Hannah Kazis-Taylor

Each year, more children in the U.S. die from child abuse and neglect than pediatric cancer. Last month, Yale-New Haven Hospital pediatrician Barbara Chaiyachati published the paper “Gray Cases of Child Abuse: Investigating factors associated with uncertainty” with the aim of identifying just these cases, based on the nature and context of children’s injuries as well as their family’s social and medical history.

Chaiyachati’s paper describes several indicators — both injuries and family’s social and medical history — that help physicians better identify patients who may be suffering from abuse. Certain injuries, including rib fractures or bruising on the ears, torso or neck, are immediately associated with abuse, but others are more difficult to classify and leave the child classified as a “gray case,” one in which it is not clear whether the child is the victim of abuse, according to the paper. When treating a gray case, a pediatrician may express concern for the accidental nature of an injury, but also may not be confident in classifying the injury as abusive. While her study found no significant correlations between abuse and a specific individual element of the incident, history or injury, Chaiyachati said that based on the study’s sample size, the project never intended to revolutionize how child abuse is treated in pediatric care. Instead, she intended to publish her work as an observational and exploratory study on gray cases, which are generally not very well-researched.

“There’s uncertainty in studying uncertainty,” Chaiyachati said. “Gray cases are a clinical conundrum.”

Chaiyachati’s study used a seven-point scale that indicated the likelihood of abusive, gray and accidental injuries based on medical and social context. She evaluated 154 studies from YNHH, searching for similarities in the nature of injury, context of injury and families’ social and medical histories between gray cases and more absolute accidental or abusive cases.

The study examined, among other patients, a seven-month-old girl with Beckwith-Weidmann Syndrome —a congenital overgrowth disorder that leads to a heightened risk of cancer — who showed signs of delayed development. The child, an example of a gray case, arrived at the hospital with a left femur fracture, an injury her mother was unable to explain. The mother claimed that she had placed the patient down to sleep with her two-year-old sister and had returned to find her lying in a different position. While the family left before receiving care, a pediatrician diagnosed the injury the following day. The family in question had a history of Child Protective Services involvement two years earlier.

Solving gray cases is crucial for preventing child abuse, said Gary Kleeblatt, communications director of the Connecticut Department of Children and Families. Child abuse pediatricians are primary consultants on abuse cases, and the Department of Children and Families relies heavily on their expertise and judgment, he added.

Gray cases and their uncertain nature create a predicament for pediatricians in which neither true negatives — abusive injuries classified as accidental — nor false positives — accidental injuries classified as abuse — are acceptable, Chaiyachati said. Misclassifying an injury as abusive may lead to negative repercussions for the accused parents and children, and potentially breed a mistrust of the health care system, Chaiyachati added. On the other hand, a gray case classified as accidental allows the risk of letting the victim of abuse return to the environment where the abuse originated. Beyond the physical pain it creates, abuse also affects a child’s development and the interpretation of the world they build as they become adults, according to Child Help, an international organization focused on the prevention and treatment of child abuse.

Within the U.S. prison community, 14 percent of men and 36 percent of women were abused as children, twice the rate seen in the general population, according to Child Help.