For the Defense - Vol. 6, Issue 1 - 32

the parents or caretakers and the child's interaction
with them. The records may also include overall
child assessments, which are performed frequently
throughout each day. Finally, the consultation and
follow up notes by the hospital or center social
worker provide further insights into the family
and social environment of the child along with
recommendations by the social worker.
An expert will also review other parts of the
medical records to support a specific finding, i.e.,
all of the basic blood tests (complete blood counts,
blood chemistries, basic coagulation tests), other
laboratory tests (such as urinalysis and urine drug
screen testing) and all imaging reports (X-rays
including a skeletal survey and possible bone
scans, CT scans, MRIs and others).6 Skeletal surveys
view all bones for old and new fractures and their
various stages of healing as well as the overall
" strength " of the bones. In addition, there should
be specific and more detailed tests for fractures
(such as calcium and phosphorus), bruises (more
specific tests for bleeding disorders), head injuries
(bleeding disorder tests, newborn screening
results, specific metabolic blood and urine tests)
and abdominal injuries (blood tests for liver injury,
pancreatic injury).7 The testing records may include
genetic tests (blood and skin biopsies) and imaging
for specific disorders that may cause the child's
injuries.8 I have often found that evaluations may
be incomplete, which makes it is more difficult to
determine if the injuries and findings could have
a medical cause. I will ask the attorney to request
more records and if the tests were not completed
or not available, that may alone provide some
doubt for the opposing medical expert's opinions.

Commonwealth Expert Reports
It is vital for me to review the Commonwealth's
medical expert's report. Experts for the prosecution
are usually the child abuse provider at a hospital or
CAC. Their reports are comprehensive and focused
on the history, exam findings and tests used to
formulate their opinions. As an expert, I usually
can find in their reports more detailed histories
of the events surrounding and including the
incident(s). There are several red flags to consider
in the medical history that increase the probability
of abuse, including denial of a history of trauma
(car accident or major fall) for injuries that can
only be explained by major trauma if not physical
abuse, inadequate or implausible explanations for
the injury, contradictory caregiver explanations or
inconsistencies over time and unexplained delay in
seeking care.9 In addition, family and social histories
are often more complete in the expert report, as
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For The Defense l Vol. 6, Issue 1

they are focused on risk factors and family members
who have similar findings due to genetic disorders
which may provide an alternative explanation for
an injury. Medical histories and other information
about siblings in the expert report are important.
Social and environmental histories provide
important information about the child and all
household members and caretakers, which may
substantiate or undermine a particular finding.
Some of this information may be included in the
Commonwealth expert's report. However, defense
counsel may need to supplement this information
from other sources. There are risk factors based
on the child, including prematurity, physical or
developmental abnormalities and learning or
behavior problems.10 Environmental risk factors
include domestic or partner violence, stressors like
divorce or illness and unrelated adolescent or male
caregivers in the household.11 Parental or caregiver
risk factors include young or single parents, prior
abuse history for the parent or caregiver, alcohol
or substance abuse, lower education levels
and unrealistic expectations for the child and
their development.12 Other important historical
information that is useful for a medical expert
includes prenatal, delivery and postpartum history
for the mother, family methods of discipline, child
and parent/caregiver temperament, prior Child
Protective Services (CPS) history with the family and
mental health and criminal history backgrounds
for the family and caregivers.13 It may be helpful to
review any court ordered psychological assessments
of the parents or caretakers.
The exam by the child abuse provider should be
more detailed and specific for each site/system of
the body.14 Particular focus should be the areas
with obvious external injuries, but all body systems
should be thoroughly checked with documented
positive and negative findings pertinent to the
child's injuries and findings. There are individual
injuries or certain patterns of injuries that are
more likely a result of inflicted trauma, such as
a patterned bruising, specific fracture types and
patterns, specific head injuries and combinations
including subdural hematomas, rib fractures and
retinal/eye hemorrhages.15 In addition, certain
injury patterns may mimic specific diseases
and need to be differentiated, such as genetic
disorders like osteogenesis imperfecta and von
Willebrand disease.16 Factors such as the age and
developmental status of the child, as well as the
timing and severity of the injuries help to identify
those requiring further evaluations by specialists
and further testing. Exam findings more likely
to be as a result of abuse include any injury to
For the Defense - Vol. 6, Issue 1

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