Medical Issues

PIFLogoFeb2016The modern era of child protection essentially started in 1962, with the publication of Dr. C. Henry Kempe’s call to action, “The Battered Child Syndrome,” in the Journal of the American Medical Association. Within a decade, most states had passed child-abuse statutes that established social service organizations charged with removing children from abusive homes and required doctors, teachers, and other “mandated reporters” to report all cases of suspected abuse to the authorities. Doctors began establishing guidelines for how to identify abused children.

From the beginning, the guidelines tended to emphasize the “discrepant history,” that is, an explanation offered by the parents that doesn’t adequately explain a child’s injuries. If a parent reports that an infant rolled off a changing table, for example, but the child arrives at the hospital with broken bones and bruises in unlikely locations, the treating doctors conclude that the baby was beaten.

sealsSeattleInevitably, these decisions are subjective. Objective scientific research in the arena is almost impossible to conduct, because there is no way to know what happened before the child’s first medical contact. Much of the child abuse literature is based on observational studies, which begin with the sorting of cases by the child abuse experts into groups of “abused” and “non-abused” patients. The researchers then analyze the differences between the groups—with the result that the original sorting algorithm  appears to be validated by the study. See, for example, this 2000 paper by some of the leading authors in the field: http://archpedi.jamanetwork.com/article.aspx?articleid=348423

Early on, doctors adopted a number of guidelines that were never tested against reality. Spiral fractures, for example, were once considered a convincing sign of abuse, even though doctors generally agree that adults can suffer a spiral fracture from a fall, or any other trauma capable of breaking a bone, and recent research has revealed that spiral fractures are no more common in abused children than transverse fractures (see http://www.ncbi.nlm.nih.gov/pubmed/10906863, in which the authors note that “many practitioners think spiral fractures are pathognomonic of abuse”). Based on their own observations, child abuse doctors have also designated posterior rib fractures in infants as a sign of abuse, although recent research has shown that children can suffer posterior rib fractures from birth trauma (http://www.ncbi.nlm.nih.gov/pubmed/18941740).

Similarly, the “classic metaphyseal lesion”—a discontinuity at the edge of a bone’s growth plate—is often described in court as a sure sign of abuse, on the theory that the lesion is caused by twisting of the limbs during an assault, and is never produced by natural events. Recently, doctors looking at the bigger picture have noted that CMLs actually look a lot like some of the lesions seen in rickets, a condition that had become quite rare by the time the child-abuse doctors were establishing their guidelines (see http://www.ncbi.nlm.nih.gov/pubmed/24370143). And as various researchers have noted, rickets is now making a come-back, as North Americans tend to be deficient in vitamin D.

In the early 1970s, Dr. A. Norman Guthkelch in Britain and Dr. John Caffey in the U.S. proposed that children with subdural hematomas (bleeding in the lining of the brain) and retinal hemorrhages (bleeding at the backs of the eyes) but with no obvious signs of impact, might be the victims of abuse by shaking. This hypothesis was quickly adopted in the courtroom by way of expert opinion, without objective scientific support.

Though more rigorous procedures are now entering the equation, for several decades the child protection teams charged with evaluating abuse cases routinely concluded that the cluster of symptoms that defined shaken baby syndrome always proves abuse by shaking, without considering other causes. Some physicians, however, have looked further and found underlying conditions that can produce the same symptoms or predispositions to those symptoms. The list is long and growing, and there are likely others still unidentified.

Physicians also testified historically that children who were shaken collapsed immediately following the assault, so that the person last with the child could reliablly be identified as the perpetrator. This position has been shown to be false: Children who are abused or suffer accidental head injury react in widely varying ways, and their condition is not always obvious, even to experienced care providers.

Finally, there is the problem of short falls. Child abuse pediatricians have historically claimed that household falls cannot cause the findings commonly attributed to shaking. Report of falls from high chairs, changing tables, the arms of parents—even falls down stairs—were historically rejected in favor of a diagnosis of abuse, even when the falls were witnessed by others. The American Academy of Pediatrics no longer takes this position, although some physicians still testify to it in court.

Unfortunately, all of this research and experience has taken place in the context of the courtroom. Child abuse doctors have become accustomed to defending their opinions in court, against the opinions of doctors for the defense. The result is that the two sides do not communicate as colleagues looking together for the truth, but as bitter enemies. Allied with the prosecution, the child abuse experts are in the habit of rejecting the explanations offered by doctors outside of their own specialty, and continuing to accept what they’d been taught by their teachers and what they’ve observed in their own clinical experience. After seeing their honest opinions confirmed by legal outcome, they believe that shaken baby syndrome has been proven, that fractures in an infant too young to walk prove abuse, and that their critics are either incompetent or cynical opportunists hired by the defense to get guilty parents and caretakers off the hook.

This way of thinking will not help children or families. We need an objective organization to take a careful look at the lack of science behind the opinions that are still sending accused people to prison. Among our other activities, we are calling for a review of the scientific basis for diagnoses of child abuse by the National Academy of Sciences, which in 2009 produced an influential report (http://www.nap.edu/openbook.php?record_id=12589&page=1) about forensic science in the courtroom.

11 thoughts on “Medical Issues

  1. Denise

    I need help, my daughter has been taken from me and really, her father and I, have been accused of injuring my child’s brain she was 3 months old when she was taken she is now two and a half and a jury trial is coming up July 22nd because they are terminating our rights. Please no one hurt don’t worry child. please email me with any links or anything that can help. I can explain more in detail. I am so desperate…

    Reply
  2. Kenzey Kane

    Hello,

    I need some help or advice. Me and my partner at the time were accused of non accidental injury. We’re both adamant a year after my daughter became unwell that we did not cause her symptoms.

    I’m from the UK. I know your based in America but I’m looking for independent medical experts to look at mine and my family’s medical history and also the weeks and days leading up to my daughter becoming seriously un well.

    Please help if you can.

    Reply
      1. G

        This person was convicted and sentenced to three and a half years in prison. Her partner received 18 years!

    1. Charlene mcgowan

      Just watched your programme .my daughter went through a similar thing but it was her ex partner accusing her and it was all lies. They made her out to be a monster.
      Watching the programme was so similar.
      Her ex partner got custody and he was the abusive partner it’s unbelievable.
      His mother is schizophrenic, he is abusive, his brother has a temper and they all live in the same house as my precious grandson.
      Like you, my daughter found she was pregnant but sadly lost the baby but god forbid maybe it was for the best as she also would of had the baby taken from her.
      I’m so sorry for you and your children

      Reply
  3. unpomamma

    Hello,
    We need help, a medical consulting. Our beautiful and lovely daughter was only 40 days when she gone in disease: she is never ever fall down or injured the head, but the symptoms are the same of the AHT so there seems that no one would research another possible reason. Our parental rights are suspended and our daughter is in another family, and she’s now becoming 6 months aged. We’re really scared and worried about her health situation. Thank you for the attention: we just need to feel that we’re not alone in this nightmare.

    Reply
  4. Debbi Carlson

    My Goddaughter’s son wasn’t eating and had a fever. She took him to the doctor, at the office he had a seizure. He was rushed to the hospital and they were told he might not make it through the night. His skull was fractured. Because he was only one month old it was ruled a non-accidental injury. CPS came and took their two-year-old son. They are recommending non-reunification because they cannot say how the baby was injured, Where does she start to fight this? It seems like you are damn if do and damned if you don’t. Any guidance you can provide would be greatly appreciated, Thank you for what you are doing.

    Reply
    1. Sue Luttner Post author

      Please accept my condolences to your family. I do hope the baby is recovering well.

      Your Goddaughter needs a complete set of medical records so her attorney can find a doctor to figure out what is really going on.

      I have sent you a private email with a checklist and some resources. I hope both children can return soon to the people who love them.

      Reply

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