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AJR May 2017

Cindy W. Christian, MD
Anthony A. Latini Endowed Chair in Child Abuse and Neglect Prevention,
The Children's Hospital of Philadelphia
Professor, Pediatrics
Associate Dean for Admissions
The Perelman School of Medicine at The University of Pennsylvania and
The Children's Hospital of Philadelphia

Properly identifying and imaging suspected abuse in young children can often present many challenges. While it’s important to report and take the appropriate steps for the well-being of the child, radiologists also have to be aware of common childhood injuries and misdiagnoses that could mistakenly present as abuse. In this interview, Dr. Cindy Christian discusses some of the common injuries that are mistaken for child abuse, proper steps to reporting such cases, and best practices for keeping children safe.

1. How often are common injuries mistaken for child abuse?

Answer: The majority of injuries sustained by healthy children are due to preventable, accidental trauma. Only a small percentage of childhood injuries are related to abuse, and there are also medical diseases that must be considered in the differential diagnosis. Most common injuries are easily recognized as accidental, especially in verbal, healthy children who can provide a history of their trauma. The concern about abuse is greatest in infants and young children. In this population, accidental injury or disease should be included when thinking about possible abuse.

2. What are some of the common misdiagnoses for suspected child abuse?

Answer: The most common cause of injury in childhood is accidental trauma to an otherwise healthy child. On occasion, because of social or other concerns, or because of biases in reporters, children with accidental injury are reported to child protective services for investigation of possible abuse. In terms of medical diseases that may mimic abusive injuries, categories that physicians need to consider include coagulopathy (i.e., bleeding disorders) in children who present with bruising or abnormal bleeding, metabolic or genetic bone diseases in children who present with fractures, or other less common, metabolic diseases in some infants.

3. What is the radiologist's role in ensuring proper diagnosis and ethical reporting for any suspected abuse?

Answer: As licensed physicians, radiologists are mandated reporters of suspected child maltreatment. In practice, however, many radiologists assume that front line clinicians will make reports to child protective services when there are concerns of abuse. This may or may not occur, and radiologists have a legal mandate to help protect children. A radiologist’s role is to accurately read radiographic studies, provide a diagnosis or a differential diagnosis based on their interpretation, recognize findings that suggest child abuse or neglect, and report concerns so that children can be protected.

4. If child abuse is suspected, what are the best practices for reporting the case to protect the child?

Answer: All physicians should know how to make a report of suspected abuse in their state, as the systems of reporting vary by state. The radiologist should also coordinate care with the physician responsible for the child’s care, to ensure that the appropriate reports are made to Child Protective Services (CPS). They should be aware that they are mandated reporters. They are responsible for reporting suspected abuse, unless they know that a report has been or is being made when there are reasons to suspect a child is a victim of abuse.

5. What protocols would you recommend for ensuring proper imaging and, if needed, proper reporting for suspected child abuse?

Answer: Radiologists should all be familiar with the standards set by the American College of Radiology for skeletal imaging in cases of possible abuse, and they should be familiar with their state’s reporting laws on suspected child abuse and neglect.


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