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How Did This Happen?

Vanderbilt’s CARE Committee objectively evaluates victims of suspected child abuse and neglect

By John Howser
February 2012

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They arrive broken and battered with injuries so obvious there can be little question for the origin. At other times, however, victims of abuse and neglect treated at the Monroe Carell Jr. Children’s Hospital at Vanderbilt arrive with symptoms so subtle the hospital’s highly experienced team of clinical and legal experts must solve a forensic puzzle to clearly identify sophisticated efforts to conceal the damage done by abusers.

In those instances the CARE Committee, a team of physicians, nurse practitioners, social workers and lawyers come together to evaluate physical evidence and statements from parents or caregivers about a child’s injuries when abuse or neglect is suspected.

Children’s Hospital, along with other services such as Vanderbilt’s Regional Burn Center, treats more than 500 incidents of suspected child abuse and neglect each year. During the past five years Vanderbilt has examined 2,849 cases that were reported to Tennessee’s Department of Children’s Services (DCS) and local law enforcement agencies.

Because Vanderbilt is a tertiary referral center, suspected cases of child abuse and neglect are referred from throughout Middle Tennessee and Southern Kentucky.

Child abuse is a medical diagnosis, with its own International Statistical Classification of Disease and Related Health Problems (ICD-9) code; however, it is also a legal finding to be determined by DCS or the court system.

The CARE Committee reviews cases of children who present with questionable physical injuries such as atypical fractures, concussion, cerebral hemorrhage, retinal bleeding, burns, bruises and contusions. The committee also evaluates instances of medical neglect.

At Vanderbilt there have also been highly deceptive cases of child abuse involving poisons or misuse of medications by parents and guardians.
Child neglect assumes many forms: withholding essential medications, especially in chronic illnesses; missing necessary medical appointments; and feeding or nutritional neglect. Exposure to illicit drugs during pregnancy is also a form of neglect and these cases are reported after the baby is born.

Deborah Lowen, M.D., associate professor of Pediatrics and director of Child Abuse Pediatrics, joined Vanderbilt in 2010. A passionate advocate with subspecialty training to detect the signs and symptoms of abuse, she is more than up to the task.

Social worker Mary Murray, left, and Deborah Lowen, M.D., partner to assess each case of suspected abuse. Photo by Joe Howell.

Social worker Mary Murray, left, and Deborah Lowen, M.D., partner to assess each case of suspected abuse. Photo by Joe Howell.

“My primary role is to perform clinical evaluations of children when there are concerns about possible abuse or neglect. With this responsibility comes an obligation and a necessity to liaison and interact with community responders such as the Department of Children’s Services, law enforcement and the prosecutor’s office,” she said.

Along with direct clinical responsibilities, Lowen is also responsible for educating faculty, colleagues, residents, medical students and other caregivers within Children’s Hospital, as well as members of the law enforcement community, about the signs and symptoms of child abuse and neglect and how to respond appropriately.

“This is a big problem. You just can’t put your head in the sand,” she said.

A Significant Public Health Problem

When suspected child abuse presents, Lowen is contacted for consultation. Every case she sees is taken before the CARE Committee for discussion.

“I tell parents the reason I’m there is that I am called upon to examine children when they have unusual injuries. I will perform a thorough physical evaluation of the child, frequently in the presence of the parent or caregiver, where I am also asking them questions while performing the examination,” Lowen said.

“Then I’ll conduct a very in-depth, detailed evaluation of the child’s medical records, looking through all the records with a fine-toothed comb. I’m looking at such factors as what the parents said to the staff at another hospital if the child was transferred here, what they said at the time the child presented, what was the child’s condition at that point. I also look at all the imaging studies. If necessary, I will again talk to the family to get a thorough history about the child, everything I can find out.”

Through this very detailed process a complete family, medical and social
history takes shape that helps make a determination regarding the child’s current circumstances.

“These lengthy conversations with the family so that I can obtain a history might take anywhere from 20 minutes to an hour-and-a-half depending on how many caregivers there are, how many injuries a child may have and other circumstances,” she said.

Lowen conducts these evaluations in close concert with social workers. If there is reason to suspect abuse she is bound by Tennessee law to report the findings to the DCS, and also to law enforcement.

The state of Tennessee mandates only one person suspect abuse before reporting is required.

“Only after we have gathered all the information and put the data together do we arrive at a conclusion. Sometimes the investigative authorities don’t like it when we don’t make a determination right away. I will push back if necessary and say that I am not going to give a determination I am uncomfortable with because I am well aware of the ramifications. I tend to be very conservative on calling abuse,” she said.

Children Most at Risk

Child abuse may involve repeated acts over time, called battered child syndrome, or may involve a single, impulsive incident. With child neglect, injury or death can occur from a caregiver’s failure to act.

According to the Department of Health and Human Services, children younger than 1 year died from child abuse and neglect at a rate of 17.89 per 100,000. Nearly 80 percent of child fatalities due to abuse or neglect were caused by one or more parents. Thirty percent of fatalities were perpetrated by the child’s mother acting alone and one-fifth of child fatali­ties were caused by both parents. Perpetrators without a parental relationship to the child accounted for 12.5 percent of fatalities.

“Some people take out their frustrations on their kids,” Lowen said. “And occasionally there are caregivers who abuse children simply because they’re mean. Those are the rare cases, but I’ve seen them. But in most cases what we see is a caregiver taking out their frustrations on the child.”
An indicator for intentionally inflicted injury may be a parent or caregiver delaying medical intervention. Other indicators may include a changing history from the parent or caregiver for how an injury occurred; a stated history of the child’s injury not matching the injury’s pattern; or a caregiver reporting a child did something to cause an injury they’re not able to do from a developmental age.

Lowen says burns to the buttocks and genitals of toddlers are a frequent response to parental frustration over toileting accidents, while school-age children present with injuries after being beaten with belts or electrical cords for poor grades.

Devastating Injuries Through Intentional Burns

“There is an intentional form of child abuse that involves burning,” said Jeff Guy, M.D., associate professor of Surgery and director of the Vanderbilt Regional Burn Center. “It’s not as common a form of child abuse as beating children, but it’s still pretty common.”

Jeff Guy, M.D., estimates 20 percent of children treated in the Vanderbilt Regional Burn Center are victims of abuse. Photo by Joe Howell.

Jeff Guy, M.D., estimates 20 percent of children treated in the Vanderbilt Regional Burn Center are victims of abuse. Photo by Joe Howell.

As the only resource of its kind in Tennessee, the Burn Center treats children from throughout the region. Guy estimates as many as 20 percent of the children treated in the Burn Center are victims of some form of abuse.

“There are patterns for burns we can look at and determine with significant certainty the injuries were intentionally inflicted,” he said. “My obligation is to the child and not to the parent. So sometimes it can get contentious when we say we have some unanswered questions because the story they’re telling us doesn’t fit the pattern of the injuries.”
Guy says each instance of a suspected intentional burn must be objectively evaluated.

“Intentional scalding is the most common burn we see. It’s usually centered around toilet training with children who are less than 3 years old,” he said. “A lot of these are immersion burns. Some of these pattern injuries are easy to identify based on the injuries themselves or where they occur. It’s not uncommon for children to assume a defensive position when being burned so the pattern of injury will indicate their posture.”

Work with intentionally burned children is emotionally wrenching.

“These children touch everyone’s lives,” Guy said. “It’s bad when you receive an injured child to treat. It really sets everyone on edge. However, when you have an abused child to treat it really tears at you.”

Reporting Child Abuse

Tennessee’s aggressive statute, Tenn. Code § 37-1-403, was created to address the frequency of child abuse and to encourage reporting. The statute has two emphases. First, all citizens, including health care workers, are required to report suspected child abuse. Second, persons who report in good faith are immune from civil and criminal liability for reporting.

Despite years of experience, Julia Morris, J.D., deputy general counsel for the University, is still unnerved by the types of abuse injuries she sees. Photo by Joe Howell.

Despite years of experience, Julia Morris, J.D., deputy general counsel for the University, is still unnerved by the types of abuse injuries she sees. Photo by Joe Howell.

“One thing we always have to keep in mind is that while we collect a lot of information that may support suspicions of abuse or neglect, we’re not the investigating arm. We want to leave this work for investigating agencies to perform,” said Julia Morris, J.D., deputy general counsel in the University’s Office of General Counsel.

Reporting suspected child abuse or neglect is a medical judgment, but within a legal context.

Once reporting has occurred, myriad issues must be addressed such as who can visit, who can continue to receive information about the child and who will interface with DCS and law enforcement.

“After a child has been placed in DCS custody when severe abuse or neglect has been determined, we may be dealing with end-of-life issues, which can become very difficult because DCS will not take a position on the removal of life support,” Morris said. “There may be a court-appointed guardian who will perform a thorough evaluation and make the determination to discontinue support.”

Multiple instances have occurred at Children’s Hospital when an abuser sought to block removal of life support because criminal charges would be elevated from assault to manslaughter or murder.

“Unless parental rights have been terminated, it can be difficult for physicians and staff when parents suspected of the abuse still have authority to make medical decisions,” she said.

Morris has been involved in thousands of cases of child abuse but is still unnerved by some of the things she sees. “Seeing photos of injuries, particularly those which take real intent, I’m always shocked,” she said. “This is the saddest part of my job, especially when a child dies in one of these cases.”

The Role of Social Workers

Mary Murray, director of Social Work for Children’s Hospital, has been with Vanderbilt more than 30 years. Her team is always involved in cases of acute abuse, general abuse and neglect. Social workers perform their responsibilities in concert with other members of the health care team, partnering to conduct a thorough assessment in each case of suspected abuse.

“Once a determination has been made, a report needs to be made to the state. The social worker will be the one who fulfills this responsibility on behalf of the whole team,” Murray said. “We never act alone.”
Response from DCS is addressed by a codified system with the most serious cases receiving more immediate attention.

“DCS will take our report and determine whether the situation is acute, where the situation is life-threatening, whether it can wait a few hours, a day or seven days,” she said.

Murray says she and her team approach each situation objectively.
“Due to our training we start with each person at the same place and are nonjudgmental on every approach we take,” she said. “We are able to continue to do this difficult work over time because we maintain this stance. It really is possible to continue to do this work because you learn through the years that circumstances vary so much from case to case.”
Murray says when family members or caregivers are suspected of abusing their child and confronted, they can become confrontational or sad.

“Some family members who work in professions where children are involved, such as the school system, say they expect questions about possible abuse or neglect. However, those who are otherwise not familiar can be very upset and react quite negatively. Typical reactions can be predicted. ‘Should I get a lawyer? I can’t believe you would think this about me. I didn’t do anything to hurt my child,’” Murray said. “Or they may start proposing alternating versions of the events that led to the injuries.”

Parents or caregivers are almost always told when suspected abuse or neglect is going to be reported to DCS.

Murray has been involved with thousands of child abuse cases, yet says her mentors have helped her and her team continue to maintain a high level of caring and enthusiasm for what is perhaps the hardest part of their work.

“It’s an important job to do, and to make sure the families are handled correctly. We don’t want the families to feel like they are judged. We realize that every piece of this is about treating everybody with dignity and as best as we can,” she said.

“A big part of our assessment is to identify risk to make sure the children are safe. So you know that every day you are working toward helping children be safe. That’s a pretty good way to spend your day.”



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