Age Estimation in Adults Can Be Performed Using All of the Following Indicators Except:
Dtsch Arztebl Int. 2022 Jan; 113(4): 44–50.
Review Article
Forensic Historic period Interpretation
Methods, Certainty, and the Law
Andreas Schmeling
iInstitute of Legal Medicine, Academy Hospital Münster
Reinhard Dettmeyer
2Institute of Legal Medicine, University of Gießen
Ernst Rudolf
3Main Care Physician, Attnang-Puchheim
Volker Vieth
ivSection of Clinical Radiology, University Hospital Münster; Department of Radiology, Hospital Ibbenbüren
Gunther Geserick
5Institute of Legal Medicine, Charité—Universitätsmedizin Berlin
Received 2022 Sep vii; Accepted 2022 Nov 23.
Abstract
Background
Forensic age estimation is requested by courts and other government government so that immigrants whose real historic period is unknown should not suffer unfair disadvantages because of their supposed age, and and so that all legal procedures to which an individual's historic period is relevant tin be properly followed. 157 age estimations were requested in Berlin in 2014, more than than twice equally many as in 2004.
Methods
This review is based on pertinent manufactures retrieved by a selective search in the PubMed and MEDPILOT databases, supplemented by relevant recommendations and past the findings of the authors' own research.
Results
The essential components of historic period estimation are the history, physical examination, X-rays of the hands, panorama films of the jaws, and, if indicated, a thin-slice CT of the medial clavicular epiphyses, provided that there is a legal ground for X-ray examinations without a medical indication. Multiple methods are ever used in combination, for optimal accuracy. Depending on the legal issues at hand, the examiner may be asked to judge the private'due south minimum age and/or his or her virtually probable age. The minimum-historic period concept can exist used in determinations whether an individual has reached the age of legal majority. It is designed to ensure that practically all persons classified every bit adults take, in fact, attained legal majority, even though some other persons volition be incorrectly classified as minors.
Conclusion
Forensic historic period interpretation lets courts and other government authorities determine the official age of persons whose actual historic period is unknown—in almost cases, unaccompanied refugees who may exist minors. The goal is to carry out historic period-dependent legal procedures appropriately in accordance with the rule of law. The minimum-age concept is designed to prevent the erroneous classification of minors as legal adults.
In Frg, equally in many other countries, proof of existence nether or over the legally defined age limits is required for legal decisions about procedural privileges or social benefits (for example, right to shelter and services of the child care facilities past youth welfare offices after taking in unaccompanied refugee minors). The relevant age limits in Deutschland for various legal bug range between 14 and 21 years of age (Table 1). Increasing cross-border migration has resulted in more people in Germany who can non bear witness their chronological age with valid identification documents. If doubts nigh the given age of an individual cannot exist otherwise eliminated, authorities and courts can request a medical age assessment issued by an practiced. In general, every physician who has the necessary expertise can be chosen as a medical expert. In our estimation, age assessments are prepared mainly by forensic physicians, radiologists, dentists, principal care physicians, and pediatricians. It should be noted that a medical expert is not jump under the care principle of the physician–patient relationship but is rather obliged to maintain strict neutrality.
Table 1
Legal areas, legally relevant age limits, and legal issues in Federal republic of germany (for detailed comments see [e18])
| Legal expanse | Age limit (northward) (years) | Legal issue(s) | Legislation |
|---|---|---|---|
| Criminal Law | 14 | Criminal responsibility | § 19 StGB |
| Criminal Law | 18, 21 | Applicability of youth or adult criminal law | § 1 JGG |
| Family Law | eighteen*i | Guardianship | § 1773 BGB |
| Immigration Law | 16*2 | Capacity for actions and processes | § fourscore AufenthG, § 12 AsylVfG |
| Social Law | 18 | Taking into care unaccompanied minors past youth welfare offices | § 42 SGB 8 |
| Social Law | 18 | Granting educational assistance | §§ 27 ff. SGB Eight |
A first transregional analysis of forensic age methodology was made in 1999 at the "10th Lübeck Meeting of German language Forensic Physicians" (ane). At this meeting, the germination of an interdisciplinary working group was suggested to standardize the as yet heterogeneous approaches used in expert reports, by developing a set up of recommendations. The Study Group on Forensic Age Diagnostics (Arbeitsgemeinschaft für Forensische Altersdiagnostik; AGFAD) of the German Society of Legal Medicine was founded in March 2000, and information technology soon has 134 members from 18 countries (2). The AGFAD recommendations for age estimations for adolescents and immature adults, with or without a legal footing for X-ray examination, accept been adopted (2).
Nationwide information on the number of age assessments requested annually are not bachelor in Deutschland. Even so, in Berlin, for instance, 157 cases were requested in 2014, more than double the 73 cases requested in 2004 (iii, 4).
Hither we provide an overview of evidence-based methods for age assessments of adolescents and young adults, based on the most important legal principles. We further discuss the significance of good opinions for medical age assessments. Political and upstanding aspects of age assessment of unaccompanied young refugees of disputed ages are non the discipline of this commodity.
X-ray examinations without medical indication
The nature and extent of the age assessment methods to exist employed depend on whether or non a legal framework for carrying out X-ray examinations is present. Co-ordinate to the German language X-Ray Ordinance, the utilise of X-rays on humans requires either medical indication or a legal basis for say-so. The German legislature has made it clear that an X-ray exam due to legal requirements besides requires a justifying indication. This does not necessarily require a do good for the health of the private, but can as well be considered as the expected benefit of the relevant laws to the public.
Ten-ray examinations in the context of forensic age estimation are not washed for medical reasons. It is therefore necessary to examine whether a legal footing for authorization is nowadays before carrying out X-ray examinations. In case law, unlike authorization grounds take been stated for 10-ray examinations to assess historic period without medical indication (Box 1).
The case police force on the question of the admissibility of X-ray examinations outside of criminal proceedings is inconsistent. Yet, a tendency has been observed: decisions to reject X-ray examinations for forensic age estimation are usually explained in brief, while decisions to allow 10-ray examinations address the legal situation and the possibility of determining age tend to be explained in much more detail (5).
Criticisms of the legal requirements are of course legitimate, even those from the German language Medical Assembly (6, seven). Yet, resolutions made by the German Medical Assembly express professional statements and are not legally binding (8, ix).
Using X-ray examinations for historic period estimation in criminal proceedings and for the Residence Act should not have detrimental health furnishings for the person examined. In this regard, the Administrative Court (VG) Hamburg (Az. three E 1152/09) stated, already in 2009, that this requirement should be interpreted to indicate that "in accord with the principle of proportionality, 10-ray irradiation is a wellness risk within the normal range, and non a health disadvantage in the meaning of the provision, for the person examined."
In Table 2, the effective radiations doses of Ten-ray procedures used for historic period cess are listed. These doses are far beneath the natural effective doses in Frg, which amounts to an boilerplate of 2.1 mSv, and in some regions 2.6 mSv, per year (10). Thus, the variation of the natural radiation exposure in Germany is college than the additional radiation exposure from the 10-ray method for age assessment. Furthermore, the increased risk through the 10-ray examinations for historic period assessment is in the range of other daily risks, such as participation in road traffic (ten). Therefore, 10-ray exposure for age assessment should not be causeless to be outside the range of normal wellness hazards.
Table 2
Effective radiation doses of X-rays used for historic period cess (10, e19, e20)
| X-ray examination | Effective dose (mSv) |
|---|---|
| Hand X-ray | 0.0001 |
| Orthopantomogram | 0.026 |
| Computed tomograpy of medial clavicular epiphysis | 0.4 |
Historic period assessment methodology
The scientific basis of forensic historic period assessment in adolescents and immature adults is the predetermined temporal progression of defined developmental stages of diverse characteristics that are identical for all people, such as physical development, skeletal maturation, and dental development. For historic period cess, reference studies are used in which these defined developmental stages have been correlated with both the sex and the known historic period of the examined persons from a reference population.
If there is a legal requirement for Ten-ray examinations without medical indication, the AGFAD recommends combining concrete exam, an X-ray of the hand, and dental exam with a panoramic radiograph of the jaw region. If hand skeletal evolution is complete, an additional X-ray or computed tomography (CT) scan of the clavicles should be taken (ii). These methods have been evaluated with numerous reference studies (eleven– 24).
Medical history and physical exam
The AGFAD recommended test procedure begins by taking the medical history, with questions near illnesses and medications that could accept influenced growth. A subsequent physical examination records anthropometric data, such as height, weight, and body type, too as externally visible sexual maturity characteristics (for boys, genital development, pubic hair, underarm hair, beard growth, and laryngeal prominence; for girls, breast development, pubic pilus, and hip shape). The principal purpose of this initial medical cess is to identify or rule out growth and developmental disorders. Inference of the chronological age from the biological age (based on skeletal and dental ages) tin merely be assumed for people with no conspicuous findings.
Pre-existing illnesses can lead to a developmental delay and thus to an underestimation of historic period, which in legal terms has no agin consequences for the person concerned. However, it is critical to avert overestimating age due to disorders that accelerate development. Such disorders are infrequent, just include specially endocrine disorders, which can affect not merely adult height and sexual maturation, only also the skeletal maturation.
Endocrine disorders that pb to accelerated skeletal maturity include:
-
Precocious puberty
-
Adrenogenital syndrome
-
Hyperthyroidism.
Physical examinations should therefore accept into account symptoms of hormonal development dispatch, such equally gigantism, acromegaly, dwarfism, virilization in girls, dissociated virilism in boys, goiter, or exophthalmos (25).
No age assessment tin be made in almost i% of cases, due to abnormalities in either the medical history or the physical test (26). Most often, evidence of hyperthyroidism is found, which may so require further diagnostic evaluation (26).
X-ray examination of the hand
Radiography of the hand forms the second colonnade of forensic age interpretation. Criteria for evaluating manus radiograms are size and form of the individual bone elements and the ossification condition of the epiphyseal plates. The radiograph is then either compared with standard radiographs of the relevant age and sexual practice (atlas method) (e1– e3), or the bone maturity is determined for selected bones (single bone method) (e4, e5). Studies have shown that the single bone method, which is more time consuming, does not increase prediction accurateness. The atlas methods by Greulich and Pyle or Thiemann et al. are therefore considered appropriate for forensic age estimation (27). The ossification charge per unit in the relevant age groups depends primarily on a person'southward socio-economical status (28, 29). Applying the relevant reference studies to individuals of a lower socio-economic status is non legally detrimental for the immature person concerned, since it leads to an underestimation of age (28, 29).
X-rays of the mitt have a double advantage in the context of age assessment. First, a non-mature skeletal manus indicates with high probability a minority youth. Second, X-ray of the paw serves equally an indicator for CT scan of the clavicles, which is associated with a significantly higher radiation exposure.
Dental examination
In the dental examination, the developmental characteristics of eruption and mineralization of the third molars are of particular relevance for historic period interpretation. The assessment of dental eruption distinguishes between the stages of alveolar eruption, gingival eruption, and having reached the occlusal plane (30) (eFigure ane). The latter two stages can exist determined by oral visual inspection and practise non require an X-ray. The mineralization of third molars is assessed with an orthopantomogram. To evaluate tooth mineralization, the staging by Demirjian et al. (31) (eFigure 2) is the most appropriate, because the stages are divers by changes in shape, independent of speculative estimates of length (32). Since the timing of the eruption and mineralization of third molars is dependent on the immature person's ethnicity, population-specific reference studies are to exist used for the assessment report (thirty, 33).
Eruption stages of 3rd molars (stage A: occlusal surface at least partially covered with alveolar bone; phase B: complete resorption of the alveolar bone on occlusal surface; stage C: penetration of the gingiva past at least one dental cusp; stage D: emergence on the occlusal plane)
Mineralization stages of the third molars (stage A: calcification of the cusps; stage B: unification of the cusps to an occlusal surface; stage C: incipient germination of the cervical region; stage D: complete formation of the tooth crown; stage E: incipient root bifurcation; stage F: root at to the lowest degree as long as the crown, funnel-shaped root endings; stage G: parallel root culvert walls, upmost endings still partially open up; stage H: complete closure of the root tips)
Exam of the clavicles
Following the manus skeletal development, the assessment of the ossification stage of the medial clavicular epiphysis is a further important cess tool, equally the clavicles are the last bones to ossify in the entire skeleton (34). Numerous studies accost the timing of clavicular ossification (reviewed in [35]). Of the currently available imaging methods for determining the ossification stage of the medial clavicular epiphysis, thin-slice CT is the method of selection (35, 36). Clavicle ossification is evaluated according to a 5-stage classification organisation (21, 37) (eFigure three). Stages 2 and 3 can each be divided into three substages (22) (eFigure 4). Phase 3c indicates a minimum age of 19 years (22, 24, e6, e7), while stage iv indicates a minimum age of 21 years (21, 24, e8, e9).
Master stages of clavicle ossification (stage ane: non-ossified epiphysis; stage 2: isolated ossified epiphysis; stage 3: partial bony fusion between epiphysis and metaphysis; stage iv: consummate bony fusion between epiphysis and metaphysis with definable epiphyseal scar; Stage 5: consummate bony fusion between epiphysis and metaphysis without visible epiphyseal scar)
Substages of clavicle ossification (stage 2a: the length of ossified epiphysis is maximally one-third the metaphysis width; stage 2b: the epiphysis length is betwixt one-third and 2-thirds [maximum] the metaphysis width; stage 2c: the epiphysis length is more than than two-thirds the metaphysis width; phase 3a: a maximum of one-third of the epiphyseal plate is ossified; stage 3b: between one-tertiary and two-thirds [maximum] of the epiphyseal plate is ossified; stage 3c: more than two-thirds of the epiphyseal plate is ossified)
Final age cess
The analogous expert consolidates the results of a physical examination, Ten-ray of the manus, dental examination, and, where appropriate, radiological evaluation of the clavicles to achieve a concluding historic period assessment. The age-relevant variations resulting from the application of the reference studies for the examined person, due for example to differences in ethnicity, socio-economic status, and perhaps due to accelerated development or developmental disorders, have to exist discussed in the study. This report should also include any effects that these parameters might have on the estimated age, and if possible, a quantitative assessment of any such upshot should be given (2). Differences in age estimations by the different diagnostic tools can be due to a possible endocrine disorder, as dental development is far less affected than the skeletal maturation by such disorders (38). Such a case would crave further diagnostic clarification. The procedures for an age cess report with a legal basis for Ten-ray examination is shown in Box 2.
Procedures without legal ground for Ten-ray examination
For age estimates without a legal basis for X-ray examinations, AGFAD recommends carrying out a physical examination that takes into account anthropometric data, signs of sexual maturity, potential age-related developmental disorders, and a dental examination including the recording of dentition status (ii). Radiological findings of the teeth, the paw skeleton, or any other radiological features of individual maturation may only be used in this legal circumstance if identity-secure reports with a known date of origin are already bachelor.
The confidence level of such age assessments can exist expected to increase if non-10-ray–based imaging methods are used. Initial studies on sonographic assessment of ossification of various skeletal structures are available (reviewed in [39]). Since the objective documentation of sonographic studies for subsequent evaluation by a 2d expert is problematic, the staging for age estimation should be performed independently and a consensus reached by two experts with experience in skeletal sonography (39). A farther non–X-ray imaging technique to be considered is magnetic resonance imaging. Likewise, initial studies are available also for this method (for example [40, e10–e17]).
Significance of forensic age assessment
Depending on the issue to be addressed in the evaluation, the historic period assessment study should bespeak the about likely age and/or the minimum historic period of the young person examined and comment on the plausibility of the reported age.
If at least one of the studied developmental characteristics (physical development, skeletal maturity, dental evolution) is not mature, the nearly likely age of the assessed person tin can exist reported. This is determined based on the combined individual findings and a disquisitional discussion of the specific case. If the virtually likely age is higher up the legally relevant historic period threshold, it is probable that the historic period limit has been exceeded. As there is currently no reference study in which all relevant age characteristics take been collected simultaneously, information technology is not nevertheless possible to summate the statistical spread of the combined age assessments. The written report should assure that assessment variations and statistical spread of age-related parameters are addressed beneficially for the affected person to requite them the legal benefit of the doubt.
In the case that the legally relevant age limit is surpassed with the highest standard of proof ("with probability bordering on certainty"), the minimum-age concept is applied. The minimum historic period is derived from the age minimum of the reference study for the determined characteristic value; this is the historic period of the youngest person in the reference population who had the ascertained feature value. If several characteristics were examined, the highest established minimum historic period shall prevail. The awarding of the minimum-age concept ensures that the forensic age of the assessed person is never overestimated just instead is about ever less than the actual age. If the determined minimum age lies over the legally relevant age limit, that age has been surpassed with probability bordering on certainty. If the determined minimum historic period lies over the age provided past the young person beingness examined, the given age can be nigh ruled out. If the given age is over the determined minimum age, the given age mentioned is compatible with the reported findings. Effigy 1 shows the age assessment as described in a case report.
X-ray findings in a possible minor (age <18.0 years) with a disputed historic period, and age assessment parameters. The male person examined was from Somalia and claimed to exist 17.five years old. Medical history and physical examination showed no evidence of developmental disorders.
a) The ossification (Oss.) of the hand skeleton (HS) was complete.
b) The mineralization (Miner.) of the 3rd molars (M3) was complete.
c) The ossification (Oss.) of the medial clavicular epiphyses (MCE) was not complete. Both sides were classified as ossification phase 3a, according to Kellinghaus et al. (22).
d) The minimum ages corresponding to the determined developmental stages were 16.1 years old, 17.3 years onetime, and xvi.4 years onetime (20, 23, 24). The highest minimum age (17.3 years) determines the minimum age of the person examined. The most probable age of the person being examined, according to the relevant median historic period of stage 3a ossification of the medial clavicles, is 19.five years old, and the maximum historic period is 22.3 years (24). Since the minimum age of the examined person is below 18.0 years, a minority condition seems possible. Finally, as the minimum age diagnosed falls below the historic period specified by the person being examined, the assessment evidence is compatible with the age indicated by the person examined
Summary
Forensic age assessments are requested by authorities and courts. Medical experts called on for this are obligated to conduct out the assessment; an unfounded refusal can pb to a budgetary fine against the commissioned expert. Expert opinions for forensic age assessment, like other expert opinions, ensure a well-functioning legal state, the lack of which is in fact a reason why many people are fleeing their home countries. The skillful report must include clear statements on the historic period assessment reliability in order to allow the decision-making body (dominance, courtroom) to consider whatever uncertainty such that it leads to the more favorable legal outcome for the affected people.
Acknowledgments
Translated from the original German by Veronica A. Raker, PhD.
Footnotes
Conflict of interest argument
The authors declare that no conflict of involvement exists.
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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4760148/
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