Jennifer Stokes had a problem. Earlier in the day, a pediatrician outside Springfield called her child advocacy center about a 3-year-old girl in his office who had vaginal bruising and bleeding. The child’s caregivers claimed she fell on a piece of gym equipment; the girl said that wasn’t what happened, but would not say what did. The doctor didn’t know what to do. It looked like a case of child abuse, but how could he know for sure? What happened next could carry huge implications for the child’s treatment and for her protection–not to mention legal proceedings, perhaps even criminal prosecution, for those who brought her to the doctor in the first place. All that would depend on somebody being able to diagnose and document–accurately, if not unimpeachably–child abuse. And to do it right now. Unfortunately, there was only one doctor in all of western Massachusetts qualified to do that. And he wasn’t in his office.
Dr. John Dallenbach of Pittsfield is the de facto medical expert on every child-abuse team west of the Quabbin Reservoir, and that’s in addition to his regular pediatric practice. Baystate Medical Center, in Springfield, once had two doctors with expertise in child abuse, but one left, and the resulting overload of cases drove the other out as well.
In the rest of the state, the situation is not much better. UMass Memorial Medical Center in Worcester has one child-abuse expert on staff, hired last year after a prolonged search, and that’s it for central Massachusetts. Even the medical hub of the universe, as Boston likes to think of itself, has just three. This in a state with 29,633 substantiated or “likely” cases of child abuse and neglect in 1999.
A report published earlier this year by the Institute of Medicine and the National Research Council of the National Academy of Sciences characterizes the condition of family-violence training for health professionals as “chronic neglect.” Few here would quarrel with that assessment. The Northeast in general is short of these medical specialists, according to Dr. Betty Spivak, a forensic pediatric consultant for the medical examiner division of the Kentucky Justice Cabinet. Spivak recently flew into Boston to testify at a murder trial–not the first time prosecutors have had to import such expertise on child homicide cases, admits David Deakin, a Suffolk County assistant district attorney.
Still, not long ago Massachusetts led the field, with such nationally recognized experts as Dr. Bob Reece, director of the child-abuse referral and evaluation clinic at the New England Medical Center’s Floating Hospital for Children in Boston, and Dr. Eli Newberger, founder of the child protection team at Children’s Hospital in Boston. But the Bay State’s stature–and diagnostic capability–has slipped. Newberger has left the field, in part because he was burned out by its rigors and its controversies, and Reece is approaching retirement. No homegrown talent is in the pipeline. When UMass looked to replace its retiring expert, pediatrician Ed Bailey, its two top candidates were out-of-staters, both of whom declined to relocate. Pediatrician Gabriel Otterman was promoted to the position, but he has since left for private practice in Pittsfield and is not specializing in abuse cases.
Massachusetts is among the most aggressive of the 50 states when it comes to prosecuting the instances of child abuse that come to light. Prosecutors around the state have set up specialized units to bring those who hurt children to justice. But doing so requires evidence, and evidence has gotten harder to come by as the medical expertise for identifying the mistreatment of children has dwindled, a casualty of controversy, funding, and institutional resistance.
We would like to think that the Commonwealth cares for its children, but when it comes to abuse, the evidence suggests otherwise. The state, its hospitals, and its medical schools lag other states in funding, coordination, and training, and there is little disciplinary action when the medical community fails to detect and report abuse. “It’s a very important problem,” says Dr. Alan Ezekowitz, chief of pediatrics at Massachusetts General Hospital. But not one that’s given much importance. As a direct result, experts assert, abusers in the Bay State may get second, third, even fourth chances to harm the children in their care.
That’s what happened to Emily Harling. On May 31, 1998, her father, Eric Lizotte, slammed the 4-month-old’s head against an electric infant swing, threw her against a wall, shook her violently for 10 minutes, and finally dropped her from shoulder height onto the floor. Emily is permanently brain-damaged; Newberger, who saw her only when it was too late, becomes emotional when describing the vegetative state in which Emily will live her life.
The crime is self-evident. The tragedy is that on two occasions, hospital staff may have had the opportunity to prevent it. On May 5, 1998, Emily was admitted to Brockton Hospital, where she was treated for bruising on her abdomen, abdominal distention, and elevated liver function. A week later Emily was seen again, this time at Mass. General in Boston, with elevated liver function and a bruise near her eye. Both times, she was treated and released–without the hospital notifying the Department of Social Services, the state agency responsible for combating child abuse.
Lizotte, who confessed to beating his daughter, will spend five to 10 years in state prison. But attorney Ann Marie Maguire thinks the medical personnel who discharged Emily and sent her home for more beatings need to be held responsible as well. Maguire’s firm, Keches & Mallen of Taunton, has filed suit against four employees at Brockton Hospital and two at Mass. General.
The Harling case may be the first attempt in Massachusetts to sue for malpractice over a failure to report child abuse, and the Commonwealth’s Board of Registration in Medicine has yet to revoke a doctor’s license for failure to report abuse. The state almost never prosecutes physicians under its mandatory reporting law–the one the Legislature recently expanded to cover clergy–and if it did, the maximum penalty is a mere $1,000 fine. In California, in contrast, a physician who “knows or reasonably suspects”abuse but fails to report it can serve six months in jail. In Minnesota, a non-reporting doctor who “reasonably should know” about such mistreatment can get two years behind bars.
The hospitals that stand behind those physicians get off even easier. The maximum criminal fine for a Massachusetts institution that breaks the mandatory reporting law is the same paltry $1,000. And the Bay State’s unique $20,000 cap on civil liability for charitable institutions–defined, quite charitably, to include not-for-profit hospitals and HMOs–effectively immunizes them from litigation. Maguire, for example, has deliberately not named either hospital in the malpractice suit, because the cost of suing them would far exceed the possible reward.
“Hospitals have no incentive at all to protect the children,” says Leonard A. Simon, a Boston attorney who specializes in liability litigation. Incentive or not, this failure of medical practitioners to blow the whistle on child abuse is not unusual. Less than 10 percent of child-abuse cases are first reported by medical personnel, according to a 1999 US Department of Health and Human Services report.
Which is not to say there is no cause to do so. An expert would have immediately recognized Emily’s symptoms as abuse, according to Newberger, a pioneer in child-abuse detection. But neither hospital had a specialist on hand–not Mass. General, with all its prestige, and not Brockton Hospital, even though that city has the state’s fifth-highest rate of reported abuse. Without an abuse specialist to call on, emergency-room personnel are likely to believe a parent’s story, and see no reason to look further. “If the parent says the child fell off a changing table, they might do nothing, or they might just do a CAT scan,” says Dr. Andrea Vandeven, director of the child protection unit at Children’s Hospital in Boston.
That would not have been enough in the case Vandeven just had, a badly bruised 9-month-old who, according to the parent, fell out of a crib. The small hospital in central Massachusetts that initially treated the child did the wrong kind of X-ray. “They don’t have any pediatric radiologists,” she says. Several weeks later the Department of Social Services sent the child to Children’s Hospital. “We were able to do the appropriate tests and find a skull fracture,” which a fall from a crib would not cause, says Vandeven.
The location of a bruise, the type of burn mark, the nature of a head injury–these can all be signs of abuse as surely as spots on an X-ray may be signs of a tumor, experts say. But it takes practice to recognize them. A typical pediatrician won’t see more than a couple of cases a year, making it difficult to get a feel for diagnosing abuse, according to Dallenbach. In the absence of certainty, he says, the innocent explanation gets benefit of the doubt.
“I can’t tell you how many times I’ve talked to a pediatrician who has insisted that this was not an abuse injury,” says Dallenbach. “People just naturally don’t want to go there.”
Or they have nowhere to go. Berkshire County, for example, has only one video culposcope, a device for examining the vagina that is a key tool for collecting evidence of abuse. Not only must the patient come to the one site, but the county can’t afford to have an individual dedicated to its use, so there isn’t always someone who can perform the procedure. Many incidents may go undetected or get caught by chance, as with a 4-year-old girl who was recently treated for a urinary tract infection: The lab found semen in a urine sample.
How medical professionals deal with potential evidence on the examining table is crucial, says David Capeless, first assistant district attorney in Berkshire County. “The most serious cases deal with the youngest of all victims–infants,” says Capeless. “They are the most likely to be seriously injured, and the least able to speak for themselves.” On top of that, he says, “the evidence is the child,” and children will heal. “So you have to document [the abuse] at the time.”
likely to be seriously injured, and the least able
to speak for themselves.”
“A 3-month-old cannot be a witness, so you have to rely on the medical expert,” says Timothy Cruz, the district attorney in Plymouth County, where Eric Lizotte was prosecuted. In abuse prosecutions, nothing makes the same impression on a jury as an MD who has an expertise and history dealing with pediatric injuries, says Cruz.
That is, if you accept child abuse as a legitimate field of medical expertise–a concept that’s relatively new, and not universally accepted.
It was in 1962 that the first scholarly paper detailed the signs and symptoms of what was then called “the battered child.” That article, by C. Henry Kempe in the Journal of the American Medical Association, asserted that certain fractures, bruises, and forms of internal bleeding could only be caused by abuse at the hands of an adult. For the medical profession, it was a wake-up call.
“People started asking themselves, have we been missing this?” says the Floating Hospital’s Bob Reece. “We began to take a new look at the issue of injuries in children.” By the 1970s, state law mandated that medical professionals, as well as teachers, report suspected abuse to the state’s child protection services. Doctors did so, though perhaps with more zeal than precision. “For a while we were probably over-reporting,” Reece allows. “Then the backlash began.” Accused families and defense attorneys became more aggressive in their attacks on physicians’ credibility. “This forced us to do what we should have done earlier, which is develop a science,” Reece says.
The American Academy of Pediatrics launched its section on child abuse and neglect in 1990, with Reece and Newberger among its leading lights. The subspecialty has since become among the AAP’s largest, with 550 members. Protocols were developed for the initial treatment of suspected child abuse, with doctors acting as evidence collectors.
But it hasn’t been easy to make a science out of this medical detective work. Diagnosis of child abuse is virtually unique in medicine, in that the doctor is likely to be lied to. Nobody makes up a story to excuse their abdominal ailment, but they will explain away a child’s suspicious bruise. “You couldn’t believe the complexity [of the] deception we’ve heard,” says Mass. General’s Alan Ezekowitz.
Deception aside, not everyone believes the signs of mistreatment are cut-and-dried. A diagnosis of abuse gets held up to a different kind of scrutiny. In medicine, the ultimate authority is usually the doctor–tempered, perhaps, by a second or even third opinion. In the sexual or physical abuse of a child, however, the ultimate authorities may be judge and jury.
“We [have] to be sure that when a child is brought into the hospital that everything is done to check the other possibilities that will be asked [about] in court,” says Reece. Take a child who shows up with multiple fractures, and whose parent tells a story that seems transparently false. “Well, we know it’s abuse,” says Reece. “But we also know that somebody is going to ask whether we had checked for osteogenesis imperfecta,” a bone-weakening condition.
Eli Newberger’s hairline is receding, and he became a grandfather four years ago, but he demonstrates no shortage of energy. He writes, appears on talk shows, kayaks, performs with a jazz band as a tuba player, and has his own Web site (www.elinewberger.com).
Clearly, the 61-year-old Newberger did not have to retire at the end of 1999. But that’s what he did. The burnout factors that work upon child-abuse specialists came crashing down on him in 1997. And they did so in Court TV fashion, when nanny Louise Woodward faced trial for the murder of 8-month-old Matthew Eappen.
the Louise Woodward trial.
In that trial, the medical profession’s child-abuse expertise was judged as harshly as was the British au pair. And Newberger became the public face of Shaken Baby Syndrome.
Newberger testified that “the [Eappen] child was violently shaken for a prolonged period” of roughly 60 seconds, followed by “severe traumatic impact against a hard surface.” Newberger rejected the defense’s theory that the infant could have sustained the injuries many days, or perhaps weeks, earlier. But for hour after televised hour, the defense attacked him. They assaulted his credentials, they pilloried his diagnosis, and they rebutted him with an array of doctors.
In the end, Newberger and his diagnosis were exonerated, after a fashion. The jury found Woodward guilty of second-degree murder, which carried a life sentence. Judge Hiller Zobel reduced the conviction to manslaughter and sentenced her to time served, freeing her to return to her native England.
Shortly thereafter, Newberger left the child-abuse field. He had other interests to pursue, including child development, which resulted in the bookThe Men They Will Become, a tome on the nature of raising boys. But the Woodward trial put him off the child-abuse track.
“That was a remarkable and chastening experience,” Newberger says. “I was named as part of a junk science.”
Had the Eappen baby died a day earlier or a day later, Andrea Vandeven would have been the abuse specialist on call, and possibly the professional casualty. “That probably would have ended my career, trundling up to the stand like Eli did,” says Vandeven.
Vandeven dodged the Eappen case, but she has had others. This past winter she testified in a shaken-baby case that had the Department of Social Services trying to take a child away from its parents. Vandeven testified that the child had been severely shaken. Serving as the sole expert, she presented findings from neurologists, eye doctors, orthopedists, and others at Children’s Hospital–a precaution against defense attorneys tearing witnesses apart one by one.
The defense brought in a half-dozen experts from across the country to dispute her diagnosis–and grilled Vandeven on the stand for three days. “It was awful,” she recalls. “All you need is one case where you get tortured in court and you start wondering why you’re doing this.”
Why, indeed. The court appearances are hardly the only things leading to burnout, however. Dallenbach recalls fearing for his family when an irate mother called him at home to scream at him. “If a person is violent to a child, they could be violent to a physician,” he says.
The prospect of violence notwithstanding, the biggest barrier to increasing the number of specialists is, not surprisingly, money. Private insurance rarely reimburses for child-abuse consultations and never pays for the specialist’s time in legal proceedings. “Medical insurance programs will find any way to not pay for child-abuse evaluations,” says Spivak of the Kentucky medical examiner’s office.
As a result, the state is almost always the payer, usually through a flat fee per patient. That funding varies widely from state to state. Some states pay $300 to $350 per evaluation, says Spivak; others cough up as much as $1,000. Massachusetts pays $50 per case.
Even in Kentucky, which provides $375 for an evaluation, Spivak used to work one-third of her time in an intensive care unit to justify her salary. Recently, the state created a salaried position in the medical examiner’s office to determine the causes of children’s injuries, fatal and nonfatal. Now, she says, “I don’t have to worry about generating my income.”
A few states, notably Florida and North Carolina, have created interdisciplinary teams to investigate child abuse. Florida has seven such teams, with the salaries of lead doctors paid by the state. “That’s a model for what Massachusetts could do,” says Newberger. A bill sponsored by state Sen. Susan Tucker of Andover would establish regional evaluation centers for the sexual abuse of children.
Newberger admits that, for hospitals, child-abuse units are money-losers. Much of the work, especially time in court, is not billable. The lab tests–for sexually transmitted diseases, bacterial infection, or HIV–are often not reimbursable by third-party payers. But hospitals in Boston support other money-draining units, such as organ transplantation, covering their costs in part with income from these institutions’ large endowments, he says; they could do the same with child abuse. The Massachusetts Medical Society is looking into the issue now, but so far it has made no statement on how to support child-abuse clinics.
Just south of the Massachusetts border, in Providence, RI, Dr. Carol Jennings has a fellowship, thanks to Hasbro, the toy maker, which also pays for three internships. The only similar fellowship in Massachusetts (at Children’s Hospital) has been discontinued. “Around here, they’re not interested in this,” says Reece.
One exception is Mass. General, which developed an around-the-clock consulting team, led by child-abuse specialist Alice Newton, three years ago. “It’s a luxury we can afford to do because the hospital has given us the money to fund this,” says Ezekowitz. Given the fiscal pressures in health care today, however, Ezekowitz doubts that other hospitals will follow suit–and he even wonders how long Mass. General can continue to support the team.
That pessimism comes, in part, because research grants –which bestow not only bucks but also prestige in the world of academic medicine–are in short supply in this field. “If you look at the kinds of people that Harvard hires and promotes,” says Spivak, “they want people who have done a great deal of research, who have federal grants that they can bring to Harvard. That pipeline [of federal funding] does not exist for child abuse at this time.”
At Children’s Hospital, Newberger had a grant from the National Institute of Mental Health (which paid for training Vandeven, among others), but that spigot has since been shut off. “There are precious few research dollars available for research on child abuse,” he says.
For now, the state makes do with a handful of specialists, who cannot possibly see every questionable case. So most pediatricians and emergency-room doctors will need to make the diagnosis themselves. And they can–up to a point. “About 10 percent of the cases are real easy [diagnoses of abuse], 10 percent are clearly accidental, and the rest are murky,” says Reece.
It’s the murky ones that pose the risk of missing the diagnosis–and putting the child in continued danger. And there’s plenty of reason for pediatricians to err on the side of potentially abusive parents. “If you’re wrong, the downside is significant,” says Ezekowitz. “You break the relationship with the child and the family. You burn that bridge.”
Which is why advocates like Reece say pediatricians should view abuse as a medical subspecialty–and make a referral rather than a snap judgment. But many doctors who would not hesitate to refer a patient to a pediatric oncologist rather than rely on their own expertise won’t acknowledge that there is much about abuse they don’t know. Experts say that’s wrong. “There’s a huge literature now,” says Reece. Indeed, a new 450-page textbook on medical diagnosis and management of child abuse has just been published. “There is a lot of knowledge that is unique to the field.”
But this knowledge has not spread to the entire profession. “We put an obligation on every physician and nurse to report [abuse],” says prosecutor Capeless, “but don’t require them to be trained to do it.” Only two states, Iowa and New York, require doctors and nurses to receive continuing education on child abuse. Spivak notes that two years ago California began funding a program that trains physicians all over the state in diagnosing physical abuse. Here, there is only Reece–recently slowed down by hip surgery–who travels the Bay State and trains pediatricians, emergency-room doctors, physicians’ assistants, and nurses how to spot, and rule out, abuse.
And then there is another problem: Physicians aren’t exactly flocking to this kind of training. When Vandeven put together a project to train physicians at community health centers–often the front line for spotting abuse–“the interest from physicians was just about zero,” she says.
Sometimes it takes tragedy to force the issue. The East Boston Neighborhood Health Center brought Reece in for a series of presentations, but only after the staff failed to intercede in the case of 4-month-old Christina Andrews. In 1993, the health center staff treated Christina for injuries without identifying them as signs of abuse–until finally she came in beaten nearly to death. Her parents, Anna Maria Turavani and Michael Andrews, were convicted and sent to prison, but too late to save Christina, who is in a permanent vegetative state.
But not everyone thinks training is the answer. A little learning can be a dangerous thing, warns Janet Fine, executive director of the Massachusetts Office for Victims’ Assistance and founder of the Suffolk County Child Advocacy Center. “I would really be concerned about these people thinking they are experts,” she says. “They are not going to see the number of cases [necessary] to really understand the nuances.”
And the training is clearly no panacea: Reece gave a full-day presentation and short follow-up session at Brockton Hospital in the spring of 1997–12 months before physicians there missed the diagnosis of Emily Harling.
What pediatricians really want, Vandeven says, is not training but a hotline they can call to get questions answered and a specialist to see the child immediately. The state requires medical facilities to have a consultant available, but usually that means having someone like Dallenbach in the Rolodex–someone with a full practice who takes abuse referrals on the side. With only a handful of specialists in the entire state, child advocacy centers must make quick decisions about which kids need to be seen immediately and which can wait. Those who wait can end up waiting weeks, even months.
Fine sees a better solution in the use of cross-disciplinary teams, which have been successful with regard to sexual abuse, prosecuting abusers and supporting victims, but which are just recently being formed on physical abuse. In these new teams, medical specialists will have to take on a more central role. (Such teams have been formed in Suffolk and Middlesex counties under the district attorney’s office, with similar programs under development in Norfolk, Plymouth, and Franklin-Hampshire. Hampden County has a hospital-based unit, while Berkshire County and Cape Cod prefer freestanding operations.) With most sexual-abuse cases, Fine points out, the victim is reporting incidents in the past, so there is rarely physical evidence, and less often immediate concern for the danger of the individual.
What Vandeven and others in the state want is a network of eight well-staffed regional centers statewide. Tucker’s bill would copy the ambitious system established in Florida, which not only centralizes and coordinates evaluation and treatment, but also provides training for medical students. Unfortunately, even this model system has bogged down under its own weight: Florida’s Department of Children and Families has revealed that the system has a backlog of more than 30,000 cases waiting to be investigated.
Until the Commonwealth finds a way to provide for the medical diagnosis of abuse and nurture the development of diagnostic expertise, the safety of children will depend on the efforts of a small, and shrinking, band of specialists who labor in a field that gets little support from their institutions and little respect in their profession. “I’ve had professional colleagues call me a glorified social worker,” says Vandeven. “And people act like you’re in the child-abuse racket.”
David S. Bernstein is a freelance writer in Watertown.