Category Archives: 2nd Med Opinion

2nd Med Opinion, Child Abuse, CPS Tainted Numbers, Indifference, Physical Abuse, StopChildAbuse

Good Information And For My Doubters

.jpg photo graphic included with Mayo Clinic article
How Medical Professionals should address Child Physical Abuse.

Medical Professionals – Trauma: How to address Child Physical Abuse

Arne H. Graff, M.D., is the division chair of Child Abuse Pediatrics at Mayo Clinic’s campus in Rochester, Minnesota.  His desire is to equip providers for potential child physical abuse (CPA) cases, helping them feel as comfortable as possible and removing the fear of reporting.  He offers perspective on CPA and what trauma professionals’ responsibilities are in this scenario.

How did you get into the child abuse field?

While I was working in North Dakota, a physician at Sanford Medical Center in Fargo talked me into working with him in a volunteer clinic.  While there, I ran into enough child abuse cases that I realized I needed to get out of it or get better.  So I did a fellowship in child abuse pediatrics.

Is child abuse common in Minnesota?

Around 84,000 reported cases of child maltreatment are reported each year in Minnesota, according to the Minnesota Department of Human Services and documented in the Child Maltreatment Report for 2017.   Minnesota has as high an incidence as some other states, like California, but doesn’t see as large of numbers due to population differences between Minnesota and the other states.

There are about 1,500 identified maltreatment deaths in Minnesota each year, but this is assumed underreported due to the difficulty in identifying many of the deaths as clearly caused by maltreatment.  In Rochester, Minnesota, and the immediate region, we have around 400 reported maltreatment cases each year.

(1,500÷365=4.1 Child Maltreatment deaths per day just in Minnesota, so how can so many distort the numbers by saying there has ever been 5 Child Maltreatment deaths each day in the last 100 years and possibly the last 150 years)

Which children are at highest risk of abuse?

A young child or infant is at highest risk.

Are any children overlooked for abuse?

Yes — teenagers.  I don’t want us as providers to just focus on little kids.  Teens have a similar CPA pattern as other children.  It’s important you consider whether abuse is occurring if you see a 15-year-old with an injury that doesn’t align with the history. Don’t assume because they’re teenagers, they aren’t experiencing abuse.

Who abuses children?

People who have access to children hurt children: parents, child care providers, grandparents and school personnel.  Anyone has the capacity to hurt children.

That said, it’s important to know that 82% of abusers are ages 18 to 44, and 80% of CPA is inflicted by parents, according to data from Child Welfare Information Gateway.

Is denial of mechanism of injury common in these cases?  If so, any advice?

Since we don’t know how often abuse is missed, we can’t guess at how often it’s denied.  Personal experience is that even with serious injuries, denial is common. Considering that one of the caregivers may not have knowledge of events that occurred with his or her partner, denial can be a normal answer.  Therefore, asking about domestic as well as pet violence is important, and also interviewing caregivers separately.  By emphasizing mandated reporting requirements and indicating concern about their child, we hopefully will maintain a working relationship with the family.

Any tips for assessing a child’s injury?

Every injury presented must be consistent with the child’s medical history and developmental ability.  If it doesn’t line up, ask why.  It doesn’t mean there’s abuse occurring, but it does mean something’s going on that doesn’t make sense.

Our job is to consider the injury’s cause — medical, accidental and then nonaccidental trauma — as well as medical history and mechanics.  It’s not our job to immediately assume, if we don’t like how it looks, that somebody’s abused the child. We have to start with ruling out other options, especially with a nonverbal child.

In 30% to 40% of cases we see, we have to say we can’t determine if an injury was abuse or accidental, and we need to consider potential options for the injury.

How should I determine which tests are needed?

First, it’s important to know that exams have limits.  You can’t determine abuse simply by physical exam.  However, being financially responsible means to not shotgun and do every test available.

If you need to consult on a potential CPA case, my colleague Donald (Chris) C. Derauf, M.D., and I are available 24/7 every day for curbside consults at no cost.  We do 300 to 400 of these a year.  You may call us through the MATC to discuss what you’re seeing in a case, and we can advise on screening.  We are your resource and encourage people to call and bounce things off us.

How do I figure out who did it?

You and I don’t care.  It’s not our job.  Our primary role is to prove it’s not abuse and look at accidental injuries or other conditions that may have caused the injury.  Also, our job is not to rule out people who may have abused the child, or determine reason or intent — leave that to the legal system.

How can I help stop CPA?

If you can recognize CPA early through a sentinel event — a case where injuries in children nonmobile or under age 4 can’t be explained by a simple accident, such as significant bruising to the head or neck — you can make a difference.  For these children, consider the injury to be caused by someone.  Bruising in a nonmobile child should be a red flag if not immediately explained by multiple people.

Sentinel injuries, without witnessed accident, carry high risk of further injury or death.  According to an article by Sheets and others in the April 2013 issue of Pediatrics, 27% of kids who’ve been seen by a provider and demonstrated to have had a sentinel event will return with serious injuries or dead.

What’s my responsibility?

 These are critical steps for providers in potential CPA cases:

  • Identify other possible injury causes.
  • Recognize these things are serious.  Once considering CPA as a potential cause, you are a mandated reporter.  It doesn’t have to be proved, just suspected.  You can’t simply write in your notes that you’re concerned and not report.  You must contact child protective services about a safety plan and tell them why there’s concern.
  • Conduct testing in a timely manner; it’s important for safety and complete diagnosis.
  • Remember multiple types of abuse can coexist.  Do a complete exam for neglect; don’t just focus on a bruise.
  • Don’t send the family home until all test results come through, or the child potentially may be going into an unsafe environment.  While you’re doing your work, child protective services (CPS) will develop a safety plan.  We can’t send the family out until this plan is finished and documented by the physician.
  • Make a complete description of the injury, including photos.

Any suggested approach with the family if CPA is suspected?

Since it’s not our role to decide who did it, I usually use this approach and advise providers to consider it.  I say to the caregiver present: “With this type of injury, without a known medical problem causing it or a witnessed accident, I am concerned someone may have hurt your child.  Because of this, I am a mandated reporter and have already spoken with child protective services.  They will want to talk with you about safety plans for your child.  I also want to recommend some tests that may better tell us why the injury occurred and if there are other injuries present we cannot see on the exam.”

It’s important to help families understand that just because the child looks happy and OK, it doesn’t rule out other injuries.

Any pitfalls you’d suggest avoiding with CPA?

We fail to recognize our blinders.  If you’re homeless or a minority, statistics say CPA cases are overreported, according to a 2011 publication in Journal of the National Medical Association.  However, studies indicate if you’re white middle class and present with an infant to the emergency room, people don’t even think about abuse. Also, if we know members of the family personally, there’s a tendency to say, “They are nice people.  They wouldn’t do this.”

If we think there might be abuse, we need to get CPS involved, period.  Letting our biases influence who we report puts kids at risk.  Remember, reporting may help services be put in place to assist the family.

Which patients who’ve survived potential CPA need transfer for further work-up?

The work-up needs to be completed at the time the concern is raised.  Depending on the child’s age, it may include:

  • A dilated eye exam by an eye expert, to be completed within 48 hours
  • A skeletal survey immediately and again in two to three weeks
  • A head CT if under age 1 or obvious head trauma
  • Abdominal labs

If testing can’t be completed, transfer to a larger center is indicated.  If testing can be done and a safety plan put in place, the child may be evaluated at the local site only and be watched overnight or be sent home, depending on tests and exam.

Resource: MayoClinic.org
This publication can be seen HERE complete with links.

2nd Med Opinion, Child Abuse, False Accusation, Neglect, Physical Abuse, Shaken Baby Syndrome

FL Law Maker Likes TX Law Makers Decision

3 Comments
.jpg photo of Florida law maker concerned about misdiagnosis by medical professionals
Representative Anna Eskamani (D) of Orlando, Florida.

Florida parents wrongly accused of Child
Abuse by state experts is ‘shocking,’ says
lawmaker

TAMPA, FL  –  A Florida lawmaker believes the state’s medical experts on child abuse need more checks and balances after an I-team investigation revealed several pediatricians have made questionable calls against parents who appeared to have done everything right.

“Any position of authority that isn’t checked by something is concerning,” said Florida Democratic Representative Anna Eskamani of Orlando.  Eskamani was responding to our investigation that found several cases where child abuse pediatricians, who were hired to be the state’s experts on abuse, wrongly accused Florida parents of child abuse.

Child abuse pediatricians are a recent specialty medical field and hold enormous influence over whether a child’s medical condition is the result of abuse.  Their conclusions can also determine if a child needs to be removed from their parents. But court records show, these doctors don’t always make the right call causing children, often babies, to be removed from their parents for months unnecessarily.

Our investigation also found cases where doctors appeared to have come to far reaching conclusions without thorough investigations and, in other cases, where parents were arrested after a doctor’s conclusion of abuse.  In 2015, it happened to Jeremy Graham.

Graham, a firefighter and paramedic on Florida’s west coast, was arrested and charged with aggravated child abuse after a child abuse pediatrician determined his 4-month-old son’s seizure was caused by a brain bleed, the result of physical abuse, according to court records provided to us by Jeremy and his wife Vivianna.

About a month leading up to the seizure, the Grahams had visited several doctors because their son was vomiting and “wasn’t acting right,” said Vivianna.

After an 8-month fight, the state dropped its case against the Grahams over “insufficient evidence.”

Last year, Nydia Ortiz’s son and daughter-in-law were torn about from their newborn daughter after a child abuse pediatrician in Miami concluded their newborn daughter’s bruises were also the result of abuse.  Turns out, it was a rare genetic disorder.

It’s a problem impacting families around the country.

In Texas, recent media scrutiny has led some state lawmakers to consider introducing a bill next year that would require an independent second medical opinion in some cases before a child is separated from their parents.

“That system would provide the oversight and accountability that parents deserve in facing the potential of a false accusation of abuse,” said Eskamani.

Representative Eskamani believes the additional measure could make sense in Florida.  We found child abuse pediatricians who serve as medical directors of child protective teams in Florida often answer to no one and operate independently from region to region.

THE FLORIDA INVESTIGATIVE TEAM

Last summer, Vadim Kushnir and his wife found themselves on the defense after seeking help for their newborn son, who was having seizures.  A state child abuse pediatrician determined their newborn’s seizures were “the result of shaken baby or blunt force trauma,” according to court records.

“It took them two minutes of investigation to say we were abusers,” said Kushnir.

The Kushnirs fought back spending $30,000 on attorneys and experts who argued the baby’s condition resulted from a complicated birth not abuse.

The judge agreed and in the final order, even criticized the state’s doctors for not knowing their month old son wasn’t breathing at birth, the umbilical cord wrapped tightly around his neck.  One doctor who provided testimony admitted he “never reviewed all his medical records,” according to court records.

With the legislative session starting this week, Eskamani says it may be too late to file legislation here this session, but she vows to bring up the issue in Tallahassee and invites other families to share their stories with her of being torn apart and wrongly accused.

Contact Representative Eskamani

“The doctor was probably in the room with us less than 10 minutes,” said Vivianna Graham.  “It’s just sad,” added her husband Jeremy whose son, Tristan, is now a healthy 4-year-old.

The Florida Department of Health oversees child abuse pediatricians who serve as experts for the state.  According to an agency spokesperson, their top priority is the health and safety of children but says child protective teams are open to receiving input from others who are also involved in protecting the health and safety of Florida’s children.