Age Estimation of Adolescents for Legal Purposes
Condition: Adolescence; Bone Maturation
Study type: Observational

Summary: 
      Economic globalisation has been associated with a rise of cross-border migration in Europe.
      In France, courts commonly demand appropriate medical tests aimed at age estimations of
      supposed minors without documentation. Determining the age of foreign adolescents may be
      important in order to define the rights and protection afforded them by law depending on this
      status, and the conditions in which they may be detained or held in police custody if they
      are under suspicion. Age estimation is considered to be ideally based on the combination of
      clinical, skeletal, and dental examinations. A number of forensic physicians do not integrate
      published recommendations or the results of published studies into their daily practice.
      Previous studies have shown that medical practice is heterogeneous in this area. Factors
      determining this heterogeneity are unknown.

      We hypothesize that the personal and professional development of the physician, as well as
      the characteristics and the circumstances of medical examination can affect medical response
      on age determination, beyond clinical and radiological data. The purpose of this study is to
      identify factors determining medical response to courts.
    

Detailed description: 
      Economic globalisation has been associated with a rise of cross-border migration in Europe.
      Courts commonly demand appropriate medical tests aimed at age estimations of supposed minors
      without documentation. Determining the age of foreign adolescents may be important in order
      to define the rights and protection afforded them by law depending on this status, and the
      conditions in which they may be detained or held in police custody if they are under
      suspicion.

      Guidelines for age estimation in living individuals have been proposed and are based on the
      combination of general clinical, skeletal, and dental examinations. However, guidelines for
      paediatricians in the UK and a national consensus conference in France on doctors' attendance
      on detainees in police custody have stated that the currently available methods generally do
      not enable a doctor to state with confidence if a detainee is a minor or not. The validity of
      currently used methods has also been questioned by the French National Consultative Ethics
      Committee on Health and Life Sciences.

      As any middle school teacher can testify, anthropometric measures such as height and weight,
      and visible signs of sexual maturity vary widely from one adolescent to another, so that
      general clinical examination has limited value for age estimation. The skeletal examination
      is considered more reliable. In the reference radiological method, X-ray examination of the
      left hand and wrist is compared with standard images from an atlas published by Greulich and
      Pyle, who collected standards obtained in the 1930's and 1940's from an American white
      middle-class population. The main criteria applied for dental age determination are the
      eruption and development of the third molars, based on external and X-ray examination.

      Age estimation is considered to be ideally based on the combination of clinical, skeletal,
      and dental examinations. However, it is not easy to determine from available published series
      if the estimated age of a given individual is a precise age or a spectrum of possible ages,
      and in this case how broad is the proposed spectrum. Indeed, the information in the
      radiological atlas by Greulich and Pyle is statistical, not individual. The use of such data
      for forensic purposes has never been intended by the authors, nor validated. Moreover, the
      ethnic and socioeconomic characteristics of the adolescents examined today in Western Europe
      may differ largely from those presented in the atlas, as previously suggested. The role of
      ethnic factors in skeletal maturation has been repeatedly studied and gave conflicting
      results. In most series evaluating skeletal age in different populations, hand and wrist
      X-rays were obtained from healthy subjects or patients received for evaluation of trauma. The
      conclusions of these studies may not be validated, or at least should be considered
      cautiously, when extrapolating results to adolescents without documents involved in judicial
      procedures, who have heterogeneous and largely unevaluated psychological and socioeconomic
      characteristics. A number of forensic physicians do not integrate published recommendations
      or the results of published studies into their daily practice. Previous studies have shown
      that medical practice is heterogeneous in this area. Factors determining this heterogeneity
      are unknown.

      We hypothesize that the personal and professional development of the physician, as well as
      the characteristics and the circumstances of medical examination can affect medical response
      on age determination, beyond clinical and radiological data. The main objective of this study
      is to identify factors determining medical response to courts. A secondary objective is to
      evaluate how evidence-based data obtained from medical journals are taken into account in
      medical decision making by forensic physicians.

      The main evaluated criterium is the medical response transmitted to courts regarding age
      determination.

      Methods Prospective observational study of 500 age determinations requested by courts in
      migrant adolescents without documentation, in 18 departments of forensic medicine in France.
      Non-inclusion criterium is the refusal of the adolescent to undergo a medical examination.
    

Time perspective: Prospective
Sampling method: Non-Probability Sample
Study population: 
        Adolescents or young adult addressed by the judicial police officer,for age determination
        in one of the participating centers
      
Keywords: Skeletal age; Chronological age; Adolescent