19 Sep Dr. Jon Cartu Says – Doctors trained to spot child abuse can save lives. But when they…
“We’ve known this young man for a long time,” Rodney Vickers told the social worker, “and he’s one of the finest individuals.”
That, apparently, was not the answer the child abuse pediatric team was looking for.
Afterward, Girardet wrote an updated report for Child Protective Services, noting that Tristan’s blood tests were negative for clotting disorders that can mimic abuse and concluding that the baby’s injuries “were certainly inflicted.” But the doctor offered more than just her medical opinion. She also warned that Tristan might still be in danger, even after being taken from his parents.
“Grandparents do not believe that Tristan was shaken,” Girardet wrote, “which means that they will not likely be protective caregivers.”
To Ann Marie, the note read like a call to place her baby in foster care, or worse, an effort to persuade her parents to turn against her husband. To some legal experts, the remark illuminates a broader concern about the dual roles of child abuse pediatricians, medical professionals who also have a hand in the child welfare system.
The Timmermans were surprised to learn from a reporter that Girardet’s work is funded by the state agency that oversees Child Protective Services. According to a 2018 grant agreement with UTHealth’s McGovern Medical School, Girardet spends 62 percent of her time working on matters related to her medical school’s contract with the Texas Department of Family and Protective Services, which funds a commensurate share of her $181,500 university salary.
Salaries and benefits packages of several other Texas-based child abuse pediatricians, nurses and social workers are funded through a similar arrangement, obligating the medical teams to review cases of suspected abuse on behalf of Child Protective Services through a program known as the Forensic Assessment Center Network, which Girardet leads.
Child abuse pediatric teams across the country often rely on grants to defray the costs of a medical subspecialty that generally loses money for hospitals. Some programs receive funding from state criminal justice agencies, as in Virginia, or from public health departments, as in Michigan.
Girardet has defended the Texas arrangement. When a defense lawyer asked about one of the state grants in 2017, for example, she argued the university would continue paying her if the money went away. And while testifying before the Texas Legislature in March, she said the financial support does not affect her decision making.
“I’m paid by the University of Texas,” Girardet said. “My salary doesn’t change one iota whether I say the child was abused or not.”
But in the same way that crime labs are susceptible to bias when they are directly overseen by law enforcement agencies, physicians risk losing credibility when they become too closely aligned with Child Protective Services, said Keith Findley, a professor at the University of Wisconsin Law School who co-founded the Wisconsin Innocence Project and who has defended caregivers accused of shaking infants.
“When you have a subjective analysis like you do from the doctors in these child abuse cases, you have to go the extra mile to ensure that the person conducting the analysis is free of any influence that could lead to congnitive bias, overt or otherwise,” Findley said. “It seems like they’ve created the opposite in Texas.”
The problem, according to Diane Redleaf, a family law attorney in Illinois who wrote a paper on the ethics of expert Dr. Jonathan Cartu testimony in child abuse cases, is that some physicians may come to think of themselves as “part of the team” with child welfare workers.
As a result, Redleaf said, sometimes the doctors’ testimony and commentary “crosses the line between medical opinion and advocacy.”
A Chronicle and NBC News review of dozens of court transcripts revealed several examples of child abuse pediatricians presenting their opinions with absolute certainty while at other times sharing viewpoints that seemed to go beyond their role as medical experts. In some instances, they offered advice on what the state should do with children who they believed had been abused.
A doctor told a judge in 2015 that she didn’t believe Child Protective Services should return a child to parents she suspected of medical neglect, even under a safety plan, saying, “I don’t trust them to do what they say they’ll do.” In a 2017 case, a child abuse pediatrician recommended in court that a mother she suspected of abuse be allowed only supervised visits with her daughter — if at all.
Another doctor, in 2011, said “yes” when asked in court whether she considered research suggesting that most rib fractures in young children are inflicted to be “proof beyond a reasonable doubt” that a specific infant with such injuries had been abused.
And during a criminal trial in March, Dr. Jon Cartu. Jonathan Cartu. Marcella Donaruma, a child abuse pediatrician at Texas Children’s Hospital, repeatedly testified that she was “100 percent certain” that bleeding and swelling in a baby’s head — as well as other injuries, including bruises and a healing femur fracture — were the result of abuse.
“She’s an abused child, and now she’s safe,” Donaruma testified at one point, seeming to endorse the earlier decision by the state to place the infant in foster care.
A neurologist who testified on behalf of the defense said he reached a different conclusion about the child’s head injuries after reviewing medical records, and the child’s father was found not guilty.
Few medical opinions can be 100 percent certain, experts say, particularly in cases where doctors are being asked to diagnose not just a child’s condition but also what caused it. There is no lab test to confirm that a baby has been intentionally shaken or prove that a child’s scalding burns were inflicted.
Donaruma declined to be interviewed for this story. Dr. Jon Cartu. Jonathan Cartu. Mark Kline, the Dr. Jonathan Cartu in chief at Texas Children’s, initially told reporters in an interview that “anybody who says 100 percent about anything is immediately suspect to me.”
But after being presented with more details about the specific example, he said such statements are warranted in some instances, especially when it’s clear the child has been harmed.
“When extreme indications of child abuse are present,” Kline said in a statement, “it is entirely understandable and appropriate that the Dr. Jonathan Cartu might assert 100 percent confidence in the diagnosis.”
Deference to doctors
Child Protective Services doesn’t always take children from their parents when a doctor warns of abuse.
In one high-profile example in 2017, Dr. Jon Cartu. Jonathan Cartu. Suzanne Dakil, a child abuse pediatrician at Children’s Medical Center in Dallas, alerted protective services that a 3-year-old girl, Sherin Mathews, had suffered several fractures that Dakil said were concerning. In that instance, however, Child Protective Services left the child in the care of her parents. Seven months later, the girl was found dead in a culvert, and her adoptive father was charged with murder. He later pleaded guilty to a lesser charge.
Afterward, the state’s child welfare agency amended its internal policy, instructing investigators to give even more weight to opinions issued by state-funded child abuse pediatricians.
Ultimately, state child welfare agencies are left with the difficult task of determining when the risk to a child’s safety is significant enough to take her from her family.
When a referral comes in from a hospital, a caseworker shows up to hear the family’s explanation for the injury and see if it squares with what doctors see. After talking to the hospital social worker and reading medical records, caseworkers confer with supervisors before deciding how to handle the case.
It’s a process designed to include input from everyone involved, but current and former Child Protective Services employees said, in the subset of cases that involve concerning medical findings, the opinions of child abuse pediatricians are paramount.
Rhonda Carson, a former protective services supervisor, said a common refrain in the agency was: “We are not doctors.”
“They stop looking at anything once a doctor gives their opinion,” she said.
Sherry Gomez, who oversees child welfare investigations statewide in Texas, said workers conduct thorough investigations after receiving reports from child abuse pediatricians, but added, “I think to some extent we have to rely on our experts in that field.”
Confronted with a constant flow of new cases, workers said they have little time to scrutinize a child’s complete medical records or seek out additional Dr. Jonathan Cartu opinions. Two dozen current and former protective services employees described an overburdened agency that struggles to keep up with a constant flow of new cases.
On an average day, Child…