Pediatric Program Takes On Child Abuse

Jill Glick, MD, was considering a difficult diagnosis: whether a child's red and blistering skin was the result of abuse. The mother insisted it was an accident. The child would only say “mommy burned me.”

“Is it a plausible story? Sure,” Glick told a team of collaborators who considered the parent's statement. “Is it really what happened? We don't know.”

Comer Children's Hospital at the University of Chicago has an interdisciplinary team of experts to evaluate possible child abuse cases. Glick, medical director of Child Protective Services, works alongside Lindsay Forrey, LCSW, Child Protective Services program manager and 10 licensed social workers. The team also includes two liaisons from the Illinois Department of Children and Family Services (DCFS) and a case coordinator from the Chicago Children’s Advocacy Center.

The team investigates all suspected pediatric cases of neglect, sexual abuse or physical abuse. The vast majority of cases are investigated for concerns of physical abuse (injuries to the head, bones or internal organs) or neglect (severe malnourishment, frequently missed appointments or incorrect home management of the child’s chronic condition). Nationally, abuse is the fourth leading cause of death for children. Glick said a thorough investigation is particularly important for children under 3 years old, because they have the highest death rate from abuse and also because they cannot communicate how they obtained their injuries the way older children can.

At the University of Chicago Medicine, every employee is required to consult with the Child Protective Services team on suspected cases of abuse and neglect, just as a medical specialist would be called in to observe a patient for a medical consultation with regard to a diagnosis. The team has a systematic, scientifically based approach.

Without these extra measures, Glick maintains that many cases of abuse would go unnoticed. “It's hard for a pediatrician to be objective,” Glick said. “It's really difficult to accept that this person staring at you may have injured their baby.” For children too young to speak, Glick insists mandatory evaluations by a medically directed child abuse team, lead by a child abuse pediatrician, are the only way to be sure.

In 2009, the team investigated 491 inpatients for concerns of abuse or neglect. The Comer Children’s Hospital Kids First Clinic is the outpatient arm of CPS and provides a medical home for children in high-risk families. Last year, 79 children were seen in the Clinic and 48 percent of them had been hospitalized previously for abuse or neglect. Most children have been evaluated by CPS while hospitalized and are referred to the clinic for ongoing care. Many have fallen through the cracks in the health care system because their families face barriers such as mental illness, family violence or cognitive impairments, said Staley, the Clinic's director. In addition to support from the University of Chicago Medicine, the Clinic receives funding from Chicago White Sox Charities, the Visiting Nurses Association and the Chicago Blackhawks.

The Child Protective Services team also aids Chicago community hospitals that do not have a specialist in child abuse injuries. In 2001, Glick championed the Multidisciplinary Pediatric Education and Evaluation Consortium, which requires that children under age 3 who are reported to the DCFS be assigned to a child abuse pediatrician at one of three hospitals to work in an interdisciplinary manner with DCFS and police to assess the injuries.

"Many children's hospitals unfortunately have not made the necessary commitment to support a child abuse pediatrician-lead, interdisciplinary team," Glick said. "This program is the only mandated medical expert consultation program in the country."

DCFS assigns the case to a specialist at one of three larger hospitals in the city, including Comer Children's Hospital. A medical specialist reviews the injury, interviews the parent and the child, and then advises DCFS. The team meets with liaisons from DCFS and the Chicago Children's Advocacy Center every Tuesday to review that week's cases.

“The doctors help us understand the medical dynamics,” said Shirley Dukes-Robinson, public service administrator for DCFS. “They know what to look for, what to ask and how to push the case forward.”

This means that if DCFS has determined that a child’s case should go to court, physicians like Glick are called in to testify, based on medical expert consultations, on whether a child’s injuries were accidental or deliberate, said Lindsay Forrey, LCSW, a social worker and program manager on the Child Protective Services team.

Through the efforts of Glick and other abuse prevention advocates, child abuse pediatrics is now recognized as a medical subspecialty by the American Board of Pediatrics. Last November, Glick passed the first board examinations along with about 200 other abuse experts.

April 2010