct a longitudinal study to evaluate the change in bruises over time. We will use sequential images of bruises at intervals from the time of injury: to evaluate the change of colour and appearance and whether this method can be used to age bruises.
Study 3: DNA of the perpetrator can be found on the skin of adult strangulation victims. This has the potential to identify or eliminate the perpetrator of an abusive bruise.
We have already developed a novel method to collect DNA from the faces of infants and young children and mapped normal levels of carers? DNA found on the head and neck. We will extend this baseline mapping to the rest of the body, infants at different developmental stages and accidental bruises. The technique will eventually be applied to DNA from bruises in children referred under the child protection procedures to determine whether a child has been hit or slapped and to identify the perpetrator.
Study 1: We propose a prospective observational study to compare the pattern of bruising in 4 groups of children after: abuse, accidents, every day activity and coagulation disorders. We have previously developed a prototype mathematical tool of probability from Bayesian Principals using the number, sizes and distribution of bruises to calculate the likelihood that bruising is due to abuse. We will collect relevant data in the above comparison groups to further develop this scoring system and produce a diagnostic tool of probability that a bruise is abusive or not. The score will be applicable to infants and across the differential diagnosis of bruising. We will evaluate its use in clinical practice.
Study 2: There is no scientific evaluation of the changes in childhood bruises (size, shape, orientation or colour) over time or nationally accepted standard photographic techniques in this field. Ageing of bruises involves visual assessment of colour in a bruise or photograph. Studies show that both are inaccurate.
We will develop standardised digital photographic and colorimetric techniques to give an objective measure of colour, size and appearance of a bruise. We will conduct a longitudinal study to evaluate the change in bruises over time. We will use sequential images of bruises at intervals from the time of injury: to evaluate the change of colour and appearance and whether this method can be used to age bruises.
Study 3: DNA of the perpetrator can be found on the skin of adult strangulation victims. This has the potential to identify or eliminate the perpetrator of an abusive bruise.
We have already developed a novel method to collect DNA from the faces of infants and young children and mapped normal levels of carers? DNA found on the head and neck. We will extend this baseline mapping to the rest of the body, infants at different developmental stages and accidental bruises. The technique will eventually be applied to DNA from bruises in children referred under the child protection procedures to determine whether a child has been hit or slapped and to identify the perpetrator.