No one wants to see a child harmed, whether the bad actor is a parent or another adult. However, some families unjustly accused of child abuse, as well as family rights advocates, argue that the system is biased too far in the direction of suspicion and doesn’t demand enough proof before separating parents from their children – particularly when it comes to the relatively new accusation of “medical child abuse.”

Chronic or complex medical conditions afflicting children, mandatory child abuse screening as part of the pediatric hospital admissions process, and deference shown by courts and other physicians to child abuse pediatricians can combine to tear apart families where no wrongdoing has occurred.

This is the second article in a three-part series delving into the concept of medical child abuse and how it affects families challenged with unusual medical conditions. In this series, we share the perspectives of affected families, family rights attorneys and legal scholars to illuminate this dark corner of the child protection system and point a way toward the better future that is possible.

The first piece in this series told the story of a local couple separated from their children for months when they were accused of medical child abuse (MCA). Today’s article tells the story of another family, as well as pointing to biases toward suspicion that have become embedded in the child protection system – a system which reaches into hospitals, unnoticed until it harms families.

One family’s

separation story

Hospital staff are trained to recognize “red flags” for medical child abuse; however, these “symptoms” are not limited to mentally ill or abusive parents, and may manifest themselves in parents coping with a child’s complex medical condition. According to a 2019–2020 series of investigative reports written by Mike Hixenbaugh and Keri Blakinger and co-published by NBC News and the Houston Chronicle, “Doctors who suspect medical child abuse look for a mother who (among other things) is unwilling to leave a sick child’s side” and “is fluent in medical terminology.”

Hospitals also look for moms who seek multiple providers for their kids, the underlying assumption being that parents are diagnosis-shopping. Families may need to visit multiple doctors, however, to find a specialist with experience in their children’s areas of illness.

Patti Krueger was just such a mother when the Dept. of Children and Family Services (DCFS) of Illinois took her three children away for more than a year. Patti gave birth to her second son – we’ll call him “Billy” – prematurely after a difficult pregnancy. Billy was in respiratory distress at birth and was diagnosed with several other conditions during his infancy. Seeking treatments for Billy’s numerous health problems, as well as working within the subset of medical practices that accept Medicaid, Patti and her husband Jacob took Billy to several different doctors, including some outside Illinois.

Before Billy was a year old, DCFS began investigating the Kruegers in response to an anonymous tip accusing the parents of medical child abuse. Although state law limits DCFS investigations to 60 days, with the possibility of a 30-day extension for “good cause shown,” the agency investigated the Kruegers for 17 months.

At the end of the investigation, having observed no harmful behavior on the part of Billy’s parents, and not having received any formal report of medical child abuse from the child abuse pediatrician (CAP) working with DCFS, a DCFS employee told the Kruegers that their case would be closed out as “unfounded.”

A few days later, Billy developed a respiratory illness and was treated multiple times over the next two weeks in two different hospitals and at his primary care physician’s office. During a hospitalization two weeks after he became ill, he was moved to a room where cameras recorded everything. No one told his parents, but the CAP who had initially evaluated Billy’s medical records had requested the change to monitor the family.

When the CAP introduced herself as part of the medical team involved in planning Billy’s discharge from the hospital, Billy’s father was alarmed, and said he did not want the CAP involved. A short time later, the CAP called DCFS to report that she had made an investigative finding of MCA; within a few days, she would file a report that, unlike her previous report, said that she had determined that Billy was a victim of MCA.

Within the next few days, Billy was taken away from his parents, followed by his older brother, “Adam” – who was allegedly at risk, despite no prior suggestion that he suffered from MCA or any type of abuse at the hands of his parents. When Billy’s younger brother “Charlie” was born four and a half months later, he was taken away from his parents almost immediately.

None of the children returned home until mid-2020, when Patti and Jacob were exonerated of any wrongdoing by a Macon County Juvenile Court. Their time apart amounted to a separation of 465 days for Adam, 467 days for Billy and 330 days for Charlie.

The breakup of the family was devastating at the time, and continues to cause pain.

“After these allegations,” Patti explains, “our lives will never be the same. I have a son who, when he goes to a doctor’s appointment, panics that he’s going to be taken. I have a 6-year-old who cries if he hasn’t been warned that a pizza man is coming – that knock on the door gives him anxiety because he thinks someone is coming to take him. It’s traumatic for parents, but for the kids, that is almost abuse. It is abuse, what they’ve done emotionally to these kids.”

Years into the future, Charlie will be affected too.

“They took our baby at 4 hours old, and we got him back three weeks before his first birthday. We always talk like, what’s going to happen when he’s older and he’s asking for pictures – we have videos of the first two of their first steps, and first crawling… we don’t have any of that for him.”

During the ordeal, Patti says, she was stunned by the lack of a speedy resolution in her and her husband’s favor.

“You just think, ‘I’m a good mom, I’m doing the right thing,’” she says, “and when you get accused, you think, ‘This will be over soon.’ […] It didn’t work that way.”

Shift toward screening every child may result in false positives

Although Patti’s story is not a common one, it is becoming more common-and many families are potentially vulnerable to a similar confrontation with the system. The number of children in America who suffer from chronic conditions, including complex chronic conditions, is not small. CDC data from 2019 show that 4.8 percent of children ages 5 through 17 missed 11 or more school days in the prior 12 months due to illness, injury, or disability. The same source indicates that 2.7 percent of children under 18 were considered to have “fair” or “poor” health status.

Children with complex or chronic medical conditions may receive care from various kinds of specialists. A CAP working for a hospital, however, sees only a snapshot of the child’s health; isn’t trained in specialties like pulmonology, gastroenterology or cardiology; and typically chooses not to confer with the child’s other medical care providers.

Child abuse pediatrics did not exist as an official subspecialty until roughly 2009, when the American Board of Pediatrics began its certification process. Now, however, CAPs are often working at hospitals, where, more than ever, staff are trained to screen every child for signs of abuse.

LVHN’S screening study

At the 2016 meeting of the Pediatric Trauma Society, a research team at Lehigh Valley Health Network presented the findings of a study piloting a new child abuse screening protocol and training system. A newly developed child abuse screening tool was initially deployed for every trauma patient younger than 15, and subsequently extended to all patients evaluated in the pediatric emergency department and admitted to the children’s hospital.

The screening tool was posted prominently, and staff were educated, reinforced and “re-educated” through numerous meetings and communications; seminars on child abuse screening were mandatory for all staff in contact with children.

The hospital established a child protection team (CPT) led by a full-time CAP who had been certified by the American Board of Pediatrics. Additionally, child abuse screening was made part of the electronic health record creation/update during the admission process. A single “yes” to any of the screening questions (such as a bruise deemed suspicious by medical personnel, the appearance of poor dental hygiene, or some “other concern”) resulted in a call to the state child abuse hotline and the filing of a CY-47 form.

The team found that the new system increased the number of child abuse reporting forms (CY-47 forms) filed by roughly one report per month, and deemed it a success. (Curiously, in the early days of the rollout, more CP-47 forms were filed than screens performed, a data point the researchers cannot fully explain.)

In July 2019, the team published its findings in the journal Pediatric Surgery International under the title “Every child, every time: hospital-wide child abuse screening increases awareness and state reporting” https://pubmed.ncbi.nlm.nih.gov/31115655/). “When a screening tool is used universally for all patients,” they noted, “it makes it a regular part of the medical encounter.”

No figures were published regarding the ultimate adjudication of the CY-47 reports, i.e., whether the children flagged by hospital staff had actually been abused. The study authors explained, “Though chart monitoring and follow-up of DHS [Pa. Dept. of Health Services] investigations for patients with positive screens was conducted in the clinical setting, this information was not used in the study […] Therefore, it is possible that we are over-reporting.”

“However,” they opined, “in the case of evaluating for NAT [non-accidental trauma], higher sensitivity is prioritized over specificity to prevent missing abused children.”

Too much deference to child abuse pediatricians?

Family rights lawyers contend that hospitals and courts err in giving more weight to the views expressed by CAPs than those of other physicians, including specialists.

Family rights attorney Diane Redleaf relates the story of one particularly troubling case. A child abuse pediatrician had identified a child as a victim of abuse based on the presence of subdural hematoma (SDH, or bleeding under the membrane that covers the brain). The pediatrician said that the child had been shaken by a caregiver, causing the hematoma.

The neurosurgery resident at the hospital, who had several years of experience in the field, disagreed. He diagnosed the child with benign external hydrocephalus (BEH), a condition that he believed predisposed the child to SDH. Existing medical literature supported the neurosurgery resident’s position.

“The child abuse pediatrician denied that BEH was a cause,” Redleaf said. “She insisted it was a shaking case. She did not acknowledge having a conversation with the neurosurgery resident […] That case kind of clued me in [that some doctors] were not necessarily worthy of as much deference as they wanted to have from the courts. How they came to their opinions was worthy of scrutiny.” She adds, “The child welfare agency in Illinois […] deferred to them to the exclusion of orthopedists and neurosurgeons.”

A bias toward suspecting abuse can entrench itself through what Redleaf calls “circular reasoning.”

“[Some doctors] think rib fractures are always the result of abuse, but that’s because they have come to study rib fractures where there’s an allegation of abuse,” she said. “And the criterion for listing a rib fracture as due to abuse is the opinion of child abuse pediatrician.” Another reinforcement of bias can occur when “the child abuse pediatrician says it’s child abuse, and nobody’s on the other side contesting it, then it gets recorded as child abuse, and it may not be.”