We had met about one year before. She was a quiet, sheltered 16-year-old from West Africa who had recently settled with her family in San Francisco. I was a first-year resident in pediatrics.
The young woman came to my teen clinic frequently, sometimes for allergies, sometimes for rashes that I couldn’t see. I wondered if, like a lot of my female teen patients, she might be coming primarily to chat.
On what was to be our final visit before she left for college, I refilled her allergy medications and we said our good-byes. As she turned her head on the way out the door, I noticed minor swelling around her eye.
When I asked about it, she said, without hesitation, “Oh, my father hit me.”
Like all pediatricians, I am mandated by law to report any concern of child abuse. The laws differ by state, but in most places they require professionals in contact with children to report all suspicions of physical, sexual and emotional abuse or neglect in those younger than 18, whether or not there’s substantiating evidence. The laws were clear that I should report the young woman’s father. My conscience wasn’t so certain.
This case was different
Each year in the United States, an estimated 2,400 children die as a result of mistreatment, and more than 500,000 are seriously injured or disabled. Certainly, mandatory reporting protects children, and, until this case, I’d never questioned my role in the system. In my short career, I’ve filed dozens of suspected child abuse reports, mostly for young children with suspicious breaks or burns. In medical school I attended seminars about how to recognize abuse patterns and the requirements for reporting.
This case was different. This time my patient was only months away from her 18th birthday, at which point mandatory reporting laws would no longer apply. Never before had I explained the reporting process without a parent present. (Her mother, through an interpreter, had given me permission to see the teen on her own.) Never before had a patient urged me not to report her father, insisting that although he had intentionally bruised her, it was an acceptable punishment in her culture. Never before had I thought seriously that reporting a case of abuse might not be in my patient’s best interest.
I wasn’t sure what to do. On one hand, I had more than just suspicion of parental violence against a child under age 18. On the other, reporting the abuse would clearly undermine this patient’s trust in me and possibly disrupt her life.
I asked my supervisor for help. “This is why mandatory reporting exists,” she told me. “The law helps you make the right decision despite your emotional connection to the child and the family. Your job is to recognize and report child abuse. It is Child Protective Services’ job to weigh the nuances of what you described and to determine if they need to intervene.”
I told my patient I’d be making a child abuse report. She didn’t respond.
For six days after I filed the report, I heard nothing from Child Protective Services or from my patient. I was relieved. I assumed the case had either been dropped or handled without too much difficulty. On the seventh day, my patient showed up in my office in a panic. The authorities had visited her home, and she was afraid her father would be deported. She couldn’t go to college now, she said. Her family was going to need her financial and emotional support.
But her biggest fear was that her father would never forgive her. He’d been in the right, she insisted. “To accuse my father of wrongdoing is the worst thing I could do,” she told me. “I don’t understand what he did wrong. Don’t all fathers punish with their hands?”
Day after day, she begged me to rescind the report. “Please, call the caseworker and tell her that I lied, that nothing happened. Please.”
I did call the caseworker, hoping I could find out what was happening and urge the investigator to weigh the potential benefits of intervention with the risk of dissolving a family and destroying this young woman’s opportunity for a college education. I left a phone message. I never received a response.
Perhaps, as someone suggested later, the case had been passed to another caseworker. Only later did it occur to me that I could have tried to track down a supervisor.
After four weeks of visits from my distraught patient and silence from Child Protective Services, the young woman stopped coming to my office. I received a handwritten note from the agency telling me that the case had been closed without any action.
I didn’t know what had happened — and still don’t. But my assumption was that my patient had denied the abuse.
My initial reaction was gratitude. I was thankful that the young woman had learned enough about the system to lie to protect herself and her family. Although this was clearly child abuse, reporting it harmed her chances of going to college and leaving the abuse behind. But the more I thought about it, the angrier I became. How is it that we’ve developed a system that encourages patients to lie?
A survey in the early 2000s by the American Academy of Pediatrics found that in 27 percent of cases in which pediatricians thought injuries were “likely or very likely” to have been caused by abuse, they chose not to file reports. In 76 percent of cases in which doctors considered injuries to have been “possibly” caused by abuse, clinicians chose not to file reports.
One of the most common reasons for non-reporting was lack of confidence in Child Protective Services. Many doctors say that past experiences with negative outcomes, as well as lack of communication about cases they’ve referred, make them less likely to report.
Both pediatricians and Child Protective Services have the same overarching goal: to protect children. But poor communication — on both sides — can undermine our joint mission.
Most reports of suspected abuse or neglect begin with a phone call in which an intake specialist assesses the child’s immediate safety and determines the response that is needed. Then the case is passed to an investigator to determine if the claim is valid and whether legal action, case management or a combination of the two are warranted.
In a minority of cases, the child is removed from an unsafe home. More commonly, a caseworker assists the family or refers the family to counseling or other support services. This entire process takes place in a matter of days to weeks, with responsibility for the case rapidly passing from one Child Protective Services specialist to another.
Meanwhile, we pediatricians worry about a child’s well-being once he or she enters this bureaucratic maze. Furthermore, we know that by making a child abuse report we often alienate a family. Indeed, many of the clinicians in that AAP survey said they had lost families as patients as a result of the reporting.
Changes to the system are slowly coming to fruition. There are now hundreds of child advocacy centers where medical professionals, law enforcement agents and Child Protective Services representatives work together under the same roof. These centers are a step in the right direction, but they require extensive coordinating and funding to be effective.
There are other, less expensive solutions. One is to expand physician training on how to work with Child Protective Services. A model training program already exists in Pennsylvania, in which child protection officers work with physicians on strategies for recognizing child abuse. Another solution might be expanding the training that medical students and residents who care for children receive in evaluating and reporting suspected abuse.
A nuanced response
My patient did eventually go to college. Her father remained in the United States. For a while, I was back to being her doctor. She e-mailed questions and continued to visit on occasion, but she always avoided discussing what had happened the summer before.
At one point I asked her what she’d learned from her experience with Child Protective Services. Was the lesson that sometimes she needed to lie to authorities to protect herself and her family? That she shouldn’t be open and honest with her doctors? She ignored me, then deftly changed the subject. And I wondered if somewhere along the way she’d learned that she didn’t deserve to be hit.
I’m not sure whether knowing what I know now would have changed my initial decision. But I do know that it means I want to be involved in every child abuse case I encounter by making personal relationships with CPS workers.
Although I still support the spirit of mandatory reporting laws, I recognize the need for the system to be able to respond in a nuanced way. I also recognize the need for more age flexibility in mandatory reporting laws, as the needs of older teens experiencing family violence differ from those of infants and young children.
After a few months, e-mails to my patient began to bounce back, and the family phone was disconnected. Then, this spring, I received a message from her. She’d be home from college in the summer, she wrote. Could she shadow me at work as she explored a possible career in health care?
Her e-mail gave me hope. Perhaps some day when she is wearing her white coat and sitting on her red stool across from a crying teenager, she won’t feel as helpless as I did.
Sherer recently completed a pediatric residency in the Pediatric Leadership for the Underserved program at the University of California at San Francisco. This essay was written as part of the university’s Partnership for Physician Advocacy Skills curriculum and produced by Health Affairs NarrativeMatters, from which this was adapted.