The state has just six doctors board certified in child abuse pediatrics, and they’re all on the Front Range.
By Jennifer Brown
(Originally published June 10, 2019, by The Colorado Sun)
A bruise on a baby who hasn’t yet learned to crawl. An injury near a child’s ear. A broken bone from a “fall” with a story that doesn’t add up.
A child protection caseworker who suspects abuse needs a doctor’s opinion, and even a pediatrician who examines the child might want expert advice.
But here’s the problem: in all of Colorado, there are just six physicians certified in child abuse pediatrics by the American Board of Pediatrics. Five of them are in Denver and one is in Colorado Springs, leaving the rest of the state without adequate expertise when it comes to informing decisions about whether a child is in danger.
It’s been a concern for Lucinda Wayland Connelly, the state’s child protection manager and a member of the Colorado child fatality review team. More than once, she has reviewed a child’s death from abuse or neglect and wondered what might have gone differently if past signs of suspected abuse had been examined by an expert.
The state child welfare department has been paying $80,000 per year to contract with the Kempe Center, a child abuse prevention agency based at the University of Colorado Anschutz Medical Campus, to provide in-person examinations and over-the-phone consults to caseworkers across Colorado. In the most serious cases, kids are brought to the Aurora campus for medical exams.
What the state actually needs, though, is a network of physicians throughout Colorado who have training in child abuse, say child welfare officials and child abuse experts.
“If there is a concern of abuse or neglect we don’t want it to be an accident of geography depending on where you get your services,” said Dr. Kathryn Wells, executive director of the Kempe Center and one of the six Colorado doctors who are certified in child abuse pediatrics.
Under legislation passed this year, Colorado will spend $646,000 to create the Colorado Child Abuse Response and Evaluation Network. The program is modeled after other states, most specifically Missouri, that have trained physicians to better decipher whether child abuse occurred — or to rule it out. Missouri, with a population only slightly higher than Colorado, has about 50 doctors statewide certified in child abuse pediatrics.
Whichever agency wins the state’s bid — the Kempe Center, which designed the program, is a likely pick — will set up a training program for medical providers with multiple training sites statewide and potentially an online program.
Medical professionals who complete the course will not receive the board-certified subspeciality in child abuse pediatrics, but they’ll get advanced training about giving medical and behavioral health exams to kids. It focuses on kids under age 5 in cases of suspected physical or sexual abuse and children age 12 and younger in cases of suspected sexual abuse.
The Colorado Department of Public Health and Environment was directed to pick the training agency by September, with training to begin next summer.
The finding makes senses, Leong says. “You’re a very introverted, quite quiet and shy baby who doesn’t like a lot of extra stimulation. And you’ve got this super extroverted outgoing mum who loves things that are really intense. Maybe over time, this child has learned that what my mum likes, I actually don’t really like. That might explain why if the babies had a very different temperament from their mum’s, they tended to go for the opposite object.”
If that kind of difference describes you and your baby, do not despair. On both fronts, learning likelihood and learning valence, there was encouraging news. Mothers who were more sensitive to their baby’s responses, using more eye contact and infant-directed language (the higher-pitched, sing-song cadences we naturally use with infants) were more in sync with their babies than moms who were less responsive. Those are skills that can be taught and practiced. (In a previous paper, Leong showed the power of eye contact.)
It is early days as this kind of work is so new, but Leong hopes it could have real benefit for mothers who suffer from post-partum depression or other conditions where interaction between babies and parents needs strengthening.
The work is also a sign of how nuanced social learning really is and how important it will be to study it with hyperscanning. “That’s the brain activity confirming that there are two different kinds of learning processes and they’re indexed by different neural circuits,” Leong says. “If we had only measured the brain activity of the child, we would be able to see the learning valance, but we would never have been able to see the moment-by-moment changes that predict whether the child is going to learn because all of that was happening in the interpersonal space.”
Besides learning to better diagnose abuse and neglect, doctors also will learn to prevent abuse by recognizing factors that contribute to child abuse — domestic violence, substance abuse, poverty and other life stressors, said John Faught, the Kempe Foundation’s chief executive officer.
“The biggest problem in child abuse and neglect is situations we don’t know about,” he said. “It’s a narrow net now. We want to make the net wider.”
Doctors at Kempe receive calls from family practitioners across the state who are suspicious of bruises and broken bones, especially when the family’s story of how the injury occurs doesn’t fit the injury. But doctors without specific training are often unwilling to make a child abuse diagnosis.
“The more they know, the more they are willing to look into it,” Faught said. “To determine whether there is child abuse, it’s not a quick 15-minute visit. It’s a thorough thing to make sure you have the right diagnosis.”
Physicians are “mandatory reporters” under the law, meaning that if they suspect child abuse, they are required to report it to child protection authorities. About 18 percent of the 221,969 calls to the state child abuse hotline in 2018 were from medical professionals, according to the state child welfare department. But the requirement to report is separate from actually making a clinical diagnosis of physical or sexual abuse.
A common sign of child abuse is a bruise on baby younger than 6 months old, an infant who doesn’t yet crawl or pull up to standing on their own. But just because a baby is bruised, child abuse isn’t a given, Wells said.
Further medical work is required. Lab tests would determine whether the baby’s blood is clotting normally, for example.
Bruises on or near a child’s ear, or any injury around the ear and neck — in the space protected by the shoulder — are suspicious, because a fall does not usually harm that area of the body, Wells said. Still, X-rays and labs are required to rule out other medical explanations.
And in the case of a broken bone that a family says occured in a recent fall, an X-ray that shows the bone is already healing might reveal discrepancies in the family’s story. However, it’s also possible a child’s bones are abnormally formed or are weaker than usual, meaning there is an underlying medical problem.
Wells, formerly a general practice doctor in a small town in Idaho, in 2009 was among the first physicians in the country to earn a subspecialty in child abuse pediatrics. About 400 physicians in the country now have that relatively new certification.
Medical school includes elements of child abuse screening, but in practice, it’s difficult for doctors to take on complex child abuse and neglect cases when they are busy with back-to-back patients, Wells said. A thorough child abuse exam takes about an hour and a half, and insurance usually doesn’t compensate a doctor for the extra time.
The goal is for Colorado to have experts spread across the state, meaning doctors will examine children sooner and give child protection caseworkers information to act more quickly if needed. The state will cover the cost of the training, and doctors who become part of the network will receive payment for providing exams.
In Durango, Dr. M. Cecile Fraley and her fellow pediatricians at Pediatric Partners of the Southwest regularly call the Kempe Center — six and a half hours away by car — for advice. The clinic’s eight doctors take turns being on call for Mercy Regional Medical Center in Durango and are often called to help with suspected cases of physical or sexual abuse.
When a case is complex, they consult a board-certified Kempe doctor — by phone or in person — in part because they might need the input if they end up having to testify in court on a child abuse criminal case. Children with serious injuries — such as head trauma — are sometimes transferred to Children’s Hospital Colorado in Aurora, but the first physician to see the child is often still called to testify.
“If you are going to go to court, that is just a very different world,” Fraley said. “Pediatricians don’t spend a lot of time in court.”
Fraley said she is certain one or more of the doctors and medical professionals in her office, who report numerous cases of suspected abuse and neglect to child welfare authorities every year, will take the new training when it’s offered.
“We all feel there is room for improvement,” she said.