More than 25 percent of doctors who believed a child's injuries were abuse-related failed to report their concerns to child protective services, a recent study found.
The study of 15,003 child-injury visits to doctors in more than 40 states highlighted a disparity between doctors' suspicions and their willingness to contact local authorities.
"Physicians have a lot of different opportunities to protect children from abuse and neglect," said Dr. Antoinette Laskey, an Indianapolis-based forensic pediatrician who is chair of the state's Child Fatality Review Team. "If you don't do something, it may be the child who pays the ultimate price."
Indiana law requires health care providers to examine, photograph and report to authorities any children's injuries they suspect are abuse-related. Other states have similar mandatory reporting laws.
But those laws sometimes aren't enough to persuade doctors to speak up.
A Lowell boy died in 2008 despite his pediatrician documenting her concerns multiple times in the months leading up to his death, Indiana Department of Child Services records show. The doctor of 18-month-old Anthony Mogan never shared her worries with authorities.
Anthony died of blunt force trauma injuries in October 2008, three months after his pediatrician treated the first signs of suspected abuse.
The study of child-injury visits throughout the country revealed several reasons for health care providers' reluctance to report their concerns.
Why doctors fail
Dr. Emalee Flaherty is a Chicago-based child abuse pediatrician at Northwestern Memorial Hospital and Children's Memorial Hospital who worked on the study. She said some doctors' silences are the result of:
an uncertainty as to whether the injuries are abuse-related
a lack of faith in child protective agencies' ability to stop abuse
a fear the state agency will take children away from their parents
a hesitation to get involved in a potential legal process
A local hospital was sued in 2006 after it reported the alleged abuse of an 11-month-old girl to DCS and a local police department, Lake Superior Court records show. Records did not reveal the name of the hospital.
DCS came to the hospital May 3, 2004 -- two days after the allegation was reported -- to investigate and, later that day, let the infant go home with her family. The girl's 12-year-old stepbrother was questioned during the investigation.
The girl's parents filed a lawsuit against the hospital, alleging a medical malpractice that caused the family to be separated during the investigation. Their attorney did not return multiple phone calls seeking comment.
The Indiana Court of Appeals ruled in January the hospital has immunity for reporting the alleged abuse in good faith. To do otherwise would have a "chilling effect" on the reporting of child abuse, the judges noted in their unanimous opinion.
That decision follows the lead of state courts throughout the country in protecting health care professionals who act in good faith when reporting alleged abuse or neglect.
Sharon Stanzione, attorney for the hospital in the suit, said it is important for hospitals to be able to freely report their concerns.
"They are an advocate for the child when perhaps no one else is," Stanzione said. "There shouldn't be any obstacles or deterrents to that as long as they act in good faith in making the report."
But sometimes physicians don't recognize the signs of abuse.
Doctors initially overlooked signs of abuse in one-fifth of children younger than 3-years-old who were brought to the hospital with fractures, according to a study by doctors at the Hospital for Sick Children in Toronto.
It took between one day and 160 days to correct the diagnosis, data show.
The study analyzed the medical records of 258 children who were younger than 3 and taken to a large academic children's hospital for abuse-related fractures between January 1993 and December 2007.
But the study may not tell the whole story. It does not account for how many children's abusive fractures were either never detected or never referred to the hospital's child protection team.
Flaherty, who was not involved in that study, said doctors in her experience often have difficulty distinguishing whether an injury is the result of abuse.
Many children's injuries fall in a gray area between an accident and abuse, and many doctors don't realize they don't have to be certain about abuse to report their suspicions, she said.
"In medicine, the first law is do no harm," Flaherty said. "You have to weigh the harm to the child versus the harm to the family (by reporting it). People don't always appreciate what the harm would be to the child for one separate injury."
A reasonable lie
Laskey, the Indiana forensic pediatrician, noted several things a doctor should do if a child's injury looks like it may be the result of abuse.
Laskey specializes in child abuse pediatrics, helping doctors, child services and law enforcement officials determine whether a child's injuries are the result of abuse.
Doctors should consider how a child of a particular age could sustain that kind of an injury, how well-developed the child is for his or her age and how often the injuries occur, Laskey said.
She said doctors also should do a mandatory skeletal survey for any child with a skull fracture.
Laskey said it shouldn't matter how much a doctor likes the child's family or how long the doctor has known them. Too often doctors are lulled by "a reasonable lie," she said.
"Instead of trying to make it work ... you need to step back and ask 'Is there a chance that something else is going on? Is there something I don't know?' "
Laskey said any doctor with concerns about the welfare of a child should immediately report them to DCS or a local law enforcement agency.
Those who fail to relay concerns can be charged with a misdemeanor count of failure to report. But a doctor's risk of criminal penalty doesn't compare to the potential risk to the child.
"By failing your mandated obligation, a child is placed in further harm and may die," Laskey said.
She said it is rare for a parent to get angry with her for looking out for the child's welfare. She said she simply tells them it is required by law and that it is a process they will go through together to ensure the child's safety.
DCS will not remove children from a home just because an allegation of abuse or neglect has been reported, officials point out.
Still, some doctors believe they are better equipped to look out for a child's well-being, Flaherty said.
"I have a much better perspective about what happens," Flaherty said. "I know things are not always done correctly, but I understand the law. You need to work with the system in order to make things happen."
In 27 percent of cases where a doctor believed a child's injury was "likely" or "very likely" the result of abuse, that doctor did not report it, the study shows. The doctors and physicians' assistants documented each injury themselves, referenced the likelihood of its being the result of abuse and noted what, if any, action the doctors took.
The study of 15,003 child-injury visits to doctors in more than 40 states highlighted a disparity between doctors' suspicions and their willingness to contact child protective agencies.