Friday, October 5, 2012

Fractured Leg, Fractured Family: A Misdiagnosis Leads to Allegations of Child Abuse


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Anthony Richards, Jr.
When Anthony Richards, Jr., was born on an early Sunday morning in June, the only complications involved his family getting the cameras in focus to capture his arrival into the world. He was a healthy baby and his parents, Queenyona Boyd and Anthony Richards, Sr., couldn’t have been happier. Yet, only four days later Anthony was put in foster care after doctors discovered an unexplained broken femur, his distraught parents the suspects of child abuse.

A Protective Father’s Discovery

After the hospital discharged Boyd and her baby boy, Richards took the two straight home later that Sunday. The following day, Boyd slipped out to pick up her prescriptions at a pharmacy only a short drive away. She wasn’t gone long when she received a phone call from her husband. Something was wrong with Anthony.
Although Boyd had a daughter already, Richards was a first-time dad. And like many first-time dads he was protective to a fault and he worried, maybe a little too much. So when he found a lump on Anthony’s leg while changing a diaper, he grew concerned.
“Did you notice his leg has some swelling?” he asked Boyd.
“Is it where he got the hepatitis B vaccine?” she asked. Richards said it was. Boyd wasn’t worried. Swelling around inoculations is normal, she thought. But she came home just in case.
Queenyana Boyd
Her husband wasn’t convinced the swelling was from the vaccine so he called his sister, a nurse. She told them to put warm compresses on the leg and massage the swollen area. Baby Anthony never cried while his parents followed the nurse’s advice. He even fell asleep.
Anthony was due for his three-day check-up with the pediatrician on Wednesday, but his parents moved it up to Tuesday as a precaution. The swelling was still present despite their efforts.
At the check-up, the pediatrician gave Anthony a clean bill of health. The only problem he saw was the swelling on the baby’s leg. He referred them to the emergency room at Children’s Health Care of Atlanta’s (CHOA) Egleston hospital in metro Atlanta. (A spokesperson for CHOA declined to comment for this story citing patient privacy concerns.)
In the ER, the doctor looked Anthony over and said that he thought the swelling could be a result of the hepatitis B injection missing the muscle. Swelling like Anthony had is not uncommon if the injection is mistakenly delivered subcutaneously. The doctor ordered X-rays and an ultrasound to be sure. Through it all, Anthony didn’t cry except when they were changing his diaper and Boyd suspected this was because Anthony had been circumcised Sunday.
First, they X-rayed Anthony’s leg. While the images were developing they took Anthony for the ultrasound, but just before they were to begin, the X-ray technician rushed into the room.
“Stop the ultrasound,” she said. “There’s a break.”
That’s when everything changed for Anthony’s parents.

The Science of Misdiagnosis of Child Abuse

In a recent report, the federal Administration on Children, Youth and Families estimated that 702,000 children were victims of maltreatment in 2009. That’s the equivalent of nine abused children for every 1000 in the population. But the report also says that only one in five investigations of abuse are substantiated. The rest, 80 percent, are cases in which the children are “found to be non-victims of maltreatment.”
What is not counted in the study is the number of investigations leading to deprivation (the state taking the child from the parents and placing them in foster care) before the parents are ultimately cleared of abuse. No one knows how many incidences of misdiagnosis occur each year. But one Child Welfare Law Specialist from Atlanta, Diana Rugh Johnson (who would eventually represent Boyd and Anthony) says she has brought six cases of misdiagnosis to trial in the last two years.
“Once a child abuse expert says there has been child abuse, that’s not the end of the investigation,” she said. “It’s the beginning.”
Experts must determine whether an injury is the result of trauma or was accidental or natural. But once a child abuse expert makes a determination of abuse, says Dr. Julie Mack, professor of radiology at Hershey Medical Center in Pennsylvania, it becomes very difficult to change the tenor of the conversation.
“The problem,” Mack wrote in an email, “is with the assumption of trauma — it becomes the default diagnosis, the one that is assumed as most likely. This is a dangerous assumption for the patient (who may have an underlying medical disease) and for the parents (who will appropriately deny trauma if none existent).”
In her cases, Johnson has found the same thing. She relies on out-of-state medical experts because she often cannot find a doctor locally who would publicly disagree with CHOA’s child abuse expert.
“Once [the child abuse expert] says it’s child abuse, everyone else shuts up,” she wrote.
But in infants especially, Mack wrote, “it is not appropriate to assume trauma is the most likely diagnosis, particularly in the absence of outward evidence of trauma.” Although, she adds, no physician she knows believes child abuse is not a reality. “Children are abused by their parents,” she wrote. Because of that, it is important to work hard to find the correct diagnosis.
“Fractures in the absence of history of significant trauma,” she wrote, “are also a characteristic feature of fractures caused by bone diseases such as osteogenesis imperfecta, bone disease of prematurity, and bone disease associated with vitamin deficiencies (rickets).”
Often cited as a contributing factor is rickets, a disorder that causes weak or soft bones.  Rickets is often caused by a deficiency of vitamin D and in many cases a vitamin D deficiency in the mother will lead to the same deficiency in their newborn. But vitamin D deficiency may be hard to diagnose.
In a commentary in the journal Pediatrics, Dr. Colin Patterson of the University of Dundee, Scotland, writes that one difficulty in the diagnosis of vitamin D deficiency, “is that the radiologic signs may be absent or unimpressive in cases of children with biochemically severe deficiency, which is particularly true of infants younger than one year.”
The conundrum, Mack says, occurs in an infant with fractures. “If a child presents with multiple fractures, but no clinical history or signs of trauma, ‘hidden’ (abusive) forceful trauma is often assumed,” she said. “The logic used is ‘abuse is present because the parents have failed to explain the fractures.’”
Queenyana Boyd struggled with a vitamin D deficiency throughout her pregnancy with Anthony.

“Are you here to take my child away?”

Boyd and Richards were in shock. How could Anthony’s leg be broken? You must have the wrong family, they told the X-ray tech. They had brought the newborn to the hospital because of complications from a vaccination. But the tech confirmed their details. It was true; Anthony had a broken leg.
When Boyd and her husband returned to their room in the ER, the doctor and a social worker met them. The doctor spoke first.
X-ray of Anthony Boyd's fractured leg.
“I’m sorry,” he said. “I should have asked you if you could have dropped Anthony or if he could have fallen.”
Absolutely not, Boyd and Richards told him. The social worker spoke up wanting to know what happened, so Boyd told them both the story, from the moment her husband discovered the swelling to when they arrived at the ER.
Richards’ eyes were tearing up. “Are you here to take my child away?” he asked the social worker. Boyd refused to believe that. They’d done nothing wrong.
“Well,” the social worker said, “we’re going to have to admit him to the hospital and do further tests.”
No one took their son that day. In fact, Boyd and Richards were allowed to stay in the hospital with Anthony, often alone in their room with the door closed, while Anthony was breastfed.
A caseworker from Georgia’s Child Protective Services (CPS) arrived later that day and began interviewing Anthony’s family. He spoke with Boyd and Richards, Boyd’s 7-year-old daughter Anya, Boyd’s sister and Richards’ mother, who had flown in after the birth. He also interviewed the nurses who had treated Anthony in the hospital. No one had a negative thing to say. The caseworker even told Boyd that her Anya was very happy and showed no signs of abuse. (Repeated calls to CPS were not returned.)
Boyd then asked the caseworker to contact Anthony’s pediatrician. She was told he would get to that later. He then explained to Boyd and Richards they needed to meet with a representative from the hospital’s child protection division. In the meantime, doctors continued to run tests on baby Anthony.
The next morning, the couple arrived for the interview with the child protection division. Once again they told the story of finding the swollen leg and how they had wound up in an interview with protective services. The representative said that she saw no indications of abuse; the break looked like “one of those things that happens.” Boyd agreed. She was also struggling to pinpoint when or how the leg could have broken.
Following the interview, a doctor from the child protection division spent a few minutes examining Anthony. He told the parents that Anthony appeared to be completely healthy, save for the broken leg.
Boyd and Richards were beginning to feel a little relief. They felt that if the hospital or CPS truly suspected abuse they would have contacted the police by now. At this point, it had been more than a day since the break was discovered. Boyd and Richards had been left alone with Anthony on multiple occasions. No one involved in the case had indicated seeing any signs of abuse. But as the day wore on, the couple began to worry. Although it was true no one had said their case looked like abuse, no one had told them they were cleared either. The pair repeatedly called the CPS caseworker asking for information but they never received any.
That evening, the CPS caseworker walked into their hospital room with a security officer. “I’m sorry,” he said, “but I have to take your son into custody.”
With those words Boyd felt the air go out of her. “Why?” she managed to ask. “Why are you taking our son?”
The caseworker explained that the report from the child protection division doctor who had examined Anthony concluded the break was non-accidental and to investigate possible child abuse.
“There’s nothing we can do,” he told her.
Boyd pleaded with the caseworker, asking if her sister could take Anthony rather than placing him in foster care. She was told that was impossible. He had no choice but to put Anthony in foster care. As CPS took her son away, Boyd felt like Anthony was being kidnapped. She had no idea where her son was — CPS wouldn’t tell her — and she had no way of continuing to breastfeed him. Boyd wouldn’t learn where her child was for five more days.

How Big a Problem?

Misdiagnosis of child abuse occurs, especially in infants. It is the word of the parents against the medical opinion of the doctor who examines the child. But is it a growing problem?
“I think it has been a problem since the 1990s or maybe a little earlier -– we just didn’t know it,” Seattle attorney Heather Kirkwood said. “In the past decade, it has begun to spiral, I think . . . one of those pendulums that swings too far and is due for correction. [The same thing] happened in antitrust, too, just not with such disastrous consequences. Here, I suspect that we are looking at hundreds to thousands of destroyed families and falsely imprisoned parents and caretakers.”
Kirkwood has handled a number of high profile cases of misdiagnosed child abuse. Her cases have been written about in The New York Times and The Chicago Tribune. Others were featured on the PBS documentary series, Frontline, as well as on NPR and ProPublica.
According to Kirkwood, many misdiagnoses originate “simply because we don’t know (or in some cases have forgotten) how to diagnose vitamin D deficiency (rickets), vitamin C deficiency (scurvy), etc.”
“Often the key to the diagnosis,” she said, “is that the child has no bruises, no pain and the ‘fractures’ are self-curing — with good nutrition, the bones will develop normally without any other intervention.  Not, in short, your typical fracture picture.”
The first step for Kirkwood when investigating is to do a retrospective diagnosis.
“In that stage,” she said, “I work with experts and read the literature to see how the medical findings fit together, both within the disciplines and with the clinical history. Sometimes it takes quite a few tries before we begin to put the entire picture together.”
Over time, in what is an evolving process, she has learned what to look for.
“When I first began to review cases,” she said, “I assumed that one fracture might be accidental but that multiple fractures without a major accident must be abusive.”
As she examined more cases, however, she began to conclude “that in cases in which the baby has no bruises or signs of abuse and otherwise seems well cared for, the opposite is true: the more fractures there are, the more likely it is that we are looking at some type of metabolic bone disease.”
And rickets often leads to fractures. Patterson, in his commentary in Pediatrics, writes, “In a recent retrospective study, fractures were found in seven of 40 children younger than 24 months with overt radiologic evidence of rickets.”

A Mother’s anguish

It was Wednesday evening. Boyd’s son had been placed in foster care earlier in the day. She was distraught and couldn’t understand why CPS wouldn’t let Anthony go with a family member. She called her aunt who had been in the delivery room when Anthony was born.
She was feeling hysterical and needed to talk to someone she trusted who would calm her down. While on the phone, her aunt began flipping through the pictures she’d taken at the delivery. And that’s when — in the middle of the conversation — Boyd’s aunt made a startling discovery that would further alter the course of events.
“I’m going to send you a picture,” her aunt said. “Did you see your son’s leg?”
Boyd’s aunt immediately emailed the camera phone picture to her. Boyd looked at the photograph, taken moments after delivery before the umbilical cord was cut; Anthony’s leg was already swollen in the photo. Boyd searched her own pictures for a higher resolution picture and found another that showed Anthony’s leg was swollen at birth. She discovered a picture on her camera taken at nearly the same moment as her aunt’s picture. It two appeared to show swelling on Anthony’s leg.
If the leg was broken before Boyd had even held her baby — and the swollen leg in the photos would seem to indicate that — CPS had no case. This was all the evidence she needed, Boyd thought. She emailed the photos to CPS the same night and asked that they be shown to the doctor at the child protective division at CHOA hospital. She never heard back.
Outraged at CPS for not communicating with her and impatient for the first hearing Monday (delayed until after the weekend because of a state furlough day on Friday), Boyd enlisted the help of Johnson. When shown the photos from the delivery, Johnson was astonished.
Photo from just after Anthony Boyd was born showing his swollen right leg.
“The leg looked completely messed up,” she said later.
A mandatory “72-hour” hearing was held Monday to determine if further foster care was necessary for Anthony. The judge granted Boyd and Richards’ daily visitation rights with their son. They could spend three hours a day with him, but they weren’t allowed to bring him home yet. The judge scheduled an ad judicatory hearing for nearly three weeks later.
Adjudication is similar to a trial, but the judge makes the final ruling without a jury’s involvement. In this case, the judge would decide if the allegations of child abuse were true. The hearing lasted five hours. The prosecutor argued that Anthony must have been abused, as there was no other explanation for the broken femur. Both the CHOA hospital child protective division doctor and the obstetrician from Anthony’s delivery testified that the kind of break that Anthony had could not have happened at delivery. They were too rare.
Johnson brought in Dr. Julie Mack, a medical expert from Lancaster, Pa., who countered that claim. Mack had research that showed numerous similar cases. In nearly every one, the break wasn’t diagnosed until days later, even if the baby never left the hospital. She also compared the photos from the delivery with Anthony’s X-rays, showing that the swollen area in the picture was where the break was in the X-ray.
The judge ruled for Boyd and Richards. Anthony could finally come home with his parents.
While she is overjoyed to have her son back, the experience has left Boyd scared and upset. She worries every time she has to take Anthony to the pediatrician. She’d done nothing wrong when she took Anthony in with the swollen leg. In fact, she did everything right. But CPS took her child anyway. Boyd felt as if she were guilty until proven innocent. Until CPS said otherwise, she was an abusive parent.
Anthony was later diagnosed with a vitamin D deficiency, likely inherited from his mother. However, he was never tested during the abuse investigation and has not, to date, been diagnosed with rickets.