Developmental Review 32 (2012) 205–223Contents lists availab.docx

Developmental Review 32 (2012) 205–223
Contents lists available at SciVerse ScienceDirect
Developmental Review
journal homepage: www.elsevier .com/locate/dr
Natural conversations as a source of false memories
in children: Implications for the testimony
of young witnesses
Gabrielle F. Principe ⇑ , Erica Schindewolf
Department of Psychology, Ursinus College, United States
a r t i c l e i n f o a b s t r a c t
Article history:
Available online 25 July 2012
Keywords:
Memory
Suggestibility
Children
Social interaction
Rumor
Eyewitness testimony
0273-2297/$ - see front matter � 2012 Elsevier In
http://dx.doi.org/10.1016/j.dr.2012.06.003
⇑ Corresponding author. Address: Department o
United States. Fax: +1 610 409 3633.
E-mail address: [email protected] (G.F. Pri
Research on factors that can affect the accuracy of children’s

auto-
biographical remembering has important implications for under-
standing the abilities of young witnesses to provide legal
testimony. In this article, we review our own recent research on
one factor that has much potential to induce errors in children’s
event recall, namely natural memory sharing conversations with
peers and parents. Our studies provide compelling evidence that
not only can the content of conversations about the past intrude
into later memory but that such exchanges can prompt the
gener-
ation of entirely false narratives that are more detailed than true
accounts of experienced events. Further, our work show that
dee-
per and more creative participation in memory sharing dialogues
can boost the damaging effects of conversationally conveyed
mis-
information. Implications of this collection of findings for chil-
dren’s testimony are discussed.
� 2012 Elsevier Inc. All rights reserved.
Introduction
Perhaps only one simple and straightforward claim can be made
about the accuracy of children’s
testimony: not all statements made by children are true.
Admittedly, exact accuracy is not the usual
goal of memory in everyday life. Most autobiographical
remembering is carried out for social pur-
poses, such as to build bonds and foster connectedness with
friends and family (see e.g., Nelson,
1993), and can serve these functions even when recollections do
not precisely represent the past. In
c. All rights reserved.
f Psychology, Ursinus College, PO Box 1000, Collegeville, PA
19426-1000,

ncipe).
mailto:[email protected]
http://www.sciencedirect.com/science/journal/02732297
http://www.elsevier.com/locate/dr
206 G.F. Principe, E. Schindewolf / Developmental Review 32
(2012) 205–223
fact, many everyday situations encourage some degree of
unfaithfulness. Exaggerated, improvised, or
even fabricated stories can be more engaging or more amusing
to conversational partners than verid-
ical reports. These tendencies to embellish personal experiences
may be especially pronounced at
young ages given children’s proclivity for pretense and adults’
willingness to play along. To illustrate,
only young children can get away with fantastic stories of a
fairy who gives prizes for baby teeth or a
monster that lives under the bed (see e.g., Principe & Smith,
2007).
Against this backdrop of memory in everyday life, the
courtroom is a rather unusual setting for
children’s remembering. In the real world, accounts of personal
experiences are successful to the ex-
tent that they are relayed in a compelling or affecting manner.
In the legal system, precise accuracy
is the goal. Remembering is successful to the degree that
witnesses ‘‘tell the truth, the whole truth,
and nothing but the truth.’’ Forensic settings, therefore, put
unique demands on memory that are at
odds with the way that recollections of the past typically are

used. This contrast notwithstanding,
because many criminal offenses that bring children to court,
such as sexual abuse and other forms
of molestation, lack other witnesses or corroborating evidence,
children’s testimony often serves
as the sole piece of evidence against criminal defendants.
Likewise, children’s memories impact
many civil and family court cases. For example, children’s
accounts of parental transgressions, such
as domestic violence and substance abuse, as well as more
mundane events, such as daily home rou-
tines, commonly play a role in custody, support, and visitation
decisions. Considering the centrality
of children’s testimony in many legal situations, research on
factors that can compromise children’s
abilities to provide accurate accounts of the past has
considerable relevance to forensic professionals
and fact finders.
Given that children’s testimony is elicited in interviews, many
investigators have focused on the
mnemonic effects of various suggestive features of interviews.
This voluminous literature has revealed
that a range of factors, such as types of questions asked, the
sorts of ancillary aids used, and the char-
acteristics of interviewers, can seriously derail children’s
accuracy and even lead to entirely false ac-
counts (see Bruck, Ceci, & Hembrooke, 2002, for a review).
Despite the significance of this work for
developing effective interviewing protocols, researchers have
become increasingly concerned with
examining suggestive factors outside of the formal interview
context that also can contaminate mem-
ory. This move to exploring extra-interview factors has been
prompted by findings that even when
children are interviewed under optimally nonsuggestive

conditions, some nonetheless relay fabricated
stories in line with suggestions encountered from other sources,
such as parents (Poole & Lindsay,
2002) and television (Principe, Ornstein, Baker-ward, &
Gordon, 2000).
In everyday life, one common way to encounter suggestions is
during memory sharing conversa-
tions with others. A compelling reason for focusing on
conversational forms of suggestion concerns
the social nature of autobiographical memory. Sharing
memories through conversations with friends
and family members is a typical and frequent part of children’s
everyday social interactions. During
such exchanges, however, children constantly are encountering
others’ versions of the past. Different
versions can arise unwittingly when conversational partners
misremember what happened, but also
can occur when they purposefully exaggerate or even fabricate
details to tell, say, a more glamorous
story than give a precisely accurate account. Given that memory
is constructive (Bartlett, 1932), it is
within this realm that bits and pieces of the suggestions and
stories told by others may find their way
into children’s recollections of their experiences.
Emphasizing the social nature of remembering are theories of
collective memory (e.g., Hirst & Man-
ier, 2008; Reese & Fivush, 2008) that characterize memories of
shared experiences as dynamic repre-
sentations that are shaped by group conversational processes. In
this framework, as memories of the
past are reconstructed within a group, its members negotiate a
collective version of experience. Con-
sequently, individual representations are revised to become
progressively alike among group mem-

bers (see Harris, Paterson, & Kemp, 2008). However, when
misinformation is introduced into group
remembering, either deliberately by a confederate (Meade &
Roediger, 2002) or unknowingly by a
group member who experienced a slightly different version of
the event (Gabbert, Memon, & Allan,
2003), individuals are prone to later recall occurrences that
were nonexperienced but merely sug-
gested by their conversational partners.
The practical importance of studies of conversational sharing
for discussions of children’s testi-
mony comes from real world examples demonstrating that
witnesses often talk with one another.
G.F. Principe, E. Schindewolf / Developmental Review 32
(2012) 205–223 207
Consider, for instance, Paterson and Kemp’s (2006a) finding
that over 80% of witnesses to a crime or
serious accident reported discussing the event with another
witness, or other work showing that it is
not uncommon for multiple witnesses to be questioned at the
same time (e.g., Garven, Wood, Malpass,
& Shaw, 1998). Issues of conversational contamination are
particularly relevant to situations involving
multiple abuse victims, as children caught up in these cases may
attend group therapy sessions or
community meetings where allegations are shared (Rabinowitz,
2004).
There are also reasons to suspect that young children may be
especially vulnerable to the contri-
butions of others in their constructions of experience. First,
young children’s difficulty keeping track

of the source of their memories (e.g., Poole & Lindsay, 2002)
may put them at increased risk for mis-
takenly attributing events relayed by others as their own actual
experiences. Second, young children
are somewhat dependant on others to help them figure out how
to represent and recount their expe-
riences. Such collaboration benefits children’s construals of
novel events and narrations of existing
memories (Nelson, 1993), but it might also lead to problematic
distortions in memory when others
incorrectly frame legally relevant events. Consider, for
instance, a father who frames sexual abuse
as a special game or a mother in a custody dispute who says,
‘‘Daddy hurts you when he gives you
a bath, doesn’t he?’’ Third, younger preschoolers do not yet
realize that others can have memories that
are false; rather they believe that the mind literally copies
experience and that everyone therefore has
only true memories (e.g., Perner, 1991). This tendency usually
is not problematic in the real world but
it can be in legal situations. To illustrate, when a child hears
from a friend that she saw Santa put pre-
sents under the Christmas tree or that their teacher Mr. Bob
does bad things, both claims are unques-
tionably believed. Finally, young children rarely receive
feedback on what a false memory feels like.
Adults do, for example, when they remember parking their car
on the second level of the garage
but find it on the first. Children, in contrast, get away with all
sorts of memory errors, such as claiming
to have spent the afternoon with an invisible friend.
As this brief analysis indicates, examination of the sorts of
conversational activities that might be
linked to later errors in remembering is central to an
understanding of children’s ability to provide tes-

timony in legal settings. However, because the extant literature
on memory errors focuses almost
exclusively on the effects of suggestive questioning or other
forms of scripted misinformation, we
know very little about the ways that memory may be
transformed in the normal course of discussing
the past with others. With these theoretical and applied issues in
mind, in the remainder of this article,
we offer an overview of a programmatic series of studies
carried out by our research group concerning
how knowledge gained from and within conversations with
agemates and adults can shape children’s
constructions of the present and reconstructions of the past.
Co-witness influence
Our exploration of mnemonic effects of memory sharing began
in the context of a study on the
influence of naturally occurring interactions with peer witnesses
on children’s memory for a personal
experience (Principe & Ceci, 2002). Given extant
demonstrations of the potency of collective remem-
bering in shaping individual memories in the direction of the
group, co-witness discussions might, at
least at times, cause children within a peer group to construct a
collaborative story that does not
veridically reflect the independent experiences of each group
member. This issue may be especially
important for legal cases involving multiple purported victims
because fact finders may rely on the
number and similarity of allegations to determine the credibility
of any single child’s testimony. It
is likely very compelling to hear child after child tell the same
story, especially if one believes that each
witness has arrived at the same storyline independently. In some
situations, however, the exact oppo-
site might be the case. The story may have been arrived at in a

collaborative manner among peers who
initially had very different representations of the event.
There are numerous real world examples that discussions among
co-witnesses can influence chil-
dren’s testimony. Consider, for instance, the following
exchange between a young witness and a foren-
sic investigator in the Wee Care Nursery School case in
Maplewood, New Jersey. In this case, Kelly
Michaels, a teacher at the school, was accused of sexually
molesting her students. Here a child reveals
that the source of her allegation was another child rather than
her own observation:
(2012) 205–223
Interviewer: Do you know what [Kelly] did?
Child: She wasn’t supposed to touch somebody’s body. If you
want to touch somebody, touch your
own.
Interviewer: How do you know about her touching private
parts? Is that something you saw or
heard?
Child: Max told me.
(Ceci & Bruck, 1995, p. 150)
To explore co-witness contamination, three groups of 3- to 5-
year-olds participated in a staged
event at their preschools, namely an archaeology dig with a
confederate archeologist named Dr. Diggs.

Children used plastic hammers to dig pretend artifacts, such as
dinosaur bones, gold coins, and jewels,
out of specially constructed blocks of mortar mix and play sand.
Each dig included two ‘‘target’’ arti-
facts: a bottle with a map to a buried treasure and a rock with a
message written in a secret language.
One third of the children, those in the Witness condition, saw
Dr. Diggs ruin the target artifacts (here-
tofore referred to as target activities). He ‘‘accidentally’’
spilled coffee on the map, smearing the ink
and rendering the map illegible. He appeared upset and said, ‘‘I
messed up the map! Now I’ll never
find the buried treasure!’’ Dr. Diggs also dropped the rock,
shattering it into pieces, and said, ‘‘I’ve bro-
ken the rock! Now I’ll never know what the secret message
says!’’ A second third of the children, those
in the Classmate condition, did not witness the target activities
during the dig but were the classmates
of those in the Witness group. We expected that some of these
children would hear about the ruined
map and broken rock through natural conversations with their
classmates who saw these activities.
The remaining children in the Control condition were drawn
from different preschools than the Wit-
ness and Classmate children. These children did not have any
opportunities to interact with those who
saw the target activities nor did they see these activities
themselves. This group provided the likeli-
hood that target activities would be reported by a random
nonwitness without exposure to any peer
witnesses. Teachers were discouraged from initiating or
participating in conversations with children
about the dig.
Given evidence of the use of suggestive techniques in forensic
settings, we also examined whether

suggestive interviews might augment the influence of co-
witnesses. Following the dig, all children
were questioned on three occasions spread out over a 3-week
interval. Half of the children received
neutral interviews, whereas the remaining half were questioned
in a suggestive manner. Embedded
in the suggestive interviews were strongly worded leading
questions that implied that the target
activities had occurred. Thus these questions were in line with
what the Witnesses children had seen,
but inconsistent with the experience of the Classmate and
Control children.
Four weeks after the dig, a new interviewer questioned all of
the children in a neutral manner and
asked them to recall ‘‘only things that you remember happening
to you—things that you really did or
remember seeing with your own eyes.’’ The hierarchically
ordered interview began with an open-
ended prompt: ‘‘Tell me what happened when Dr. Diggs visited
your school.’’ After exhausting
open-ended recall, specific questions were asked if one or both
of the target activities had not yet been
reported (e.g., ‘‘Did anything happen to a treasure map?’’). For
each target activity relayed, children
were asked to elaborate (‘‘Tell me more about that.’’) Children
who made reports of target activities
also were asked for the source of their memories, that is,
whether they actually saw the target activity
Table 1
Mean percentages target activities reported as actually
occurring at the final interview as a function of
experimental group and degree of prompting.
Open-ended Specific Total

Witness/neutral interview 34 47 81
Classmate/neutral interview 16 15 31
Control/neutral interview 0 0 0
Witness/suggestive interview 68 23 91
Classmate/suggestive interview 50 36 86
Control/suggestive interview 23 33 57
(2012) 205–223 209
occur with their own eyes or merely heard about it from
someone (e.g., ‘‘Did you see Dr. Diggs spill his
drink on the treasure map with your own eyes, or hear that he
did it?’’).
Table 1 shows the proportion of target activities reported and
the degree of prompting needed to
elicit the information at the 4-week interview. As shown,
children in the Witness conditions evi-
denced quite good recall of these actually experienced
activities, with both groups reporting over
80%. However, the Classmate children, who did not witness the
ruined map or the broken rock, also
reported many of these activities. Under both interviewing
conditions, the Classmate children wrongly
reported more target activities than the Control children,
demonstrating that natural contact with
peer witnesses can induce false accounts in non-witnesses. In
fact, many errant accounts were at
the open-ended level of questioning, indicating that the effects
of peer witnesses are not limited to
cued reports can but can result in abundant spontaneous errors.
Perhaps the most interesting finding
to emerge from this study is that when the Classmate children
were exposed to the suggestive inter-

views, they reported as many target activities as those in the
Witness conditions who actually expe-
rienced these activities. Thus the combined effects of exposure
to peer witnesses and suggestive
interviewing among the non-witnesses resulted in levels of
recall that were indistinguishable in terms
of magnitude from those of the Witness children.
Several other findings also are of interest. First, among those
non-witnesses who reported target
activities, the Classmate children were more likely than the
Control children to report actually seeing
these activities occur with their own eyes (as opposed to merely
having heard about them). Such
claims of seeing suggest that natural conversations with co-
witnesses not only can induce false re-
ports but they also can lead to source confusions. Second, given
that fact finders often consider detail
as an index of testimonial accuracy (Ceci, Kulkofsky, Klemfuss,
Sweeney, & Bruck, 2007), we explored
the narratives accompanying the reports of target activities. As
expected, the Witness children gener-
ated relatively detailed accounts of these experienced events.
Many non-witnesses, however, also re-
layed elaborate reports of these occurrences they never saw but
merely heard about, with many
embellishing with details that went beyond the Witness
children’s experiences but nonetheless were
consistent with them. Consider, for example, a Classmate child
who said that after spilling coffee on
the map ‘‘Dr. Diggs walked away and then we just got in big
trouble. . . all my friends and he had to
be punished for a whole weekend. . .The ladies in the cafeteria
cleaned it because he didn’t have a
mop. . .They took him away and put him in jail.’’ In fact, the
Classmate children’s false accounts of

the target activities were more voluminous than the true
narratives of the Witness children. This pat-
tern demonstrates that narrative detail is not diagnostic of
accuracy when children have been exposed
to peer witnesses, and is consistent with other work showing
that false accounts induced by other
forms of suggestion can be more elaborate than true reports
(e.g., Bruck et al., 2002; Poole & Lindsay,
2002). Interestingly, examination of the content of children’s
narratives indicated that this group dif-
ference occurred neither because the Classmate children more
completely relayed their peers’ expe-
riences or the interview suggestions nor because they more
readily invented fantastic or
idiosyncratic embellishments, but because they generated more
original constructions consistent with
the notions of a ruined treasure map and a broken rock.
Rumor mongering and remembering
In our next study, we sought to extend our (Principe & Ceci,
2002) demonstration of the impact of con-
versational interactions by determining whether peer
interactions can influence children’s reports of an
experience even when none of them actually witnessed the event
in question. To do this, we planted a
false rumor about an experienced event among some members of
preschool classrooms and examined
the degree to which the rumored information leaked into their
own and their classmates’ recollections
when later interviewed. We also explored the degree to which
the interfering effects of the rumor might
be exacerbated when paired with suggestive interviews that are
consistent with the rumor.
We chose to study rumor transmission because a large literature
in social psychology demonstrates

that rumors often are generated about events that are meaningful
and upsetting where the truth is
unclear (see Rosnow, 1991). These conditions sound a lot like
those created by the sorts of offenses
that usually bring children to court, such as sexual abuse and
other forms of maltreatment, because
(2012) 205–223
they are unsettling and typically lack corroborating witnesses or
physical evidence. In such cases, ru-
mors may emerge to fill in the gaps of missing information or to
impose an explanation on an unset-
tling allegation. Considering that individuals generally assume
that information exchanged during
everyday conversations is true (Gilbert, 1995), shared rumors
likely have much potential to prompt
revisions in memory in line with overheard information.
There also are real world examples of rumor contamination. One
comes from a case in which chil-
dren who were absent from school on the day of a sniper attack
recalled seeing things that only their
peers, who were present, could have experienced. A rumor
allegedly began to circulate that a second
sniper had eluded police and was on the loose. When the
children were asked to describe the attack
several months later, many described in detail how the second
sniper had escaped and still was loose
in the neighborhood (Pynoos & Nader, 1989).
To examine whether rumor can leak into memory, four groups
of 3- to 5-year-olds saw a scripted
magic show in their preschools (Principe, Kanaya, Ceci, &

Singh, 2006) in which a magician named Ma-
gic Mumfry tried to pull a live rabbit out of his top hat. After
several failed and frenzied efforts, Mumfy
apologized and left the school. Immediately after the show,
children in the Overheard group overheard
a scripted conversation between two adults in which one alleged
that the trick failed because Mum-
fry’s rabbit had gotten loose in the school rather than residing
in his hat. We maximized children’s
attention to the rumor by having them stand quietly in a line
awaiting a sticker during the planned
conversation. Children in the Classmate group did not overhear
the adult conversation about the es-
caped rabbit but were the classmates of the Overheard children.
Of interest was whether these chil-
dren would learn about the alleged lost rabbit through natural
interactions with their classmates who
heard the rumor and whether details in line with the rumor
might leak into their later recollections.
Control children had no exposure to the rumor; they were not
the classmates of those who overheard
the rumor, nor did they overhear it themselves. The remaining
children in the Witness group had no
exposure to the other three groups but experienced the event
suggested by the rumor, namely seeing
Mumfry’s rabbit loose in their school after the failed trick. One
week later, all children were ques-
tioned in either a neutral or suggestive manner. Embedded in
the suggestive interviews were coercive
questions that implied that the interviewee had witnessed
Mumfry’s escaped rabbit, when in fact only
those in the Witness group did.
Two weeks after the show, all children were questioned by a
new, neutral interviewer in the same
hierarchical manner as in Principe and Ceci’s (2002) study. As

shown in Table 2, all of the Witness chil-
dren correctly recalled that Mumfry’s rabbit had gotten loose in
their school. Table 2 also illustrates
the powerful effects of the rumor on children’s accounts. All
but one of the Overheard and Classmate
children wrongly reported a loose rabbit. Thus these children
were as likely as those who actually saw
a live rabbit to report that Mumfry’s rabbit was loose, thereby
eliminating differences in levels of recall
between true and false accounts. This pattern not only shows
that information overheard from adults
can lead to near ceiling levels of false reports of
nonexperienced events, it also indicates that rumors
transmitted by peers can be as detrimental as those spread by
adults. Moreover, the majority of the
Overheard and Classmate children’s reports of the escaped
rabbit were in response to open-ended
probes, demonstrating that errant rumors can lead to high levels
of spontaneous fabrications. Further,
many Overheard and Classmate children claimed to have seen,
as opposed to heard about, the loose
Table 2
Percentages of children who reported the target activity as
actually occurring at the final interview as
a function of experimental group and degree of prompting.
Group Open-ended Specific Total
Witness/neutral interview 90 10 100
Overheard/neutral interview 86 10 95
Classmate/neutral interview 86 14 100
Control/neutral interview 0 10 10
Witness/suggestive interview 87 13 100
Overheard/suggestive interview 87 13 100
Classmate/suggestive interview 91 9 100
Control/suggestive interview 9 50 59

(2012) 205–223 211
rabbit. These reports of seeing a nonoccuring event represent a
considerably more extreme demon-
stration of peer-generated suggestibility than our prior study
(Principe & Ceci, 2002) considering that
none of these children witnessed the event in question. Further
demonstrating the potency of rumor,
the non-witness children described the rumored loose rabbit
with much elaborative detail that went
above and beyond the literal rumor. To illustrate, a Classmate
child said that, ‘‘The rabbit was in the
playground, and then it was over the gate and, the rabbit was
over, the rabbit jumped, hopped over the
gate. . .I tried catching him with a bucket but he bited me on the
finger. . .They found him in the potty.’’
In fact, the Overheard and Classmate children’s descriptions of
the rumored-but-nonoccurring loose
rabbit were twice as voluminous as the accounts of the Witness
children, demonstrating that false
narratives engendered by rumor can be much more elaborate
than true narratives generated on the
basis of experience.
Considering the ease with which suggestive questions can
induce false reports (see Ceci, Kulkofsky
et al., 2007), it is worth noting that the loose rabbit
misinformation engendered higher levels of error
when planted via a rumor than when suggested during an
interview. Those children who heard the
rumor from an adult or peers gave more errant reports of the
nonevent, were more likely to wrongly
recall seeing (as opposed to hearing about) it, and embellished

their accounts with more elaborative
detail compared to those for whom the very same false
information was suggested during an inter-
view. This finding is particularly noteworthy given that the
Overheard children were not instructed
to share the rumor with their peers but ended up naturally
propagating this information to them in
a manner that was more mnemonically damaging than an
aggressively suggestive interview.
Conflicting rumors
The major finding of our initial study on rumors was that
overheard false information that provides
a reasonable explanation for an earlier ambiguous event can
lead children to mistakenly recall details
consistent with the rumor (Principe et al., 2006). This finding
prompted us to consider whether the
effects of rumor might be less powerful in situations where the
rumored information conflicts with
the past rather merely fills a gap. This contrast was of interest
because when rumors only fill a gap,
overheard details can be imported into memory without
displacing or overwriting any experienced
details. But when rumors conflict with the past, there is a …
Chapter 9: Patient Safety, Quality and Value
Harry Burke MD PhD

Learning Objectives
After reviewing the presentation, viewers should be able to:
Define safety, quality, near miss, and unsafe action
List the safety and quality factors that justified the clinical
implementation of electronic health record systems
Discuss three reasons why the electronic health record is central
to safety, quality, and value
List three issues that clinicians have with the current electronic
health record systems and discuss how these problems affect
safety and quality
Describe a specific electronic patient safety measurement
system and a specific electronic safety reporting system
Describe two integrated clinical decision support systems and
discuss how they may improve safety and quality
Patient Safety-Related Definitions
Safety: minimization of the risk and occurrence of patient harm

events
Harm: inappropriate or avoidable psychological or physical
injury to patient and/or family
Adverse Events: “an injury resulting from a medical
intervention”
Preventable Adverse Events: “errors that result in an adverse
event that are preventable”
Overuse: “the delivery of care of little or no value” e.g.
widespread use of antibiotics for viral infections
Underuse: “the failure to deliver appropriate care” e.g.
vaccines or cancer screening
Misuse: “the use of certain services in situations where they are
not clinically indicated” e.g. MRI for routine low back pain
Introduction
Medical errors are unfortunately common in healthcare, in spite
of sophisticated hospitals and well trained clinicians
Often it is breakdowns in protocol and communication, and not
individual errors
Technology has potential to reduce medical errors (particularly
medication errors) by:
Improving communication between physicians and patients
Improving clinical decision support
Decreasing diagnostic errors
Unfortunately, technology also has the potential to create
unique new errors that cause harm

Medical Errors
Errors can be related to diagnosis, treatment and preventive
care. Furthermore, medical errors can be errors of commission
or omission and fortunately not all errors result in an injury and
not all medical errors are preventable
Most common outpatient errors:
Prescribing medications
Getting the correct laboratory test for the correct patient at the
correct time
Filing system errors
Dispensing medications and responding to abnormal test results
5
While many would argue that treatment errors are the most
common category of medical errors, diagnostic errors accounted
for the largest percentage of malpractice claims, surpassing
treatment errors in one study
Diagnostic errors can result from missed, wrong or delayed

diagnoses and are more likely in the outpatient setting. This is
somewhat surprising given the fact that US physicians tend to
practice “defensive medicine”
Over-diagnosis may also cause medical errors but this has been
less well studied
Medical Errors
Unsafe healthcare lowers quality but safe medicine is not
always high quality
From the National Academy of Medicine’s perspective, quality
is a set of six aspirational goals: medical care should be safe,
effective, timely, efficient, patient-centered, and equitable
Value relates to how important something is to use
Cost-effective?
Necessary?
Affect morbidity, mortality or quality of life?
Quality, Safety and Value

Most adverse events result from unsafe actions or inactions by
anyone on the healthcare team, including the patient
Missed care is “any aspect of required care that is omitted either
in part or in whole or delayed”
Many of the above go unreported
Unsafe Actions
Most near-miss events are not reported. Many are not witnessed
The tendency is the blame the individual, but healthcare is
complex and there are often “system errors”
Most safety systems are retrospective; we need to move to be
proactive
We need good data, such as the ratio of detected unsafe actions
divided by the opportunity of an unsafe action, over a specified
time interval
Reporting Unsafe Actions
9

Patient Safety Reporting System: event is recorded and if it is a
sentinel event, it is investigated.
Most systems are not integrated with the EHR
Root Cause Analysis: common approach to determine the cause
of an adverse event. This has limitations
HEDIS measures can help track quality issues
Patient Safety Systems
Current reimbursement models mandate quality measures, e.g.
Medicare Patient Safety Monitoring System, now operated by
AHRQ. The new system is known as the Quality and Safety
Review System. Still labor intensive and manual
Global Trigger Tool: evaluates hospital safety. Said to detect
90% of adverse events. Select 10 discharge records and two
reviewers review the chart for any of the 53 “triggers”
Patient Safety Systems

Paper records have multiple disadvantages, as pointed out in the
EHR chapter
Expectations have been very high regarding the EHR’s impact
on safety, quality and value
Unfortunately, results have been mixed and there has not been a
prospective study conducted to prove the EHR’s benefit towards
safety and quality
Using the EHR to Improve Safety, Quality and Value
High expectations that CDS that is part of EHRs will improve
safety
As per multiple chapters in the textbook, CDS has mixed
reviews, in terms of safety and quality
Adverse events regarding CDS, includes ”alert fatigue”
The FDA will regulate software that is related to treatment and
decision making
Clinical Decision Support

Results in altered workflow and decreased efficiency.
Physicians are staying late to complete notes in the EHR
In an effort to save time physicians may “cut and paste” old
histories into the EHR, creating new problems
EHRs may create new safety issues “e-iatrogenesis”
Because of the multiple issues, it is very common to see offices
and hospitals change EHRs, not always solving the problem
Clinician’s Issues with EHRs
Roughly 2/3 of EHR data is unstructured (free text) so it is not
computable.
While natural language processing (NLP) may help solve this,
we are a long ways away from resolution
Multiple open source and commercial NLP programs exist but
they require a great deal of time and expertise to match the
results a manual chart review would produce
Clinician’s Issues with EHRs

Governmental Organizations Involved with Patient Safety
US Federal Agencies:
Department of Health and Human Services (HHS)
Agency for Healthcare Research and Quality (AHRQ)
Centers for Medicare and Medicaid Services (CMS)
Non-reimbursable complications: (3 examples)
Objects left in a patient during surgery and blood
incompatibility
Catheter-associated urinary tract infections
Pressure ulcers (bed sores)
Hospitals must assemble, analyze and trend clinical and
administrative data to capture baseline data and measure
improvement over time
Health IT-based interventions are expected to assist
Governmental Organizations
Office of the National Coordinator for HIT
Learn: “Increase the quantity and quality of data and knowledge
about health IT safety.”
Improve: “Target resources and corrective actions to improve
health IT safety and patient safety”
Safety goals will be aligned with meaningful use objectives.
Lead: “Promote a culture of safety related to health IT”

Governmental Organizations
The Food and Drug Administration
MedWatch: posts drug alerts and offers online reporting area
Center for Devices and Radiological Health (CDRH)
Plan to regulate mobile medical applications designed for use
on smartphones
State Patient Safety Programs: By 2010, 27 states and the
District of Columbia passed legislation or regulation related to
hospital reporting of adverse events to a state agency
Meaningful Use Objectives and Potential Impact on Patient
Safety
Objective: Use computerized provider order entry (CPOE) for
medication, laboratory, and radiology orders directly entered by
any licensed healthcare professional who can enter orders into
the medical record per state, local, and professional guidelines
Objective: Use clinical decision support to improve
performance on high-priority health conditions

Meaningful Use Objectives and Potential Impact on Patient
Safety
Objective: Automatically track medications from order to
administration using assistive technologies in conjunction with
an electronic medication administration record (eMAR)
Objective: Generate and transmit discharge prescriptions
electronically (eRx)
Non-Governmental Organizations and Patient Safety
National Patient Safety Foundation (NPSF) Goals:
Identifying and creating a core body of knowledge
Identifying pathways to apply the knowledge
Developing and enhancing the culture of receptivity to patient
safety
Raising public awareness and fostering communication around
patient safety
National Academy of Medicine (was the Institute of Medicine
or IOM)

Institute of Medicine (IOM) Recommendations
Congress should create a Center for Patient Safety within the
Agency for Healthcare Research and Quality
A nationwide reporting system for medical errors should be
established
Volunteer reporting should be encouraged
Congress should create legislation to protect internal peer
review of medical errors
Performance standards and expectations by healthcare
organizations should include patient safety
FDA should focus more attention on drug safety
Healthcare organizations and providers should make patient
safety a priority goal
Healthcare organizations should implement known medication
safety policies
IOM Report - 2003
Patient safety must be linked to medical quality

A new healthcare system must be developed that will prevent
medical errors in the first place
New methods must be developed to acquire, study and share
error prevention among physicians, particularly at the point of
care
The IOM recommended specific data standards so patient
safety-related information can be recorded, shared and analyzed
IOM Report - 2011
Report focused exclusively on health IT and patient safety and
quality
Publish an “action and surveillance plan”
Push health IT vendors to support the free exchange of
information about health IT experiences and issues
Public and private sectors should make comparative user
experiences public
Health IT Safety Council should assess and monitor safe use of
health IT
Specify quality and risk management processes health IT
vendors must adopt
Establish an independent federal entity to investigate patient
safety deaths, serious injuries, or potentially unsafe conditions
associated with health IT
Support cross-disciplinary research toward the use of health IT
as part of a learning system

Non-Governmental Organizations and Patient Safety
The National Quality Forum
The Joint Commission:
Published the 2018 National Patient Safety Goals
They also published an alert about the potential for HIT to
create new patient safety issues
LeapFrog Group
HealthGrades
Institute for Safe Medication Practice (IMSP)
HealthGrades 2017 Patient Safety
Excellence Awards
Award recognizes hospitals with the lowest occurrences of 14
preventable patient safety events, placing the hospitals in the
top 10% in the nation for patient safety
This organization reviews the data from inpatient Medicare and
Medicaid cases each year and rates hospitals, in terms of patient
safety
They estimate that the top ranking hospitals represent, on

average, a 43% lower risk of a patient safety adverse event
compared to the lowest ranking hospitals
Quality Care Finder
www.hospitalcompare.hhs.gov
Allows consumers to review quality metrics e.g. morbidity and
mortality making decisions
Technologies with Potential to Decrease Medication Errors
Computerized provider order entry (CPOE) Benefits:
Improved handwriting identification
Reduced time to arrive in the pharmacy
Fewer errors related to similar drug names
Easier to integrate with other IT systems
Easier to link to drug-drug interactions
More likely to identify the prescriber

Available for immediate analysis
Can link to clinical decision support to recommend drugs of
choice
Jury still out on actual reduction of serious ADEs
Health Information Exchange (HIE):
Improve patient safety by better communication between
disparate healthcare participants
Automated Dispensing Cabinets (ADCs): like ATM machines
for medications on a ward
Home Electronic Medication Management System: home
dispensing, particularly for the elderly or non-compliant patient
Pharmacy Dispensing Robots: bottles are filled automatically
Electronic Medication Administration Record (eMAR):
electronic record of medications that is integrated with the EHR
and pharmacy
Intravenous (IV) Infusion Pumps: regulate IV drug dosing
accurately

Bar Coding Medication Administration: the patient, drug and
nurse all have a barcoded identity
These must all match for the drug to be given without any alerts
Bar codes are inexpensive but the software and other
components are expensive
Some healthcare systems have shown a significant reduction in
medication administrative errors, but many of these were minor
and would not have resulted in serious harm
Medication Reconciliation
When patients transition from hospital-to-hospital, from
physician-to physician or from floor-to-floor, medication errors
are more likely to occur
Joint Commission mandated hospitals must reconcile a list of
patient medications on admission, transfer and discharge
Task may be facilitated with EHR but still confusion may exist
if there are multiple physicians, multiple pharmacies, poor
compliance or dementia

Barriers to Improving
Patient Safety through Technology
Organizational: health systems leadership must develop a strong
“culture of safety”
Financial: Cost for multiple sophisticated HIT systems is
considerable
Error reporting: is voluntary and inadequate and usually “after
the fact”
Unintended Consequences
Technology may reduce medical errors but create new ones:
Medical alarm fatigue
Infusion Pump errors
Distractions related to mobile devices
Electronic health records: data can be missing and/or incorrect,
there can be typographical entry errors, and older information is
sometimes copied and pasted into the current record

Patient safety continues to be an ongoing problem with too
many medical errors reported yearly
Multiple organizations are reporting patient safety data
transparently to hopefully support change
There is a great expectation that HIT will improve patient
quality which in turn will decrease medical errors
There is some evidence that clinical decision support reduces
errors, but studies overall are mixed
Leadership must establish a “culture of safety” to effectively
achieve improvement in patient safety
Conclusions
Chapter 10: Health Information Privacy and Security
John Rasmussen MBA

Learning Objectives
After reviewing the presentation, viewers should be able to:
Explain the importance of confidentiality, integrity, and
availability
Describe the regulatory environment and how it drives
information privacy and security programs within the health
care industry
Recognize the importance of data security and privacy as
related to public perception, particularly regarding data breach
and loss
Identify different types of threat actors and their motivations
Identify different types of controls used and how they are used
to protect information
Describe emerging risks and how they impact the health care
sector

Confidentiality refers to the prevention of data loss, and is the
category most easily identified with HIPAA privacy and
security within healthcare environments. Usernames,
passwords, and encryption are common measures implemented
to ensure confidentiality
Three Pillars of Data Security
Availability refers to system and network accessibility, and
often focuses on power loss or network connectivity outages.
Loss of availability may be attributed to natural or accidental
disasters such as tornados, earthquakes, hurricanes or fire, but
also refer to man-made scenarios, such as a Denial of Service
(DoS) attack or a malicious infection which compromises a
network and prevents system use. To counteract such issues,
backup generators, continuity of operations planning and
peripheral network security equipment are used to maintain
availability

Integrity describes the trustworthiness and permanence of data,
an assurance that the lab results or personal medical history of a
patient is not modifiable by unauthorized entities or corrupted
by a poorly designed process. Database best practices, data loss
solutions, and data backup and archival tools are implemented
to prevent data manipulation, corruption, or loss; thereby
maintaining the integrity of patient data
Data must be classified to determine its risk
Healthcare organizations must develop a set of controls to
protect confidentiality, integrity and availability of data
One layer of defense is not likely to be adequate
Healthcare organizations will need technical, administrative and
physical safeguards
Defense in Depth for Healthcare

Administrative Safeguards
Administrative Safeguards
Security management processes to reduce risks and
vulnerabilities
Security personnel responsible for developing and implementing
security policies
Information access management-minimum access to perform
duties
Workforce training and management
Background checks, drug screens, etc. for new employees
Evaluation of security policies and procedures
Physical Safeguards
Limit physical access to facilities
Workstation and device security policies and procedures
covering transfer, removal, disposal, and re-use of electronic
media
Badge with photo
Physical Safeguards

Technical Safeguards
Access control that restricts access to authorized personnel
Audit controls for hardware, software, and transactions
Integrity controls to ensure data is not altered or destroyed
Transmission security to protect against unauthorized access to
data transmitted on networks and via email
Unique usernames and passwords, encrypted software, anti-
virus software, secure email, firewalls, etc.
Technical Safeguards
Healthcare Regulatory Environment
Health Insurance Portability & Accountability Act (HIPAA -
1996)
Laid ground work for privacy and security measures in
healthcare . Initial intent was to cover patients who switched
physicians or insurers (portability)
Next important Act was the American Recovery and
Reinvestment Act (ARRA - 2209) & HITECH Act that imposed
new requirements for breach notification and stiffer penalties

Health Plans: Health insurers, HMOs, Company health plans,
Government programs such as Medicare and Medicaid
Health Care Providers who conduct business electronically:
Most doctors, Clinics, Hospitals, Psychologists, Chiropractors,
Nursing homes, Pharmacies, Dentists
Health care clearinghouses
Covered Entities or Those Who Must Follow HIPAA Privacy
Rule
Request and receive a copy of their health records
Request an amendment to their health record
Receive a notice that discusses how health information may be
used and shared, the Notice of Privacy Practices
Request a restriction on the use and disclosure of their health
information
Receive a copy of their “accounting of disclosures”

Restrict disclosure of the health information to an insurer if the
encounter is paid for out of pocket
File a complaint with a provider, health insurer, and/or the U.S.
Government if patient rights are being denied or health
information is not being protected.
Covered Entities: Patient Rights
Life insurers
Employers
Workers compensation carriers
Many schools and school districts
Many state agencies like child protective service agencies
Many law enforcement agencies
Many municipal offices
Organizations That Do Not Need To Follow HIPAA Privacy
Rule

Individually identifiable health information:
Information created by a covered entity
And “relates to the past, present, or future physical or mental
health or condition of an individual”
Or identifies the individual or there is a reasonable basis to
believe that the individual can be identified from the
information.
Protected Health Information (PHI)
HIPAA
Protections apply to all personal health information (PHI),
whether in hard copy records, electronic personal health
information (ePHI) stored on computing systems, or even verbal
discussions between medical professionals
Covered entities must put safeguards in place to ensure data is
not compromised, and that it is only used for the intended
purpose
The HIPAA rules are not designed to and should not impede the
treatment of patients

Privacy Rule Mandates Removal of 18 Identifiers
Names
All geographic subdivisions smaller than a state
All elements of dates (except year)
Telephone numbers
Facsimile numbers
Electronic mail addresses
Social security numbers
Medical record numbers
Health plan beneficiary numbers
Account numbers
Certificate/license numbers
Vehicle identifiers and serial numbers, including license plate
numbers
Device identifiers and serial numbers
Web universal resource locators (URLs)
Internet protocol (IP) address numbers
Biometric identifiers, including fingerprints and voiceprints
Full-face photographic images and any comparable images
Any other unique identifying number, characteristic, or code
Permitted Uses and Disclosures of Patient Data
To the individual

For treatment, payment or health care operations
Uses and disclosures with opportunity to agree or object
Facility directories
For notification and other purposes
Incidental use and disclosure
Public interest and benefit activities
Required by law
Public health activities
Victims of abuse, neglect or domestic violence
Health oversight activities
Judicial and administrative proceedings
Law enforcement purposes
Decedents
Cadaveric organ, eye, or tissue donation
Research
Serious threat to health or safety
Essential government functions
Workers’ compensation
BAs are related to the covered entity (CE), such as an EHR
vendor or a transcription service
They must have a BA agreement with the CE
This forces the BA to comply with all security requirements
The BA can be penalized for violating HIPAA requirements
Business Associate (BA)

Unauthorized acquisition, access or use. Exceptions:
Data is encrypted. This is considered a safe harbor; or
“Any unintentional acquisition, access, or use of protected
health information by a workforce member or person acting
under the authority of a covered entity or a business associate,
if such acquisition, access, or use was made in good faith and
within the scope of authority and does not result in further use
or disclosure”; or
“Any inadvertent disclosure by a person who is authorized to
access protected health information at a covered entity or
business associate to another person authorized to access
protected health information at the same covered entity or
business associate, or organized health care arrangement in
which the covered entity participates, and the information
received as a result of such disclosure is not further used or
disclosed”; or
“A disclosure of protected health information where a covered
entity or business associate has a good faith belief that an
unauthorized person to whom the disclosure was made would
not reasonably have been able to retain such information.”
Breach Requirements under HIPAA

If a breach is determined, the covered entity must notify the
individual(s) impacted by the breach. They must inform them
within 60 days of when the breach is identified. The
notification must include:
A description of what happened
A description of the type of PHI that was breached
Steps the individual can take to protect themselves
What the covered entity is doing to investigate the breach and
mitigate harm
Contact information for the individual to contact the covered
entity 23
If a breach exceeds 500 individuals, the covered entity must
notify the media and must report the breach to the Office for
Civil Rights (OCR).
Regardless of the number of individuals impacted by a breach,
all breaches must be reported to the OCR annually
Breach Notification
Administrative Requirements for the Privacy Rule
Develop and implement written privacy policies and procedures
Designate a privacy official

Workforce training and management
Mitigation strategy for privacy breaches
Data safeguards - administrative, technical, and physical
Designate a complaint official and procedure to file complaints
Establish retaliation and waiver policies and restrictions
Documentation and record retention - six years
Fully-insured group health plan exception
Policy regarding information security practices is often set by
chief information officers (CIOs), chief technology officers
(CTOs), information technology (IT) directors or similar; often
with input from chief medical informatics officers (CMIOs),
HIPAA compliance officers, or the like
Depending on resources, the information technology teams may
consist of network, system administration, security and data
personnel, or could be the very same technical staff relied upon
for all office or clinic IT needs
Organizational Roles

Insiders
Hackivists
Organized crime
Nation states
Threat Actors
Social Engineering: most common
Phishing: via email or text messaging
Shoulder surfing: attacker looks over the shoulder
Tailgating: attacker uses someone else's ID
Free software: USB drive is found and plugged into a computer,
introducing a virus
Types of Attacks
Denial of Service (DOS): website is flooded with traffic,

shutting it down
Brute Force: random credential are rapidly thrown at website
hoping to gain access
Doxing: gathers info about a victim and publishes that to harass
or embarrass the individual.
Types of Attacks
Security Breaches and Attacks
Identity theft on the rise
Physical Theft
Stolen laptops, computers, storage devices and servers
The HHS website lists all of the reported data breaches
affecting over 500 users. The site lists the covered entity, the
number of breach victims, the type of breach and the location of
data (laptop, server, paper, etc.)
Breaches: https://ocrportal.hhs.gov/ocr/breach/breach_report.jsf
The next slides will list some of the recognized

countermeasures employed by healthcare organizations
Threat Countermeasures
Authentication and
Identity Management
Accomplished with photo identification, biometrics, smart card
technologies, tokens, and the old standard; user name and
password
Basic Authentication may vary depending on sensitivity of data,
the capabilities of the systems, resource constraints - both
technical and monetary, and the frequency of access
Methods discussed here rely on what is known as two or multi-
factor authentication: something one knows, something one has,
or something that one is
Basic authentication:
Username and password combination still employed by a
majority of users today, combining two things that a user knows

Another option is utilizing a grid card, smart card, USB token,
one time password (OTP) token, or OTP service in combination
with something a user knows, such as a passphrase or PIN
Authentication and
Identity Management
Authentication and
Identity Management
Single Sign On (SSO)
One set of credentials to easily access many of the resources
one uses every day securely; example is Google
Smart Cards: Used in Healthcare in many countries
Vital information with a self-contained processor and memory
Low cost, ease of use, portability and durability, and ability to
support multiple applications
Capable of encrypted patient information, biometric signatures
and personal identification (PIN)
Drawbacks: lack of standardization and positive identification

Smart Cards in Healthcare
Authentication and
Identity Management
Biometric Authentication
When combined with passphrases or the tokens, cards, and OTP
solutions discussed previously, a two or multi-factor
authentication solution can be employed
Physical user identifiers: fingerprint, retinal scan, voice imprint
32
Theft Countermeasures
Render data unusable to thieves

Encryption standards such as FIPS 140-2
Hardware and software encryption techniques
See encrypted USB device to the right
Theft Countermeasures
Security of healthcare data is critical for future success of HIT
ARRA/HITECH supplement the administrative, physical and
technical safeguards implemented by HIPAA
Security measures will continue to improve but so will the
efforts of hackers and criminals who seek access to healthcare
record data and identity theft
Conclusions
ANRV307-CP03-13 ARI 20 February 2007 19:5

Unwarranted Assumptions
about Children’s
Testimonial Accuracy
Stephen J. Ceci,1 Sarah Kulkofsky,1
J. Zoe Klemfuss,1 Charlotte D. Sweeney,1
and Maggie Bruck2
1 Department of Human Development, Cornell University,
Ithaca, New York 14853;
email: [email protected]
2 Department of Psychiatry & Behavioral Sciences, Johns
Hopkins University,
Baltimore, Maryland 21287
Annu. Rev. Clin. Psychol. 2007. 3:311–28
First published online as a Review in
Advance on January 2, 2007
The Annual Review of Clinical Psychology is online
at http://clinpsy.annualreviews.org
This article’s doi:
10.1146/annurev.clinpsy.3.022806.091354
Copyright c© 2007 by Annual Reviews.
All rights reserved
1548-5943/07/0427-0311$20.00
Key Words
suggestibility, open-ended questions, false reports

Abstract
We examine eight unwarranted assumptions made by expert wit-
nesses, forensic interviewers, and legal scholars about the
reliability
of children’s eyewitness reports. The first four assumptions
mod-
ify some central beliefs about the nature of suggestive
interviews,
age-related differences in resistance to suggestion, and
thresholds
necessary to produce tainted reports. The fifth unwarranted
assump-
tion involves the influence of both individual and interviewer
factors
in determining children’s suggestibility. The sixth unwarranted
as-
sumption concerns the claim that suggested reports are
detectable.
The seventh unwarranted assumption concerns new findings
about
how children deny, disclose, and/or recant their abuse. Finally,
we
examine unwarranted statements about the value of science to
the
forensic arena. It is important not only for researchers but also
expert
witnesses and court-appointed psychologists to be aware of
these un-
warranted assumptions.
311
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Contents
INTRODUCTION . . . . . . . . . . . . . . . . . 312
Unwarranted Assumption 1:
Suggestive Interviews Can Be
Indexed by the Sheer Number
of Leading Questions . . . . . . . . . . 313
Suggestibility Is Primarily a
Problem for Younger Age
Groups . . . . . . . . . . . . . . . . . . . . . . . 314
Multiple Suggestive Interviews
Are Needed
to Taint a Report; Milder Forms
of Suggestion Do Not Produce
Tainted Reports . . . . . . . . . . . . . . . 316
Children’s Spontaneous Reports
Are Always Accurate . . . . . . . . . . . 317

Erroneous Suggestions
Ineluctably Lead to Erroneous
Reports by Children . . . . . . . . . . . 318
Unwarranted Assumption 6: False
Reports Produced by Suggestive
Interviewing Are
Distinguishable from Accurate
Reports . . . . . . . . . . . . . . . . . . . . . . . 320
Children’s Disclosures of
Traumatic Events Are Delayed,
Denied, and Often Recanted . . . 322
Laboratory Research Is Not
an Accurate Reflection of Child
Witnesses’ Experiences
in the Real World . . . . . . . . . . . . . 323
CONCLUSION . . . . . . . . . . . . . . . . . . . . 324
INTRODUCTION
In recent years, an increasing number of chil-
dren have entered the legal system to pro-
vide testimony in a broad range of cases. In
the United States alone, hundreds of thou-
sands of children are deposed, interviewed,
and examined each year as part of civil and
family court proceedings, abuse/neglect in-
vestigations, and other types of criminal in-
vestigations. Before the early 1980s, children

rarely were permitted to testify in criminal
cases1 (see Ceci & Bruck 1993, p. 408). Now,
however, it is so common that most English-
speaking nations have developed special inter-
viewing procedures and techniques to mini-
mize children’s discomfort (e.g., video links
that allow them to testify remotely, barri-
ers between them and the defendant) and in-
crease the reliability of their statements (e.g.,
Home Off. Dept. Health 1992, Natl. Soc.
Prev. Cruel. Child. Childline 1993, Smith &
Goretsky-Elstein 1993).
Given the recent ubiquity of children’s par-
ticipation in forensic matters, it is not surpris-
ing that beginning in the 1980s researchers
turned their attention to the sensitive issues
that arise when children enter the legal arena.
This research has made significant contribu-
tions to the theoretical and applied science
of child development. It has provided new
and often surprising insights into the capa-
bilities and weaknesses of children’s cognitive,
linguistic, social, and emotional development.
This research also has dispelled myths or com-
mon beliefs about aspects of child develop-
ment both in and out of the forensic arena.
In this review, we first outline how some of
the current research has challenged miscon-
ceptions about the reliability and credibility
of children’s statements. Given that many of
the issues concerning children in the court-
room revolve around cases of suspected sex-
ual abuse, it is not surprising that having the
science accepted in the courtroom has been

1 An anecdote from the John Grisham novel The Last Ju-
ror underscores the scientific research. It concerns a cross-
examination of a newspaper publisher set in Mississippi in
1970: Attorney: Mr. Traynor, how many cases did you find
where children aged five or younger were allowed to testify
in a criminal trial? Newspaper Publisher Traynor: None.
Attorney: Perfect answer, Mr. Traynor. None. In the his-
tory of this state, no child under the age of eleven has ever
testified in a criminal trial.
312 Ceci et al.
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a difficult process. To illustrate this point, we
end the article with a misconception of the
usefulness of the science to the forensic arena
and show how scientists attempt to deal with
efforts to keep the current science out of the
courtroom.2
Suggestive Interviews Can Be

Indexed by the Sheer Number
of Leading Questions
The suggestiveness (and thus the risk of elic-
iting false information) of an interview is not
adequately reflected by the number of lead-
ing questions. Rather, one must consider how
the concept of interview bias plays out in
the current interview, as well as in all pre-
vious interviews. Interview bias characterizes
those interviewers who hold a priori beliefs
about what has occurred and mold the inter-
view to maximize disclosures that are consis-
tent with such beliefs. The means by which
the bias is communicated to the child goes
well beyond the use of misleading questions;
other suggestive techniques include provid-
ing positive and negative reinforcement (e.g.,
praising the child for disclosing information
consistent with the interviewer’s beliefs, crit-
icizing the child or withholding benefits such
as trips to the restroom for not disclosing),
utilizing peer or parental pressure (e.g., telling
the child that his or her friends or parents have
already disclosed), creating a negative or ac-
cusatory emotional tone (e.g., urging the child
to help keep the defendant in jail), and re-
peating questions or interviews until the child
provides a desired answer.
The following testimony of an expert in
a trial illustrates this point. She testified that
her questioning was not suggestive because
technically speaking she did not ask sugges-
tive questions. But as seen from her testimony,

2 In preparing this review, we drew upon several examples
from a recent article of ours (Bruck & Ceci 2004), but have
gone considerably beyond it.
her approach is characteristic of interviewer
bias:
I usually say, “Mama talked about that some-
body did some bad touching.” And that’s
still pretty open ended. I’m not saying who
and I’m not saying exactly what. I’m just
introducing the subject. Or I will say, “I
see many children, and children come and
tell me when bad things happen to them,
and I’ve heard other kids tell me when bad
things happen. So it’s okay if you want to tell
me.” (In the Matter of Riley, Shelby, and Austin
Blanchard v. John Blanchard 2001, p. 876)
A number of studies have demonstrated
the negative effects of interviewer bias (see
Ceci & Bruck 1995 for a review). In one type
of study examining interviewer bias, children
witness a staged event and are then inter-
viewed by an individual who is given misinfor-
mation about what has occurred. The inter-
viewer is allowed to interview the child in any
way he or she deems appropriate; that is, the
interviewer is simply told to find out what hap-
pened. These studies have found that children
who are interviewed by an individual who has
been misinformed (or who has a bias) about
what has occurred begin to report this misin-
formation themselves (e.g., Bruck et al. 1999,
White et al. 1997). For example, if the inter-
viewer has been misinformed that the child

had her knee licked by another child, she ends
up getting the child to assent to this false claim
(White et al. 1997).
Another set of studies has examined the ef-
fects of combining multiple suggestive tech-
niques in eliciting false reports from children.
These studies demonstrate that misleading
questions asked by a neutral interviewer do
not have the same effect as multiple sug-
gestive techniques, implying that misleading
questions alone are not sufficient to expose
an interviewer’s bias. For example, Garven
and her colleagues (1998, 2000) examined
how the techniques used by investigators in
the infamous McMartin Preschool case (State
of Calif. v. Buckey 1990) can taint children’s
www.annualreviews.org • Unwarranted Assumptions 313
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testimony beyond the damage that mislead-

ing information alone can cause. In one study
(Garven et al. 2000), the researchers asked
kindergarten children to recall details from
when a visitor named Paco came to their class-
room and read a story, gave out treats, and
wore a funny hat. Half the children were given
interviews that included misleading questions
about plausible events (e.g., Did Paco break
a toy?) and about bizarre events (e.g., Did
Paco take you to a farm in a helicopter?). Be-
tween 5%–13% of the children falsely agreed
with the misleading questions. A second group
of children was also questioned, but these
children were given feedback after their an-
swers to the misleading questions. “No” re-
sponses were negatively evaluated, whereas
“yes” responses were positively evaluated. For
example,
Interviewer: Did Paco take you somewhere
in a helicopter?
Child: No.
Interviewer: You’re not doing good.
Interviewer: Did Paco break a toy?
Child: Yes.
Interviewer: Great, you’re doing excellent
now.
This latter group of children provided the
desired but false answer to 35% of the plausi-
ble questions and to 52% of the bizarre ques-
tions. This study demonstrates that a simple
count of misleading/leading questions would
not reflect the suggestiveness of the interview.
It was the added use of selective reinforcement
that provided the child with sufficient infor-

mation about the interviewer’s bias—to make
“yes” responses for all statements regardless
of their plausibility. In a follow-up interview
two weeks later, when children were simply
asked nonleading questions with no selective
reinforcement feedback, the same level of be-
tween group differences was obtained. Thus,
interviewer bias in a prior interview can pro-
duce false reports in a later unbiased/neutral
interview. This is an important point to bear
in mind when analyzing transcripts of an in-
terview: Just because that particular interview
may be neutral, prior interviews may have
been suggestive, seeding false claims made in
the neutral interview. The bottom line is that
the number of leading or suggestive questions
deployed in an interview is neither a good in-
dex of how suggestive it is, nor a good index of
whether prior (nonrecorded) interviews that
were more suggestive are responsible for false
claims by the child.
Suggestibility Is Primarily a Problem
for Younger Age Groups
The erroneous view that preschool children
are the only population vulnerable to sugges-
tion can be found in many experts’ testimony.
Consider the following example: “Well, in vir-
tually all these studies, two and three-year
olds do not do well in suggestibility, and the
four and five-year olds. . . [d]o pretty well” (ex-
pert testimony by prosecution witness In the
Matter of Riley, Shelby, and Austin Blanchard v.

John Blanchard 2001). “It’s true that the sorts
of questioning that were asked of the children
are not supported by basic research into sug-
gestibility, but these children were all over
the age of 6, the cut-off for suggestibility-
proneness in scientific studies” (transcript,
p. 1441).
This view that only the youngest children
are vulnerable to suggestive questioning re-
flects the disproportionate attention to the
study of preschool children at the end of the
twentieth century. This practice was directly
motivated by forensic concerns. During the
1980s and 1990s, there were a number of
high-profile criminal cases in which preschool
children’s horrific claims about sexual abuse
by day-care workers, parents, and other unfa-
miliar adults were presented to the jury (see
descriptions of several of these cases in Ceci &
Bruck 1995). Although the case facts showed
that these children had been subjected to
highly suggestive interviews, at that time there
was no relevant body of scientific literature to
indicate the risk of these interviewing tech-
niques in producing false allegations about
314 Ceci et al.
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a range of salient events. When researchers
began to fill in this empirical void, most of
the studies focused on preschoolers, with few
examining age-related differences. Those that
did include age comparisons usually found
ceiling effects for the older children, leading
to the conclusion that only preschoolers are
suggestible (e.g., Ceci et al. 1987) and that
there is little need for concern when older
children are subjected to suggestive interview-
ing practices.
However, the conclusion that suggestibil-
ity is minimal among grade-school children
and young adults is discrepant with the find-
ing of another body of literature that shows
that many of the suggestive techniques used
in the child studies also produced tainted re-
ports or memories in adults (e.g., see Loftus
2004). Indeed, much of the earliest work on
the malleability of memory was conducted
with adults, not young children. For example,
in a highly cited study by Loftus & Pickrell
(1995), adults ranging in age from 18 to 35
were convinced through a variety of sugges-
tive techniques that that they had been lost in
a shopping mall as young children, and they
developed elaborate, albeit false memories of

these events. Similarly, Hyman and his col-
leagues have conducted a number of stud-
ies whereby through suggestive techniques,
college-aged students developed false mem-
ories of events, such as spilling a punch bowl
at a wedding (e.g., Hyman et al. 1995).
By inference then, one might assume that
children in middle childhood must also be
quite suggestible, given the knowledge of both
the younger children and older groups. Re-
cent evidence supports this view: Susceptibil-
ity to suggestion is highly common in mid-
dle childhood, and under some conditions,
there are small or even no developmental dif-
ferences. For example, Finnila et al. (2003)
staged an event (a version of the Paco visit
described in Garven et al. 2000) for two age
groups of children (four- and five-year-olds,
and seven- and eight-year-olds). One week
later, half the children were given a low-
pressure interview that contained some mis-
leading questions with abuse themes (e.g.,
“He took your clothes off, didn’t he?”). The
other children received a high-pressure inter-
view during which the interviewer told them
that their friends had answered the leading
questions affirmatively. Children were praised
for assenting to the misleading questions, and
when they did not assent, the question was
repeated. In both the low- and high-pressure
conditions, there were no significant age dif-
ferences, although a significant number (68%)
of misleading questions were assented to in
the high-pressure condition (see also Bruck

et al. 2007, Zaragoza et al. 2001).
Under some conditions, older children are
even more suggestible than younger chil-
dren are (e.g., Ceci et al. 2007, Finnila et al.
2003, Lindberg 1991, Scullin & Ceci 2001,
Zaragoza et al. 2001). For example, in a recent
study, researchers administered a suggestibil-
ity test to four-year-olds and nine-year-olds
(Ceci et al. 2007). Children were read a short
story that focused on a series of objects. Later
children were given misinformation about the
objects in the story. Days later, they were
asked to recall the objects that were part of
the original story. The direction of age differ-
ences in suggestibility was predicted by age
differences in children’s semantic represen-
tations of the similarity between the actual
and suggested object. For example, compared
with younger children, older children were
much more likely to erroneously report that
there was an egg sandwich in a story in which
they actually heard about a cheese sandwich.
This is because older children find eggs and
cheese to be more similar than younger chil-
dren do. Similarly, compared with older chil-
dren, younger children were more likely to
report the false suggestion that there was a
soda in the story when there was actually milk.
Again, this was because younger children per-
ceive milk and soda as more similar than do
older children.
These newer findings reshape current
views of developmental trends in suggestibil-
ity and challenge current conceptualiza-

tions of the developmental mechanisms in
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children’s suggestibility. Specifically, current
mechanisms that have been touted for chil-
dren’s suggestibility (e.g., theory of mind,
social compliance) are commonly known to
have developed by the end of the preschool
years (Wellman et al. 2001). Clearly, a wider
perspective needs to be taken, and skills
that develop throughout the childhood years
should become the focus of future study (e.g.,
appreciation of the ramifications of false state-
ments, insight into questioner’s motives). The
bottom line is that, expert testimony notwith-
standing (Bruck & Ceci 2004), all age groups
are vulnerable to misleading suggestions, even
if preschoolers are disproportionately more
vulnerable.

Unwarranted Assumption 3: Multiple
Suggestive Interviews Are Needed
to Taint a Report; Milder Forms
of Suggestion Do Not Produce
Tainted Reports
A third scientific misconception concerns the
view that it is difficult to implant memories or
to taint reports and, therefore, repeated sug-
gestive interviews are required, especially to
produce a false report for salient events (e.g.,
Ceci & Bruck 1995). For example, the expert
in the Matter of Ryan D. Smith (2001) testified,
“[s]uggestions must be repeated for children
to incorporate them into their reports” (tran-
script, p. 886).
We have been as responsible as anyone
has for this view because often when we de-
scribe our own findings, we report that our
methodology involved multiple suggestive in-
terviews of children over time (e.g., Bruck
et al. 1995a, Ceci et al. 1994a, Leichtman &
Ceci 1995). Although this is a correct descrip-
tion of our own methodology and results, it
does not gainsay the many studies that have re-
ported that children can incorporate sugges-
tions about salient events after a single sugges-
tive interview (Bruck et al. 2007, Garven et al.
2000, Thompson et al. 1997). Importantly,
the effects of a single interview that produced
false reports had powerful and lasting effects:
Children’s initial false responses to sugges-
tions, which may have reflected social pres-
sure, continued in later interviews even when

questioned by different (neutral) interviewers.
This enduring pattern may reflect that with
time children come to believe that the false
suggestion actually happened; in other words,
they developed a false belief about a statement
they initially realized was false.
Significant tainting and production of false
beliefs can also occur with a single mildly sug-
gestive interview. For example, in two studies,
Poole & Lindsay (1998, 2001) had parents
read their child a brief narrative that out-
lined the child’s previous encounters with a
character known as “Mr. Science” at the re-
searchers’ laboratory. Unknown to the par-
ent, some of the details in the brief narrative
they read to their children were inaccurate and
thus were not experienced by their child when
they met Mr. Science. Nonetheless, even un-
der these mild conditions, significant numbers
of children (four- to eight-year-olds) later told
an interviewer that they had experienced the
suggested events.
In a similar line of research, Principe
and her colleagues (Principe & Ceci 2002,
Principe et al. 2006) found that children ex-
posed to rumors by their peers or by over-
hearing adult conversations were as likely to
falsely report being part of the event as those
who actually did participate. In one study
(Principe & Ceci 2002), a group of children
participated in a scripted event that contained
two highly salient events (the target activi-
ties). The second group included classmates
of the first group; these children participated

in the same scripted event, but they were not
shown the two target events. A third group
of children was taken from a different school;
similar to the second group, they experienced
the scripted activity without the target events.
The children were then interviewed in either
a neutral or a suggestive manner. Children
who were classmates of those who participated
in the target event made more false claims
alleging that they had viewed the target ac-
tivities than children who did not view the
316 Ceci et al.
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target events and were from a different school.
These data suggest that there was contami-
nation from classroom interactions; children
who had not experienced the target events
learned of them from their classmates who
had, and thus were more likely to assent to
false events. In a second study, Principe et al.

(2006) found that children who overheard a
child talking about a target event (a rabbit
that escaped from a magician) were as likely
to falsely claim to have seen the event in ques-
tion as were peers who actually saw it escape.
Moreover, in this study, the effect of sugges-
tive questioning did not notably increase their
false reports; they were as likely to report
falsely if they overheard peers talking about
the rabbit, regardless of whether interviewers
employed suggestive questions.
So far, we have only focused on the extent
to which one exposure to false information can
lead to high rates of misreporting about salient
events. Some studies directly compare the ef-
fects of multiple versus one suggestive in-
terview on children’s suggestibility. Evidence
suggests that, contrary to common psycho-
logical principles, a number of circumstances
exist in which one suggestive interview pro-
duces the same amount of taint as two or more
suggestive interviews. The impact of a second
interview depends on the spacing of the in-
terviews from the initial events and from the
final interview, and also on the strength of the
original memory trace (Marche 1999, Melnyk
& Bruck 2004).
In light of these considerations, it is re-
grettable that expert witnesses create the im-
pression that interviewing methods must be
repetitive, egregious, and coercive to taint
a child’s statement about abuse. In a post-
testimonial brief, one expert witness made
just such a claim, arguing that short of us-

ing what she felt were repetitive, egregiously
coercive forms of interviewing, one could ex-
pect children’s statements to be highly ac-
curate: “[Q]uestioning that is ‘merely’ sug-
gestive (e.g., occasional leading questions
embedded in an interview with neutral and
direct questions) yields a 92–100% accuracy
rate on abuse-relevant or trauma-relevant
questions” (Dalenberg 2000, p. 11). In her
words,
In the Janitor, Sam Stone, and Garven et al.
(in press) studies . . . the authors subject chil-
dren to the following procedures: Repeated
affirmative statements that the perpetrator
is guilty, not just questions about his acts.
Refusals to hear and acknowledge the child’s
denials of a perpetrator’s guilt . . . statements
to the child that she is not doing a good
job when she says something that the in-
terviewer does not want to hear. Offering
of evidence to the child that the perpetra-
tor was guilty (such as telling the child that
her mother, or other children, knows that
the perpetrator is guilty or that the trauma
occurred [as in the Garven studies or Mouse-
trap studies], or showing the child physical
evidence of the crime [as in the Sam Stone
study]). Taking the methods of these studies
into the sexual abuse arena, the questioner
would have affirmatively told R.B. that her
father was a sexual abuser, falsely told her
that there was physical evidence that she was
abused, and then repeatedly, even if she de-
nied a type of abuse each and every time she

was queried, asked if her father was angry
when he abused her, where he went after he
abused her, etc. . . . I see no evidence that the
interviewers of R.B. went this far.
Children’s Spontaneous Reports Are
Always Accurate
A commonly held belief is that although chil-
dren’s prompted statements may be suspect,
their spontaneous statements are generally ac-
curate, and errors only occur when children
are asked specific, often misleading questions.
Similar to many of the other assumptions,
this too made its way into expert testimony.
For example, Dr. Constance Dalenberg testi-
fied for the prosecution In the Matter of Riley,
Shelby, and Austin Blanchard v. John Blanchard
2001 that “[s]pontaneous statements are
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likely to be accurate statements” (transcript,
p. 39).
It is true that children tend to be more
accurate when asked open-ended questions
compared with more directed questioning.
This has been recognized since Binet’s (1900)
earliest studies on children’s suggestibility.
However, it is not the case that children’s
spontaneous statements are always accurate
statements. When children have been ques-
tioned suggestively, the suggestions can taint
both what they later spontaneously report
as well as their answers to specific ques-
tions. For example, the children in Poole
& Lindsay’s (2001) Mr. Science study, dis-
cussed above, were simply asked to describe
everything they remembered from interact-
ing with Mr. Science after they had been
exposed to a misleading narrative by their par-
ents about the event. A full 21% of the state-
ments children reported were events they had
not actually experienced. Furthermore, some
of these events included bodily touch, such
as Mr. Science putting something yucky in
the child’s mouth. In a different study, Poole
& White (1993) interviewed children about
an event that had occurred two years pre-
viously. Following the first event the chil-
dren had …

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