The death of a child – relying on medical data has controversies

The death of a child is devastating at the best of times. When the child dies in unexplained or suspicious circumstances, it tends to create a volatile mix of emotions ranging from sadness through to anger. The community questions what went wrong. How could this be allowed to happen? What might have prevented this? But surely, the big question is who is to blame.

For child protection workers, there is a more complex question – are there other children who might be at risk? If so, what needs to be done to protect them? CPS must consider this question quickly while the investigation is underway around the death of the child.

A core issue that must be resolved is whether or not the death was accidental or non-accidental. If the latter, how did the child die? This may well determine case planning for other children. If the cause of death is non-accidental, then what is the risk for other children?

Medical data becomes essential to resolving the puzzle. Of course, police also want the answers. Diagnostic conclusions are needed. What if that data is questionable? We have seen this issue in Canada with a number of cases in Ontario where autopsy reports proved inaccurate. Several people were incarcerated based on these results. The criminal convictions were overturned.

This led to the Goudge report in Ontario which was released in 2008. He refers to the basis of the concern with autopsy reports by summarizing a review of the work of one pathologist. On p.7, Goudge states:

"1 In all but one of the 45 cases examined, the reviewers agreed that Dr. Smith had conducted the important examinations that were indicated.
2 In nine of the 45 cases, the reviewers did not agree with significant facts that appeared in either Dr. Smith’s report or his testimony.
3 In 20 of the 45 cases, the reviewers took issue with Dr. Smith’s opinion in either his report or his testimony, or both. In 12 of those 20 cases, there had been findings of guilt by the courts."

Goudge recognizes that there must be restored faith in the forensic pathology work and makes four cornerstone recommendations:

"1 legislative change that provides both proper recognition of the vital role foren- sic pathology plays in death investigation and the foundation for proper organization of a forensic pathology system;
2 a commitment to providing forensic pathology education, training, and certification in Canada and strengthening the relationship between service, teaching, and research;
3 a commitment to the recruitment and retention of qualified forensic patholo- gists; and
4 adequate, sustainable funding to grow the profession." (p.35)

It seems that Canada is not alone in facing a lack of confidence in the results of autopsies and their role in child abuse and death cases. These same issues are emerging as an area of significant concern in the United States. PBS Frontline has reviewed the issue in their program this week. You can view it at pbs.org

The report done by PBS, NPR and ProPublica notes:

Often, authorities had little to go on other than autopsy findings. Many of the doctors who conducted post-mortem examinations failed to consult specialists in childhood injuries or ailments, or to thoroughly review medical records that could have affected their conclusions. In several cases, forensic pathologists worked so closely with authorities, they effectively became agents of law enforcement, rather than objective arbiters of scientific evidence.

This appears to be a call for ensuring that the kinds of steps called for by Goudge should be applied in the United States as well. CPS should welcome such a step as it will create greater certainty from which to do case planning.

The report and allied material goes on to raise yet another major challenge for child protection. Can diagnostic conclusions made in autopsies or by other medical specialists be relied upon? They use the example of Shaken Baby Syndrome (SBS) that has been undergoing a serious reconsideration. The medical community may well be divided on it. Yet, those of us working within CPS systems need to be able to rely on these medical conclusions for effective case planning. Can the family be preserved or must the children be removed?

The ProPublica report suggests that SBS has perhaps too easily been seen as the cause of death in many cases where reviews of medical evidence says that the cause was something quite different. The reports suggests that SBS is not such a diagnosis that can be relied upon if the traditional triumvirate of symptoms is relied upon. They state:

"Under the theory, certain patterns of bleeding and swelling of the brain, and hemorrhages of the retinas came to be seen as conclusive evidence that a child had been assaulted with terrible force, even if there were no other signs of trauma.

But many experts now view the diagnosis with increasing skepticism. In Canada and Britain, large-scale official reviews have uncovered at least nine cases in which people may have been wrongly convicted based on the shaken-baby theory."

In child protection, it is vital that we are aware of these debates so that we can ask better questions of the various experts involved in a case. The implications are enormous. Thus, in SBS cases, we will need to ensure we ask careful questions about whether alternative explanations might exist for injuries incurred.

Divorce: Ten Rules to Guarantee the Kids are Screwed UP!

Doing assessments within the child protection system, I also find myself involved in divorce cases. They are usually referred because of various allegations, sometimes true, sometimes exaggerated, sometimes fabricated. As I have considered these cases, it has become increasingly clear that there are 10 quite clear ways to ensure that, as a divorcing parent, you can guarantee that your children will be screwed up by the process. Here are my 10:

1. Before you actually start the divorce, begin to bad mouth the other parent. Start a campaign that shows your kids what a horrible person the other parent is and how much more you love them. Create the environment where your children's loyalty to you is rewarded so that they come to your side.

2. After the separation, do as much as possible to sabotage time that the other parent spends with the children. Effective tools include changing schedules at the last moment; not being home when the parent is to pick the children up or fail to answer phone calls made from the other parent.

3. If you are the visiting parent, don't show up regularly for the visits. If you do come, take as much time as possible to blame the other parent for what has gone wrong. You can also come back early; feed the children junk food that gets them hyper; come back quite late so that the children don't get a good night's sleep. Finally, make a scene during the exchanges so that the children are embarrassed.

4. Be over reactive to the other parent or anything even slightly negative that the children tell you. This will allow you even more opportunity for put downs, name calling and threats that the other parent will never see the children.

5. Don't pay child support on time or regularly. This will leave the other parent guessing; limit funds for children's activities and again allow the other parents opportunities to lambast what a worthless parent you are.

6. At the last minute, refuse permission for important opportunities like a trip to Disneyland. Tell the children that you had to do this because you were sure that the parent who was going to take them away, was really going to kidnap them.

7. Accuse the other parent of child abuse or sexual abuse. When doing so, take the child to the doctor so that they can be subject to a difficult physical examination. When making these accusations call both the police and child welfare.

8. At parent teacher meetings or school events, make a scene when the other parent shows up.

9. Alienate the children from the other parent by telling them that that person is unsafe; doesn't care about the kids; has replaced their own kids with a new partner's children; share the gory details of the divorce and let them know that you are the only one who really cares for them

10. Refuse to consent to therapy. That would only allow your children to tattle on you anyway.

Of course, there is Number 11 - Litigate, Litigate, Litigate. This will ensure that your kids are subject to endless court processes, interviews, constant complaining about the courts and multiple opportunities for the children to be interviewed by professionals (like me) putting them in the middle. Really ensure that you make it clear that you expect their loyalty.

I am sure that there are other tips that you might come up with that will help to screw the kids up.

This may all sound very cynical. Yet, day in and day out, I see parents who apparently loved each other once, so engaged in battle with the other parent that they do these things. The battle, and winning it, is much more important than their own children's well being. If only they could stop and see the harm.

Medecins Sans Frontier Campaign - Starved for Attention

Child protection within the international community means, at times, linking up with the work of major organizations that have a strong track record of success. MSF is one such organization. They have a campaign underway right now - Starved for Attention.

195 Million Stories of Malnutrition
It’s Time to Rewrite the Story

Doctors Without Borders/Médecins Sans Frontières (MSF) and VII Photo present “Starved for Attention,” a multimedia campaign exposing the neglected and largely invisible crisis of childhood malnutrition.

“Starved for Attention” aims to rewrite the story of malnutrition through a series of multimedia documentaries that seamlessly blend photography and video from some of the most accomplished and award-winning photojournalists working today.

VII photojournalists Marcus Bleasdale, Jessica Dimmock, Ron Haviv, Antonin Kratochvil, Franco Pagetti, Stephanie Sinclair, and John Stanmeyer traveled to malnutrition “hotspots” around the world—from war zones to emerging economies—to shed light on the underlying causes of the malnutrition crisis and innovative approaches to combat this condition.

“Starved for Attention” captures frontline stories of malnutrition from Bangladesh, Burkina Faso, Democratic Republic of Congo, Djibouti, India, Mexico, and the United States.
An estimated 195 million children worldwide suffer from the effects of malnutrition, with 90 percent living in sub-Saharan Africa and South Asia. In fact, malnutrition contributes to at least one-third of the eight million annual deaths of children under five years of age.
Many families simply cannot afford to provide nutritious food—particularly animal source foods such as milk, meat, and eggs—that their young children need to grow and thrive. Instead, they struggle to survive—far from the media spotlight—on a diet of little more than cereal porridges of maize or rice, amounting to the equivalent of bread and water.

By signing the “Starved for Attention” online petition, you can be part of the campaign to rewrite the story of malnutrition and demand that the 195 million malnourished children get the attention they need and deserve to escape the deadly cycle of malnutrition.

You can sign the petition at

http://www.starvedforattention.org/take-action.php

Family as the primary source of child protection

A rather interesting study in the UK suggests that a great deal of child protection work may be done informally and by family. Kinship carers step in when parents can't manage to raise the children. The study found that about 1/77 children in the UK were living in kinship care with about 90% of them there within informal arrangements. In essence, here is a large number of children that are being protected within the larger family system. This is a child protection process typically running below the radar but quite apparently powerful in its impact.

The report found that older children, above 13 and particularly 15-17 years of age were the biggest age group versus younger children. The authors saw this as an unexpected age distribution.

Another surprising result was who the kinship carer turned out to be. The report notes in the Executive Summary.One of our most important findings is that between one fifth and half of children living with kin were in fact living with a sibling. (p.12)" Grandparents were the other major carer group.

Unlike kinship carers who did so under the auspices of a formal agency arrangement, those doing do under these informal processes did it without any additional supports. This created financial hardship for many carers. Various forms of deprivation were found to be common creating more concerning outcomes for these children.

There are significant policy implications. How do you support these arrangements that have the benefit of keeping children connected to family? Pulling them out of family is unlikely to be beneficial so supporting these arrangements may help. Yet, it is also possible that formal child protection assessments would find these caregivers worrying. From a policy perspective, however, we are better off supporting these family based solutions. Bringing this many children into care would be worrying indeed.

This is one of the many challenges of child protection policy. There are no perfect solutions - only those that are better than others. In most cases, supporting children within family systems will serve the child better.

The report can be found at http://www.buttleuk.org/data/files/Research_Documents/Spotlight_on_Kinship_Care_-_Exec_Summary.pdf
 

New Research Highlights Data on Sexual Abuse Disclosures

A study by Schaeffer, Leventhal & Asnes just published in Child Abuse and Neglect has given child protection workers and others who investigate or assess sexual abuse cases powerful new insights on children's disclosures. This information has very significant implications for clinic work. It is worth a read but here are some of the highlights.

In understanding why a child discloses, the authors state in the abstract, that, "The reasons children identified for why they chose to tell were clas- sified into three domains: (1) disclosure as a result of internal stimuli (e.g., the child had nightmares), (2) disclosure facilitated by outside influences (e.g., the child was questioned), and (3) disclosure due to direct evidence of abuse (e.g., the child’s abuse was witnessed)." From this, we can see that asking matters as well as ensuring that what is observed is not ignored.

The researchers also considered what prevents disclosures. Again, from the abstract, they state, "The barriers to disclosure identified by the children were categorized into five groups: (1) threats made by the perpetrator (e.g., the child was told (s)he would get in trouble if (s)he told), (2) fears (e.g., the child was afraid something bad would happen if (s)he told), (3) lack of opportunity (e.g., the child felt the opportunity to disclose never presented), (4) lack of understanding (e.g., the child failed to recognize abusive behavior as unacceptable), and (5) relationship with the perpetrator (e.g., the child thought the perpetrator was a friend)."

The barriers help us to see that creating an opportunity for disclosures is an important step. Also, continuing to help children see what is and is not abusive along with opportunity to tell will increase the possibility of a disclosure.

In the articles discussion, they note that age seems to influence who a child will first tell. "Younger children were more likely to disclose to adults and older children were more likely to disclose to peers" (p.350).

This research will help interviewers and others close to the child understand why disclosures happen but also why they do not. The authors affirm that it makes sense to ask the child why and to whom. There appears to he a logical explanation. For example, they note, "nowing why a particular child told or waited to tell about sexual abuse will allow investigators to see not only what happened to the child but to contextualize the child’s disclosure within a fuller understanding of his or behavior. For example, rather than cast doubt on the veracity of a child’s disclosure, a delay in telling about abuse, once explained, can be understood as a marker of another form of child abuse, such as when a perpetrator threatens a child with violence if he or she were to tell about the sexual abuse"(p. 351). By asking about the process of disclosure then, one might well learn that the child has previously reported but to a person that did not act. By asking, therefore, what appears to be a first telling of the story may not be. Also by asking about barriers, a lack of telling may contextually make more sense.

The authors further note that this material will help prosecutors explain disclosure to the courts more effectively. It will also help parents understand timing of disclosures.

I recommend the study to anyone working with children reporting sexual abuse.

Reference:

Schaeffer, P., Leventhal,J.M. & Asnes, A.G. (2011). Children’s disclosures of sexual abuse: Learning from direct inquiry. Child Abuse and Neglect, 35, 343-352.

Adverse Childhood Events - More Evidence - Updated

In research conducted by Felitti and colleagues in the USA, data has shown that the more we are exposed to adverse childhood events (ACE), the greater a likelihood of later emotional and physical adverse outcomes. This research has been replicated in many other studies but it has significant implications for child protection. A new study by Burke et al., to be published in Child Abuse and Neglect, has added new understanding for youth in urban areas.

One of the more important conclusions is that physicians are not asking enough about the trauma exposures of youth. I suspect that this could be said of many professionals who come into contact with youth from troubled urban areas. Too often, it is easy to see the traumas from environments as something that is normal and that the youth come to see as just part of their life. This research helped to show that children do not just get used to their challenging neighbourhoods. Rather, they live in constant states of stress and trauma effects grow. As the authors note, if you don't ask about the impact then you are taking it as normal and that nothing can be done. Yet, we know that trauma can be treated.

Felitti's work was astounding because he and his colleagues found significant impact in a middle class population. The current study was done in a higher risk population and, not surprisingly, found greater adverse childhood effects. An important further finding was, "Another alarming finding in this study was the greater prevalence of learning/behavior problems among children who had experienced at least 4 ACEs as compared to those children without such ACEs (51.2% vs. 3%, respectively)." Thus, in children with higher number of ACEs we should also be looking at learning - is this a huge surprise - how do you learn when you are under chronic stress?

The authors go on to state in their conclusions, "Specifically, the alarming prevalence of aversive childhood experiences being endorsed in this urban population supports the dire need for the implementation of ACEs screening procedures across urban health-care settings. Furthermore, due to the association between ACES and both obesity and learning/behavior problems found in this study, the authors advocate for pediatricians and mental-health care providers be aware of the potential influence ACEs may have on preventative and intervention measures for these two more common childhood problems."

When one considers this research in context of child protection populations, such screening should be almost automatic.

Reference: Burke, N. J., et al. The impact of adverse childhood experiences on an urban pediatric population. Child Abuse & Neglect (2011), doi:10.1016/j.chiabu.2011.02.006

No sooner have I posted this than another study comes to my attention. Journal Watch Psychiatry (JWP) reviewed two new studies that help us to see that there are long term genetic and neuroanatomical impacts from ACEs. In their commentary on the research, JWP states, "Comment: These results bolster the negative impact of early childhood adverse experiences on genetic and neuroanatomical factors, and argue for primary and secondary prevention, especially given the relationship between telomere length and duration of institutional care. The findings are particularly relevant to practitioners caring for psychiatrically impaired parents, with regard to the need for providing adequate child care when the parents are unable to do so. For example, social services within adult psychiatric clinics able to attend to children's needs would be useful."

— Barbara Geller, MD

Citations

Drury SS et al. Telomere length and early severe social deprivation: Linking early adversity and cellular aging. Mol Psychiatry 2011 May 17; [e-pub ahead of print]. (http://dx.doi.org/10.1038/mp.2011.53)
Gerritsen L et al. BDNF Val66Met genotype modulates the effect of childhood adversity on subgenual anterior cingulate cortex volume in healthy subjects. Mol Psychiatry 2011 May 17; [e-pub ahead of print]. (http://dx.doi.org/10.1038/mp.2011.51)

JD Schramm: Break the silence for suicide survivors | Video on TED.com

On of the things that we know about children in the child protection system, is that their risks of attempting suicide is much greater. Their life experiences often have them on a trajectory of self harm in various ways. This brief talk on ted.com is worth a watch as it helps to spread the idea of openly talking about suicide.

JD Schramm: Break the silence for suicide survivors | Video on TED.com

By the way, if you have yet to discover ted.com, you are about to enter a rich resource for challenging, creative and interesting talks that come with abosultely no strings attached other than your willingness to think.

Some 115 million child labourers globally engaged in hazardous work – UN

There are occasions when simply linking to the summary report is worthwhile. I think this is one of those occasions as the topic is so important and the UN overview so impactful.

Some 115 million child labourers globally engaged in hazardous work – UN

Child Trafficking - Not Just a third world issue

This USA report available on YouTube is an important way to recognize that human sex trafficking is not only a third world concern

http://www.youtube.com/watch?v=G8YBlLPGPUg&feature=player_embedded