http://www.nytimes.com/2009/05/12/health/12klas.html?_r=1&ref=educationThe Marks of Childhood or the Marks of Abuse? By PERRI KLASS, M.D.
Published: May 11, 2009
I had just started out in practice when one day I examined a little boy, maybe 4 years old, and discovered around his neck the clear mark of a noose. I asked him what had happened; he said he didn’t know. I asked his mother; she said she didn’t know, but it was the fault of her ex-husband. I had to tell her I was filing a report with the Department of Social Services — the child had clearly suffered an inflicted injury.
My training had included many slide shows about the stigmata of cigarette burns, belt marks and other suspicious injuries, but it was the first time I had been the person alone on the front line, looking at a mark on a child, knowing something was wrong.
My colleague Dr. Lori Legano is a pediatrician who specializes in child abuse at the Frances L. Loeb Child Protection and Development Center at Bellevue Hospital. Part of her job is to testify in court and to speak to judges and juries about a range of marks and bruises and what they indicate.
She has to integrate a pediatrician’s understanding of child development and behavior with a growing body of forensic information about child abuse. Bumps and bruises, after all, can be expected in any young child who is learning to walk. But some injuries are inconsistent with developmental stage: “If you don’t cruise, you don’t bruise.”
So a child who isn’t mobile shouldn’t have those marks, let alone broken bones. And then there are intrinsically suspicious marks, or marks in the wrong places.
This year, the study of child abuse is coming of age as a medical specialty. In November, the first medical board exam will be offered in a new official specialty, child abuse pediatrics. Knowledge and research that have accumulated over decades about the effects of physical abuse and sexual abuse are being codified into a curriculum; fellowship training in the field will have to meet certain standards; an expert, testifying in court, can expect to be questioned about being board-certified.
“When I started doing this in 1984, nothing that I do now was even known,” said Dr. Carole Jenny, a professor of pediatrics at Brown and the director of the child protection team at Hasbro Children’s Hospital in Providence, R.I. “The first week I was working in the field, it was a child who had reportedly had a torn hymen or no hymen, and the defense attorney said, ‘But doctor, aren’t some children born without hymens?’ and I said, ‘I don’t know!’ And we initiated a study in the newborn nursery and we counted 1,100 baby girls.” Every one had a hymen.
Like most pediatricians, I am intimidated by the idea of testifying in court. But all of these specialists have answered questions from lawyers on many occasions; the witness box is a basic part of the landscape of the new specialty.
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So many of these victims are children who could never explain to us what happened to them — they’re not swearable,” said Marjory D. Fisher, chief of the special victims bureau in the Queens district attorney’s office. Without pediatricians trained in child abuse, she continued, “we would never be able to prevail in these cases because the victims are too young; they don’t possess the ability to testify.”
In my training, from the beginning, I was taught to worry about burns. Cigarette burns were always suspicious; immersion burns suggested that a child might have been punished by being dunked in too-hot water. So, of course, it was cigarette burns that brought my own young son to the emergency room one night during my residency when I was on call; he had run full tilt into a stranger in a restaurant who was holding a lighted cigarette. (Yes, I trained so long ago that people could smoke in restaurants.)
Dr. Philip Hyden, medical director of the Kapi’olani Child Protection Center in Honolulu, is an expert on burns. To help figure out whether a burn could have occurred accidentally (as in an apartment building in which someone in another apartment flushed a toilet and the bath water suddenly turned scalding hot), he asks detectives to check the water temperature at the same time on the same day of the week that the injury occurred.
Go to the home, turn on the hot water, wait to see how hot it gets — and then you’ll have an idea how long the child would need to have been in contact with the water for the burn. Could it have happened with a single splash, or was the child held in hot water?
“If Mom says the kid fell into the tub and you go into the bathroom and the water won’t go higher than 125,” Dr. Hyden told me, “you know that water can burn that kid, but it’s going to take a lot of time to do it.”
Regularly, he says, he finds himself trying to explain the physics of burns to a judge or jury: “The hotter the water, the much quicker the burn is, exponentially quicker rather than just linear.”
When my son came to the emergency room with cigarette burns, I found out what it was like for a parent to watch doctors suspect child abuse. Did this story make sense? (Yes.) Did the child confirm it? (Yes.)
But the incident made enough of an impression on my colleagues that a year or so later, when the same child came back with a broken femur at age 4, an attending doctor said to me, with the harsh humor of the emergency room: “I don’t know, Perri. First cigarette burns, now a major fracture — doesn’t look so good for you.” (I knew enough to be theoretically glad that abuse was on his mind; on the other hand, 20 years later, I haven’t forgotten or forgiven the remark.)
To be board-certified in this new specialty will also mean thoroughly understanding the medical conditions that are sometimes mistaken for child abuse — the easily broken bones of osteogenesis imperfecta, for example, or the dramatic bruising that can happen with hemophilia. The parents of children with these medical conditions are often themselves traumatized when the suspicion of child abuse is raised, and one role for a specialist is to make sure that even esoteric alternative explanations are considered.
“We spend a lot of time ruling out abuse,” Dr. Jenny said.
Forty percent of the children referred to her for evaluation turn out, in her best judgment, not to have been abused.The child abuse experts don’t want the rest of us in the profession to stop thinking about the subject. “I think the average pediatrician can diagnose this, even though it’s becoming a specialty,” Dr. Legano said.
But it’s an emotionally difficult diagnosis for a pediatrician to contemplate, especially when it concerns a family you feel you know well. And all too often, it is a diagnosis we fail to consider in families that don’t match our mental profiles of abusers.
That’s why pediatricians and parents alike need all the clinical experience and all the science we can get, deployed on the side of the children.
