So my name is Jonathan Beaver. I'm one of the postdoctoral fellows, postdoctoral scholars with the Rock Ethics Institute. I'm really happy to be here, and I want to thank my colleague Nikolai Murar, and our staff members Rob Peeler, who's at the back, Deborah Charlonis, and Carol Lombrick for their help in...
organizing this series. Want to also thank Doug and Julie Rock for their ongoing support of our work here at the Rock Ethics Institute. It's my pleasure this evening to welcome to University Park all the way from Hershey, Dr. Benjamin Levi, physician and professor Professor of Pediatrics and Humanities at the Penn State University College of Medicine and the Penn State Children's Hospital. Dr. Levi received his MA, his PhD, and his MD from the University of Illinois at Urbana.
He is a board-certified pediatrician and fellow of the American Academy of Pediatrics. Besides regular and ongoing supervision of clinical work and his own patient care activities, Dr. Levi also teaches bioethics regularly to medical students, residents, and nurses. He leads at least three research projects, including an interactive online decision aid related to advanced care planning called Make Your Wishes Known, an online resource for mandated reporting of suspected child abuse called Look Out for Child Abuse, and Penn State Suspicion Project, an ongoing research project on reasonable suspicion in the context of child abuse reporting.
This evening we're very excited to have Dr. Levi here for a talk titled, Suspecting Child Abuse Challenges and Guidance. Dr. Levi will give us 45 seconds. a 45 or 50 minute talk and we'll have a great period of questions and answers at the end.
So without further ado, please help me in welcoming Dr. Benjamin Lieber. Well, first of all, thank you all for your interest in this topic and I hope to raise some interesting questions and challenges and perhaps provide some guidance as well. So uncovering child abuse is not just a just a diagnostic dilemma, it's a dilemma in terms of values and ethics. What I'm going to try to do in the next 45 minutes or so is first provide a bit of the landscape of the issue, talk about some of the ethical...
challenges that arise, provide you some data from some empirical work that we've done, talk to you a little bit about both the analysis of these data, but also how we think they ought to be framed, and lastly, to hopefully provide a bit of an action plan about what we can do to move forward. So on the one hand, what could be simpler than the ethics of child abuse? If you do it, stop. If you see it, stop it.
But they're actually what may seem to be the most important. seem clear on its surface belies much deeper problems in terms of definitions, in terms of accuracy, in terms of judgment calls. And I'm going to talk about each of those in some detail. So when it comes to underlying questions in terms of definition, the very notion of what counts as abuse is itself disputed. The editor of, former editor of JAMA, Catherine DeAngelis.
tells a story about how when she was at Baltimore at Hopkins, she used to teach the police officers about child abuse. And she would begin her lecture by asking, how many people spanked their children and every hand was raised? And then she said, all right, how many of you beat your children? And she said, no hand was ever raised.
And then she asked how to tell the difference, and the fun began, as she said. And that's both in terms of physical abuse, but it's also what counts as a crime. is neglect. There's an author, an essayist named Lenore Skenazy, who a few years ago ignited this national fire about, you know, how old your child should be before you allow to leave them home alone. In her case, it was actually, she was in New York City and she allowed her nine-year-old to go home on his own via the subway.
And some people applauded her for having done, you know, not be a helicopter parent and other people were ready to report her for neglect. In the realm of emotional abuse, it can be very difficult to draw a line between harsh parenting. If you were in the car with me and my daughter driving up, actually my whole family, she would give you a different answer about what counts as emotional abuse than certainly I and her mother would.
Imminent risk is, if you don't already know, it's when something, it would have counted as abuse and neglect, but for... bad luck. So I take a hatchet and I throw it at my son and I miss.
The fact that I had bad aim doesn't make it non-abusive. It just means I had bad aim. Sexual abuse in terms of definitions is a very different animal. Sexual abuse compared to the other kinds of abuse is typically much more premeditated. It is really sort of a whole other can of worms.
And so it's something to be distinguished. Another kind of uncertainty that we deal with is accuracy, both in terms of mechanisms of injury, how did an injury occur, people's intentionality, and intentionality matters. If a child comes in and they've got huge bruise on their forearm and dad did it when he grabbed his arm really hard, it matters whether he was trying to pull his son out of the way of oncoming traffic or something else. And figuring out what people's intentions were or are can be a very important part of the process.
be challenging. So too it's challenging to figure out whether a story is credible and I'm going to tell you several clinical stories in just a little bit but whether you how you believe and what you believe is is certainly in flux. And then lastly the question that people often don't want to discuss openly is the value or utility of actually reporting a child and whether the intervention of Child Protective Services is actually going to help this child or or not. So, too, we have issues of judgment.
What are acceptable thresholds of risk? We had an ethics consult come to the hospital. I used to direct the ethics consult service at Penn State Hershey Medical Center.
And it was a physician who had a 10-year-old child with an immune deficiency whose parents were planning to take the child on a mission trip for several years to literally the jungles of Central Africa. And the concern was, you know, that's a problem. That puts this child at greater risk, given their underlying immune problems.
Does that count as an unacceptable risk? Reasonable protections. How far must we go in order to protect a child? If you talk to my son, Dewey, when he was in grade school, he would tell you at great length how they weren't allowed to do anything on the playground.
When I asked him why that was, he says, because they're all moms. All the playground monitors were moms. there was a dad out there, a dad would let them do all sorts of things.
And so gauging what counts as a reasonable protection for a child is in dispute. And, you know, I should say before I go on that this is particularly acute when we have a child who's in the hospital and we think that they need a particular safety plan before they go home and Children and Youth Services says, no, no, we don't need that. This is sufficient.
Whose judgment prevails in terms of what is an adequate safety plan? Or a lot of work that I've done, empirical work, is about what should be the threshold for reporting suspected abuse, and I'll go into that. And then some more recent empirical work I've done is about, you know, if reasonable suspicion is the front end, the back end is reasonable medical certainty. When a physician or other clinician is asked to go into court and testify that there's reasonable medical certainty that the injury or condition was due to abuse, what does that mean? So sometimes there can be resolution.
if we have better data, we have better correlates. There's a woman, Mary Clyde Pierce in Chicago, she's an ED physician. She's developing an algorithm for what kinds of bruises are more likely to be abused.
It turns out the most specific is circumferential bruising of the ankle. Almost nothing causes it other than an abusive type of grab. Similarly, if we have experts, board certified pediatricians who do their work well, we're more likely to to resolve some of these problems.
Improved communication, this is the bugaboo. People don't always listen, they don't always ask good questions. And if you develop relationships with people, it can make things go better. It can improve understanding. You ask a child how things went, he says, my dad beats me every morning.
You oughta find out whether it's in chess or whether it's with a stick. So, you know, we can't assume on its face that what we think we understand is what is actually going on. To that end, if we do a better job analyzing things, we can often move beyond the assumptions and biases that we begin with before we do that kind of analysis.
If we have better definitions of what counts as abuse, we're going to do better. And unfortunately, if we had better consensus, because we often don't, there can be resolution. Where the ethical challenges often come in is when... and we don't have. certainty.
We don't know what to believe. So imagine that a dad comes and you see a child and child has a rope burn around their neck, halfway across the neck, and the dad says, you know what, what happened was... I was in the front yard, I was raking leaves, and I heard the scream from the backyard.
I went in the backyard, and my daughter was playing horse with the next-door neighbor. There was a rope tied around my daughter's neck because she was the horse and they were going around. fell and this is what happened. Do you believe that?
Funny story. It's what happened to me. My daughter, Rosie, was playing horse with our next door neighbor, Kara, and as soon as I made sure she was okay, this is almost 10 years ago, I thought, oh great, you know, she's going to go to school and I'm going to get reported for suspected abuse.
We often are left with uncertainty. What's the actual risk of abuse? A few months ago, I saw these two boys that I've been taking care of since they were babies. 10 years old and eight years old. Typical well child checks, they're fine.
And I do the eight year old first. I do my physical, do my history, everything else. And when I do my physical, check out their private parts. And for boys, it's, I mean, for both boys and girls, it's as a general pediatrician for a general exam, it's pretty straightforward. I make sure his testicles are both down.
I push a finger up to see if he's got a hernia. I say, pretend like you're taking a poop, but don't, you know, and push down and. And so I did it with the 8-year-old boy, and he was fine.
And then I went to the 10-year-old, and I was doing his exam at the very end. And I uncovered their genitals for maybe eight seconds. And I said, now we're going to check out your private parts when we do that because I'm a doctor, because your mom's here.
And I remind kids about a thing called bad touch. And a bad touch is if someone touches you and it makes you feel bad. And it may be because they're hitting you or they're touching you where you don't want to be touched. But if it feels bad, you tell your mom. That's as far as I go.
And before I go, I'm going to tell you a story. Before I could even finish that, this boy started crying, I mean inconsolable crying. We couldn't get him to stop. It took four or five minutes.
He did not want me to examine his private parts. This is a big red flag. I talked to his mom right there in the room. I asked a bunch of questions.
There were no risk factors, but this was really unusual. Does that rise to the level of needing to report? Yeah.
actual risk of abuse. I mean, it could be he's just really shy, right? It could be that he doesn't, maybe he's less endowed than his brother and he doesn't want the comparison. It could be that he's been hearing about, you know, what happened with Sandusky and he's fearful.
Could be that he has an anxiety disorder or that, you know, he's internalized something and he's struggling with it, or it could be abuse. I have no idea what the likelihood of abuse is in that kind of case, right? So these are the kinds of...
situations where we don't have anything resembling certainty. We also don't know how to often interpret the guidelines. And I'm going to tell you about a case that got me started.
This is what got me started almost a dozen years ago. I was covering acute clinic, which means I was supervising residents and medical students. And I was the attending, so I needed to oversee everything. And I went into a room, and it was a Friday afternoon, because it's always a Friday afternoon. And there was a dad.
with his two daughters and they were eight and six and they were there for a cold which always makes you go hmm why is an experienced parent here for a kid with a cold and it was dad dad's usually don't bring in their kids it's usually moms and a few things that you're late he's a friend of mine he and I and when I came in the room there were these two girls both with colds in their dad and and I happened to notice that this girl had a really bruised swollen nasal bridge and i'm i'm a curious guy so i always ask what happened and if dad had said well you know what we're playing ball in the front yard and i threw the ball and right as she was about to catch it her mom opened the screen door and she turned to look and it hit her right in the nose i might have been done but that's not what the dad said what the dad says well we don't know all right we don't know what happened she just came into our room at night her nose was bleeding and And, you know, she sleepwalks, so we figured she hurt herself. I looked through the chart, no unusual emergency department visits, no documented concerns, but doctors are often terrible about documenting things, and even if they do, you can't read their writing. And so the dad was impatient, and the more I asked, the angrier he got at one point, saying, we don't beat our kids if that's what you're asking.
I said, well, you know, that's not what I'm asking, but it's part of my job to make sure kids are safe. And I noticed that dad had a lot of issues with that. That hat is hand bandaged.
curious guy so I asked him what happened and he had 78 stitches about 10 days ago because he'd almost cut his hand off in a bandsaw accident and I know that I'm less patient with my kids when I'm in discomfort and so it all sort of figured into my thinking. So there's the case. And I went to my colleague who was their regular pediatrician.
I'd never met them before. And my colleague, who's an otherwise very good pediatrician, said they're a good family. They wouldn't hurt their kids.
And that is just ignorance. Almost nobody wakes up in the morning and says, they haven't hurt a kid today. You know, they get frustrated, they don't know what to do, and they lash out. And the things that predispose to abuse, if you cut across everything else, it's stress. It may be financial stress, it may...
be social stress, it may be that the kid has a chronic illness, it may be the kids be in a pain that day, it may be that parents have untreated ADHD or that they have alcohol or drug abuse problems. There are any number of things but stress is is what cuts across everything else. And I went to the nurse, and the nurse said to me, this is a family that's on the brink.
The slightest push could blow this family out of the water. That was a direct quote, I remember. And so the question is, does this rise to the level of reasonable cause to suspect?
So let me ask you these questions. If you'd raise your hand for them, how many people think it's possible that this was due to abuse? Go ahead, raise your hands. Keep your hands up. How many people have some suspicion that this is due to abuse?
No hands have gone down. How many people would say that you have reasonable suspicion? That's the threshold for reporting. At least half, two-thirds of the hands go down. How many of you believe that this was due to abuse?
Almost all hands, all but a couple of hands go down. And that is an exercise in the power of language. Language matters.
It matters because how you can say it. conceptualize something determines whether you may report it or you're not going to. And this is a big deal. It shows that words matter.
So the laws around the country use very different kinds of words. This is arguably, I think, the best. This is from the California Penal Code. It says it's objectively reasonable for a person to have reasonable suspicion based upon facts that could cause a reasonable person in a like position drawing when appropriate upon his or her training experience to suspect abuse, right?
This is a normative standard, right? And if people, it's what most people would do. Now, you saw the difference between suspect and belief, and if you look at laws in the United States, the yellow are those that use some variant of belief and the blue are used some variant of suspicion, right? And there are 11 different statutory wordings and guess what? It actually makes a difference which wording you use, right?
So a student and I did an analysis of these different statutory wordings and it turns out that you get different reporting rates. total is the number of kids who are reported per thousand, all right, so reason to suspect or cause to suspect, both of those, 41.9 children per thousand, all right, and so you see some variation. I'll make it a little bit more straightforward.
If we divide them into suspicion versus belief, different categories, you see there's a difference. Those states that use suspicion as part of their statutory wording have 50.4 kids per thousand that are reported versus 41.9. 21.9, right? And of those 50.4, 29.3 of those kids, they say, yeah, we're going to investigate this.
And 21.1 say, no, they're not. And you again see, this is not just, you know, general, the public, this also includes healthcare personnel. And this matters.
I mean, we're talking about between these two thresholds, a difference of over 600,000 referrals and 324,000 screened in calls, right? And, you know, an investigation for child abuse can be about as gentle as a tax audit. it.
And what happens depends upon what county you're in, at least in Pennsylvania. In some counties, they'll whip a kid out of a home in a heartbeat. In other counties, the kid has to have a spear sticking out of their head before they'll do anything.
So it matters, and it matters to families. And so we're often left with uncertainty. And in a survey that we did of Pennsylvania pediatricians, we asked people, you know, given the practical implications of, you know, you know, will intervention help, right? They don't know.
What people say is, well, one person says, sure enough, I have to be sure enough to warrant the disruption, the loss of. Trust, the decrease in the relationship, and the turmoil that I put a family through. Because these things actually make a difference.
And the problem is the system is deeply flawed. The child protection system, if not the system, not broken is enormously bent out of shape and it's the only system we have. All right, so it's the only system we can rely upon and to not rely upon the system is to throw a child's safety to the winds.
And it matters. It matters. This, it seems to me, and this is why I began to take this question seriously, that I need to be prepared for this girl coming back to my office in 10 years and saying to me, why didn't you report me?
You were the only person who ever saw physical evidence of what my father did to me. It took me 10 years to escape his clutches. Why didn't you report me? I need to have an answer for that. I also need to have an answer if she comes back in 10 years and says, why did you do that to my family?
It blows my mind. blew us apart, I haven't seen my sister for four years. Why did you do that to us? And it seems to me conceptually, all of us who are mandated reporters of suspected abuse, which is a lot of people, we owe it to the children, we owe it to the families, we owe it to ourselves to have a conceptual and an applied understanding of what this is.
Now, the problem is, of course, is that lots of things put kids at risk. And there's a certain role that luck plays about who gets hurt and who doesn't. You know, kids will get on your last nerve and jump.
on it just to see what happens. We were going, we were one time when my kids were a little bit younger, they were 14 and almost 11 now, and my son Dewey, he was about 4 and a half or 5 then, and we were running late because we always run late and it drives me crazy. And we were, I had kids in the car and I need to go.
And Dewey was on the floor searching for someone on Froot Loops or something. I don't know what. And he, I said, Dewey, you got to get up in the seat. And he said, I'll just be a minute.
I said, Dewey, we got to go. He said, I just, just be, I just got to find this. And, and finally I said, Dewey, I have a meeting.
I got to get going. And he said, he sort of threw back over his shoulder. That's okay. You can wait. That's what kids will do.
Another time we were running late, we were going to someone's house and we were all dressed up. I remember exactly when it was. We had just gotten what for us was a brand new car, a nice Honda Pilot, first car I ever had that had a CD player in it. I was excited and we were running late and Dewey was looking for something and he didn't want to go. So he was four and a half.
And so, you know, I do what any good dad does. I picked him up, put him under my arm. We're walking out the door and he grabs a hold of the... of the doorknob with one hand he grabs a hold of my shirt with the other and as I go he yanks this button off and there's no time to change I mean we were running late these people were expecting us I was furious we went to the car and I tossed him in the car and throw him over and I just tossed him in the car and I slammed that door And as soon as I slammed that door, I thought to myself, oh my goodness, what if he had reached out?
If he had reached out, I would have broken his arm in four places. It would have been an open, accommodated fracture. It would have needed at least two or three surgeries. And every person would have been right to report me for suspected child abuse, injuring my son in a fit of anger. Why didn't I get reported?
Because of the luck that my son did not reach out. We had a young, newly minted child abuse pediatrician at our institution some time back who was telling a courageous story about how there was a four-year-old boy who had gotten a broken arm. And the way he got a broken arm was he was... He was riding a scooter, one of these scooters. And he and his family, this is part of their culture, and they go riding every weekend at these rallies.
And he was going 40 miles an hour. He was wearing his helmet. And he's 4 half years old and he broke his arm and the parents were totally not apologetic. I mean this was just something that happens it's part of the sport and the child protection team was increasingly frustrated and eventually they threatened the family that if they didn't sell this motorcycle they would report them for abuse and neglect.
And so the family did. But who did they sell it to? They sold it to somebody else with a four and a half year old. There are rallies where four and a half year olds race.
So are they, does that mean we should be justified in going to these rallies and charging everyone whose kids have not gotten... injured yet for abuse and neglect they haven't had the bad luck that their kids been injured I mean how do we figure out how luck makes its way into our understanding now not everybody views that some people The world is much more simple. The world is a world of black and white. So when we ask people what reasonable suspicion means, we had one person who wrote, I'm projecting this was their voice, that reasonable suspicion constitutes any suspicion.
It's ludicrous. to quantify any percentage before you report any incident. And their cousin then also wrote, reasonable suspicion is just that.
If there's one iota of suspicion, I report. Wow. It seems to me you'd be reporting a lot of people.
I think a better answer, and this was somebody else's, this is my colleague Cheryl DellaSega and I wrote this paper a couple years ago, that it's reasonable, not far-fetched or outlandish, possibility that the injury occurred by abuse. Not just that it's in a long line of possibilities. This person, this physician wrote, cancer can always be on the differential or on the rank order list for a kid with fever, but most of the time it's not reasonable to think it is a likely cause.
And I think these things require careful thought if you're being intellectually honest, because the first grader who says that she fell from the monkey bars may have been abused. So too the happy-go-lucky preschooler who's suddenly always sad. where the seventh grader, who was inexplicably withdrawn, I once saw a 15-year-old boy, Friday afternoon always, who came in for a 10-minute appointment for a sore throat, and I went to swab his throat, and he was like, And he was really anxious. Are you getting to sense? I'm a curious guy.
So I turned to mom and I said, is he always this anxious? And mom said, well, you know, he has been for the last few months whenever he was getting ready to go visit his dad for the weekend. And over the next 10 minutes, to my shock and mom's horror, we learned that, at least according to the young man, that dad had not only been physically abusing him, dad had been sexually abusing him. And the last time he was at dad's house, they were fishing in the river and dad held his hand underneath.
the water for a minute. That was from a kid who's unusually anxious. So if you're not looking, you're not asking the right questions, you're not going to find these things, right?
So when there's one iota of doubt, report, you're going to be reporting a lot of your practice, a lot of the kids you... see in your class and school, a lot of the, you know, you're going to be reporting to a lot of people. There's enormous variability in terms of individual interpretation, and this creates real ethical problems in terms of how we allocate scarce resources. and how we treat parents, if we do so in a fair, just manner, and frankly, how we protect children.
If you don't have standards, it's a hard business to protect kids in an appropriate way. So here's some empirical data about how do professionals understand and interpret reasonable suspicion. And this was my question.
This is what I really wanted to understand. And I didn't want to know what are the signs and symptoms of abuse or what they think the risk factors or red flags are. and I along with various colleagues did a variety of studies asking these questions and I you these are the various populations of people RR stands for response rate and you can see quite readily when I discovered that a five dollar gift certificate to Starbucks will get you a better response rate okay you And I wanted to abstract away from all the clinical relevant issues. I'll give you the physician version of this, which was, imagine you've encountered, actually no, this is everybody. Imagine you've encountered a child who has an injury or condition that could have been caused by abuse, and you've gathered as much information as you feel it's reasonable to do, given the source is readily available.
on a list of possible explanations, right? How likely would abuse have to be? So if I come in and you say, how you doing, Benny?
I say, I got a headache. My headache could be due to stress. It could be due to lack of sleep. It could be a migraine. It could be, I got hit by somebody.
It could be I've increased intracranial pressure. I could have a brain tumor. I could have, you know, any number of things.
And one of those things you're going to rank, if you're smart, it'll be stress and lack of sleep as those are the two highest ones on the different, on this rank order list. And so what I want to know is, was how high on this rank order list does abuse have to be before you feel you have reasonable suspicion? Would it have to be most likely? Could it be the least likely thing?
We just arbitrarily cut this off at 10 or somewhere in the middle. And so this is what we found. all over the board.
Now these, it's sort of a busy slide, but you see the first group that I surveyed were pediatricians, that's the hot pink, nursing students, nurses, daycare providers, community mandate reporters, abuse experts, and undergrads, right? All over the map. As many people People said that abuse would have to be second most likely, a seventh most likely.
So there's no standard at all. And the reason this matters is that sometimes people say, well, if you think it's a possibility, report. Well, how likely a possibility must it be? And you notice, by the way, that for child abuse experts, these are clinicians and researchers in the field of child abuse, the Health First Society, they're no different than really anybody else on this. So this is, I don't think, a great way to conceptualize the issue.
I would rather conceptualize it in this way. I use the same stem, right? You've been carrying a child. yada yada.
How likely would abuse have to be? How great a likelihood would have to be before you felt you had reasonable suspicion? Would it have to be only 1% likely?
99% likely or somewhere in between? Mark an X on this line. I encourage you, I'll take five seconds just with your finger, right on your palm. Where would you mark, where would you put this?
Would you put 50%, 75%, 1%? percent. I'm telling you, you can't be wrong. This is what we found all over the board. As many people put it at 30 percent as 90 percent.
So this means that if whether I'm going to get reported for my daughter playing horse with our next door neighbor, Kara, on a given day, depends entirely who I run into. And this is a problem. It's a problem in terms of protecting children.
It's a problem in terms of the ethics of people being treated fairly and equally. It's a problem for us who are mandated reporters because we're told we have to report if we have reasonable suspicion, and there's no standard. So that reasonable person standard is gone. There is no reasonable person. So that's the problem that I was engaged in.
So I did this conceptual work. You see again, abuse experts are no different than anybody else. And then we did this paired relationship.
So you know, if you start with that rank order list, the number one thing on that rank order list might be 50% likely, or it might be 1% likely, and number two might be 0.9% likely. But if you go there, so you can't make, you have no idea. where you start. But if you start this way, right, you can make some correlations because the question of whether something is abuse is a binary issue. Either it's abuse or it's not abuse.
There's nothing else, right? It's like arson, right? A house burns down either because of arson or it's not arson. They may have faulty wiring. It may be old.
It may be cluttered. It may be more prone to be put on. fire but it's either arson or it's not.
So the list of things that are possible explanations all together have to add up to no more than a hundred percent. Because it's either abuse or everything else. So if something if someone says that it's to be reasonable suspicion it has to be greater than 50 percent then all the other possibilities have to be less than 50 percent.
So if I'm being logically consistent consistent, if I put it has to be greater than 50% estimated probability to be reasonable suspicion, I should put it as number one on my list, my rank order list. And if I say it's greater than 33%, at least second, you know, and you can do the math. And I've done this math many times to make sure it's right. And here's what we found.
The blue are those that are logically consistent. So let's start in the middle, 326, right in the bang on the middle, in the middle of the circle. So those Those 326 people said that abuse had to be 50% likely before it was a reasonable suspicion, but it could be the fifth most likely thing of causing it. Down in the, you know, down towards the corner, there's six people who said it had to be 90% likely, but it had to be, it could be as low as the ninth most likely thing.
So, you know, you could say people are just illogical and inconsistent, or another way to interpret this. is to say, and this was across all these different populations, and there was no difference. It was almost, for every population, it was roughly 13% to 15% of people were logically consistent.
And what this tells me is that how you conceptualize... Reasonable suspicion again makes a difference because you're not going to have the same answer. If someone says well if it's on in the top 10 possibilities that's reasonable suspicion, you're going to have a very different answer than if someone says well it should be more likely than not or at least should be at least a one in three chance of this is abuse.
So that's the top end. Reasonable suspicion, so all mandated reporting. is triggered by someone having reasonable suspicion.
So it's a big funnel. The end of the funnel is reasonable medical certainty. When a case goes to court and someone has to say, yes, I think there's reasonable medical certainty that this is caused by abuse. And our hypothesis was adapted from the views of a famous existentialist, Humpty Dumpty. When I use a word, it means just what I choose it to mean, neither more nor less.
Okay. And we got this because this was the advice or the response given to one of my colleagues, Mark Diaz, a pediatric neurosurgeon. When he asked one of the lawyers in the court where he was about to testify, they said, but the definition of reasonable medical certainty is just what you define it to be, doctor.
So we asked people, how do they interpret this presumably diagnosis? And we asked, we did a list survey of various listservs. that deal with child abuse.
And what we found among these groups, we had just under 300 respondents. Go back there. Almost half were child abuse pediatricians. We had forensic pathologists, neurosurgeons, and so forth. And these were people, 95% of them overall, had testified in court.
Almost two-thirds of them had testified in more than 25 cases in the last five years. So these are people who actually are going into court and testifying. Almost half of them had been directly involved in the care of the child for whom they had testified. Others were independent witnesses. And interestingly, fewer than half said that they had ever been trained about what constituted reasonable medical certainty.
So one of the first questions we asked was, how comfortable are you with this terminology? Because doctors don't talk about reasonable medical certainty. They're asked to talk that way in court.
And what we found was that only... Only less than 40% had any level of comfort with this term. Over 40% said that they were either somewhat uncomfortable or very uncomfortable with the term. We asked how many had ever received formal training on reasonable medical suspicion.
Interestingly, pathologists, more so than others, said that they had, which is sort of interesting. We asked them, what was your threshold? If you're going to set the mark, where is that mark? And you see it's again sort of all over the board, not near as much as the reasonable suspicion, right, but again it's interesting actually I don't think I've included these data here but child abuse pediatricians set the threshold the highest.
But one of the things this means is that if I'm on a jury and someone says reasonable medical certainty, they may be meaning, well, if I flip a coin, it's more likely than not child abuse. Or they may be meaning it's, oh, there's a 99% likelihood that it's abuse. You can't but imagine that a judge or a jury would be influenced by whether or not, which threshold they chose.
Because it's framed almost like a diagnosis. And interestingly, there was no correlation for where people set this threshold with any demographic factor. Their age, their training, their field, nothing. Now, interestingly though, it was influenced by what type of court. So in those cases where there was a criminal case versus it was a civil, a family case.
A quarter of people, of these experts, changed the threshold for where they would set reasonable medical certainty, which is sort of odd because again, if it's a diagnosis, that shouldn't make a difference. And I would argue that these findings tell us more about these people than they tell us about what this actually means. And the absence of any significant correlation suggests the training experience also have little bearing on how reasonable medical certainty is understood and should leave us wondering what it means, reasonable medical certainty, that is, as a threshold other than personal. opinion. So what we see depends really on who we are.
Now on one level this is not necessarily surprising when you have competing values at stake and when there's not certainty there are competing values in play. So we ask people which is worse mistakenly leaving a kid in a home where abuse is occurring or is it It's worse to remove a kid from a home where there's no abuse. And we found that 6 out of 7 people said it's worse to leave a kid in an abusive home.
When we asked which is worse, convicting an innocent person by mistake or letting a guilty person go free, we found that 7 out of 8 said convicting an innocent person is worse than letting a guilty person go free. But when we really posed the dilemma, which is worse, putting an innocent person in jail or leaving a child in an abusive home, it was pretty evenly split 50-50. Now what's challenging is that what we're working with is an enormously overwhelming problem and it's something that's chameleon-like.
This is, you may have seen these, this is, there's this guy in China who paints himself like a background. This is, he actually paints his body and his clothes and he stands in front of things and gets photographed, right? And child abuse is a little bit like that, right?
It's everywhere, right? So when I get asked in interviews as in my capacity as director for the Center of Protection of Children, what do I think about the scandal at Penn State and so forth, I say, you know, for people in this field, We know that this kind of behavior, what did happen and what didn't happen, happens in every community all throughout the United States and throughout the world. What was different is that this got people's attention. People in the field of child...
abuse and child protection have been screaming about this issue for years and now there's a platform on which we can focus our efforts to make a difference. So this is everywhere and if you're not looking for it you're not going to find it. And part of the problem is we have inadequate data. We don't have sufficient resources. We have poor predictive value.
And we often lack the time, the personnel, and the tools to accurately find the truth. And the problem is that this is a big deal. Because if you miss it, then a child remains in harm's way.
And if you're not looking, you won't find it. And if you don't know what to look for, you won't find it. And here's the man right there.
You can see him now. Because people blend in with their surroundings. And certainly child abuse does. Now, the challenge of course is how do you define where these thresholds ought to be? And I think it's a social calculus.
It depends upon what we as a society believe. How much we're willing to spend to protect children, what kinds of harm we're willing to tolerate, how much harm we're willing to tolerate. And there's no objectively correct answer to this.
It's also the case that improving this system can be very challenging. It is a behemoth. The things we have to change, everything is connected to something else. Now, especially here in Pennsylvania, this is a big deal because the laws that are on the horizon have looming problems. When it becomes the case next year, as it will, that if you're a professional who's a mandated reporter and you don't report when you should have had a reasonable cause to suspect, your license is going to be taken away.
a lot of people are going to report a lot of instances that, you know, I don't know this kid or this family. If it's between, you know, fulfilling my professional responsibility or losing my license, well, sure, why not? I'll report them.
It's not clear that it's going to help anybody if the reporting rate triples or quadruples, and we have a signal-to-noise ratio that results in the system being overwhelmed. And it's calling upon the wisdom of Dumbledore. door that sometimes we must face a choice between what is easy and what is right.
And there's a price with doing the right thing sometimes. And this is where, you know, hard cases make bad law, as is famously said. So, you know, these are, we're facing conceptual and practical dilemmas that don't have necessarily a ready answer. So one question is, well, what can we do?
A colleague and I, who's down at University of North Carolina, North Carolina Charlotte, Sharon Portwood, and I wrote a conceptual paper about giving people, both raising this issue from a policy standpoint, but asking how we should ourselves operationalize this. And I'll break this down a little bit. So I think what we can begin with is just the clear-cut question of is, are you certain that abuse occurred? And if the answer is yes, then report.
If the answer is no, then the question is, well, do I have reasonable suspicion? And reasonable suspicion is the umbrella terminology for all those 11 statutory thresholds. And if the answer to that question is yes, then go ahead and report.
If the answer is no, I don't have a reasonable cause to suspect in Pennsylvania, then don't report. The $64 question is, how do we figure out when I have reasonable suspicion? And what I and Sharon came up with was that there's some questions.
that we can ask ourselves, and this is a partial, this is one part of it, I think the key part, is to recognize that suspicion is a feeling. And so one of the things you want to ask yourself is whether you have confidence in the soundness of your observations. Have you spent enough time observing? Are you familiar with what you're looking at?
You see all these round scars or blisters on a child's back. Do you know that those blisters are not? what's the, cupping, which is a common tradition in Asian medicine to remove sort of evil humor, so to speak, from the body.
I mean, are you familiar with this? Do you know that that bruise on the back is definitely not a Mongolian spot? We had a couple of residents at our medical center who had a little baby that got taken away from them for three days because someone was ignorant and did not know that that mark on their lower back was a Mongolian spot and not a bruise.
Are we clear about what we think we heard? We call the, my father beats me. Beats me at what? Did you observe it firsthand?
Or is this one of those games of telephone? By the time it got to you, it's morphed. Do you have confidence in your judgment because of your own experience and the fit of the explanation? argued elsewhere that I think that suspicion is a feeling. Oftentimes it's thought of as a weak form of belief.
I think that's wrong. I think it's a feeling that's, as I say, imbued with meaning. And what that means to me is that, you know, it's a sensation you have.
a feeling in your gut in a sense. And the meaning comes into play if you walk into a room and there's this horrible smell and you say, what is that? And someone says, oh, it's this food that it turns out you actually quite like. You smell it again and the smell actually changes because of the meaning that the smell had. So the sensation itself is varied based on meaning.
And I think that reasonable suspicion is exactly that thing, or suspicion is. It's it's. based part upon meaning. So how do we approach this? That's a little bit of an algorithm.
I think part of it is there's a certain kind of a stance we take, an attitude, being aware, sensitivity that this is an issue and that we need to understand what needs to be understood, that we approach these situations with humility. I consternate the residents who work with me periodically. we are reminded in the net how little we know. 95% of the universe is dark matter. We don't know what it is at all.
So let's be humble about what we assume we know and what we don't know. In that regard, we need to be open to possibility. Open to possibility.
that a wonderful family we like and trust might act on you know sort of out of anger whether the person we think is great with children has been sexually abusing them his entire adult life and that requires a certain intellectual honesty and by that and I put a lot of stock in this is that intellectual honesty demands that we acknowledge where our reasoning is weak where we don't have good evidence for what we believe or what we're concluding and that we acknowledge our biases. In my house, there's a room, there's a Yiddish word called mishigas. And mishigas means it's something you believe and you sort of, you know, you hold to it, but you don't really have any good reasons.
So an example is if you believe, any of you, that it is better, right, for the toilet paper to come from the top or the bottom, that's mishigas, okay? And in my house, if you are willing to acknowledge that what you want, where the forks are, are supposed to be placed or whatever. If you acknowledge it's Mishigas, you get in your way. But you have to acknowledge it's Mishigas.
And so part of what this demands, in a sense, is that you acknowledge where your biases are. I think there's also a process of discovery that we need to pay attention to. How we respond to people.
It's easy to jump on people and judge them for what they've done. What about my son and the door that I slammed? How would I be judged now versus if he had actually reached his hand out? We need to think about how we ask questions.
When I'm in clinic, I don't say, so, do you understand? It's an intelligence test. If I say, does that make sense? Because I don't always explain things real well.
I take it on me if I didn't communicate well. I don't put it on them. And learning to ask good questions is important. And relying on sort of your resources, taking a systematic approach to things. Talk to your colleagues.
Talk to people who are responsible. Be prepared for resistance. People say, that's not a problem, they're fine, this is a good family.
they wouldn't hurt their children. And be transparent. Acknowledge to people what you're thinking. When I report people for suspected abuse, I tell them that I'm going to.
I tell them I don't know what happened, I wasn't there, and I'm worried. And we need... to invoke the system that is set up to protect children, even though it's a flawed system, and that they need to be prepared for people accusing them and judging them, and that the more honest they are and the less defensive they are, the better the process will go for them. And I come back, as always, to this business of being intellectually honest about that. And people will challenge you.
You're about to put me through this horrible ordeal in my family. Why are you doing that? And, you know, you can hide behind terminology and, you know, all sorts of things.
of things where you can be intellectually honest and acknowledge what you're thinking and what your uncertainties are. And it requires a certain, I think, strength of mind and of purpose to do that well. And if what we're after is to protect children, there are a whole range of these conceptual and practical matters that are unresolved. And yet, I think we need to take a stand. These are the Moriaki boulders.
They're on the South Island of New Zealand, and they only exist. on this one beach and one beach in South America. No one knows exactly how they form, but it's clear that some are more stable than others. So where you take your stand, you want to be careful because some foundations are better equipped to support your weight than others. And thinking through these conceptual issues and thinking through their practical implications is, I think, very important.
And with that, I'll stop and ask if people have questions. I'm wondering if you could speak a little bit about that broader conception of preventing child abuse and how people in your field think about that in terms of just if you have any thoughts on what it might be to take some of those steps and whether you think it actually might be better to start talking about child abuse in the future. about those broader preventative issues as opposed to the responding issues.
Not to the exclusion of, but in addition to. I mean, your point is just perfectly well taken. Everything you say is exactly on the money. And the challenge is, is how do you who addresses these issues and how. There's a wonderful paper in the journal Pediatrics, the flagship journal for the American Academy of Pediatrics, about all the things that as a physician, as a pediatrician, you're supposed to do in terms of anticipatory guidance to help people at any given age.
And if you did them all, a well child check would last three and a half hours for every child. So, you know, the question is, what do you do? And I think that, you know, there are some practical answers.
And I will tell every parent of kids. kids up through at least school age, I'll ask them about, are they getting time to themselves? Where someone else takes care of their child and they get to get out and just talk, go for a walk, go to Applebee's for dinner, right? Because they're going to have different ideas about how a child should be raised.
And if they want to know the right way, I'll tell them it's my way. And most of us think that. And so they need time to sort out differences.
They need time to invest in their own relationship because presumably they didn't come together just to have. have children. So I think there are a whole bunch of those things and none of them are sexy.
You know, none of them will grab a front page. You know, I can make them humorous. I'll write people a prescription to go out every, at least once every three weeks. And usually there's one partner who needs that more than the other person to show the one and say, we need, doctor said, we need to go out.
So there, those kinds of preventive things are really important. And, you know, the, I think that the challenge is to link what is you know, good parenting, being a good family member, being a supportive friend, being a supportive community. How do you take those things and you link them with a problem, which is child abuse? And I think that you've got to find the lever. You know, nowadays, the lever is Penn State and Sandusky to move things forward.
My center, the Center for the Protection of Children, was a direct outgrowth of something that has been happening in communities all over America, right? So why? Well, because it got someone's attention. One of the ways you can do that is to You get people's attention in America is by talking about money.
You look about the costs and the direct costs alone from child abuse, annual. direct costs are $70 billion. The indirect costs add about another estimated $200 billion.
And when they do studies of people who are in jail, it turns out that about 75% to 80% of them will admit that they were abused as children. How do you get people to invest in those mundane type of processes? That's the big question.
But I think your point is well taken. And if you're... When a mom comes in four times in the first three weeks of their child's birth for things that are nothing, some people think, why is she here? And other people should be thinking, and many people do, what's going on here? Is there a point of stress?
Because if you can relieve that, if you can help someone recognize that children cry, the average six-week-old baby cries three hours a day. And if you can turn the noise down, it's a lot easier to take. And those are called earplugs.
I've. look for your plexiglass to get rid of all the noise, they don't exist. Or that you teach a parent that if their child cries for an extra hour and a half on a given night, they'll be just fine, but they're better off walking away for 20 minutes to gather themselves than shaking a child and injuring it forever.
Those kind of preventive things are really important, and building them into the daily practice of all the other things we do, it's a challenge to get people to recognize the antecedents of a cry. crisis and how important they are. But your point is perfectly taken.
We actually didn't ask about reporting. We asked about how they understood the concept because the concept drives reporting, but only partially. There are plenty of studies that demonstrate.
There's actually a guy up here named King, I'm forgetting his first name, who's done a bunch of this work in the 90s. I think he's in psychology, who showed that fully a third of... pediatricians and almost half of social workers when surveyed said that there are times when they they had reasonable costs to suspect and they decided not to report right and the reason they decided not to report was because they didn't think it was in the kid's best interest or they didn't think it would do any good or they didn't want to ruin their relationship with the with the family or they thought they could do it better themselves or so i'm trying to you know as a philosopher i'm interested in the concept as a pediatrician and a member of society i'm interested in the impact it has but the relationship between the concept and how people act that's it that's a it's a separate question related but but definitely separate And judges have many times tried to explain to juries what on earth the unreasonable doubt is and what a reasonable doubt is.
And many of them have truly watched it. Is there some empirical data in that field that would be relevant to and about the US? in your work? Yes.
Kathleen Kagehiro. She has written, she used to be at the, at Temple University School of Law. She is out in private practice now in Virginia somewhere.
And she took college students and she gave them, they gave them cases and gave them instructions either in verbal probability, likely, probable, you know, et cetera, or in numerical probability. And as it turns out, there's an enormous literature among cognitive psychologists about this and these people are either the most generous people in the world or the loneliest people in the world because when you email them they send you back pages and pages of emails in response. And there are some people at the University of Illinois, Badescu and others that I've corresponded with.
And I actually tried to track down Kathleen Kagehiro, could not find her and I called a co-author on her paper and I called him at his law office and I says, do you have any idea where she is? And he said, I think she's next door today. So. I actually spoke with her about this, and what she found, and what cognitive psychologists have found, is that if you give people information, they prefer to have it, and they do a better job if you give them that kind of information in terms of numerical probability. You don't say, you say, what's the lowest standard?
Where it's more likely than not. Pardon? No, the American language, the U.S. language is...
I'll think of it. I just present, I have it in my data for the reasonable medical... certainty but it's more likely than not so if you say greater than 50% likelihood people do a better job in the court of law adhering to that standard similarly if you say you're greater than 70 or 75 percent for you know substantial evidence and if you say greater than 95% for reasonable, beyond a reasonable doubt, people do better. They don't like to give the information. So people, most people like to receive information in terms of verbal, numerical probabilities.
They prefer to give information in terms of verbal probabilities. So I think the way to go is to use numerical probabilities. And people will usually say, well, people are terrible at numeracy.
But the examples I've given in the past is about, you know, if someone says there's a 5% chance of rain, you don't bring your umbrella. If there's a 95% chance of rain, everyone brings their umbrella. And it turns out, if you look in the literature, weather forecasters have actually tested this about whether people who hear weather forecasts This paper came out in 2010. Do they understand and can they make appropriate daily activity judgments based on numerical probabilities for weather forecasting?
The answer is yes. So if you ask people to manipulate numbers, they're not very good. But if you ask them to understand numerical probability, they know that when Barry Bonds has a 330 batting average, that he's getting a hit every one in three at bat.
Can I just quickly follow up? Sure. If numbers are that, do you have a view about what kind of numbers you should give people on the reasonable suspicion? I'm often pressed for that. I'm hesitant because I think there's your calculus.
What we need is we need a set of well-done, broadly sort of disseminated experiments that look to see what's the effect on the system if you set the threshold at 75%. versus 50 versus 25. We know, we have some evidence, that it makes a difference. There are a couple of graduate students, Black and Flieger, who in the 90s did their PhD dissertations on this with school teachers, where they either used verbal probability or they said 25% likelihood.
Well, if they used 25% likelihood, they found that school teachers were 2.3 times more likely to report physical abuse in the same scenario, and over three times more likely to report physical abuse. sexual abuse. So we know it makes a difference but should it be said at 25, 50, 55, 70? I don't know and I think part of it depends upon which population you're talking about because if you ask a pediatrician, you may get a different answer than if you ask a school teacher or someone else.
So I think, I don't give an answer, I mean, I have my own internal answer, but I do a lot of work on this and I think about it a lot. Well, thank you very much for your interest.