By Sara Werner, Contributor, Imani Worthy, Parent Leader and Keyna Franklin, Assistant Editor

In When the Misdiagnosis Is Child Abuse, published in The Atlantic and The Marshall Project, journalist Stephanie Clifford reported about child abuse pediatricians — doctors who are trained to determine whether kids’ injuries are accidental or inflicted. In most cases, these conclusions can’t be made with certainty — but the child welfare system often takes them as fact. As Clifford documented, this has resulted in the unnecessary separation of families, incarceration of parents who have not harmed their children and trauma for both children and parents.

Here, Clifford discusses her reporting process and what she learned from parents, as well as the role of power dynamics, racism and classism in these situations. She shares recommendations for change and for how parents can protect themselves from a false accusation.

Q. Can you tell us about your reporting process and the  experiences of parents who talked with you?

A. After talking with someone who worked in family court and was familiar with child abuse pediatricians, I began looking into the field of child abuse pediatricians. I looked at statistics about how the field has grown and at studies about child abuse pediatricians’ diagnoses. I also talked with families who’d been accused of child abuse by child abuse pediatricians and wanted to share their stories.

These families had brought their babies to the hospital, thinking that the people they were talking to would help them figure out what was going wrong. They didn’t realize that,in a hospital, some of the people asking questions may be child abuse pediatricians who may help to form a case against you. The words they said to these pediatricians were later repeated back to them in court as evidence against them.

In one case, a dad was wrongfully charged with homicide for murdering his child. He spent a year and a half in prison. The father and mother both spiraled into depression and considered suicide. It’s really wrenching what these families went through and how scary it was for them to lose their children.

Q. What is the role of racism and classism in doctors’ suspicions of child abuse and neglect?

A. Several studies show that Black, Hispanic and Native children are over reported for suspicion of child abuse. In one study, child abuse pediatricians were given cues about the race and class of the family and then the researchers reversed those cues, keeping everything else the same. The pediatricians’ diagnoses changed in 40% of cases. Clearly, race and class are a big part of these doctors’ diagnosis.

In training, child abuse pediatricians are taught to look closely at single-parent families and military families — at indicators that in their mind have a higher link to child abuse, but also have troubling socioeconomic and racial overtones.

Q. How are child abuse pediatricians trained to determine whether a child’s injury involves abuse or neglect?

A. They go through regular pediatrician training and then take extra training on child abuse — which bone breaks are consistent with induced fractures rather than accidental fractures and what bleeding patterns occur in the brain when a child is shaken. They look at a multitude of factors, but there’s no test you can do to say with 100% certainty whether abuse has or hasn’t taken place. This training can give the impression of over-certainty that abuse has occurred when there are other explanations.

In one case, a dad I spoke with was accused of shaking the baby hard enough that the baby had hemorrhaging in his brain. It turned out that the baby had a rare blood disorder that caused excessive brain bleeding — even a really mild rollover could have caused it.

In another family, the child presented with fractures. He had just come out of a long hospital stay. The doctor said it was likely that the fractures occurred at home. After the child and his sister had been separated from the parents for six months, another doctor took a look and said that, in fact, the child’s bones were really thin from earlier treatments and the fractures could have occurred even with gentle handling.

As a family defense lawyer said, “The problem is that when you’re trained to see child abuse, you just see child abuse.” Also, once the child abuse pediatrician’s opinion gets transferred to the child welfare or family court system, it’s taken as fact, even if it’s a nuanced opinion. Police and child welfare workers repeat it. In one case, the doctor said, “This is likely, I can’t say for certain” — but it was translated by child welfare as, “It’s child abuse. We have to separate this family immediately.”

Child abuse pediatricians look at the evidence and try to make their best guess as to what happened. They want to help catch child abuse, which is especially hard with little kids. They make a medical evaluation and often believe that police and child welfare will do a completely independent, full investigation. That doesn’t usually happen. Once the child abuse pediatrician makes that diagnosis, it takes on a life of its own. A lot of them are unaware of how much power they have.

Q.  Can you tell us more about the power dynamics?  

A.  A child welfare worker has little to gain by challenging a doctor’s opinion. Child welfare investigators’ training is relatively short compared to doctors’ training. These doctors are trained to testify in court and regularly work with child welfare departments — with the child-welfare workers’ bosses and colleagues. The doctors are considered experts. Their conclusions are incredibly complex. One of the medical reports I reviewed was just fancy medical words. I didn’t understand what the doctor was saying. I would be surprised if the child welfare worker did unless they had medical training. Still, they just copy and paste the doctors’ very technical medical findings into their reports.

In one case, the child welfare worker did follow up. She met with the dad in jail, met with the mom and talked with the dad’s ex to see if there was any history of problems with the other children, which there wasn’t. All she could do was put that into a report saying, “I talked to these people, but the doctor says it’s abuse, so we’re going with that.”

Q. Your article mentions that child abuse practitioners don’t have to identify their roles to parents and are often funded by child welfare. What needs to change?

A. Both are conflicts. When you’re funded by child welfare, even if you say you’re independent, you lean toward child welfare as a point of view. I saw that in emails I obtained between child abuse pediatricians and the child welfare departments in Florida, where child abuse pediatricians were helping to shape cases against parents. They’re working on the side of child welfare and not as independent experts.

Legally, they don’t have to identify themselves. The courts have determined that they’re not state actors, meaning they’re not like police, so they don’t have to tell you who they are or what they’re doing. That’s really problematic because, as a parent, if you bring your kid to the E.R., doctors ask questions about what happened and you try to answer them. When child abuse pediatricians look for signs of abuse, they look for shifting explanations from parents. As a parent, if you have no idea how something happened, you try to come up with explanations, “I don’t know, maybe his sister hit him or our dog knocked him down.” You don’t realize that these statements may be going into an official record and can be used as evidence that you’re trying to cover something up.

Ethically, hospitals should think hard about requiring child abuse pediatricians to tell parents that they’re investigating possible causes and parents’ possible role, so parents aren’t at such a disadvantage.

Q. Did you learn about any recommendations for addressing this issue?

A. Child abuse pediatrics is one of the only medical fields where they have no idea of outcomes — they make decisions and there’s no follow up. They don’t know if the child was returned to the family or whether or not there were further suspicious injuries. There needs to be more follow up and post-diagnosis analysis so they understand what they’re getting right or wrong and why.

The Texas state legislature is considering narrowing the definition of neglect and adding due-process rights for parents, under State Bill 190. There’s also an idea that second opinions should be required in child-abuse pediatrics — any time a child abuse pediatrician is called in, a second doctor will independently also make a decision based on those records. A child abuse pediatrician may be looking one way at things, so it’s helpful to have another pediatrician look at the same records and say, “Maybe there’s a little more nuance here.”

Another problem is that child welfare workers are worried about missing a case of abuse and ending up on the front page of The New York Post.  There’s so much fear that a lot of child welfare workers don’t consider the flip side — that taking a child away from a family even in the short term has long-term consequences for the child and family. Child welfare workers could be more open to hearing families’ experiences about what it’s like when a kid is taken away and how hard it is to get a kid back and have a little more understanding of what it means when they file for separation.

Q. What can parents do to protect against false accusations from child abuse pediatricians?

A. Unfortunately, parents have to be on guard when they take their children to pediatricians or hospitals.  If there are genetic issues in your family like bleeding issues or bone breakage, it’s important to document them and have a file ready. If there’s an unexplained injury, a child abuse pediatrician may be called in. Knowing what I know now, if I brought my kid to a pediatric E.R. and didn’t know how they had been injured, I would Google the doctors’ names to find out their role. That way, I would know if a child abuse pediatrician is asking questions that may be used to build a case against me.

They look for people being standoffish or defensive or not answering questions — things that shouldn’t be part of an assessment. Parents can try to be helpful and open while also protecting yourself and your family. It’s a hard line to walk.

The moment a child abuse pediatrician is involved, stop talking and reach out to a lawyer or service that can help with defense. It’s critical to have a lawyer well versed in medical cases. That doesn’t necessarily mean a private lawyer. In New York, the family defense agencies have excellent public defenders who are well versed in medically complex cases. The lawyer can get experts to evaluate records to see what may have been going on medically. They’re generally able to get better custody and visitation agreements. The system is stacked against parents and you need a lawyer to help balance it out.

Q. If the child abuse pediatrician is wrong in accusing a parent of abuse or neglect, are they held accountable for the trauma families experience?

A. One of the families I reported about had a great public defender who fought their case very hard and the charges against the dad were dropped. But they didn’t have money to hire lawyers for additional lawsuits, which would be needed for a civil suit.

The other family had more resources. They were upset by what had happened and were well aware that they were an exception, being a well-off white family. They said, “If we had to go through this, so many people who don’t have the same resources probably go through this as well.” They brought a civil case against the hospital, the child welfare worker and the doctor, but these cases are very hard. Generally as long as it’s not a severe and intended misdiagnosis, the judge will say, “The doctor may have made the wrong call, but there’s not much we can do.” The judge dropped the case against the doctor and hospital. The case against the child welfare worker is still going on. I looked at several cases where parents sued the doctors and they’ve all been dropped.

Q. Did the parents you talked to have a parent advocate or other support while going through this type of accusation?

A. One family found a support group for parents, but they didn’t know about it while the case was going on. That family is now working and volunteering with the same group, which helps parents in this situation. It’s called the Family Justice Resource Center.  There’s also a group pushing for policy changes on this front called United Family Advocates.

In court, there is a lawyer for the parents, but the lawyer is not an emotional support person. This is one of the worst things that can happen to parents — having your child taken away and being accused of hurting them. Both families felt alone and ashamed. One of the families lost custody of their children for six months. They didn’t tell their close friends because they felt like they’d done something wrong and were bad parents. They didn’t do anything wrong and weren’t bad parents. They could have used a lot of support. One of the moms would lay on the floor next to the empty crib at night and cry. Maybe if she were able to talk to another parent who had gone through that or who was going through that, she would have felt a little more supported and a little less isolated.

Q. What impact do you think your article had?

A. I received many emails from parents who had been or were going through this. A lot of them didn’t realize that other parents had been through this or that there are child abuse pediatricians nationally. Hopefully, it helps people to hear that they’re not alone and haven’t done something wrong. Ideally, it will help change the system and make it a little fairer for parents. Perhaps it will help child abuse pediatricians understand the power of their diagnoses so that they consider all the factors more before they make the call — or if they’re not sure and it looks like it could be child abuse, but might not be, to make that clear in their reports so it doesn’t seem like hard fact.