A scientific foundation for new standards in the clinical assessment of child abuse.
Submitting InstitutionCardiff University
Unit of AssessmentPublic Health, Health Services and Primary Care
Summary Impact TypeSocietal
Research Subject Area(s)
Medical and Health Sciences: Public Health and Health Services
Studies In Human Society: Social Work
Psychology and Cognitive Sciences: Psychology
Summary of the impact
Responding to the crisis in confidence amongst clinicians involved in
child protection, Cardiff University developed the world's first research
programme to provide the scientific basis for more reliable clinical
assessments of child abuse and neglect. The programme, which involves 21
systematic reviews (updated annually) and related primary studies, has
directly informed five national clinical guidelines, the National Child
Protection training program and the first NICE guidance on child
maltreatment. Through the Core-Info website, the evidence base created by
the Cardiff team is accessed each year by 100,000 users. Key messages from
their research have been published in a series of Core-Info leaflets which
have reached more than 250,000 allied professionals nationally. The
Cardiff research informs standardised national clinical practice, training
and legal decisions, ultimately improving the recognition and protection
of children from abuse or neglect.
Ten years ago there were no evidence-based standards or clinical
guidelines to inform clinical assessments of suspected child abuse or
neglect. When cases went to court, expert medical opinions were provided
by a handful of clinicians who relied on their clinical experience, rather
than scientific evidence. Clinicians were accused of misrepresenting
evidence and being instrumental in the wrongful prosecution of mothers for
causing the deaths of their babies. Media and legal criticism led to a
lack of confidence in and amongst clinicians working in child protection.
An evidence base for the recognition and assessment of child abuse.
In 2002 Professor Alison Kemp (Senior Clinical Lecturer 1993-2005, Reader
2005-2009, Professor / Program Director 2009-present) and Dr Sabine
Maguire (Clinical Lecturer 2002-2008, 2008-present Principle Investigator)
established Cardiff Child Protection Systematic Reviews (CCPSR), funded by
the National Society for the Prevention of Cruelty to Children, to develop
a scientific foundation for child protection policies and practice. The
research team includes two researchers, an information specialist from
SURE (Support Unit for Research Evidence at Cardiff University), a
statistician and a national panel of expert reviewers trained in critical
By 2013, CCPSR had completed 21 systematic reviews critically appraising
the world literature relating to the recognition and investigation of
child abuse. The group has published 28 peer- reviewed papers.
Methodological developments have included a novel ranking system for the
security of diagnosis of child abuse; this system has been adopted
internationally by other child protection research groups.
Some of the most significant findings into clinical approaches and
practices regarding suspected cases of child abuse and neglect, are
- Ageing of bruises: In 2005 Maguire and colleagues from CCPSR
concluded that it is not possible to age bruises in children
accurately with the naked eye [3.1].
- Ageing of fractures: Responding to the paucity of scientific
evidence, CCPSR carried out a primary study (2010-12) which concluded
that it is possible to age fractures within broad time frames
- Characteristics of abusive bruises: In 2005 the Cardiff team showed
that in non-mobile infants, bruises over soft tissue areas that carry
the imprint of an implement were indicators of abuse, as were multiple
bruises of uniform shape [3.3]. This review led to the group's
successful application for the first MRC-funded study on bruising in
- Abusive fractures: A CCPSR review (2008) found that rib fractures,
fractures to the shaft of the humerus in infants and femoral fractures
in non-mobile babies have a high probability of being caused by abuse
- Abusive head trauma (AHT): The CCPSR created a database of
individual patient data collected from six international studies
(2009-11). The team developed a method for `individual patient data
analysis' and proposed a model to estimate the probability of AHT (a
contentious diagnosis) from clinical features [3.5]. The model has
subsequently been validated in clinical practice to improve the early
recognition of cases of suspected AHT.
- Retinal haemorrhages are important features of AHT; the AHT
systematic reviews identified a lack of internationally recognised
reporting standards for haemorrhagic retinopathy in cases of AHT.
The CCPSR researchers developed and validated such a tool (2010-12)
The quality of the group's work on bruising was cited in a Lancet
editorial (Cabinum-Foeller, E. and L. Frasier. 2005. Bruising in
Children. The Lancet 365(9468), pp1369-1370): "The
conclusions are clinically intuitive, but provide a more empiric
literature-based review that provides an essential framework for any
clinician attempting to determine the cause of bruising." The
independent validation and application of several methodologies
developed by CCPSR (e.g. the diagnosis security ranking system, the AHT
probability model, etc.) also demonstrate the quality of the group's
References to the research
2. Prosser I, Lawson Z, Evans A, Harrison S, Morris S, Maguire S,
Kemp AM. A timetable for the radiologic features of fracture
healing in young children. American Journal of Roentgenology.
3. Maguire S, Mann MK, Sibert J, Kemp A.
Are there patterns of bruising in childhood which are diagnostic or
suggestive of abuse? Archives of Disease in Childhood. 2005;90(2):182-186.
4. Kemp AM, Dunstan F, Harrison S, Morris S, Mann M,
Rolfe K, Datta S, Thomas DP, Sibert JR, Maguire S.
Patterns of skeletal fractures in child abuse: systematic review. British
Medical Journal. 2008;337:a1518.
5. Maguire SA, Kemp AM, Lumb RC, Farewell DM.
Estimating the probability of abusive head trauma: A pooled analysis. Pediatrics.
6. Ng WS, Watts P, Lawson Z, Kemp A, Maguire S.
Development and validation of a standardized tool for reporting retinal
findings in abusive head trauma. American Journal of Ophthalmology.
Note: CCPSR researchers in bold. All publications available on
request from the HEI.
Key funding sources
• Systematic review of physical abuse. National Society for the
Prevention of Cruelty to Children (NSPCC). A Kemp (PI). £788,971.
• Developing diagnostic tools for clinicians to improve diagnostic
accuracy and identify patterns of bruising in physical. Medical Research
Council. Research grant ref: G0601638. A Kemp (PI). £1.12 million.
Details of the impact
The first UK child protection clinical guidelines
The Cardiff systematic reviews have directly informed five national
guidelines in the field child `protection:
- The first NICE evidence-based maltreatment guidelines (2009)[5.1].
- The first joint guidelines published by the Royal College of
Radiology and Royal College of Paediatrics and Child Health (RCPCH) in
2008. As a direct consequence of these guidelines, skeletal surveys
now routinely include oblique views of the ribs for all children in
the UK under the age of two years where physical abuse is suspected
- The RCPCH Child Protection Companion — the clinical guidance for
all paediatricians (2006) across UK and the second edition of the
Companion (Kemp co-edited), published in 2013, to include evidence
from all 21 of CCPSR's systematic reviews [5.3].
- National standards for ophthalmological examination in suspected
abusive head trauma (2013). The Royal College of Ophthalmologists were
preparing guidelines as of July 2013.
`Child Protection and the Dental Team: an introduction to
safeguarding children in dental practice' published 2006,
updated in 2009 with new developments in the Cardiff research. This
live document accessible online (and supported by a website) was
commissioned by the Department of Health and distributed to all dental
practitioners in the UK to highlight their role and responsibility in
child safeguarding, with information on how to recognise suspected
child abuse or neglect [5.4].
National compulsory training programme
Cardiff's evidence base informs the national child protection training
programme which meets the Intercollegiate National Safeguarding six
levels of competences. This training is delivered to all healthcare
staff across the UK. Cardiff's research informs the training manuals
[5.3] for the RCPCH/NSPCC/ALSG training programmes at:
- Level 2: Child Protection Recognition and Response (accessed by 400
trainers and 4000 trained health practitioners who work with children)
- Level 3: Child Protection in Practice (1700 Child protection
Since 2008 Kemp and Maguire have also delivered over 100 invited
lectures to present CCPSR findings and recommendations, reaching an
estimated 15-20,000 child protection practitioners in the UK, Europe and
International reach — online training and information resources
The publication of national guidelines and the delivery of compulsory
training into evidence-based clinical assessment of child abuse has
embedded Cardiff's research into UK clinical child protection practice.
Since 2008 the Cardiff group has also disseminated its findings to
professionals and practitioners through the Core-Info website
(www.core-info.cf.ac.uk) which hosts the findings from the 21 systematic
reviews and meta-analyses that are updated annually. Commenting on
Core-Info, the former president of the Royal College of Paediatrics and
Child Health noted: "This resource does not only allow easy access
for improved clinical decision-making, the evidence base also
underpins improved expert evidence in courts around the world"
[5.7]. The influence of Cardiff's work has also been highlighted by the
American Academy of Pediatrics [5.6].
Core-Info analytics show that the website is used by 100,000 health
professionals, social workers, law enforcement, the judiciary and
researchers from 40 countries annually. A recent survey of child
protection paediatricians in the UK and Australia confirms that
Core-Info is used by 60% of these professionals to inform clinical
decisions, provide continuing professional development and education
material, inform legal reports and give scientific validation to expert
opinion. It is considered to be "one of the most important
developments in the field, supporting better clinical decision making,
training and expert opinion in court, and increasing overall
confidence of paediatricians" [5.5].
Six Core-Info leaflets developed jointly by the Cardiff team and the
NSPCC (2007-2013) translate key research findings into practice for
allied professionals in child protection. Since 2008, approximately
200,000 hard copies (plus numerous downloaded copies) have been sold to
non-specialists who work with, or come into contact, with children. The
Core-Info leaflets are regularly updated to reflect the latest evidence
and are widely used for national training (Levels 1-2) and as a quick
reference source for health visitors, social services, general
practitioners and police.
Impact on practitioners and services — an evidence base for clinical
As a consequence of the wide-spread national and international
dissemination of CCPSR's research findings through national guidelines
and training, child health professionals now base assessments, diagnoses
and court evidence on scientifically informed and clinically validated
models and practices. The significance of this shift in practice is
summarised by the National Clinical Director for Children at the
Department of Health: "This work is at the forefront in supporting
evidence based practice in a sensitive clinical field of great
The evidence base provided by the Cardiff group has helped child
protection professionals and expert witnesses to re-establish trust. The
standardised evidence-based practice means that convictions in court and
child-protection interventions are more reliable, with a lower
likelihood of wrongful convictions.
Impact on child health and welfare
The ultimate beneficiaries of this work are the children who are being
abused. Through the adoption of national guidelines and the
implementation of standardised evidence-based practice across the UK, it
is now more likely that abuse will be recognised and appropriately
investigated and abused children are more likely to be protected from
The Deputy High Court Judge in the Family Division and Recorder in the
Crown and County Court states that one of the major benefits of
Cardiff's work has been the improvement in the scientific validation and
quality of expert opinion presented in Family and Criminal Child
Protection Court Cases, in particular the eradication of police and
paediatricians using colour to estimate the age of a bruise [5.9].
In 2013 the CCPSR group won the BMJ Child Health Team of the Year in
the BMJ Improving Health Awards [5.10].
Sources to corroborate the impact
- NICE guideline 2009: When to Suspect Child Maltreatment,
(pp v, 107, 142-143) [Also saved as a pdf on 24.04.13 and available
from HEI on request].
- Standards for the radiological investigation of suspected Non
Accidental Injury 2008
(pp 5, 6, 51, 52, 55) [Also saved as a pdf on 24.04.13 and
available from HEI on request].
- Child Protection Companion: RCPCH 2013 (2nd edition) http://www.rcpch.ac.uk/child-health/standards-care/child-protection/publications/child-protection-publications
(pp 238, 244, 245, 246, 247, 248, 249, 260, 261) [Also saved as a pdf
on 24.04.13 and available from HEI on request].
- Child Protection and the Dental Team: An introduction to
safeguarding children in dental practice. Cardiff research directly
cited pp 5.2, 5.5. [Also saved as a pdf on 24.04.13 and available from
HEI on request].
- Individual corroboration from the President Royal College of
Paediatrics and Child Health. Confirms the Core-Info website has been
used to improve clinical decision making and the standard of expert
- Contactable individual: Chair, Committee for Child Abuse and
Neglect, American Academy of Pediatrics. Can confirm the Core-Info
website has been used to improve clinical decision making and the
standard of expert testimony internationally.
- Individual corroboration from the President RCPCH. Confirms the
Core-Info website has been used to improve clinical decision making
and the standard of expert testimony.
- Individual corroboration from the National Clinical Director for
Children, Young People and Maternity, Department of Health. Confirms
the importance of the research in supporting evidence based practice
in UK and internationally.
- Contactable individual: Deputy High Court Judge in the Family
Division and Recorder in the Crown and County Court. Can confirm the
use of the research in several court cases regarding the colour of
bruises over time and the inability to age bruises accurately due to
their colour has been crucial to the case outcome and the future care
of the child.
- BMJ Improving Health Awards: http://thebmjawards.bmj.com/previous-winners/2013/child-
health-team-of-the-year [Also saved as a pdf on 17.06.13 and
available from HEI on request].