The pre-schooler bouncing around Exam Room 3 of the pediatric emergency room is that iridescent combination of precociousness and politeness uniquely the domain of garrulous 4-year-old girls. “I need to wash my hands,” announces the child, gently peeling a pink butterfly sticker off her tiny right hand. Moments later, washed and dried with two towels (“Two at a time!” she squeals), her beaded, neat cornrows disappear under a window shade. “Look!” exclaims the slightly muffled voice, whose owner is now staring up into the dusk. “The Moon! It looks just like a cookie!”
The observers in the room laugh, but the girl’s mom is not among the smiling. In fact, mom’s not even in the room. She’s 50 feet away, on the other side of electronically secured double doors that she could not breach if she wanted to—and she most certainly does. For while she is known to the little girl as “Momma,” to the two security guards, one police officer, two social workers, crime lab photographer, nurse practitioner and pediatrician who stand between her and her baby, the woman now wears a far more ominous moniker: Alleged abuser.
|> The concept behind the Child Protection Team, says Allen Walker, is straightforward: “to present a unified voice” of multi-disciplinary expertise. Suspected child abuse cases are fast-tracked through the pediatric ED, where they're thoroughly evaluated by a phalanx of expert social workers, nurse practitioners, and physicians.
The allegation is as plain as the inch-long rainbow-colored bruise under the child’s right eye. It was noticed by her teacher earlier in the day, reported to authorities as the law requires, and the child was quickly brought down to Hopkins to have her injury evaluated. And therein lies the question. For while the injury is blazingly apparent, its cause is not. Accident or abuse? The former, claims the mother, who says she wasn’t even present when the child, at her grandmother’s, tripped and fell face-first into the edge of a coffee table.
Which is exactly the tale the child tells to the specially trained social worker in Exam Room 3, before adding seven words full of both innocence and damnation:
“That’s what they told me to say.”
The social worker takes a deep breath.
“OK, now tell me what really happened.”
Sorting fact from fiction and making an informed recommendation is what the Johns Hopkins Child Protection Team headed by Allen Walker is all about. The CPT is first on the scene in the Hopkins pediatric ED, which, by city order, is where Baltimore City police bring all suspected cases of physical child abuse for initial evaluation.
That alone is a daunting responsibility. According to the Baltimore City Data Collaborative, from 2000 to 2005, the city’s rate of child abuse and neglect ran almost three times higher than the state’s average. For 2005, that meant 11.3 per 1,000 city kids had suffered everything from malnutrition to beating, burnings, and other horrific injuries at the hands of adults. In that same year, more than 30 of each 1,000 city children were removed from their homes by social workers, the vast majority because of suspected neglect or abuse. For children ages 6 to 11, homicide was the third leading cause of death between July, 2001 and May, 2005: For those under 6, it was the second leading cause of death.
A few of the more heinous cases are etched in memory. Two-year-old Bryanna Harris, whose drug-using mother, annoyed by the little girl’s crying, purportedly gave her methadone to hush her up. It killed the toddler. Then there was the case of
Emmoney and Emmonea Broadway, the twins delivered at Hopkins, who were found beaten to death a month later.
The fact that city social workers were aware that the mothers in both cases were at high risk for being child abusers isn’t lost on Allen Walker. Throughout the physician’s 30-year career in pediatrics, he’s sought better methods for identifying potential abusers and preventing child abuse.
The soft-spoken Walker practiced in Reno before coming to Hopkins in 1985. For years he’s fought the prevailing American sentiment that how a parent raises a child is not any outside agency’s business, a mindset that he says only furthers the cycle of child abuse by limiting educational opportunities. “You look at some of the Scandinavian countries, mothers get a year off after they deliver to bond with their kids. They get a regular home visitor who teaches them about being a parent,” says Walker. “I don’t think anybody in the United States would seriously think we have either the political will or financial means to do that. Yet that’s the sort of effort that, at least from the medical literature, it’s going to take to prevent this.”
Walker has led the Child Protection Team since its inception here in the 1990s. The concept, he says, is straightforward: “to present a unified voice” of multi-disciplinary expertise. Suspected child abuse cases are fast-tracked through the pediatric ED, where they’re thoroughly evaluated over several hours by a phalanx of expert social workers, nurse practitioners, and physicians. The resulting reports are immediately passed on to the police and city child protective service authorities—all in an effort to keep children safe and potential abusers from slipping through the cracks.
Prior to the team’s formation, “It was almost impossible to prosecute a physical child abuse case in the city of Baltimore,” says Julie A. Drake, chief of Baltimore City’s Felony Family Violence Division. The reason? While city and state detectives, child protective service workers, and Hopkins’ own physicians often had information that could help determine whether abuse had occurred (or, as importantly, did not), that information often was not shared with the right people or in a timely manner.
Now, a formal agreement between CPT, Drake’s office, the Baltimore City Police Department’s Child-Abuse Unit, and the Department of Child Protective Services has led to more successful prosecutions and cleared cases, often using CPT members as expert witnesses on the stand. “[Dr. Walker] is the most credible medical expert on pediatric trauma and physical child abuse in the state,” says Drake. The CPT team is also involved with many cases in Anne Arundel and Baltimore counties, as children critically injured there are often flown to Hopkins for CPT evaluation.
In all, officials from these jurisdictions meet with CPT personnel to discuss more than 500 cases annually. It is a triage of a different kind, where diagnoses can set into motion both the wand of caduceus and the wheels of jurisprudence.
Making those diagnoses is equal parts science and art. Technical advancements in neuro-imaging, MRI, and CT have brought to light many abusive injuries that were once difficult to pinpoint. “Without CT scans, something like a subdural hemotoma (essentially a bruise to the brain)—which is one of the hallmarks of abusive head trauma or Shaken Baby Syndrome—is almost impossible to diagnose,” says Walker.
These scans have led to new computer and biophysical models that have experts rethinking what once were considered “pathoneumonic,” or absolute, guaranteed signs that a child had been physically abused. “What people said 10 years ago as being tried and true abuse is absolutely wrong,” says another member of the CPT team, pediatrician Mitchell Goldstein. He uses spiral femur fractures as an example. “The thought was that you had to grab and twist the leg to get that fracture,” says Goldstein. “In fact, it’s not an uncommon injury in ambulatory toddlers; they put their foot in a hole, plant and twist, and get that fracture pattern. People had their kids removed from the home and spent time in our jail for our naivete.”
Actually, says Goldstein, “very few injuries say, ‘this is absolute abuse.’” Like an undated black-and-white photo of strangers plucked from a family album, images and scans often raise as many questions as answers. With many plausible explanations for an injury, it’s the art of the interview—and the skill of the interviewer—that often narrows the possibilities. That’s where the work of CPT’s social workers and nurse practitioners comes into play.
“You have to be careful not to ask leading questions,” says social worker Kathy Kopf. “That’s very important because otherwise [the victims] testimony won’t stand up in court.”
“The goal,” adds nurse practitioner Shawna Mudd, “is to get an injury history from a kid. If I say, ‘Tell me what brought you here today,’ a 7-year-old can go from there,” says Mudd. As an example, she plays out a hypothetical dialogue involving a belt or extension cord, which is the most common abuse object. When a child admits to a beating applied by dad with a belt—and many kids see it as just a normal part of their upbringing—Mudd will seek specifics that hopefully match the physical evidence. “Tell me about the belt,” she’ll say. “How was your dad holding it? What’s the color of it? Who does it belong to? Did anybody see you get hit with the belt? Has it happened before? Are you scared?”
With younger children—and Kopf says it’s even possible to get tangible leads from barely verbal toddlers—providing a coloring book or toys is often a quick way to get them to feel comfortable enough to talk about their lives, their loves, and their abusers, as they parse out details with little understanding of potential consequences. Older kids and teens often have that understanding—some have been removed from their homes before because of abuse. They sometimes lie about their injuries at first, but generally reconsider when shown or told about the physical evidence that doesn’t match up with their story.
The social workers never emphasize punitive measures that caregivers could face: The decision whether to place a child in protective custody is made by the city Department of Social Services/Child Protective Services social worker in the ED, after reviewing the CPT’s evidence, interviews, and conclusions. As for arresting the abuser—and under Maryland Law any adult who leaves a mark on a child can be arrested for child abuse—that choice falls to the city’s detectives, again depending to a large degree on CPT’s data.
Instead, the social workers—and the whole CPT team—focus on the child’s immediate safety. It’s the message given to the child and the alleged abuser. “If I were a parent and being questioned, or my child was in a separate room being questioned, I can understand being irate,” says Kopf. “I tell parents, ‘I understand you’re upset, but this isn’t personal. Child abuse does happen, and we just want to make sure your child is safe.’ If they can see the big spectrum, as uncomfortable, as intrusive as it may seem at the time … nine times out of 10 the parents can be calmed down.
“But,” she admits, “it’s easier said than done.”
Back in the pediatric ED office just off the nursing station, nurse practitioner Joyce Ordun is studying what amounts to the crime scene on paper. In front of her is the special two-page CPT form assigned to document each case. Ordun, after examining the 4-year-old and interviewing her, has put small marks on the outline of the human body that’s part of each form. Each mark is assigned a number, used to cross-reference and explain each observed lesion in the “assessment” area opposite the drawn body. Each number represents a potential site of abuse.
On this form, Ordun has marked 10 such sites.
In addition to the obvious black eye—mark # 10—there are fresh wounds at the hairline and a tiny slash through the right eyebrow. “Red, up on her forehead, consistent with being hit by something linear, like the side of the belt. These are new,” she notes.
This is not conjecture, but corroboration. After the 4-year-old admitted being coached to lie by her mother, she proceeded to tell the rest of the story, repeating it twice separately to CPT social worker Dawn Walker (no relation to Allen Walker) and later Ordun.
“What did she hit you with?” Ordun had asked.
The little girl, coloring a small Mission to Mars comic book, barely paused to look up.
“She hit me with a belt.”
“Did she hit you with the part that hooks together, or the regular part?”
“The regular part.”
Several marks on the lower body confirm the girl’s comments that she’d been beaten before. Hyper-pigmented (older, still discolored) lesions on the back of her legs are loop-shaped (“from when you fold a belt over,” explains Ordun) and their location rule out an accident or fall as the cause of the markings. “If they were on the front of her legs I wouldn’t worry about them because the kid is [normally] moving forward. But most kids don’t get linear, hyper-pigmented lesions between their legs.”
“So she was whacked from behind?”
“Yeah,” says Ordun, peering over the paperwork. In the end, the form calls for her to check off one of four boxes. These indicate that the exam reveals physical findings consistent with physical child abuse; findings consistent with neglect; findings unclear or non-specific for physical abuse or neglect; or a history concerning for abuse but physical findings that are non-specific (physical abuse is generally considered an intentional act, while physical neglect—such as poorly nourished children—includes maltreatment due to inattentiveness or ignorance).
Ordun’s choice will send a ripple through both the judicial system and the lives of the girl, her mother, and another family member who now sits in Exam Room 3. Cradled in the arms of the man the little girl calls her father is a 5-month-old girl. The infant is the little girl’s sister: On her cheeks are two quarter-sized abrasions, one under each eye. The mother says her family doctor called the abrasions eczema. Though resting comfortably in the man’s arms, the infant’s size and general condition—a bit disheveled—raises the alarm of another CPT social worker watching from the corridor.
“That baby’s not big,” she says quietly, but her worried eyes clearly rephrase the thought.
That baby’s in trouble.
Even with all the technical advancements, child abuse remains a frustrating field of work. On one level, the Child Protection Team has made important inroads, especially in the coordination of care. In addition to children who come through the ED, the team is available to anyone who has a pediatric inpatient they suspect has been abused. These account for an estimated one-third of the team’s consults, a service clearly appreciated by faculty and staff.
“We take pressure off the surgeons and social workers,” says CPT social worker Sue Barker. “They can focus on the families. We can, for lack of a better term, do the dirty work.” In a sense, CPT’s presence allows the inpatient units to continue their normal continuity of care for the patient and the family while CPT begins its evaluation. The trust the inpatient team has created with the family remains intact. If CPT determines abuse has occurred, the team works with security and the city’s Child Protective Services division to limit the suspected abuser’s hospital access while the rest of the family and the child receive the social and medical services they need.
Still, for all the cases, the commitment, the sense that CPT’s efforts, as nurse practitioner Shawna Mudd puts it, “feel like the right thing,” the truth, as she says in her very next breath, is that “we don’t have data or research to show that.”
In short, while much research literature has been devoted to the downstream effects on victims of child abuse—including increased teen pregnancy and school dropout rates—precious little is known about short-term outcomes following a child abuse diagnosis. This is especially true when it comes to understanding whether medical and educational interventions prevent future episodes of child abuse. While Mitchell Goldstein is documenting whether parents who sign a nursery commitment “not to shake my baby”’ follow through on that pledge, such studies in aggregate are hard to come by. “In terms of where these kids are five years later, in terms of good solid data, we know less about the natural history of child abuse and neglect than most other diseases, because it is such a sensitive subject,” says Walker.
Between legal juvenile privacy concerns, poor data keeping by government agencies, and general turf wars by the bureaucracies involved, it’s often hard to uncover a child’s past abuse history, let alone mount research and prevention efforts. While a recent law allows the city’s Child Protective Division to disclose “active” cases, specifics often remain elusive. The consequences of this data chasm can be devastating. Abusive parents often hospital jump, so their child is never seen in the same ED twice. Certain injuries that in isolation appear accidental might be judged differently if a history of repeat occurrence were available. Only it’s usually not.
Perhaps most frustrating is the realization that, while child abuse is horrific, the abusers often act out of ignorance more than willfulness. “For the most part, there are very few evil people,” says Kathy Kopf, an observation consistently shared by other CPT members. Lack of parenting tools, repeating the discipline they themselves encountered as children … these are often at the heart of an abuser’s actions, especially those parents at wits’ end over their child’s behavior. Kopf recalls a court-ordered physical abuse offenders group she facilitated. After 16 weeks, she concluded their desires were the same as those of most parents: To have their kids stay off drugs and do well in school. The devil was in the details. “Part of it is changing a belief system; that if you hit your child that corrects the behavior. A lot of research [says] it doesn’t work. It just makes a child angry. They’re more likely to abuse a peer at school,” says Kopf. “Also, a lot of parents are religious. They believe in ‘Spare the rod, spoil the child.’ I hear that a lot. ‘The Bible says it’s OK.’”
For now, such educational research and interventions are beyond CPT’s scope, falling instead to the city’s incredibly overworked Child Protective Services division. The team itself operates more on commitment than cash, as Walker and Goldstein are part-time staff and every member of the team has other hospital and ED responsibilities.
What may improve both the research and staffing situation long term, says Walker, is the recent decision by the American Academy of Pediatrics to create a board-certified child abuse subspecialty. Such a subspecialist “would be in the academic model, seeing patients, evaluating patients, but also having time to pursue research needs in the field,” says Walker.
What may be more immediately possible is an independent one-stop clinic. “Picture, if you will, a place where Mitch [Goldstein] and I go to work, along with the State’s Attorney, some folks from Protective Services, some Child Abuse detectives, and that’s our office,” says Walker. “We spend our days talking to each other over the coffee machine, coming in from the parking lot. That’s the kind of service model that results in the best deal for kids.”
In fact, such a model already exists in the Baltimore Child Abuse Center on North Charles Street. Since 2002 the center has been the clearinghouse for suspected sexual abuse cases, with detectives on-site. “This is like working in real time,” says Lt. Thomas Uzarowski, head of the Baltimore City Police Department’s Child Abuse unit. “If in the course of a [medical] interview sexual abuse is suspected, they just call down to the first floor, where we are, and a detective goes up and sits in on an interview. If criminal allegations arise, we roll on it,” says Uzarowski, whose unit also works with the CPT. “The next step is where we evolve to doing physical abuse cases [in a freestanding unit]. It’s just a matter of dollars and cents.”
That those dollars are difficult to find is a bit mystifying to people who spend every day watching a parade of innocent children who’ve been beaten, burned, and literally boiled for something as simple as soiling when they’re not supposed to, or misplacing a T-shirt. Sometimes one can hear a Sisyphean weariness in their voices, at other times utter rage at the cases they absolutely know are child abuse, but medically can’t prove.
But perhaps the greatest miracle is that overriding all of these emotions is a sense of hope for both parent and child, that the cycle of abuse can be broken and a family can eventually be reunited. “Do I see awful things? Yes. Does it get to me sometimes? Yes,” says Kathy Kopf, who knows that separating a child from a parent should be viewed as a short-term option, not a long-term solution. “But I don’t look at it as doom and gloom. I look at it as an opportunity to get parents through this crisis situation. They made a mistake. For me it’s about what we can do so that it doesn’t happen again.”
“What’s going on back there?” demands the little girl’s mother in the ED’s waiting room.
“They’re not telling us anything!”
Social worker Dawn Walker’s face is placid in the face of such emotion—heck, that’s her job—but her internal calculus is whirring, forming an equation that’s rapidly tilting against the mother. The more she talks with the clearly annoyed woman, the greater the number of risk factors for abuse she sees. She’s a young parent. Two young children. She’s not taking this seriously, almost as if it’s a joke. Her story of how the injury occurred doesn’t match the facts. And she’s just asked if the doctors found any additional marks.
“Yes, they’re old, but the doctors did find some marks,” says Walker.
“Whaaat?” sputters the mother. “She doesn’t get abused.”
Inside the ED office, nurse practitioner Ordun takes one last look over the exam form, checks the box marked “Exam reveals physical findings consistent with physical child abuse,” and offers up her informed opinion of the case.
“Mom,” she says, “is going to jail.”
A few minutes later, a new sound comes from Exam Room 3. It is the sound of a 4-year-old suddenly stripped of her innocence. Sobs so grief-choked that they barely escape her throat. Walker puts her arm around the tiny girl, pulls her close, and attempts to explain the impossible. The CPS social worker has made a decision. For the time being, both sisters will be placed under the care of DSS. The little girl won’t be going home tonight.
“We want to make sure it’s safe when you go home again,” says Walker, offering comfort to the shattered girl. Walker can see what’s in the girl’s tear-streaked face, the notion that somehow she has brought this upon herself, she is at fault, she has caused this rip in her world. “You have to remember, you didn’t do anything wrong. You did not do anything wrong. Are you going to remember that?” asks Walker.
Distraught, the little girl seeks relief from the only person who can bring it. The person who created this trauma in the first place. Her abuser.
“I want my mommmmmy!” she cries.
Mat Edelson is a frequent contributor to Hopkins Medicine magazine.