Recently, the Portland Press Herald and other newspapers around the state reported on the death of 3-year-old Makinzlee Handrahan on Christmas Day 2022. Two months prior to her death, the child was reported to the Department of Health and Human Services by her day care because of bruises. According to her father, she was examined by two different doctors who did not find evidence of abuse.
This raises so many questions. What kind of doctors were they? What injuries were seen on the child? Were pictures taken? Was the child undressed and examined head to toe? Finally and most importantly, was a child abuse pediatrician consulted?
When a child is seen by a medical provider with possible abusive injuries one of three medical diagnoses are possible: injuries consistent with abuse, injuries more consistent with accidental injury, or injuries that do not provide enough information to determine whether they are inflicted or accidental.
The larger question, however, relates to the training and experience of the provider performing the examination. How many abusive injuries have they seen? When and how extensively were they trained in child abuse identification and diagnosis?
I can say from personal experience — first as a board-certified pediatrician, then a board-certified emergency physician, and finally over the past 35 years as a child abuse pediatrician — that few, if any, otherwise highly skilled family physicians, pediatricians and emergency physicians have the training and experience necessary to accurately determine if an injury is inflicted or accidental.
Study after study supports this conclusion. A 2009 paper reviewed children who were reported to child protective services for suspected physical abuse. All were evaluated first by a general pediatrician, family medicine physician, or emergency doctor, then by a child abuse pediatrician.
For 115 children, the first doctor offered a diagnosis of abuse or not abuse. On review by a child abuse pediatrician, 49 of these children had their diagnosis changed. In 80% of these 49 cases, the diagnosis was changed from abuse to not abuse, saving families from unnecessary intervention. In the remaining 20%, the diagnosis was changed from not abuse to abuse, protecting children from further harm.
According to a 2011 paper, 187 children referred to child protective services were compared in terms of diagnosis made by child abuse doctors versus primary care providers (pediatricians, family doctors, emergency physicians). Two independent child abuse pediatricians disagreed with the primary care provider in almost 50% of cases and disagreed with the child protective worker in almost 40% of cases.
Remarkably, the child abuse pediatrician was far more likely to rate a case as not abuse than the primary care physician and the child protective worker. In almost 30% of cases, where the expert thought abuse had not happened and child protective services and the primary physician thought it had, the child had already been removed from the home.
In these studies, a board-certified child abuse pediatrician, who has seen thousands of children for abuse assessment, who has undergone extensive training (usually three years of specialty training after three years of pediatric training and four years of medical school), and who is intimately familiar with the literature on child abuse, is far more skilled at making the correct abuse-related diagnosis than a primary care physician whose child maltreatment training is minimal at best and who might see maybe one case of abuse a year, if that.
In cases like this, where the child is seen specifically for abuse because of a referral by a child protective worker, a child abuse pediatrician must be consulted. If that didn’t happen in this case, we should not only ask why, but we should insist that future child protective protocols mandate a child abuse pediatrician consultation. Such a consultation might not have changed the diagnosis in Makinzlee’s case. What if it had?
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