Episode 081: A Curious Child Abuse Case with Dr. Niran Al-Agba

Virtually everyone agrees that children are at risk in society and need extra vigilance. Whether this is done by parents (through most of history) or the state (more recently) it is very common in the United States for government agencies to investigate allegations of child abuse. Child Protective Services (CPS) is the usual name for the state agencies tasked with protecting children who have been harmed or are living in dangerous environments.

An example of a dangerous environment would be a family living on the streets or parents who are too drunk or strung out on drugs to properly care for the needs of their children. Other examples of abuse are more obvious like striking an infant or causing bruising or the breaking of bones. It is unfortunate that abuse ever occurs in any population but it is important to not only protect children but also be mindful of the consequences of taking those children out of the home and disrupting the family. How do you find a proper balance?

My guest is Dr. Niran Al-Agba, a general pediatrician in Silverdale, WA who has been grappling with that question. As someone who has seen abuse and is charged with helping her patients (kids) she also recognizes the importance of keeping families intact and what it means for childhood development. So naturally she walks carefully the line for when to break apart a family and when not too.

However, the case she presents is an example of what can go wrong when you give too much power to one institution without any checks. The CPS along with its 'employed' (she received grants) physicians were bent on accusing Dr. Al-Agba's patient's parents a lack of evidence did not slow them down. In fact, the abuse doctor (Dr. Woods) insisted that some bruising on the buttocks of an infant was definitely from abuse even though she never examined the patient and only saw a picture. Had she examined the patient she would have realized that the marks were actually far too small to have been caused by a hand as alleged.

Fortunately, the family regained custody of their child but only after legal expenses and being separated from the baby for some time. The case is not unique and similar cases of misdiagnosis and/or sloppy doctor work occurs all over the country. Dr. Al-Agba believes that there are some measures we can use to improve the protections of families from CPS while still keeping kids safe:

• Standardize the CPS Investigation: Too often there is a randomness by CPS agents on whether to interview witnesses, parents, and others involved in the case. They don't always consult family physicians for backgrounds on families.
• Second Opinion Medical Exam: Rather than relying just on the exam of an abuse expert, CPS should have the family's primary care physician examine the child too. If the physicians disagree, then a third opinion should be sought out whether an abuse expert or someone else.
• SOAP Notes: We were taught in medical school to get histories, examine patients, and then arrive at an assessment and plan. Too often, there is just an exam without the physician making the determination on whether there is abuse without trying to determine if the family has a legitimate explanation.
• Tighter Boundaries on When to Pull a Kid from a Family: Finally, there need to be firmly established guidelines on when to remove a child from his/her family and a minimum standard of proof.