A changing history: When is it a red flag for child abuse?

Background and objective: While a changing history is frequently cited as a red flag for child abuse, no data support which changes are significant, nor the degree to which concern should be increased. We sought to measure the impact of changing caregiver histories on expert assessments of abuse likelihood.

Methods: We used a vignette survey to measure the impact of a changing history on child abuse expert assessments of abuse likelihood and willingness to undertake testing and protective interventions. By randomly varying the presence and magnitude of history changes, we determined their impact on perceived abuse likelihood.

Results: Of 494 invited participants, 267 (54 %) completed the survey. The presence of historical changes significantly affected experts' level of concern for abuse and willingness to test or report abuse, though to variable degrees. For example, while a minor change in the timing of an injury did not significantly increase willingness to perform a skeletal survey (OR: 1.5, 95 % CI: 0.8-2.9), a major change in the timing of an injury did (OR: 2.0, 95 % CI: 1.1-3.6). In addition, a change from having no initial history of trauma to then giving a history of accidental trauma significantly lowered the mean estimate of abuse likelihood and triggered significantly less reports to child protective services (OR: 0.02, 95 % CI: 0.003-0.2).

Conclusion: For abuse experts, some history changes are more concerning than others, with major changes in history, and an initial denial of trauma having the largest impact. Future research regarding changing histories should consider details of the change, rather than treating all changes equally.