A Stand Against Child Abuse : As Cases Rise, Hospitals Increase Training in Detecting Damage

Responding to a steady increase in reported child abuse cases and growing concern that too many incidents go undetected, several Orange County hospitals have stepped up training for doctors and nurses.

In workshops led by county child abuse experts, emergency room physicians and nurses are learning to recognize suspicious fractures, burns and genital injuries. They’re being taught to perform examinations and ask questions sensitively so as not to compound the trauma to a child.

And they’re learning to obtain evidence--or leave crucial exams to a handful of experts--so criminal charges will stand up in court.

One hospital, Martin Luther in Anaheim, on Oct. 1 made a move that surprised and impressed county officials: In addition to increasing training for doctors and nurses, it declared itself a child abuse center.

Martin Luther has created a “child-friendly” examining room called “The Safe Place,” with pint-size furniture, Mickey Mouse decals on the walls and an $11,000 instrument called a colposcope that is used to videotape sexual abuse exams for use in court.

In an effort to prevent abuse as well as report it, the hospital is holding a workshop Oct. 28 for educators and police called “Innocent Victims” and it plans to install a telephone “help line” offering parenting advice.

With child abuse cases in the Anaheim area accounting for one-fourth of all cases reported in the county last year, “we felt it was appropriate to take a leadership role,” explained Anthony A. Adams, president of the Martin Luther Hospital Foundation.

The new efforts by hospitals to identify child abuse marks “the beginning of a network” in treating Orange County’s abused children, said Dr. Deborah Stewart, an expert in sexual abuse who is chief of general pediatrics at UC Irvine Medical Center.

She and other local experts are hoping that as more doctors are trained to recognize child abuse, they can consult on questionable cases. Eventually, Stewart hopes, emergency rooms will be able to use the network 24 hours a day, calling on hospitals with special expertise in child abuse to help with especially difficult cases.

Such a network is needed to halt the steady increase in child abuse in Orange County. In 1985 the county’s Child Abuse Registry counted 11,440 families in which abuse was suspected; that number rose to 15,198 in 1990. This August alone, the registry counted 1,401 families in which a child was abused or neglected, a 17% increase from August, 1990.

County child abuse workers estimate those reports represent just a portion of the children who are suffering physical and emotional abuse, and they believe that Orange County hospitals report only a fraction of the incidents they see.

The reasons for the gaps in child protection are complex. Chief among them, says Ray Gallagher, director of the county registry, is lack of medical training in recognizing child abuse for emergency room doctors and nurses. Too often they accept a parent’s account that a toddler’s arm was broken in a fall, for example, when such an accident would not explain the severity of the fractures.

Or they look only at the injury that necessitated a trip to the hospital and not “the total body,” said Jeanie Ming, a nurse practitioner with the county’s sexual abuse team. If a child who has come in with a head injury also has belt marks on the buttocks or bruises on the neck, the head injury is clearly suspicious.

Sometimes doctors and nurses stray beyond their medical expertise and question parents themselves when they should call in police and social workers, the experts say.

And for many it is hard to believe the worst. Doctors “want to believe that all their patients would never hit their children, would never sodomize them,” said Dr. Betsy Grimley, the Martin Luther emergency physician who directs its new child abuse center. “You want to believe it’s a good world.”

Experts say the inherent unpleasantness of child abuse cases repels some physicians, so rather than get involved in a messy criminal case, they look the other way. Some doctors don’t want their emergency room involved in a criminal case that will require time-consuming paperwork, subpoenas and “police officers prowling around,” UCI Medical Center’s Dr. Stewart noted.

In their defense, emergency physicians note that child abuse cases can often be missed because the initial symptoms may be “vague,” the parents’ explanation of an injury may be plausible, and the child may be too young or too traumatized to talk about what happened.

“We do have limited means to evaluate our suspicions,” said Hoag Hospital emergency physician Dr. William Cloud, president of the Orange County Society of Emergency Physicians. Also, he said, “The injury may not be spectacular enough to raise suspicions.”

Given the complexity of child abuse cases, local experts are delighted that more Orange County hospitals are finally seeking training. Until now, experts such as Martin Luther’s Grimley said, the only such training doctors may have gotten is three or four hours decades ago in medical school.

But with the advent of workshops this year by the county’s Child Abuse Services Team (CAST), this is changing fast.

At the Kaiser Foundation’s Anaheim hospital and its 13 Orange County clinics, 20 nurses took special child abuse training from CAST in late September and another 15 are signed up to take the same class in December. Kaiser’s goal: to have at least one nurse who has been trained to handle child abuse on every shift.

At Children’s Hospital of Orange County, two doctors are scheduled for weeklong training next spring in examining sexually abused children. Recently, administrators began reviewing CHOC’s procedures for handling neglected and abused children.

Mission Hospital Regional Medical Center in Mission Viejo asked CAST to meet next month with its emergency room staff and pediatricians to explain how the team works with hospitals to investigate child abuse, conducts a non-invasive physical exam that can confirm and takes its evidence to court.

This fledgling network for abused children was “part of the dream” that local child abuse experts had in 1989 when they started the CAST program, said Stewart, who serves as medical director for that team.

- A 13-month-old girl was recently brought to a local emergency room with “suspicious fractures,” said CAST nurse practitioner Ming. Though police were called, officers decided the mother “seemed like a nice person.” And when an emergency physician said he was not certain that the baby’s injuries had been caused by abuse, a county social worker let the baby go home with her parents.

Three days later, the baby was brought to another emergency room, where she was found to have been sexually molested and with five fractures. In this case, the entire county system--police, hospital personnel, social worker--failed to protect the child, Ming said.

What could have been done differently?

The first emergency physician needed more training so he could have said, with conviction, that the baby’s fractures were suspicious, county officials said. Also, the doctor could have ordered more X-rays to see if there were other, older fractures and kept the girl in the hospital overnight.

- A 2-year-old boy recently was brought to CHOC to receive orthopedic care for his badly fractured arm. “Supposedly he fell down,” recounted Dr. Greg Buchert, director of CHOC’s ambulatory care. A physician at another hospital had apparently accepted the parent’s story several weeks earlier and splinted the arm.

Only there were clues that it was not an accident, Buchert said.

Both bones of the boy’s forearm were broken--an indication that he had been struck, hard, across the arm, not simply fallen with arms outstretched. Also, Buchert said, “the (CHOC) radiologist noticed old X-rays of an identical fracture one year ago--but of the other arm,” and the county child abuse workers were called.

“It was bad luck for the family,” Buchert said. They happened to come to a place where a previous X-ray was on file. If they had gone to another place, it would never have been noticed.” Even the best-trained doctors can miss a child abuse case, local experts said. But there are still other problems--systemic ones--in handling these sensitive cases.

For example, at many county emergency rooms, children who, unknown to hospital personnel, have been sexually assaulted wait as long as eight hours for a physical exam, CAST director Campbell said.

“They have no outward trauma. They’re not cut up,” she said. So they sit, sometimes next to adult patients with stab wounds or near enough to watch patients die from heart attacks. Too often, abused children are traumatized a second time by that wait, Campbell said.

Another problem: After a sexual assault, some emergency physicians “may not collect the proper evidence” for a criminal case, Campbell said. Also, “the exam may be done with instruments that create some additional medical trauma,” tearing a child’s genital tissues, she said.

In such cases, when CAST’s Ming does her requisite sexual abuse exam--a non-invasive procedure that involves magnification of a children’s genitals--she may not be able to tell what damage was done by the sexual offender--and what was done by the physician who examined the child.

Citing such problems, Campbell, Stewart and other local child abuse experts would like to see all 32 emergency rooms in Orange County step up their training in identifying child abuse. Also, they would like two or three hospitals in south and west Orange County to become child abuse “centers” just as Martin Luther will be for North County.

And they would like every Orange County hospital with an emergency room to appoint a team to review suspected abuse cases monthly. “Everyone needs one,” argued Stewart. “It’s a quality-control issue. Without it, child abuse cases get lost in the system.”

Only four of the 32 hospitals with emergency rooms have monthly review teams for child abuse. (They are UCI Medical Center, CHOC, Kaiser Foundation Hospital-Orange County and Western Medical Center-Santa Ana. A fifth, Martin Luther, expects to hold its first meeting this month.)

“Most hospitals try not to identify themselves as specializing in child abuse,” the Registry’s Gallagher said. “Because then people will start referring cases there. . . . It’s more of a drain on their finances.”

But Grimley and other hospital officials said they were determined to do something about the growing problem of child abuse in North County.

Over the past year, the 39-year-old physician has received extensive training in child abuse and is now one of only four medical experts in the county with experience in the non-invasive but precise external exam of a child’s genitals that can confirm sexual abuse.

One morning recently, Grimley showed off the small room decorated with Mickey Mouse and Pluto decals where children who may have been violated will be examined.

Beside a black examining table, Grimley proudly displayed her glistening, new colposcope, the microscope-like device that can magnify and videotape diseased or torn tissue in babies and teen-agers alike.

For all her emphasis on identifying abuse, Grimley believes the most important thing is to prevent it. But once abuse has occurred, she is determined to document it--to help send child abusers to jail.

Until now, in North County, “there was nobody” with expertise to detect evidence of abuse. Now, she and local child abuse officials are hoping, there will be a “Safe Place” to go.

Child Abuse in Orange County

Doctors and nurses at several hospitals in the county are receiving increased training to spot the signs of child abuse. County officials are concerned that too many incidents go undetected or unreported by medical workers in key positions to recognize the signs.

WHO REPORTS? Hospitals reported one-tenth of all county child abuse cases this year through September. County officials hope to train more emergency room doctors to recognize symptoms of abuse--even when parents say the injury was accidental. Public Reports: 26.9% Schools: 19.7% Therapists: 12.6% Law Enforcement: 11.1% Social Service Agencies: 10.8% Hospitals: 10% Others Required to Report: 5.6% Other Medical: 2.2% Child & Day-Care Centers: 1.1%

ON THE RISE: The number of families reported with a child-abuse problem has increased about 26% in the five-year period, 1986-1990. Figures for the first nine months of 1991 have already surpassed last year’s levels. 1986 Jan.-Sept.: 8,944 Full-Year: 12,027 1987 Jan.-Sept.: 9,290 Full-Year: 12,277 1988 Jan.-Sept.: 11,000 Full-Year: 14,857 1989 Jan.-Sept.: 11,322 Full-Year: 14,946 1990 Jan.-Sept.: 11,399 Full-Year: 15,198 1991 Jan.-Sept.: 12,488 Source: Orange County Child Abuse Registry