What Child Abuse Taught Me
Some people know that before I went to medical school, I was an investigator for Child Protective Services in Texas. I loved the work I did, and primarily pursued the job due to the volunteer work I did as a court-appointed special advocate (CASA) and curiosity on how it was to view ‘the system’ as a social worker instead of the perspective I had from my childhood. This post today isn’t about my upbringing, but about how my experience as an investigator has helped me in my clinical experiences today as a third-year medical student. General warning: some of the stories shared may be difficult for some people to read due to the nature of the topic. Information has been altered to protect the anonymity of those involved but these stories are genuine.
Finding comfort within conflict
We all know that person who always seems to be at the forefront of creating conflict, but I am not talking about that. When it comes to CPS intervening on behalf of children, there is a substantial amount of conflict that comes with the job. If you come into someone’s home due to allegations of abuse or neglect then chances are you will be met with defense and hostility. Investigating cases of abuse and neglect is not meant for everyone, but I learned early on in the job that keeping your calm is the best way to prevent escalation of a situation.
This week in clinic, I had a 10-year-old boy presenting for a well child check. The patient presented with his father and his grandmother. Due to some concerns from the history and physical, the patient needed to have blood drawn. Well, let’s just say that he was not about to get his blood drawn without a fight. I had another medical professional helping me to keep this child’s arm stabilized while he was to draw the patient’s blood. This kid was hollering, flailing his arms, kicking, and really resistant to having blood drawn…and this was before we actually touched the child. His father was yelling, the grandmother was yelling, and I was watching the events unfold. The sign to do something different happened once the father pinned this boy down by wrapping his hands around the child’s throat and threatening punishment after the visit by yelling at his child. When it seemed that chaos was at its peak in that moment, that I instinctively took a deep breath and calmly asserted myself at a voice barely louder than a whisper. This got the attention of the child to stop flailing as much while the father released his hands around the child’s throat. The other medical professional in the room advised to the family to step out of the room while we took did the blood draw for the patient’s benefit.
Now, the child still was not going without a fight but the ability to control the environment was much easier without the family involved. The louder the child became, the lower I would bring my voice. I heard this advice from my training for CPS, and it has not failed me in being able to control most situations. Although we were able to get this child’s attention, he still needed some level of restraint before his blood could be drawn. When the opportunity presented itself, I was asked if I was able to do the stick to start the draw. Without hesitation I nodded, swabbed the area, and performed the stick with a flash on the first go. Instantly, the child calmed himself and realized that he was more scared than he needed to be and that he was okay. He was even smiling before we were done drawing the vials of blood. Drawing blood from a child was a line that I did not want to cross and had not done previously, but at that moment I just wanted to end this conflict for everyone involved. I was proud of myself getting for getting the vein under the pressure of the situation. So, when the anxiety is high take a deep breath if you expect to be able to think calmly and clearly.
History Matters
One thing that definitely matters is the historical framework surrounding the family dynamic. One thing that many people assume is that child abuse is something that can be easily identified on the surface but deeper inspection usually shows you how foggy the situation can be. For example, I had a case that probably left me the most changed by how complex family matters can be. The two children of this case include a 4-year-old female and a 6-year-old female. The parents included a mother who reported long-term anxiety and depression that is untreated, and a father with self-proclaimed “schizophrenia with narcissistic rage” for which he refused to take medications. One of the earliest signs of mental health issues tends to be “letting go” of your home environment due to neglecting household responsibilities. Sure enough, this home was one of the most unfit houses I had walked into with some difficult-to-describe scenes. I will never forget the kitchen sink with the dirty dishes with standing water and undergarments in the water…. the salmon patties on a tray that had maggots crawling around…. the parent’s mattress on the ground covered with various discarded items like old milk cartons and a bicycle…the children’s closet with decomposing waste material and soiled overnight diapers… There was more than enough evidence within the home to obtain emergency custody of the children that day regardless of the well-coached interviews by the children where they stated everything in the home was fine, that they are loved and safe, and that the house is normally clean.
Like many children I removed, I chose to take the children to an emergency shelter that I thought did a great job taking care of the kids’ needs. They do a thorough screen of the children and this screen revealed an active lice infection, scabies marks on both wrists, and bloody discharge in the panties of both children. I had no clue what to think at this point since I had not encountered an entangled case such as this one but I took these children to an ER that performed SANE exams. As the temporary managing conservator, I was responsible to those children and their healthcare needs at the time so I was going to be with them at that ER for however long it took. I watched from a one-way mirror as these children were medically assessed along with an interview where the six-year-old broke down and revealed sexual practices being performed to both children without revealing any specific perpetrator (and alluding to several). How do you explain to two small children that they tested positive for chlamydia and gonorrhea? How do you explain the necessity of their antibiotics to treat their infections? How do you explain to them that they cannot go home because it is not safe? When they protest the safety of the home with great emotional distress and insist that nothing is wrong, how do you explain the reality of the situation?
Sexually transmitted infections were treatable but was the family dynamic able to be stabilized for the children to return? As with medicine, investigating child abuse requires you to look at the history. This was not the first time these girls were investigated, but the third. The parent’s showed appropriate concern and affect regarding the needs of their children, and even cleaned up the home and showed pictures within 24 hours of my initial visit. Obviously, that does not answer to the STIs these girls have but there was nothing to pin that on the parents. In the very least, there was reason to believe physical neglect of the children due to many circumstances within the home and the ability of these children to be exposed to sexual practices.
However, I was still curious though and kept digging. I ended up finding information in the system for the father’s childhood. The father had a history of a sexual assault charge as a teenager (which does not count against you as an adult), but made me curious as to any more CPS history he may have had. I eventually got ahold of records for this father and his family. He was victimized as a child around age 11 and was removed from the home and placed into a juvenile detention center. He returned at 16 to his mother who solved the problem by having her boyfriend move out of the home. According to history she remained with the alleged sexual assault perpetrator. At 16, he became the perpetrator of unwanted sexual advances onto his younger sister which led to his sexual assault charge since his mother walked in on that incident. According to testimony from the father, he claims he was forced to have sex with his sister by his mother’s boyfriend. We were now looking at possible generational incest that was highlighting the cycle of abuse and how it can propagate in each generation if care is not taken to end the abuse.
The furthest the case went in court was removing these children and placing them in the state’s care permanently until the children were adopted. I think what has bothered me the most about this case was seeing the willingness of these parents to do whatever it took to get their children back although they failed to keep the girls safe from something so horrible, the barriers their mental health proved to be their inability to care for themselves and the children, and the fact that these children will never go back to the family they love unconditionally.
There are many cases that made me cry, but this one made me grieve for the terrible events in these girls’ short lives. Even if you know it is for the best, it is never easy to explain to children of that age especially when the children truly believe home was safe and their parents were good. These girls were immediately started on intensive behavioral therapy and counseling. There was a lot of damage done to them already but if intervention happens early then maybe the cycle will not be propagated to their future. So, pay attention to the history if you intend to change the course for the patient’s future.
The Art of Humor
First day of some on-the-job training with one of the investigators in my unit. I was so excited because I was going to apply the three months of training I received out in the field. I get in the investigator’s truck, and start reading the case we were going out to see that night. The call was placed from the police as many calls involving domestic disputes originate. This one was a shooting where children were involved. There was specifically a 6-year-old boy, who’s growth for height and weight was between the 40-50th percentile, involved in this dispute. His mother was trying to flee with him strapped into the backseat from the mother’s paramour. As she was backing out of the driveway, this child was shot 10 times. As I am reading this case, that new-investigator feeling and my normally-constant smile started to fade as I’m thinking “What the hell are we about to walk into?”
Well, this is quite a way to start off in the field so let’s see how this goes…. I did not expect to see what I did at the hospital. This child was in a medically-induced coma with an abdomen still open and prepped for subsequent surgeries. He was stable at the moment for a small child hit so many times. It was a miracle that was palpable when you entered his critical care room. As you probably imagine, he did not go home anytime soon. Custody was placed into the state’s care, and this child was getting better and would need to be discharged from the hospital and placed into foster care or a shelter. Funny thing when you enter a hospital because you were shot up is that you have no clothes. The investigator I was learning from showed me where to find CPS’s version of The Room of Requirement where you are able to find clothing and supplies for children of all ages. This child was on the small side of six, and I went on the hunt with another new investigator for a shirt that we thought would fit this little guy. We were trying to guess his size based on what we knew about child development, and eventually were able to find his size from some intake information we had somewhere.
In this magical room with so many different clothes, we were only able to find one shirt that was in this child’s size and it was bright neon orange. It was the gaudiest thing, and I had serious hesitation in bringing this shirt for this boy to wear. I look at the other trainee incredulously, and I ask “Are we sure we want to bring this shirt, or will this make him more of a target?” Many people outside of high-emotional stress environments tend to look down on this type of obtuse humor, but at the moment it was what both of us needed to hear in regard to this case. It helped us openly start the dialogue of how horrible this was for the child, and process our emotions related to some of the graphic violence we had seen.
By the way, we did take this shirt for the child to wear and it looked good against his tan skin. This miraculous boy who suffered from shattered teeth, a shattered femur, perforated bowel and stomach, and a couple other injuries was able to return to school after doing some physical therapy and regaining most of his functionality. Life is too short. You never know what trauma or event you may be exposed to but I think humor is a great way to alleviate the anxiety of some situations until you can properly process the event and put it in a good place.
Education Is a Privilege Withheld from Many
Many instances of reported child abuse or neglect stem from a lack of education regarding parenting. One thing many people do not realize is that corporeal punishment is not effective after the age of five due to the ability of a child to understand the difference between right and wrong. Parents tend to parent how they were raised, or at least incorporate some aspects of the discipline they were exposed to by their parents. I had a case once where a 16-year-old African American female called CPS on her father for using a belt and for choking her. The child did have many marks and evidence of bruising on the back and legs. Both parents lived in the home, and neither of them thought the physical discipline was inappropriate at her age. The parents sparked me to inquiry what they thought was appropriate punishment, and they were forward about using items like a belt or a hanger in order “to get the point across.” Upon further questioning and obtaining a detailed history, they both were disciplined in similar ways by their parents and as active members in their community it is what has been socially deemed acceptable others. The sad fact I experienced was that the African American community of this side of town believed in some severe corporal punishment as the only effective means to change a child’s behavior. The children were viewed as property to be punished by effective means to correct the behavior. This view on punishment is too similar to the horrible experiences slaves were subjected to by their owners, and makes me think this is one cycle of abuse that is deep rooted into human history. This is not stereotypical of all African Americans. And, African Americans are not the only race or ethnicity to have this view of discipline as many other different backgrounds use physical discipline to modify behavior. This child was not taken from her home, but the parents were offered parenting classes specifically geared toward working with your teen child. The parents did not even know these services existed in their city, and with education they would gain new tools of communication and parenting that could help minimize the conflict within their household.
So, remember my 10-year-old child who needed a blood draw? It was time to talk to his father privately before letting them go. This child already had many protective factors that made me less concerned for his well-being (he was not vulnerable aged, he lived within the home with a grandparent and his father, his mother was in a separate home and custody was split, he attended school regularly and school is in season, and the boy feels safe at home), but I was concerned for this father’s use of force to restrain his child. I spoke with the father, who was embarrassed by his son’s actions earlier with the blood draw. I explained to the father that it was normal, but also confronted him that his use of excessive force was not normal. The man’s family comes from Nigeria, and it was his use of physical discipline in his relationship with the child’s mother that led her to leave the marriage. He said the shame he felt for his son’s behavior in front of doctors was what fueled so much of his anger. I talked to him about being calm and talking through things with his son who was well-capable of rationalizing the difference between right and wrong. I also explained to the father that by setting a fearful condition for his son at the doctor’s office, then we would be creating this fear of the medical setting and health management. I then asked if the grandmother ever needs to use physical discipline to which the father said no. I encouraged him to open up dialogue with his mother to find out some calm and relaxed techniques of parenting. I also recommended to the father to walk away to cool down whenever he notices he is getting frustrated with his son. The father seemed more than capable to understand that frustration clouds our ability to think, and he was going to try to calm down instead of reacting to these frustrating parenting scenarios. I lastly explained to the father that the soft tissue of the neck is not meant to be compressed by force, and that he could cause his son’s airway to collapse if he ever did that again. I was not trying to add insult to injury by having this talk with this already ashamed father, but I wanted to advocate for this child’s safety and help educate this father. I could tell the father regretted his actions and only wanted to return to his son to hold onto him. I helped this family because education is a gift we can share with others that can help enlighten those previously unaware.
Office talk after this family left included questions from staff to whether this should be reported for child abuse, and incredulous beliefs that a father could act that way toward his son. After explaining this story from the cultural perspective, I think others in the clinic understood more how culture truly affects the way we navigate our lives. It takes obtaining a history to illicit a belief system and cultural ideology in order for a physician to truly be able to provide the much-needed patient education if we expect to improve the quality of life of our patients and their families.
I could probably relay a dozen other stories from my CPS days and convey how relatable social work is to medicine, but maybe that will be for another time. We are always being educated in return as part of our payoff for educating others. I have so much to learn in medicine, and in life, and I find much joy in every patient encounter because I know walking in that room has the potential to teach me something new to improve myself as an upcoming doctor.
Thank you for reading my blog, as I hope you enjoy the content. Feel free to subscribe if you would like an email every time a new post is released. If you have any feedback, please feel free to send it my way so that I can improve myself.
~Sham H.