For the Defense - Vol. 6, Issue 1 - 33

young preambulatory infants, patterned injuries,
or multiple injuries in different stages of healing,
injuries to multiple systems and unexplained
injuries.17 Documentation of physical injuries
should include written descriptions as well as
digital photographs and/or body diagrams. These
can assist in peer review and any court testimony.18

Medical experts from the hospitals or CACs need to
assess the findings and give diagnostic impressions
and recommendations for the injuries and findings
they observe. They determine the likelihood of
abuse, which may be clear to them in certain cases,
such as injuries to multiple organs and more severe
or obvious injuries without a plausible history. If
the diagnosis is not clear, they should recommend
further testing and specialty consultations to
help determine the likelihood of abuse versus an
accidental cause and/or try to rule out medical
causes of the injuries and findings. My experience
is that some evaluations are more complete than
others, which may vary by institution or center and
by provider. Certain second and third level testing
(labs and/or images) beyond the basic initial testing
usually requires subspecialty consultation because
the disorders being tested for are very unusual.
However, second or third level testing can be
very important for the police and Child Protective
Services (CPS) investigations and ultimately for any
court proceedings.

Forensic Evidence
In addition to the medical records, it is important
for me as a medical expert to review the police,
CAC and CYS forensic records. This includes the
forensic interviews of the defendants as well
as any witnesses to these interviews. Interviews
of the child, if they are old enough, can also be
very helpful to substantiate or undermine specific
findings. In addition, preliminary hearing, pre-trial
hearing, or trial transcripts can provide valuable
information and insight about the defendant, the
child if they are able to testify, and the experts.
My experience has been that I usually receive
written summaries of the police and social work
interviews of the defendant, family members
and other witnesses. I may receive the full videorecorded interview of the child, which is more
helpful than just the written transcript. Police
and social worker interviews provide different
perspectives about a case. There are certain
aspects of the history in these interviews, as in the
medical interviews, which can raise a higher level
of suspicion for abuse. Looking for inconsistent,
implausible, or contradictory stories by the parents
or caretakers alert me to these higher risks. Police

investigators provide certain facts and statements
which can assist in establishing a timeline or raise
the possibility of other perpetrators. Social work
interviews often provide family, social/emotional
and environmental context.

Creating a timeline is very important in
determining, if possible, the timing of injuries
as well as the possibility of another perpetrator.
Police interviews of the parents, caretakers and
the witnesses help to establish the timeline.
Information about the home interior and photos
can be helpful in determining the mechanism of
injury and consistency and plausibility of the parent
or caretaker histories. Child interviews can reveal
relevant and important aspects of the history as
well as provide insight into the child's emotional
state, particularly if by video. Although not my
specific expertise, a video-recorded interview
allows observation of the psychological and
emotional state of the child during the interview.
As such, it can raise questions about the veracity
and consistency with the parent and caregiver
statements. Pediatricians are well-versed in both
the social/emotional as well as the physical and
cognitive development of children. Though not
trained as forensic mental health providers, we
as pediatric medical experts can broadly evaluate
children and can raise issues or questions to assist
attorneys in their cases and identify a qualified
expert for retention.

Additional Evidence
Follow up medical records and reports after
hospital discharge, if hospitalized, or after the
initial CAC and medical evaluations, are important
to review because there may be outstanding results
from tests initially obtained in the hospital or as
an outpatient. Some tests, such as genetic tests or
specialized metabolic or hematologic panels, often
require a few weeks to complete. In addition,
a repeat skeletal survey is necessary 2-3 weeks
after the initial one and can identify fractures
not initially seen and also help date fractures and
clarify uncertain findings.19 Distinguishing fractures
and fracture patterns of abuse from accidental or
underlying medical causes and determining the
timing of any injuries are both very important and
can be difficult. It is also helpful to review follow
up records from the specialists who see the child.
These additional records may be from the CAC
or child abuse team, neurosurgery, orthopedics,
ophthalmology, or others. Imaging such as repeat
MRIs or other tests may need to be done. It is
important to have results of the full evaluation,
which include the current status of the child and if
there are any residual findings or deficits.

Vol. 6, Issue 1 l For The Defense

For the Defense - Vol. 6, Issue 1

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