From the Doctor to DCS
In the late 1960s, child protection teams formed at many hospitals. Their initial purpose was a benevolent one. Doctors believed they were treating children with inflicted injuries due to parents’ ignorance about the dangers of shaking infants, even when just playing/rough-housing. So child protection teams educated parents about the dangers of shaking.
Through federal legislation that provided funding to states to form child protection agencies, the focus seemed to shift, however, from educating parents to punishing them. As a result of this legislation and laws mandating doctors report alleged child abuse and neglect, pediatricians became an important component of the child protection system.
In 2009, a board certification was created for a subspecialty of pediatrics focused on child abuse. Many children’s hospitals hired child abuse pediatricians (CAPs). CAPs do not, on their own, generate reimbursable costs for hospitals. Thus, hospitals largely pay for CAPs through funding received by child protection agencies. This funding is awarded through contracts between the Department of Child Services (DCS) and the child protection team at the hospital.
There are roughly 350 CAPs in the United States. Indiana currently has six CAPs. For years, the Indiana DCS has contracted with the IU School of Medicine’s Child Protection Program. The program was created in 1985.
Over the last fifteen years, the scope of the CAPs’ duties, as well as the dollar amount of the contract, has greatly expanded. In 2011, for example, the CAPs agreed to do the following:
handle all “medical cases involving the assessment of medical issues related to possible child maltreatment involving suspected abusive head trauma and trauma to the head and/or neck of any age child”;
handle up to 100 “comprehensive cases,” which involve all other cases of suspected child maltreatment (sexual abuse, physical abuse, Munchausen by Proxy Syndrome, etc.).
In return, DCS would pay up to $441,000 per year. Only one year later, however, the contract was amended to more than double the funding for the following year (2013), and to triple it in 2014. In return, DCS expanded the cases that had to be referred to the child protection team by including all fractures, suspected fractures, and burns in any child under the age of three. The amendment also limited the other mandatory referral cases with suspected head/neck trauma to only children under the age of ten. A copy of the contract and amendments can be viewed here.
Over the next several years, the amount of money paid by DCS to the child protection team continued to increase:
2014-2016: $3.12 million (contract can be viewed here).
2016-2018: $3.84 million (amendment can be viewed here).
2018-2020: $3.78 million (contract can be viewed here).
2020-2022: $3.78 million (amendment can be viewed here).
2022-2024: $5.34 million (contract can be viewed here).
2024-2026: $5.58 million (amendment can be viewed here).
Currently, every child under the age of six with suspected abusive head trauma or trauma to the head or neck must be referred to a CAP to determine whether the injury was caused by abuse or neglect. Also, every child under the age of three who suffered a fracture, a possible fracture, or a burn of any kind must be referred to a CAP to determine whether the injury was caused by abuse or neglect. Finally, in any case where someone suspects a child may have been physically or sexually abused, or may have been the victim of “factitious disorder imposed on another” (i.e., Munchausen Syndrome by Proxy) may be referred to a CAP to determine whether the child was a victim of abuse or neglect.
CAPs have a significant amount of power and influence. Doctors, nurses, and other healthcare providers are all mandatory reporters. They have been trained to contact DCS when they observe the injuries described just above. DCS then refers those cases on to CAPs, who believe they are able to diagnose abuse simply from the constellation of injuries observed.
Every case of abusive head trauma I have reviewed in my practice began with a child being brought to a hospital for an emergency, the matter being referred to DCS, and DCS consulting a CAP to determine whether the injury was intentionally inflicted. Based solely on the CAPs opinion, the child may be removed from the family, and the caregiver may be criminally charged.