Original Investigation | Pediatrics

Validation of a Clinical Decision Rule to Predict Abuse in Young Children Basedon Bruising Characteristics
Mary Clyde Pierce, MD; Kim Kaczor, MS; Douglas J. Lorenz, PhD; Gina Bertocci, PhD; Amanda K. Fingarson, DO; Kathi Makoroff, MD, MEd;
Rachel P. Berger, MD, MPH; Berkeley Bennett, MD, MS; Julia Magana, MD; Shannon Staley, MD; Veena Ramaiah, MD; Kristine Fortin, MD; Melissa Currie, MD;
Bruce E. Herman, MD; Sandra Herr, MD; Kent P. Hymel, MD; Carole Jenny, MD, MBA; Karen Sheehan, MD, MPH; Noel Zuckerbraun, MD, MPH; Sheila Hickey, MSW, MJ;
Gabriel Meyers, MSW; John M. Leventhal, MD

Abstract
IMPORTANCE Bruising caused by physical abuse is the most common antecedent injury to beoverlooked or misdiagnosed as nonabusive before an abuse-related fatality or near-fatality in a young
child. Bruising occurs from both nonabuse and abuse, but differences identified by a clinical decision
rule may allow improved and earlier recognition of the abused child.

Key Points
Question Can bruising characteristics
distinguish abusive from nonabusive
injury in young children?
Findings In this cross-sectional study of2161 children younger than 4.0 years,

OBJECTIVE To refine and validate a previously derived bruising clinical decision rule (BCDR), thethe bruising clinical decision rule (BCDR)

TEN-4 (bruising to torso, ear, or neck or any bruising on an infant <4.99 months of age), forwas 96% sensitive and 87% specific for

identifying children at risk of having been physically abused.

distinguishing abusive from nonabusive
trauma in young children based on the

DESIGN, SETTING, AND PARTICIPANTS This prospective cross-sectional study was conductedfrom December 1, 2011, to March 31, 2016, at emergency departments of 5 urban children’s hospitals.
Children younger than 4 years with bruising were identified through deliberate examination.
Statistical analysis was completed in June 2020.

characteristics of their bruising.
Meaning According to these findings,
young children with an affirmative
finding for any of the 3 components of
the BCDR are at increased risk of abuse

EXPOSURES Bruising characteristics in 34 discrete body regions, patterned bruising, cumulative

and warrant further evaluation.

bruise counts, and patient’s age. The BCDR was refined and validated based on these variables using
binary recursive partitioning analysis.
MAIN OUTCOMES AND MEASURES Injury from abusive vs nonabusive trauma was determined by
the consensus judgment of a multidisciplinary expert panel.

+ Invited Commentary+ Supplemental content
Author affiliations and article information arelisted at the end of this article.

RESULTS A total of 21 123 children were consecutively screened for bruising, and 2161 patients(mean [SD] age, 2.1 [1.1] years; 1296 [60%] male; 1785 [83%] White; 1484 [69%]non-Hispanic/Latino) were enrolled. The expert panel achieved consensus on 2123 patients (98%),
classifying 410 (19%) as abuse and 1713 (79%) as nonabuse. A classification tree was fit to refine therule and validated via bootstrap resampling. The resulting BCDR was 95.6% (95% CI, 93.0%-97.3%)
sensitive and 87.1% (95% CI, 85.4%-88.6%) specific for distinguishing abuse from nonabusive
trauma based on body region bruised (torso, ear, neck, frenulum, angle of jaw, cheeks [fleshy],eyelids, and subconjunctivae), bruising anywhere on an infant 4.99 months and younger, or
patterned bruising (TEN-4-FACESp).
CONCLUSIONS AND RELEVANCE In this study, an affirmative finding for any of the 3 BCDR TEN-4FACESp components in children younger than 4 years indicated a potential risk for abuse; theseresults warrant further evaluation. Clinical application of this tool has the potential to improverecognition of abuse in young children with bruising.
JAMA Network Open. 2021;4(4):e215832. doi:10.1001/jamanetworkopen.2021.5832

Open Access. This is an open access article distributed under the terms of the CC-BY License.
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Validation of a Clinical Decision Rule to Predict Abuse in Young Children

Introduction
Bruising is the most common injury from physical child abuse1,2 and the most common injury to beoverlooked or misdiagnosed as nonabusive before an abuse-related fatality or near-fatality in a young
child.3-5 Several studies4-6 identified bruises as the preceding injury to abusive head trauma. Failure
to recognize bruising caused by physical child abuse is a missed opportunity and an error in medical
decision-making that contributes directly to poor patient outcomes.7-10 Published evidence confirmsthat measurable differences exist between bruising from nonabusive and abusive injury in infants
and young children.10-23 An evidence-based screening tool may prevent these high-stakes failures.
Modeling these differences into an easy-to-use clinical decision rule may prevent further abuse
through improved recognition. Clinical decision rules are point-of-care tools that can improve
decision-making accuracy24,25 and health outcomes for children. Such a rule is especially critical for
infants and young children who are at the highest risk of serious, potentially fatal abuse2 and who are
too young or afraid to state what happened.
Pierce et al15 previously derived a bruising clinical decision rule (BCDR) named the TEN-4(bruising to the torso, ear, or neck or any bruising on an infant <4 months of age), which is applicable
to children younger than 4 years who have bruising. The TEN-4 rule exhibited high sensitivity andspecificity but was derived from a small retrospective sample collected from a single pediatricintensive care unit. Information on bruising in discrete regions of the face and patterns of bruises was
not available. Therefore, the objective of this study was to address these limitations and refine andvalidate the BCDR with the goal of establishing the first clinically sensible evidence-based screening
tool to distinguish bruises caused by physical child abuse from those caused by nonabuse.

Methods
Study Design, Setting, and Participants
We conducted a prospective, observational, cross-sectional study of patients younger than 4.0 years
with bruising. The children presented to 1 of the following 5 pediatric emergency departments: Ann& Robert H. Lurie Children’s Hospital of Chicago, Cincinnati Children’s Hospital Medical Center,
Norton Children’s Hospital, Rady Children’s Hospital, or the University of Chicago Comer Children’s
Hospital. All are tertiary care hospitals with differing patient demographics. This study was approvedby the internal review boards at each site. We excluded children with injuries from motor vehicle
crashes, known coagulation abnormalities, preexisting severe neuromuscular impairment resulting
in spasticity, or severe extensive skin disorders because these conditions would impact expectedbruise occurrence and characteristics. All other children had a deliberate skin examination performedby their emergency department practitioners to assess for bruising. Children with at least 1 bruise
were eligible for enrollment. Research team members collected data on consecutive patients who
underwent a consultation for possible child abuse. A waiver of authorization was granted to allow the
research team to abstract data without interfering with the evaluation process. For patients notundergoing an abuse evaluation, the research team obtained written informed consent to collectdata designed to parallel the extensive and detailed data collected for abuse consultations. For thesepatients, we used a structured sampling approach with research shifts as a feasible proxy toconsecutive enrollment. Data were deidentified. Methods for our structured sampling enrollment are
detailed in a previous publication.26 This study followed the Strengthening the Reporting ofObservational Studies in Epidemiology (STROBE) reporting guideline.
Enrollment and case classification occurred from December 1, 2011, through March 31, 2016, andstatistical analysis was completed in June 2020. At the outset, research staffs were trained to
conduct a comprehensive history of presentation and a comprehensive, deliberate skin examination.
Each skin finding was documented by photographs and recorded on a spatially mapped electronic
body diagram with predefined anatomical regions. Extensive details were collected regarding eachskin injury, including (1) type of skin injury (bruise or petechiae), (2) location of the skin injury on the

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Validation of a Clinical Decision Rule to Predict Abuse in Young Children

body (34 predefined regions), and (3) whether the skin injury was patterned (bite, loop, hand slap,
squeeze, grab, and multilinear).27-32 Total bruise count was documented. The patient’s skin tone wasassessed to determine how tone affects the visibility of bruises. A set of photographs depicting 5
skin tone categories served as a reference standard. Patient skin tone was assessed by the researchstaff during the skin examination and categorized as fair, light, midtone, brown, or dark. The
categorization was verified by the principal investigator (M.C.P.) using study photographs.
Each patient’s case information was classified as abuse, nonabuse, or indeterminate by anexpert panel composed of pediatric emergency medicine and child abuse pediatrics physicians and abiomechanical engineer, all with expertise in pediatric injury. Each panelist received deidentified
information in a standardized electronic format regarding history of presentation, examination
findings, and imaging and laboratory results, when applicable. Each expert panelist independently
reviewed the information and classified the cases based on injury and history compatibility. Theinterrater reliability of the panelists was high. The Kendall coefficient for the likelihood of abuse was
0.89 (95% CI, 0.87-0.91).33 For model refinement and validation, we used cases categorized asabuse and nonabuse and excluded indeterminate cases.

Statistical Analysis
We calculated medians and interquartile ranges for the number of bruises and body regions bruisedand compared between groups with the Wilcoxon rank sum test. We estimated differences inproportions between groups with score method 95% CIs. We also calculated the median numbers
and interquartile ranges of bruises and body regions bruised and compared between groups with the
Wilcoxon rank sum test. We calculated diagnostic accuracy statistics (sensitivity, specificity, positive
predictive value [PPV], and negative predictive value [NPV]) at our observed prevalence of abuseand positive and negative likelihood ratios with 95% CIs for our previously derived TEN-4 BCDR. We
refined the TEN-4 rule by fitting classification trees via binary recursive partitioning.34 We fit thesemodels by including the following factors: the TEN (torso, ear, neck) body regions, bruising in regions
not included by aggregate region of TEN, patient age in months, and whether there was patternedbruising. To optimize the sensitivity of the refined rule, we defined the cost of a false-negative
prediction as 20:1 relative to a false-positive prediction.34 To maintain reasonable rule simplicity, we
set the complexity parameter for the tree fitting to 0.05, precluding any recursive partitions of thedata that failed to improve the fit of the tree by this amount or more. We calculated diagnostic
accuracy statistics for the new model with 95% CIs. We internally validated the model by calculatingbootstrap estimates (>10 000 loops) of the diagnostic accuracy statistics with nonparametric 95%
CIs. All analyses were conducted in the open-source R software environment and the R library rpart(R Foundation for Statistical Computing).35,36

Results
Study Recruitment and Patient Characteristics
A total of 21 123 children were screened for bruising, and 2161 patients (mean [SD] age, 2.1 [1.1] years;
1296 [60%] male; 1785 [83%] White; 1484 [69%] non-Hispanic/Latino) were enrolled (Table).
Abused patients were younger (mean [SD] age, 1.6 [1.2] years) and more likely to be of a race otherthan White (109 [27%] vs 260 [15%]), be of non-Hispanic/Latino ethnicity (349 [85%] vs 1108
[65%]), and have government (298 [73%] vs 783 [46%]) or no (26 [6%] vs 38 [2%]) medical
insurance than nonabuse patients. Study flow, exclusions, and categorization outcomes are shownin Figure 1.

Bruising Characteristics
The median number of bruises per patient was 3 (range, 1-45). Abuse patients had higher bruise
counts than nonabuse patients overall and within each year of age (Table). Patients with fair-tonedskin had a higher bruise count (median, 4; IQR, 2-7) than patients with the 4 darker tones (median, 3;
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IQR, 1-6) (eTable 1 in the Supplement). The frequency of bruising for all 34 body regions for abuse andnonabuse patients is provided in Figure 2 in descending order of ability to discriminate abuse fromnonabuse. Patterned bruising was relatively uncommon (169 cases [8.0%]) but far more common inabuse (159 [38.8%]) than in nonabuse patients (10 [0.6%]). The differences in the regions affected
between abuse and nonabuse patients were substantial and are visually depicted on our body
diagram composites for each of the 4 age groups (eFigure 1 in the Supplement).

TEN-4 Performance and New BCDR Derivation
The previously derived TEN-4 rule identified 331 of 410 abuse patients correctly and was also positivefor 170 of 1713 nonabuse patients, producing a sensitivity of 80.7% (95% CI, 76.5%-84.4%) and a
specificity of 91.1% (95% CI, 89.7%-92.4%).15 The PPV of the TEN-4 rule was 68.5% (95% CI,
64.1%-72.6%), and the NPV was 95.2% (95% CI, 94.0%-96.1%). Thus, the sensitivity of the TEN-4
rule was unacceptably low, missing 19% of abuse patients, which indicated a need for refinement.

Table. Distribution of Clinical and Demographic Characteristics of Study Sample by Injury Classificationa
Overall(N = 2161)

Abuse(n = 410)

Nonabuse(n = 1713)

Indeterminate(n = 38)

0-0.99349 (16)160 (39)180 (11)9 (24)

1-1.99610 (28)

88 (21)509 (30)

13 (34)2-2.99644 (30)

97 (24)537 (31)

10 (26)3-3.99558 (26)65 (16)487 (28)

6 (16)

Male sex

1296 (60)243 (59)1029 (60)

24 (63)

White race

1785 (83)301 (73)1453 (85)31 (82)

Non-Hispanic/Latino ethnicity

1484 (69)349 (85)1108 (65)27 (71)Government

1102 (51)298 (73)783 (46)

21 (55)

Private971 (45)

77 (19)883 (52)

11 (29)None

68 (3)

26 (6)

38 (2)

4 (11)

Unknown or not reported

20 (1)

9 (2)

9 (1)

2 (5)

Characteristic
Age group, yInsurance

Reason for care
Medical

990 (46)

123 (30)855 (50)

12 (32)

Trauma952 (44)93 (23)847 (49)

12 (32)Child abuse evaluation

219 (10)194 (47)

11 (1)

14 (37)

GCS score <15

58 (3)

46 (11)

11 (1)

1 (3)ED discharge disposition
Home from ED

1685 (78)168 (41)

1491 (87)26 (68)Admit to hospital

283 (13)85 (21)191 (11)7 (18)

Foster care

101 (5)96 (23)

3 (0)

2 (5)

Admit to PICU

71 (3)

54 (13)14 (1)

3 (8)Fatalities

12 (1)

12 (3)

00

Skin tone
Fair

500 (23)126 (31)364 (21)

10 (26)Light

201 (9)27 (7)

168 (10)

6 (16)

Mid

1296 (60)197 (48)1080 (63)

19 (50)Brown

108 (5)35 (9)

71 (4)

2 (5)

Dark

56 (3)

25 (6)

30 (2)1 (3)Bruise count, median (IQR)
All ages

3 (1-6)

7 (3-11)

3 (1-5)2.5 (2-5)

Age 0-0.99 y

2 (1-5)5 (3-10)

1 (1-2)2 (1-2)

Age 1-1.99 y

2 (1-4)6 (3-11)

2 (1-4)3 (3-6)

Age 2-2.99 y

3 (2-6)8 (5-14)3 (2-5)2 (1-2)

Age 3-3.99 y

4 (2-7)9 (4-14)4 (2-6)

4.5 (2-8)

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Abbreviations: ED, emergency department; GCS,
Glasgow Coma Scale; IQR, interquartile range; PICU,
pediatric intensive care unit.
aData are presented as number (percentage) ofchildren unless otherwise indicated.
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To refine the TEN-4 BCDR, the classification tree we fit to these new data preserved the TEN
regions (torso, which includes chest, abdomen, back, buttocks, and genitourinary area; ear; andneck), modified the infant age threshold from younger than 4.0 months to 4.99 months and younger,
included patterned bruising (as defined above), and added the following body regions: angle of thejaw, cheeks (fleshy), eyelids, and subconjunctivae. We empirically added the frenulum as a region to
the rule. The frenulum substantially overlapped with bruising in other BCDR regions (overlap
occurred in 24 of 34 instances of frenulum injury [71%]), incurred a low cost to specificity (10additional false-positive results; 0.6% specificity loss), captured a misclassified abuse patient
admitted to the pediatric intensive care unit, and accounted for 2 fatalities. In addition, frenulum
bruising corresponded to the highest fatality rate associated with the occurrence of bruising in any
body region (2 of 34 [6%]).
We named the refined BCDR as TEN-4-FACESp, for torso, ear, neck (TEN), frenulum, angle ofjaw, cheeks (fleshy), eyelids, subconjunctivae (FACES), and patterned (p). The 4 represents any
bruising anywhere to an infant 4.99 months or younger. The rule applies only to children withbruising who are younger than 4.0 years. A positive response for any of these components signals aclassification of abuse. The refined BCDR had a sensitivity of 95.6% (95% CI, 93.0%-97.3%), a
specificity of 87.1% (95% CI, 85.4%-88.6%), an NPV of 98.8% (95% CI, 98.1%-99.3%), and a PPV of
63.9% (95% CI, 60.3%-67.7%). Additional characteristics describing the diagnostic accuracy of the
TEN-4-FACESp BCDR are shown in Figure 3. Bootstrap-derived test characteristics of sensitivity,
specificity, NPV, and PPV were slightly reduced from the estimates calculated from the full data set

Figure 1. Flow of Patient Enrollment
2526 Children <4 y of age with physical abuseconsultations (waiver of authorization)screened for bruising

18 597 Children <4 y of age presenting to pediatricEDs during research shifts who did notreceive child abuse consultation(parental consent)

17 230 Screened for bruising2407 With bruising1367 Met exclusion criteria

14 823 Without bruising

784 Not enrolled
629 Declined to participate
61 Unknown
94 Research team busy enrollingother participant

560 Enrolled with bruising1623 Enrolled

2183 Total enrolled
22 Excluded from analysis
11 Dog bites
11 Medical cause–related bruising(new diagnoses of canceror bleeding disorder)

2161 Final data set

410 Categorized as abuse
by expert panel

1713 Categorized as nonabuse
by expert panel

38 Categorized as indeterminate
by expert panel

Screening for bruising and patient eligibility with final enrollment counts and expert panel categorization of abuse and nonabuse. ED indicates emergency department.
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Validation of a Clinical Decision Rule to Predict Abuse in Young Children(Figure 3). Test characteristics did not substantially vary by skin tone (eTable 1 in the Supplement).
Cases misclassified by the TEN-4-FACESp are detailed in eTables 2 through 4 and eFigure 2 in the
Supplement.

Discussion
This prospective, multicenter study refined and validated the previously derived TEN-4 BCDR. The
TEN-4-FACESp BCDR yielded a high sensitivity of 96% and an acceptable specificity of 87%. The
intent of the validated BCDR is not to diagnose abuse but to function as a screening tool to improve
the recognition of potentially abused children with bruising who require further evaluation, while
minimizing overcapturing of children whose bruises are nonabuse related. As with other injuryfocused research, the BCDR serves only to inform and never to supplant clinical judgment.37-42
The strongest differentiator of bruising characteristics between abusive and nonabusive bruises
was body region bruised. The torso, ear, and neck alone correctly identified 81% of abuse patients.
Body regions with bruises on more than 100 abuse patients included the fleshy part of the cheeks,
the back, and the ears. The most specific regions for abuse, with 5 or fewer false-positive findings,

Figure 2. Occurrence of Bruises in Body Regions
No. (%) of children
RegionAbuse(n = 410)

Nonabuse(n = 1713)

Signed χ2statistic

Buttocks

99 (24)

5 (0)

399.0

Cheek (fleshy)

127 (31)39 (2)

374.1

Ear

111 (27)

23 (1)

366.0

Angle of jaw

74 (18)

2 (0)

303.0

Chest

84 (20)17 (1)

273.2

Back

120 (29)

68 (4)

259.2

Abdomen73 (18)14 (1)

238.6

Neck

60 (15)

3 (0)

235.2

Zygoma148 (36)144 (8)211.5

Preauricular

54 (13)

7 (0)

188.5

Mastoid45 (11)

6 (0)

154.8

Upper arm/shoulder

68 (17)35 (2)

148.4

Eyelid83 (20)59 (3)

146.9

Temporal or parietal

105 (26)112 (7)129.1

Subconjunctival hemorrhage

31 (8)

1 (0)

120.4

GU or anal

33 (8)

4 (0)

113.5

Spinous process

64 (16)61 (4)

84.5

Frenulum24 (6)

10 (1)

55.0

Orbital rim

83 (20)135 (8)53.5

Upper leg

104 (25)210 (12)

44.1

Nose

55 (13)88 (5)

34.8

Elbow

33 (8)

59 (3)

15.8

Lip

22 (5)

32 (2)

14.9

Occiput

23 (6)

39 (2)

11.8

Ankle

11 (3)

14 (1)

8.4

Forehead

135 (33)464 (27)

5.3

Chin

16 (4)

38 (2)

3.1

Lower arm

42 (10)136 (8)2.0

Abuse patients

Top of head

6 (1)

12 (1)

1.5

Nonabuse patients

Mouth

7 (2)

17 (1)

0.9

Abuse > nonabuseFoot

19 (5)

63 (4)

0.6

Philtrum (per Webster)9 (2)26 (2)

0.6

Hand

12 (3)

62 (4)–0.3

Knee

50 (12)580 (34)–73.4

Lower leg

79 (19)1090 (64)–261.3

Nonabuse > abuse
Equivalent

0

0.2

0.4

0.6

Proportion of bruised children

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0.8

The χ2 statistics were derived from tests of bruising ineach body region against abuse status, with signs
defined by direction of association (positive is defined
as abuse greater than nonabuse). Body regions are
sorted in order of discriminatory power for abuse,defined by the signed χ2 statistic. GU indicates
genitourinary.

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were the buttocks, genitourinary area or anus, angle of the jaw, neck, and subconjunctival
hemorrhage. Many regions indicative of abuse (such as the temporoparietal area) were not includedin the body region component of the final BCDR because the patients were already captured througha different more indicative body region or inclusion would have been too costly to specificity. For
example, the zygoma and forehead were common in abuse patients, but these regions also had highrates of occurrence in nonabusive injury and did not distinguish abusive from nonabusive bruising.
Consistent with the study findings, forces applied to the body from physical assault of a child (eg,grabbing the torso, neck, or face)14,27,29,32,43 would be expected to result in bruising to regions of the
body that differ from those associated with nonabusive injury (eg, falling forward onto the groundor falling off furniture). Several other studies10-12,14-16,18-23,44,45 also found bruising to the regions in
the BCDR to be highly associated with abuse. Notably, bruising to the ears, neck, angle of the jaw,
cheeks (fleshy), frenulum, and buttocks were seen most often in abuse cases and rarely in nonabusecases. Nonabusive injury most commonly led to bruising overlying bony prominences, such as to theforehead, chin, or shins (eFigure 1 in the Supplement).17 Other studies14,17 focused on nonabusive
bruising had similar findings to the current study, including bruising to bony areas of the body, suchas forehead or shins. These studies, in conjunction with the current study’s findings, support bruisinglocation as an important differentiator between abuse and nonabusive injury.
Several studies found patterns or shapes of the bruising to be important for recognizing
abuse.13,28,29,46 When a caregiver squeezes or strikes a child, causing rupture of blood vessels, thiscan result in the imprint of the hand or object onto the skin.28 Patterns can result from any object if
the strike or impact causes damage to blood vessels. Consistent with other studies, the current study
found patterned bruising to be highly associated with abuse, with 94% of patterned bruises
observed in patients categorized as abuse.

Figure 3. Bruising Clinical Decision Rule (BCDR)A Patient classification

410 Abuse
1713 Nonabuse
2123 Total
TEN-4 positive?

No(n = 1640)

Yes (classify as abuse; positive BCDR result)(n = 483)

79 Abuse
1561 Nonabuse
1640 Total
Patterned bruise?

No(n = 1612)

331 Abuse
152 Nonabuse
483 Total

Yes (classify as abuse; positive BCDR result)(n = 28)56 Abuse
1556 Nonabuse
1612 Total
No(n = 1510)

FACES bruise?

23 Abuse
5 Nonabuse
28 Total

Yes (classify as abuse; positive BCDR result)(n = 102)18 Abuse
1492 Nonabuse
1510 Total

B

38 Abuse
64 Nonabuse
102 Total

C

Classification summary
Classification summary

Diagnostic accuracy

Characteristic

Data based

Bootstrapped

BCDR result

Abuse

Nonabuse

Total

Sensitivity

95.6 (93.0-97.3)

91.5 (87.1-94.7)

Positive

392

221

613

Specificity

87.1 (85.4-88.6)

84.5 (79.7-88.1)

Negative

18

1492

1510

NPV

98.8 (98.1-99.3)

97.3 (95.7-98.7)

Total

410

1713

2123

PPV

63.9 (60.0-67.7)

58.4 (50.4-65.4)

LR positive

7.37 (6.56-8.19)

5.90 (4.42-7.50)

LR negative

0.05 (0.04-0.06)

0.11 (0.06-0.19)

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A, Classification of patients into abuse and nonabusegroups based on dichotomous independent variables(ie, TEN-4 [bruising to the torso, ear, and/or neck or
any bruising on an infant <4 months of age]), positive,
patterned bruise, or FACES [frenulum, angle of jaw,
cheeks (fleshy), eyelids, subconjunctivae] bruise)according to an expert panel. The BCDR results werepositive for 613 patients, of whom 392 were abuse
patients and 221 nonabuse patients. The BCDR results
were negative in 1713 patients, of whom 1492 were
nonabuse patients and 18 abuse patients. B,
Classification summary. C, Diagnostic accuracy
statistics. Data in parentheses are 95% CIs. LR
indicates likelihood ratio; NPV, negative predictive
value; PPV, positive predictive value.

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Validation of a Clinical Decision Rule to Predict Abuse in Young Children

Injuries that occur during early infancy are concerning for abuse owing to the child’s lack of grossmotor skills. At this young age, each injury requires a specific and detailed history, and each injury
must be plausibly accounted for in the history. There is little margin for error because infants have thegreatest risk of fatal or near-fatal injury from physical abuse.2 Several studies have identified infant
bruising to predict abuse1,14,18,21,44,47,48 and the presence of concomitant internal injuries.49 Others
have found bruising to be the most common injury (or sentinel finding) in children in whom abuse
was initially overlooked or underappreciated and who subsequently presented with a more severe
injury.5,6,50,51 The current study found that bruising anywhere on an infant 4.99 months of age or
younger was an important predictor of abuse, capturing patients at high risk for abuse that would
have been missed if only region-specific or pattern bruising components were used. Nonabusive
bruising was also observed in infants, but almost always resulted in a single bruise (Table). Others
have reported a similar finding among infants.52 Obtaining a clear history of injury causation isimperative for informing clinical judgment to assess the plausibility of the injury.
Enrolled children presented with medical, trauma, and abuse-specific concerns representing
the full spectrum of illness and severity of trauma ranging from discharge to home, hospital
admission, pediatric intensive care unit admission, and fatality (Table). Many children were referredto the pediatric emergency department from primary care offices or transferred from generalemergency departments, further supporting the generalizability of the study’s results acrossdifferent clinical settings. Including patients without trauma complaints was important because morethan two-thirds of abuse patients presented without any initial history of trauma. Other researchers
have found that the caregivers of abused children often presented for care reporting a vague medical
concern such as fussiness or vomiting.5,6,53 These findings support the importance of an informed
head-to-toe skin examination in young children regardless of chief concern and a differential
diagnosis guided by those findings.
Importantly, the TEN-4-FACESp BCDR is limited to children who have bruising present at thetime of examination. Thus, the absence of bruising in a child precludes the use of the BCDR for
identifying abuse because it is based on differences in bruising resulting from abuse vs nonabusive
injury. Stated differently, the BCDR is not negative for children without bruising—it is simply not
relevant for children without bruising. Alternative methods of identifying abuse not based on
bruising would be needed in such circumstances.

Limitations
This study has limitations. The study design required deliberate head-to-toe skin examinations on
every child, but because of limited resources, a second confirmatory examination on all 21 123
patients screened was not feasible. Some bruises may have been missed, but the screening process
was standardized. The finding of overall prevalence of bruising (14%) is higher than our previously
published results of 3.5% and results from other studies in infants.21,22,26 Enrollment in pediatricemergency departments vs primary care clinics and an enriched sampling of potential abuse patients
may account for this difference.
Skin tone is another potential limitation. We found that among children with nonabusive injury,
those with the four darker skin tones had significantly lower total bruise counts than children withthe lightest skin tone. This suggests that bruise visibility may have been impacted by skin tone
because nonabusive injuries tend to produce bruising in predictable numbers.10,17,21 Sugar et al alsosuggested that skin tone may have played a role in bruise visibility.21 Consideration of skin tone isimportant when determining the presence or absence of bruising. Although bruises may be moredifficult to see in darker-toned skin, the accuracy of the BCDR in the current study did not
substantially vary across skin tones.
One other potential limitation involves the categorization of patients as abuse or nonabuse andthe possibility of misclassification. The study used a 9-member panel composed of experts in childinjury with extensive clinical or research expertise, because there is no true criterion standard forabuse categorization. Panelist interpretation of all injury findings and conclusions of abuse or

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nonabuse were made in the context of that specific child and the associated histories. Agreement
among panelists was strong, and the panel was accurate in their classification of cases where theoutcome was definitively known.33

Conclusions
To our knowledge, this is the first validated clinical decision rule for improved recognition of physicalabuse in young children with bruising. The refined and validated rule, TEN-4-FACESp, performed
with high sensitivity, which is crucial for a screening tool, and yielded good specificity, which is crucial
when a screening test can cause undue stress, such as might occur in abuse screening. An important
next step will be implementing these findings in pediatric and general emergency departments andpediatric clinics.

ARTICLE INFORMATION
Accepted for Publication: February 23, 2021.
Published: April 14, 2021. doi:10.1001/jamanetworkopen.2021.5832
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Pierce MC
et al. JAMA Network Open.
Corresponding Author: Mary Clyde Pierce, MD, Division of Emergency Medicine, Ann & Robert H. Lurie Children’s
Hospital of Chicago, 225 E Chicago Ave, PO Box 62, Chicago IL 60611 (mpierce@luriechildrens.org).
Author Affiliations: Division of Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago,
Chicago, Illinois (Pierce, Kaczor, Sheehan); Department of Pediatrics, Northwestern University Feinberg School of
Medicine, Chicago, Illinois (Pierce, Fingarson, Fortin, Sheehan); Department of Bioinformatics and Biostatistics,
School of Public Health and Information Sciences, University of Louisville, Louisville, Kentucky (Lorenz);
Department of Bioengineering, J.B. Speed School of Engineering, University of Louisville, Louisville, Kentucky(Bertocci); Division of Child Abuse Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois(Fingarson, Fortin); Mayerson Center for Safe and Healthy Children, Cincinnati Children’s Hospital, Department ofPediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio (Makoroff); Department of Pediatrics,
UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania (Berger, Zuckerbraun); Division of Emergency
Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio (Bennett, Meyers); Department ofPediatrics, The Ohio State University, Nationwide Children’s Hospital, Columbus (Bennett); Department ofPediatrics, University of California San Diego School of Medicine, La Jolla (Magana); Department of Emergency
Medicine, University of California, Davis Medical Center, Sacramento (Magana); Department of Pediatrics,
University of Chicago, Chicago, Illinois (Staley, Ramaiah); Division of Pediatric Emergency Medicine, Advocate
Children's Hospital, Oak Lawn, Illinois (Staley); Division of General Pediatrics, Perelman School of Medicine at the
University of Pennsylvania, Philadelphia (Fortin); Norton Children’s Pediatric Protection Specialists Affiliated with
the University of Louisville School of Medicine, Louisville, Kentucky (Currie); Department of Pediatrics, Universityof Utah School of Medicine, Salt Lake City (Herman); Division of Pediatric Emergency Medicine, University ofLouisville, Louisville, Kentucky (Herr); Department of Pediatrics, Penn State College of Medicine, Penn State HealthChildren’s Hospital, Hershey, Pennsylvania (Hymel); Department of Pediatrics, University of Washington, Seattle
Children’s Hospital, Seattle (Jenny); Department of Social Work, Ann & Robert H. Lurie Children’s Hospital of
Chicago, Chicago, Illinois (Hickey); Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut(Leventhal).
Author Contributions: Dr Pierce had full access to all of the data in the study and takes responsibility for the
integrity of the data and the accuracy of the data analysis.
Concept and design: Pierce, Kaczor, Lorenz, Makoroff, Berger, Herr, Hickey.
Acquisition, analysis, or interpretation of data: Pierce, Kaczor, Lorenz, Bertocci, Fingarson, Makoroff, Berger,
Bennett, Magana, Staley, Ramaiah, Fortin, Currie, Herman, Herr, Hymel, Jenny, Sheehan, Zuckerbraun, Meyers,
Leventhal.
Drafting of the manuscript: Pierce, Kaczor, Lorenz, Bennett, Staley, Herr, Leventhal.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Lorenz, Zuckerbraun.

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Obtained funding: Pierce, Kaczor, Lorenz.
Administrative, technical, or material support: Pierce, Kaczor, Fingarson, Bennett, Fortin, Currie,
Zuckerbraun, Meyers.
Supervision: Pierce, Kaczor, Herman.
Conflict of Interest Disclosures: Dr Pierce reported receiving salary support from the National Institutes of Health(NIH) during the conduct of the study. Dr Kaczor reported receiving grants from Eunice Kennedy Shriver National
Institute of Child Health and Human Development and the Grainger Foundation during the conduct of the study. Dr
Lorenz reported receiving grants from the NIH during the conduct of the study. Dr Bertocci reported receiving
grants from the NIH during the conduct of the study. Dr Fingarson reported receiving grants from the NIH during
the conduct of the study. Dr Berger reported receiving grants from the NIH during the conduct of the study. Dr
Currie reported receiving grants from the NIH during the conduct of the study. Dr Herman reported receiving
grants from the NIH during the conduct of the study. Dr Herr reported receiving grants from the NIH during the
conduct of the study and outside the submitted work. Dr Hymel reported receiving grants from the NIH during the
conduct of the study. Dr Leventhal reported receiving payment for expert child abuse consultation and testimony
in court. No other disclosures were reported.
Additional Contributions: We thank the research enrollment and administrative teams at the data collection sites:
Emalee Flaherty, MD, Suzanne Schmidt, MD, Janet Flores, BS, Kelly Liker, MD, Tara Shenoy, MD, and Laura Turner
Martinez, BS, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois; John Kanegaye, MD,
Department of Pediatrics, University of California San Diego School of Medicine, La Jolla; and Kendra Sikes, MS,
The University of Louisville, Kosair Children’s Hospital, Louisville, Kentucky. Dr Flaherty, Dr Schmidt, Ms Flores, Dr
Liker, Dr Shenoy, Ms Martinez, and Ms Sikes received salary support from an NIH grant to support this work.
REFERENCES
1. Ellerstein NS. The cutaneous manifestations of child abuse and neglect. AJDC. 1979;133(9):906-909. doi:10.
1001/archpedi.1979.02130090034005
2. US Department of Health and Human Services, Administration for Children and Families, Administration on
Children, Youth and Families, Children’s Bureau. Child maltreatment. 2018. Accessed September 25, 2020. https://www.acf.hhs.gov/cb/report/child-maltreatment-2018
3. Pierce MC, Kaczor K, Acker D, et al. History, injury, and psychosocial risk factor commonalities among cases offatal and near-fatal physical child abuse. Child Abuse Negl. 2017;69:263-277. doi:10.1016/j.chiabu.2017.04.033
4. Atwal GS, Rutty GN, Carter N, Green MA. Bruising in non-accidental head injured children; a retrospective studyof the prevalence, distribution and pathological associations in 24 cases. Forensic Sci Int. 1998;96(2-3):215-230.
doi:10.1016/S0379-0738(98)00126-1
5. Letson MM, Cooper JN, Deans KJ, et al. Prior opportunities to identify abuse in children with abusive headtrauma. Child Abuse Negl. 2016;60:36-45. doi:10.1016/j.chiabu.2016.09.001
6. Jenny C, Hymel KP, Ritzen A, Reinert SE, Hay TC. Analysis of missed cases of abusive head trauma [publishedcorrection appears in JAMA. 1999;282(1):29]. JAMA. 1999;281(7):621-626. doi:10.1001/jama.281.7.621
7. Deans KJ, Thackeray J, Askegard-Giesmann JR, Earley E, Groner JI, Minneci PC. Mortality increases withrecurrent episodes of nonaccidental trauma in children. J Trauma Acute Care Surg. 2013;75(1):161-165. doi:10.1097/
TA.0b013e3182984831
8. King WK, Kiesel EL, Simon HK. Child abuse fatalities: are we missing opportunities for intervention? Pediatr
Emerg Care. 2006;22(4):211-214. doi:10.1097/01.pec.0000208180.94166.dd
9. Saade DN, Simon HK, Greenwald M. Abused children: missed opportunities for recognition in the ED. Acad
Emerg Med. 2002;9(5):524. doi:10.1197/aemj.9.5.524
10. Kemp AM, Maguire SA, Nuttall D, Collins P, Dunstan F. Bruising in children who are assessed for suspected
physical abuse. Arch Dis Child. 2014;99(2):108-113. doi:10.1136/archdischild-2013-304339
11. Maguire S, Mann MK, Sibert J, Kemp A. Are there patterns of bruising in childhood which are diagnostic orsuggestive of abuse? a systematic review. Arch Dis Child. 2005;90(2):182-186. doi:10.1136/adc.2003.044065
12. Dunstan FD, Guildea ZE, Kontos K, Kemp AM, Sibert JR. A scoring system for bruise patterns: a tool for
identifying abuse. Arch Dis Child. 2002;86(5):330-333. doi:10.1136/adc.86.5.330
13. Feldman KW. Patterned abusive bruises of the buttocks and the pinnae. Pediatrics. 1992;90(4):633-636.
14. Feldman KW, Tayama TM, Strickler LE, et al. A prospective study of the causes of bruises in premobile infants.
Pediatr Emerg Care. 2020;36(2):e43-e49. doi:10.1097/PEC.0000000000001311

JAMA Network Open. 2021;4(4):e215832. doi:10.1001/jamanetworkopen.2021.5832 (Reprinted)

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April 14, 2021

10/12

JAMA Network Open | Pediatrics

Validation of a Clinical Decision Rule to Predict Abuse in Young Children

15. Pierce MC, Kaczor K, Aldridge S, O’Flynn J, Lorenz DJ. Bruising characteristics discriminating physical childabuse from accidental trauma [published correction appears in Pediatrics. 2010;125(4):861]. Pediatrics. 2010;125(1):67-74. doi:10.1542/peds.2008-3632
16. Pierce MC. Bruising characteristics from unintentional injuries in children: the ‘green flag’ study. Arch Dis Child.
2017;102(12):1097-1098. doi:10.1136/archdischild-2017-313367
17. Hibberd O, Nuttall D, Watson RE, Watkins WJ, Kemp AM, Maguire S. Childhood bruising distribution observed
from eight mechanisms of unintentional injury. Arch Dis Child. 2017;102(12):1103-1109. doi:10.1136/archdischild2017-312847
18. Pascoe JM, Hildebrandt HM, Tarrier A, Murphy M. Patterns of skin injury in nonaccidental and accidental injury.
Pediatrics. 1979;64(2):245-247.
19. Williams RA. Injuries in infants and small children resulting from witnessed and corroborated free falls.
J Trauma. 1991;31(10):1350-1352. doi:10.1097/00005373-199110000-00005
20. Labbé J, Caouette G. Recent skin injuries in normal children. Pediatrics. 2001;108(2):271-276. doi:10.1542/
peds.108.2.271
21. Sugar NF, Taylor JA, Feldman KW; Puget Sound Pediatric Research Network. Bruises in infants and toddlers:
those who don’t cruise rarely bruise. Arch Pediatr Adolesc Med. 1999;153(4):399-403. doi:10.1001/archpedi.
153.4.399
22. Carpenter RF. The prevalence and distribution of bruising in babies. Arch Dis Child. 1999;80(4):363-366. doi:
10.1136/adc.80.4.363
23. Steele BD, Brennan PO. A prospective survey of patients with presumed accidental ear injury presenting to apaediatric accident and emergency department. Emerg Med J. 2002;19(3):226-228. doi:10.1136/emj.19.3.226
24. Stiell IG, Wells GA. Methodologic standards for the development of clinical decision rules in emergency
medicine. Ann Emerg Med. 1999;33(4):437-447. doi:10.1016/S0196-0644(99)70309-4
25. Wasson JH, Sox HC, Neff RK, Goldman L. Clinical prediction rules—applications and methodological standards.
N Engl J Med. 1985;313(13):793-799. doi:10.1056/NEJM198509263131306
26. Pierce MC, Magana JN, Kaczor K, et al. The prevalence of bruising among infants in pediatric emergency
departments. Ann Emerg Med. 2016;67(1):1-8. doi:10.1016/j.annemergmed.2015.06.021
27. Jinna S, Livingston N, Moles R. Cutaneous sign of abuse: kids are not just little people. Clin Dermatol. 2017;35(6):504-511. doi:10.1016/j.clindermatol.2017.08.002
28. Petska HW, Frasier LD, Livingston N, Moles R, Sheets LK. Patterned bruises from abusive squeezing. Published
online January 7, 2019. Pediatr Emerg Care. 2019. doi:10.1097/PEC.0000000000001717
29. Wells K, Castellani RJ, deJong JL. Can neck contusions in unexplained pediatric deaths be explained bycardiopulmonary resuscitation? J Forensic Sci. 2019;64(3):770-772. doi:10.1111/1556-4029.13919
30. Fingarson A, Pierce MC. Cutaneous manifestations of child abuse. In: Laskey A, Sirotnak A, eds. Child Abuse:
Medical Diagnosis and Management. 4th ed. American Academy of Pediatrics; 2020.
31. Anderst JD, ed. Visual Diagnosis of Child Abuse: The AAP Resource of Visual Findings of Child Abuse for Medical
Providers. 4th ed. American Academy of Pediatrics; 2016.
32. Letson MM, Tscholl JJ. Bruises, burns, and other blemishes: diagnostic considerations of physical abuse. Clin
Pediatr Emerg Med. 2012;13:155-165. doi:10.1016/j.cpem.2012.06.007
33. Lorenz DJ, Pierce MC, Kaczor K, et al. Classifying injuries in young children as abusive or accidental: reliability
and accuracy of an expert panel approach. J Pediatr. 2018;198:144-150.e4. doi:10.1016/j.jpeds.2018.01.033
34. Breiman L, Friedman JH, Olshen RA, Stone CJ. Classification and Regression Trees. Wadsworth; 1984.
35. R Core Team. R: a language and environment for statistical computing. R Foundation for Statistical Computing;2020. Accessed March 6, 2021. https://www.R-project.org/
36. Therneau T, Atkinson, B. rpart: recursive partitioning and regression trees. R package version 4.1-15. 2019.
Accessed March 6, 2021. https://CRAN.R-project.org/package=rpart
37. Berger RP, Fromkin J, Herman B, et al. Validation of the Pittsburgh Infant Brain Injury Score for Abusive Head
Trauma. Pediatrics. 2016;138(1):e20153756. doi:10.1542/peds.2015-3756
38. Kuppermann N, Holmes JF, Dayan PS, et al; Pediatric Emergency Care Applied Research Network (PECARN).
Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective
cohort study [published correction appears in Lancet. 2014;383(9914):308]. Lancet. 2009;374(9696):1160-1170.
doi:10.1016/S0140-6736(09)61558-0
39. Kemp AM, Hollén L, Emond AM, Nuttall D, Rea D, Maguire S. Raising suspicion of maltreatment from burns:
derivation and validation of the BuRN-Tool. Burns. 2018;44(2):335-343. doi:10.1016/j.burns.2017.08.018
JAMA Network Open. 2021;4(4):e215832. doi:10.1001/jamanetworkopen.2021.5832 (Reprinted)

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April 14, 2021

11/12

JAMA Network Open | Pediatrics

Validation of a Clinical Decision Rule to Predict Abuse in Young Children

40. Hymel KP, Herman BE, Narang SK, et al; Pediatric Brain Injury Research Network (PediBIRN) Investigators;
Pediatric Brain Injury Research Network PediBIRN Investigators. Potential impact of a validated screening tool for
pediatric abusive head trauma. J Pediatr. 2015;167(6):1375-1381.e1. doi:10.1016/j.jpeds.2015.09.018
41. Lindberg D, Makoroff K, Harper N, et al; ULTRA Investigators. Utility of hepatic transaminases to recognize
abuse in children. Pediatrics. 2009;124(2):509-516. doi:10.1542/peds.2008-2348
42. Wood J, Rubin DM, Nance ML, Christian CW. Distinguishing inflicted versus accidental abdominal injuries inyoung children. J Trauma. 2005;59(5):1203-1208. doi:10.1097/01.ta.0000196437.07011.b1
43. Kaczor K, Pierce MC, Makoroff K, Corey T. Bruising and physical child abuse. Clin Pediatr Emerg Med. 2006;7:
153-160. doi:10.1016/j.cpem.2006.06.007
44. Thackeray JD. Frena tears and abusive head injury: a cautionary tale. Pediatr Emerg Care. 2007;23(10):735-737. doi:10.1097/PEC.0b013e3181568039
45. DeRidder CA, Berkowitz CD, Hicks RA, Laskey AL. Subconjunctival hemorrhages in infants and children: a signof nonaccidental trauma. Pediatr Emerg Care. 2013;29(2):222-226. doi:10.1097/PEC.0b013e318280d663
46. Patno K, Jenny C. Who slapped that child? Child Maltreat. 2008;13(3):298-300. doi:10.1177/
1077559507312961
47. Petska HW, Sheets LK, Knox BL. Facial bruising as a precursor to abusive head trauma. Clin Pediatr (Phila).
2013;52(1):86-88. doi:10.1177/0009922812441675
48. Pierce MC, Smith S, Kaczor K. Bruising in infants: those with a bruise may be abused. Pediatr Emerg Care.
2009;25(12):845-847. doi:10.1097/PEC.0b013e3181c06217
49. Harper NS, Feldman KW, Sugar NF, Anderst JD, Lindberg DM; Examining Siblings to Recognize Abuse
Investigators. Additional injuries in young infants with concern for abuse and apparently isolated bruises.
J Pediatr. 2014;165(2):383-388.e1. doi:10.1016/j.jpeds.2014.04.004
50. Sheets LK, Leach ME, Koszewski IJ, Lessmeier AM, Nugent M, Simpson P. Sentinel injuries in infants evaluatedfor child physical abuse. Pediatrics. 2013;131(4):701-707. doi:10.1542/peds.2012-2780
51. Oral R, Yagmur F, Nashelsky M, Turkmen M, Kirby P. Fatal abusive head trauma cases: consequence of medical
staff missing milder forms of physical abuse. Pediatr Emerg Care. 2008;24(12):816-821. doi:10.1097/PEC.
0b013e31818e9f5d
52. Kemp AM, Dunstan F, Nuttall D, Hamilton M, Collins P, Maguire S. Patterns of bruising in preschool children—alongitudinal study. Arch Dis Child. 2015;100(5):426-431. doi:10.1136/archdischild-2014-307120
53. Flaherty EG. Analysis of caretaker histories in abuse: comparing initial histories with subsequent confessions.
Child Abuse Negl. 2006;30(7):789-798. doi:10.1016/j.chiabu.2005.12.008
SUPPLEMENT.
eTable 1. Bruise and BCDR Characteristics by Skin ToneeTable 2. Characteristics of Cases Misclassified by the BCDR - 18 Abuse Patients With Negative BCDR Results (False
Negatives)eTable 3. Bruising Characteristics of Abuse Patients Who Were Screened Negative by the BCDR (False Negatives)
and the Potential Impact on BCDR if Their Missed Body Regions Were Included in the RuleeTable 4. BCDR Characteristics of Non-Abuse Patients Who Were Screened Positive by the BCDR (False Positives)
Compared to True Positive Abuse PatientseFigure 1. Composite Results of Location of Bruises Due to Abuse and Non-Abuse Stratified by Body Plane andAge: A (Anterior), B (Posterior); C (Left Lateral); D (Right Lateral); E (Mandible)
eFigure 2. Body Diagram Composite Results of Abuse Patients Who Were Screened Negative by the BCDR (False
Negatives) and Non-Abuse Patients Who Were Screened Positive (False Positives) by the BCDR

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