Professor Tim Cole (Submission 5).doc

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1、Australian Human Rights CommissionInquiry into the treatment of individuals suspected of people smuggling offences who say they are childrenSubmission by Tim J Cole PhD ScD FMedSciProfessor of Medical Statistics MRC Centre of Epidemiology for Child Health, Institute of Child Health, University Colle

2、ge London, UKEmailIntroductionDuring the latter half of 2011 I was asked to give evidence in eight age assessment hearings in Australian courts, involving a total of 11 Indonesian fishermen charged with people smuggling who said they were under 18 years old when arrested. The cases came from Brisban

3、e, Melbourne, Perth and Sydney. For each case I was asked to write an expert report giving my views on the statistical basis for the prosecution expert witness names evidence about bone age assessed using the Greulich-Pyle hand-wrist x-ray Atlas. In two of the cases I also gave oral evidence by vide

4、olink or telephone. Nine of the 11 cases were subsequently withdrawn by the prosecution. I was asked but declined to give evidence in two other cases, for reasons explained later.The names of the 11 cases are as follows, in the order that their solicitors contacted me: name, name & name, name & name

5、 & *name, name, *name, name, name and name. All the cases except the two asterisked were subsequently withdrawn by the prosecution.This submission is in four parts. It starts with the expert report that I wrote on names case, which is broadly similar to my other reports. Name used the Greulich-Pyle

6、Atlas to claim that a male with a mature hand-wrist x-ray has only a 22% chance of being under 18. My report shows that this is wrong, and that a more appropriate figure is a 61% chance of their x-ray having been mature before age 18. The difference was due to name claiming age 19 as the mean age fo

7、r a mature x-ray, whereas I argue that what matters is the age of attainment of the mature x-ray, which occurs earlier at 17.6 years.Secondly, I extend the statistical argument to consider how informative bone age is for judging whether an individual is under 18. It turns out that the amount of info

8、rmation it contains depends on the age claimed by the individual (as opposed to their simply being under 18). In some circumstances bone age is informative but usually it is not. The issue here is the size of the standard deviation (SD) of the difference between bone age and chronological age, which

9、 is 15 months or more. So the confidence interval around the chronological age estimated from bone age is 30 months (i.e. 2 SDs), a range of 5 years. This lack of precision impacts on the value of bone age as evidence, and renders it uninformative except in extreme cases.Thirdly, I show how these ar

10、guments extend to the use of dental age based on third molars (wisdom teeth), and that in general dental age is as uninformative as bone age for estimating chronological age. 1. Expert Report in the case of accusedEXPERT CERTIFICATEIn the matter of: CDPP v accusedName: Professor Tim COLEWork Address

11、: MRC Centre of Epidemiology for Child Health, UCL Institute of Child Health, University College London, 30 Guilford Street, London WC1N 1EH, UKWork Telephone: PhoneOccupation: Professor of medical statisticsSTATES:1. This statement made by me accurately sets out the evidence that I would be prepare

12、d, if necessary, to give in court as a witness. This statement is true to the best of my knowledge and belief and I make it knowing that, if it is tendered in evidence, I will be liable to prosecution if I have wilfully stated in it anything that I know to be false, or do not believe to be true.2. I

13、 acknowledge that I have read the Expert Witness Code 44A; Victoria and I agree to be bound by the Code.3. I was supplied with the following documentation to assist with my report:a. Report of name, dated 14 December 2010b. Report of name, dated 27 April 2011c. Expert report of name, dated 27 April

14、2011d. Expert report of name, dated 3 August 2011 e. Transcript of evidence of name. Dated 31 August 20114. I am 64 years of age date of birth.5. I hereby certify that I am a professor of medical statistics. I have a specialised knowledge based on the following training, study and experience as a me

15、dical statistician for the past 40 years. I hold the following qualifications: MA BPhil PhD ScD FMedSci6. In addition to my expertise as a medical statistician, I also have considerable knowledge and experience in the application of statistics to human growth and development, which has been my main

16、research focus for the past 30 years. As evidence of this I attach a list of my 381 peer-reviewed research papers since 1970, of which the great majority relate to aspects of growth. In addition, in 2006 the British Royal College of Paediatrics and Child Health bestowed on me the title of Honorary F

17、ellow, for services to growth assessment in paediatrics. 7. I have been engaged by name of Victorian Legal Aid to prepare a report based on my expert opinion of:a. The intended purpose of the Greulich-Pyle Atlasb. The concept of skeletal age during childhoodc. Using the GP Atlas to assess skeletal a

18、ged. Using the GP Atlas to assess chronological agee. What the GP Atlas standard for age 19 reflectsf. Age of attainment of skeletal maturity based on the GP Atlasg. Age of attainment of skeletal maturity based on the TW3 manual h. Opinion on report of namei. Opinion on expert report of name j. Name

19、s choice of mean age 19 years and SD 15.4 monthsk. The statistical limitations of the Atlas l. Alternative probability of the subject, accused, being under 18m. Opinion on report of namen. Conclusion8. My opinion follows:a. The intended purpose of the Greulich-Pyle AtlasThe Greulich-Pyle Radiographi

20、c Atlas 1 was published in 1959 to help assess the skeletal age of children, based on the appearance of their hand-wrist x-ray. Skeletal age is one of a number of biological markers indicating how far along the road from birth to adult the child has travelled. By calibrating the distance travelled a

21、gainst chronological age it is possible to express skeletal maturity as an “age” in units of years, and on average a childs skeletal “age” should match their chronological age. b. The concept of skeletal age during childhoodThe process of bone growth takes place at the growth plates (or epiphyses) a

22、t the ends of the long bones. As the skeleton matures, the radiographic appearance of the growth plates changes in a well-defined way, so it is possible from reading the x-ray to judge, within a range of uncertainty, how far the child has travelled on their biological journey and what their skeletal

23、 “age” is. The journey ends when growth stops, at which point the child is adult. This is when all the growth plates have fused and no further growth is possible. The appearance of the x-ray is then adult, and remains so throughout life. c. Using the GP Atlas to assess skeletal ageThe GP Atlas consi

24、sts of a series of standard x-rays for specified skeletal ages, 31 standards from birth to 19 years for boys, and 27 from birth to 18 years for girls. Thus for example male standard 25 is for skeletal age 14 years. The reference sample was middle class US children from Cleveland Ohio in the 1930s. T

25、he assessor takes a child of known chronological age and compares their x-ray to the Atlas standards for the childs sex and identifies the standard best matching the childs x-ray. The skeletal age for that standard, or an intermediate age if part-way between two standards, then defines the childs sk

26、eletal (or bone) age. Greulich and Pyle explain their choice of standards for each age as follows (GP page 32):“Each of the standards in this Atlas was selected from one hundred films of children of the same sex and age. The films of each of these series were arranged in the order of their relative

27、skeletal status, from the least mature to the most mature. In most cases the film chosen as the standard is the one which, in our opinion, was most representative of the central tendency, or anatomical mode, of the particular array. The anatomical mode was frequently, but not always, at or near to t

28、he midpoint of the distribution of the one hundred films. It was farthest from the midpoint at those ages where, as a result of a major change in the rate of development, differences in the degree of skeletal development of the children resulted in a skewed distribution of the array.” To prcis, each

29、 standard is based on a group of 100 children of that chronological age, and the appearance of the standard x-ray corresponds to the typical, but not necessarily the mean, bone age in the group.d. Using the GP Atlas to assess chronological ageBy definition, all children matched to a particular stand

30、ard have the same bone age. However they do not all have the same chronological age, indeed their range of chronological ages is wide. This range can be expressed as a normal distribution and summarised by its mean and standard deviation (SD). The mean of the age distribution corresponds broadly to

31、the nominal skeletal age for the standard (Greulich and Pyles procedure (above) ensures this), while the SD of skeletal ages for different chronological ages is documented in the Atlas in Tables III to VI. This provides an alternative use of the information in the Atlas. If the mean and SD of the ch

32、ronological age distribution are known, a given bone age can be converted to a probability that the subject is older or younger than a given chronological age. However it is important to realise that the Atlass original purpose was to estimate bone age in growing children, not to decide what chronol

33、ogical age subjects with mature x-rays might be. Greulich and Pyle had no interest in such subjects, as they could not ascribe a bone age to them. e. What the GP Atlas standard for age 19 reflectsThe Atlas records the spectrum of maturity seen in boys from birth to 19 years, and the age standard for

34、 19 years documents the adult appearance of the x-ray. This is confirmed by the rubric accompanying the standard (and curiously there is nothing else in the Atlas about the age 19 standard being mature): “The fusion of the radial epiphysis with its shaft completes the skeletal maturation of the hand

35、 and wrist.” (Boys, skeletal age 19 years, GP page 122) It is important to be clear what this means: among 19-year-old males, most are skeletally mature. What it categorically does not mean is that males with an adult x-ray are on average 19 years old. Note that Greulich and Pyle could have labelled

36、 this final standard “adult” rather than “age 19”, which would have been much clearer for age assessment purposes.f. Age of attainment of skeletal maturity based on the GP AtlasSubjects with a mature x-ray have a skeletal age corresponding to that for all adults, so the upper limit of their likely c

37、hronological age is effectively unbounded, i.e. 100 years or more. However the lower limit of the range can be more precisely specified. It is clear that most 19-year-old males are skeletally mature (see above). This leads to the following questions: what proportion are mature at younger ages than 1

38、9, and what is the youngest age that adult x-rays are seen? These questions relate to the age of attainment of a subjects mature x-ray, which is quite distinct from their current age. Since most x-rays are mature by age 19, the age of attainment must for most subjects be earlier than 19. But what is

39、 the distribution of this age of attainment?Unsurprisingly the Atlas does not address the question directly, as it was irrelevant to Greulich and Pyle. However it does provide some indirect evidence, in its tables of the mean and SD of bone age for groups of children of known chronological age. The

40、first (Table III, page 51) is for boys from the Brush Foundation Study, where a large number of children were each assessed once. These children were by definition skeletally immature, as Greulich and Pyle had to calculate their bone ages, which excluded those with mature x-rays. The oldest age grou

41、p in the table is 17 years, where the mean bone age is 206.21 (SD 13.05) months. The second table (Table V, page 55) is for boys studied longitudinally by Dr Stuart at the Harvard School of Public Health. Here the oldest age in the table is again 17 years, where the mean bone age is 206 (SD 15.4) mo

42、nths. There are two striking aspects to these tables. The first is that the oldest age group is 17 years. This shows that there were too few children with older bone ages to be included, i.e. that most children past 17 years had mature x-rays. The second point is the numbers of children in each year

43、 group, as shown here: Age (years)121314151617Brush (n)1651751631249968Stuart (n)646665656560One would expect similar numbers in each group, but in the Brush Foundation Study the numbers fell off steeply after age 14, showing that children with immature x-rays aged 15 or more were progressively less

44、 common. In Stuarts longitudinal study the numbers were fairly constant across age, but even here there were drop-outs at 17 years whose x-rays were clearly mature. Overall the table suggests that after 14 years there are increasing numbers of boys with mature x-rays, and after 17 years most are mat

45、ure.g. Age of attainment of skeletal maturity based on the TW3 manual To definitively answer the question “What is the distribution of the age of attainment of skeletal maturity” we must turn to a more recent publication, the TW3 bone age manual published in 2001,2 which addresses the question direc

46、tly. TW3 obtains bone age using a sophisticated bone scoring system that rates individual hand and wrist bones rather than the global appearance of the x-ray, and its database is larger (33,178 subjects) and more recent (1969-95) than for GP (TW3 pages 17-18). The TW3 manual 2 discusses the range of

47、 ages of bone maturation based on the RUS score, which summarises the 13 Radius, Ulna and Short (i.e. finger) bones. Table 8 (TW3 page 21) gives the 97th centile for age of attainment in boys as 15.1 years, meaning that 3% of boys have already reached skeletal maturity by this age. The corresponding

48、 90th and 75th centiles are 15.8 and 16.7 years. So by 16.7 years a quarter of boys are skeletally mature. The Table does not include the 50th centile (i.e. median) age of attainment, but it can be estimated from the other centiles see below.h. Opinion on report of name and nameName and name use the

49、 Greulich-Pyle Atlas to estimate the bone age, and name purports to infer the likely chronological age, of the subject accused. He observes that the subjects hand-wrist radiograph matches the Atlas radiograph of a 19-year-old (male standard 31, skeletal age 19 years, GP page 123). Name states that “In males, skeleta