ࡱ> ed|g kbjbjVV 0r<r<c444$ :,|: 04RJ!J!J!4J! Z: Submission To Human Rights Commission Age assessment in People smuggling Cases. I am a radiologist who has prepared expert witness evidence for the defendants in approximately 10 cases related to age determination of individuals accused of people smuggling offences. I attach a copy of one of these opinions, which covers much of the topic. As you are aware the Federal Police chose to use hand and wrist x-ray evaluation by the Greulich and Pyle method as the sole objective determination of age. Specifically they have used this to decide whether the subject was likely to be above or below 18 years. As far as I am aware they did not ask an expert group whether the test could achieve what they required, but instead selectively used evidence and opinion without external expert validation. I am specifically aware that they did not approach the RANZCR or the ANZSPR . They continued to use one specific expert witness opinion and persisted with this despite significant external views that they were incorrect. Even when they had multiple cases when their expert opinion had been rejected in court they chose to persist and stall cases until the last minute. Although Greulich and Pyle has some potential value in determining age in very broad bands, the atlas has not been designed or verified for this purpose. It is can not be used to decide whether males are above or below 18 years. There are multiple problems with the use of this Atlas as it was collected using 1930 predominantly caucasian American children. There is conflicting data about its relevance to modern white populations, let alone to non-caucasians. This is further confounded by the relative effects of nutrition and hard physical labour in delaying and hastening bone maturation. The Federal police have announced that they intend to use dental analysis and the possible use of clavicle x-rays as further proof of age. The use of multiple x-ray techniques has been strongly advocated by the Germans. It seems that most of the published material, particularly on clavicle maturity is from this one group. As far as I can establish the numbers are very small and there has been no external validation of their techniques. I have no personal experience of these techniques, and indeed suspect that expertise, particularly related to the clavicle, in Australia will be very shallow. It is concerning that these techniques are likely to have the same problems of sensitivity and specificity as hand x-ray, but without the external data to confirm this uncertainty. Multiple opinions should be sought from dentists familiar with the dental technique. I am concerned about the validation processes that the Federal Police have undertaken of the techniques they have chosen and the high level of uncertainty of any age assessment technique. The inherent high level of uncertainty of any age assessment technique, combined with the relatively low level of proof inherent in the balance of probabilities means that it is very likely that teenagers will be held as adults. Given that the significance of a decision that the individual is an adult is so important, the techniques chosen need to have high level validation, and the level of proof set much higher, to ensure that as few minors are held as possible. Lastly as a health professional who actively attempts to minimize exposure of patients, and particularly minors to ionizing radiation, I deplore the use of an non-validated and unproven x-ray technique that exposes these young people to radiation for administrative purposes, without any clear opportunity to improve their health or lives. Dr James Christie MB BS FRANZCR 2 Feb 2012 Expert Opinion of Dr James Christie in the case of [accused] I have been requested to provide an opinion on the issue of age determination of [accused] which has been performed using a left hand xray. My relevant experience and qualifications are: Bachelor of Medicine Bachelor of Surgery University of Sydney 1981. Fellowship of the Royal Australian and New Zealand College of Radiologists (FRANZCR 1991). I was awarded the medal for most successful candidate in the final examination series in 1990 Subspecialty Fellowship. Specialty Fellowship training in Paediatric Radiology, Royal Alexandra Hospital for 鱨վ in Sydney 1990. Specialist Paediatric Radiology training at the Hospital for Sick 鱨վ Toronto, Canada 1991. Consultant Radiologist with primary responsibility for Paediatric Radiology Westmead Hospital Sydney 1992 to 1995. Consultant Radiologist 鱨վ's Hospital Westmead 1995-1996. Consultant Radiologist Royal North Shore Hospital Sydney 1997 to 1999. Specialist Radiologist Pittwater Radiology Partnership (now called PRPDI) 1999-2011. Specialist Radiologist 鱨վ's Hospital Westmead 2008-2011. Examiner in Paediatric Radiology for RANZCR from 1993-2000. During my working life as a radiologist with paediatric interest I have interpreted many thousands of bone age studies using the Greulich and Pyle atlas. I have provided with a left hand xray performed on [name] on 21-1-2010 and a report on this xray performed by [name]. I have been asked to review this xray and provide a report as to the likelihood that [name] was older than 18 at the time of the xray. Left Hand Xray: A single AP view has been performed. This has been performed in the standard manner used to determine bone age. The epiphyses are completely fused. The skeletal age corresponds to the last standard of Greulich and Pyle; the 19 year standard. I note on the report that the stated chronological age is [date]. I agree with [name]'s conclusion that the stated chronological age and the skeletal age are incongruous. However it not possible from this examination to draw a conclusion as to whether [name] is greater than 18 years or less than 18 years at the time of the study and I will explain the reasons for this below. Estimation of Skeletal Age: Skeletal age is estimated by x-raying a part or parts of a child and comparing them to an atlas of standard images. It is most common to use a hand x-ray and in Australia, skeletal age is usually assessed using Greulich and Pyle Radiographic Atlas of Skeletal Development of the Hand and Wrist, Stanford Press 1950. The Greulich and Pyle atlas is based on data collection in Cleveland Ohio during the 1930's. 鱨վ of known chronological age, who were felt to be normal on the basis of size and development, had serial x-rays performed of their left hands. The population used to compile this standard atlas was predominantly white and middle class. The results were collated and representative views of the hand for various ages displayed graphically in the atlas. The standards shown are approximately 1 year apart. The last male standard is 19 years. There are no further standards after this and so the x-ray of a hand of a 60 year old male, would be correctly reported as having a chronological age of 19 years. Use of the term "19 years" is misleading and a more logical term would be "Mature". Skeletal age estimation is a tool that has been developed to use as an accessory test in a work-up of children of known chronological age who have growth disturbance or hormonal problems. It is generally used in children who are short or tall for age, who appear to be reaching puberty early or late, or have endocrine disturbances or systemic illness of some other sort. The test is of most value in a single person when used serially to follow development. It is only ever used as an adjunctive test, combined with clinical examination, measurement of hormone levels and further investigation that allow an estimation of maturity. In clinical practice it would never be used as the sole determinate of the development of a child. Skeletal age determination is generally of most value and most accurate where there is a rapid change in the maturation of the bones and in general has limited value at either end of the spectrum; that is in the very young or the near mature. There is very little difference between the Greulich and Pyle male 18 and 19 year standards. Normal variation: It is obvious common sense to point out that a skeletal age value does not mean that the person is of that age. In general it means that the bone development in the left hand is closest to the average for that age. It is merely a test that shows bone maturity. Within the Greulich and Pyle atlas, there are separate charts, (referred to by [name] in his report) where the standard deviation, that is the normal variation, at specific chronological ages, has been assessed. These charts of normal variation were established for known chronological ages and in males the last documented chronological age for which variation has been established is 17 years. For example, a 17year old male may have a skeletal age, using a hand estimation, between 14 years 6 months and a 19 years and still be considered normal. The variation tables have been developed for use in children who are not yet skeletally mature. The tables cannot be used in those who are skeletally mature as there is no supporting data available. The authors of Greulich and Pyle recognised the variability of bone age estimation and on page 49 state; The limits of normality suggested above should be considered nothing more than a useful rule-of-thumb for evaluating skeletal assessment of individual children. The reader who has dealt sufficiently with children to have been impressed with their variability in rate of maturation will understand why it is not advisable to attempt to define the limits of normality in skeletal status for age precisely These tables of normal variation have not been developed, or validated, to be used in the reverse direction. By this I mean that there is no established verification that they can be used with an estimated skeletal age to determine what the potential variation in chronological age is. There is certainly no data available that allows us to establish what the potential variation in chronological age is with a skeletal age that is near mature. [Name] has used the tables of variation related to known chronological age and has attempted to show, with precise percentage values, the likelihood of a certain chronological age matching the a mature bone age. The use of such precise numbers suggests to the reader of the report that there is scientific accuracy to the estimate, where none exists. It is scientifically wrong to suggest that a standard variation curve can be applied to the end point of a population distribution, in this case the 19 year standard. For example both a 17 year old boy or a 60 year old man may both have the same skeletal age of 19. By assessing only the skeletal age, and using [name]s assumptions, you could come to the clearly false conclusion that each of them has exactly the same probability of being 18 years old. The skeletal age value assigned to each standard in the atlas is not the average or even median age at which the skeleton reaches this appearance, but merely the x-ray that the authors subjectively felt most closely represented that age. Clearly the 19 year value cannot be an average of the values between 15 years and 60 years. It also is not the median age for maturity, (that is the value where 50% will be above and 50% will be below), but is merely a descriptor that is higher than the 18 year value. G&P could have called this 20 or 30 or just Mature. The actual number means very little. As x-rays were not performed every month, but only once a year we have no way of knowing when an individual became skeletally mature. The residual subjects in G&P who were not mature at age 18 years (and hence removed from the study) and then returned one year later for an x-ray may all have been mature at 18 years and 1 month, but we do not know this from the data. Unless we know that median age we cannot apply standard variation tables, even if these were available in the G&P data. G&P were not interested in the mature skeleton, and their data shows progressive loss of numbers around late teenage life as the x-rays become mature. Scientific statistical analysis of the Greulich and Pyle data, particularly in relation to the assessment of skeletally mature patients in the context of chronological age assessment, of has been performed by Professor Tim Cole, a medical biostatistician with a particular interest and expertise in childhood growth. His report is attached in full as an appendix. He is able to provide analysis of this data at an expert level. In summary his analysis shows that the G&P data does not adequately address skeletally mature patients, and that use of the standard deviation data for 17 years is statistically wrong. To quote Professor Cole: In conclusion, the Greulich-Pyle Atlas was not designed to assess age in young people who are skeletally mature, and it should not be used for that purpose. A mature hand-wrist radiograph is compatible with any age from 15 years upwards, and more than half of boys will have reached maturity before the age of 18 years. Other authors also report that ages other than 19 may be considered to be the level of maturity. Schmeling in titled Forensic Age Estimation of Live Adolescents and Young Adults,, from the journal Forensic Patholgy review 2008 , says The skeletal development of hand bones is complete at the age of 17 in girls and at the age of 18 years in boys. Professor Cole in his review of the statistics of Greulich and Pyle in relation to assessment of mature male x-rays, not that in the Tanner and Whitehouse 3 assessment atlas approximately 60% of males will have a mature hand xray at 18 years. Accuracy of Greulich and Pyle normal standards across differential racial and socioeconomic groups: The normal standards of Greulich and Pyle have been evaluated in a number of differential groups. The sequence of ossification and maturation is fairly standard across different racial groups, however there is evidence that various groups will have faster or slower maturation than these charts would suggest. For example, a review article in the American Journal of Radiology from 1996 (Ontell et al) shows that adolescent Asian males will have advanced skeletal age compared with chronological age by a mean of 9 to 11 months. Additional papers including Zhang (Radiology 2009) and Chiang (Tzu Chi Med J 2005) have shown similar inconsistencies in the use of bone age estimates in various ethnic groups. I can find no evidence in the literature that the Greulich and Pyle standards have been evaluated against a Indonesian male population. We have no way of knowing the relevance of these standards to this population. Validity of using bone age tests to assess chronological age: Chronological age is a specific number with a precise value derived from the date of birth. Skeletal age is a broad and imprecise estimation based on a number of subjective assessments. There are an infinite number of factors which may cause variation in skeletal age, many known but some unknown. I can find no study that shows any scientific validity to using assessment of skeletal age to estimate chronological age. The Greulich and Pyle data was acquired from the viewpoint of children of known chronological age. It would presumably have some validity if you used the same population as the G&P study data, and you knew from medical examination and developmental assessment that the children were normal. There maybe limited value in using skeletal age estimation to place children into broad groups when their chronological age is unknown. It would be of most value in placing children to broad groups at the time where there is most rapid change in maturation, that is in the middle period between 4 and 15 years. The International Olympic Committee consensus statement of age determination in high level athletes, June, 2010: rejected the use of bone age to estimate chronological age in part because "..the assessment of skeletal age by xray scanning does not allow precise determination of chronological age as variation of up to 4 years in bone age have been observed in adolescents at the same chronological age". In an editorial in the Journal of Paediatric Endochronological and Metabolism 2009, Dr V. Zvi Zadik stated that "these methods were constructed for the evaluation of possible growth disorders and adult height prediction taking into the calculation the differences between chronological age and bone age, and therefore to use them for the calculation of chronological age is problematic". In 2004, over 70 academic health professionals called on the US Department of Homeland Security in a letter to abandon the use of xrays of hands and teeth to determine skeletal age for many of the reasons I have quoted above. In August 2011 a letter was sent to the Minister for Immigration and Citizenship, by a joint group comprising the Royal Australian College of Physicians, the Australian Paediatric Endocrine Group, the Australian and New Zealand Society for Paediatric Radiology and the Royal Australian and New Zealand College of Radiologists. This letter called on the Minister to abandon both X-ray and genital examination because of ethical concerns, and because the techniques were inaccurate. I have carefully reviewed the literature and can find no article that justifies in a scientific manner the isolated use of a hand bone age to determine chronological age with the accuracy needed for legal proceeding. Even that advocates of multi-test assessment acknowledge that there is significant uncertainty in the testing process, even when carried out by forensic experts. In the journal, Forensic Pathology Review 2008, in an article titled Forensic Age Estimation of Live Adolescents and Young Adults, Schmeling et al said for determining the age of live subjects a forensic age estimate should combine the results of a physical examination, an X-ray of the hand, and a dental examination which records dentition status and evaluates an orthopantomogram. To assess the age of persons who are assumed to be at least 18 years old, an additional roentgenographic or CT scan of the clavicles would be needed. Even if these things are done, he goes on to states: there is still no satisfactory way to determine scientifically the margin of error. Serinelli et al in J Legal Medicine 2011, make a similar point in their article titled: Accuracy of three age determination X-ray methods on the left hand-wrist: a systematic review and metaanalysis. ..due to the very wide age estimation range, in line with what has already been established by several authors, our systematic review and meta-analysis confirmed that age estimation in living individuals cannot be considered accurate when only X-ray methods on the left hand-wrist are used, .. [Name]'s report and evidence: I have read [name]'s report and the transcript of his evidence given on 26 November 2010. I agree with his assessment that the estimated skeletal age is 19 years, however his analysis of this, and his use of incorrect standard deviation data and his conclusions about this are flawed from a number of points of view. I will list my discrepancies in the same order as in the evidence. 1. Page 16 paragraph 3. I am unsure as to where [name] has discovered that the source of the Gruelich and Pyle data is United Kingdom and Boston. In the preference to the first addition Dr Gruelich and Pyle reveal that the source data was obtained from the work of Dr Todd in Cleveland, Ohio, obtained in the 1930's. To quote the preface, "... their families were somewhat above average in economic and education status. All the children were White, all had been born in the United States, and almost all were of Northern European Ancestry. " . 2. Page 24. This section starts to deal with the problem of standard deviation, or variation of the accuracy of the test. The variation charts relate to children of known age, and stop at age 17 years for males. There is no data to support the use of these tables in the manner that [name] has used them. [Name] has attempted to define with precision the likelihood of [accused] being of a specific age, and his use of such precise numbers suggest that there is accuracy of scientific validity to this use. There is no such validity. The relevance of this variation table to the mature skeleton is highlighted if you consider by using [name]'s approach, an x-ray of any mature male hand has a 24% chance of being 18 years old. That is to say a 30, 40 or even 60 year old male has a 24% chance of being 18 years old. This is clearly incorrect. On page 26 [name] has extrapolated standard variation data from normal maturing 1930 American males at age 17 years and has used this to assess the probablity of age in a person of different racial group, or unknown health and age and unknown age of puberty on the basis of a mature x-ray appearance. 3. Page 29. After "Exhibit 8". The discussion here about potential causes of altered bone age serves to highlight the further problems with the use of this test in this case. The Gruelich and Pyle atlas was evolved using normal children of known age. We do not know whether [accused] had normal maturation, or had any medical or other condition that may have caused premature maturation of his bones. There are many potential causes for premature maturation, mostly hormonal but sometimes associated with skeletal disorders and syndromes. 4. Page 34 [name] has incorrectly asserted that there is no evidence of variation within racial groups when there is significant evidence to the contrary. The basis for this assertion appears to be because colleages in various countries use this book it must be accurate. There are multiple studies that show variation between racial groups, including articles by Ontell (AJR 1996), Koc (Paediatrics International 2001, Zhang (Radiology 2009) and Mora (Paediatric Research, November 2001). These articles confirm that there is potential for significant interracial variation in the skeletal variation versus chronological age. 5. Page 36, second last paragraph. There has been one study (Savarides, General Paediatric Orthopaedics 2007) that has shown increase in skeletal age compared to chronological age over time. This study was performed in Scottish adolescence with x-rays looked at from 1980 and 2005 and showed that adolescents of 2005 had significantly advanced skeletal age at the same chronological age, compared with 1980. [Name] has also professed the view that the Gruelich and Pyle standards are continued to be used and have not been changed because they are relevant and remain valid. The real reason the study has not been repeated in the 21st century is that it would now be ethically unacceptable to repeatedly x-ray normal children every year for 19-20 years. 6. Page 44, third last paragraph. The most common thing that causes early skeletal maturity is early puberty. [Name] has depended on a cascading sequence of unknown factors and incorrect assumptions to attempt to provide a level of precision about estimation of chronological age that does not exist. IN SUMMARY: Summary: Bone age estimation is a well established and commonly used technique for estimating skeletal maturity in children with potential growth problems. Skeletal age has an inconstant relationship with Chronological age Bone age estimates are only ever used as part of assessment of a child, never as the sole deciding factor. The source data used in the Greulich and Pyle atlas was derived from a population different to the subjects origins. There are conflicting studies about the relevance of this atlas to non-white populations. Some demonstrate significant variation and some only little variation. The atlas data has never been evaluated against an Indonesian population. It has been shown in some studies that Asian Male adolescents may have advanced bone age. I can find no data to confirm that it is valid to use the Greulich and Pyle atlas in reverse direction, that is, to assess chronological age based on bone age. There is no data to indicate that this is valid to be used in isolation for forensic age determination, and even when used in combination with dental, clinical and other examination still has an unknown margin of error. There is significant opinion in the medical world that it is inappropriate to make age decisions based only on this test. [Name] has attempted to validate his opinion by using normal variation tables that do not apply. By using these tables he has supplied likelihood figures that appear to have scientific validation. Statistical analysis of probability of a subject having a chronological age greater than 18 cannot be made as the data is not available to assess this. G&P was not developed for this purpose. Although G&P show 19 years as the mature standard for males, we do not know what the mean age of attainment of maturity was, or have any information about the data, both essential prerequisite to development of variation tables. Other sources quote 18yrs as being the age at which an average male maybe skeletally mature. It is not possible, on the basis of an x-ray of the left hand, to come to any conclusion as to whether [accused] was less than or greater than 18 years of age at the time of the x-ray examination. 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