Child Abuse Pediatricians Are Essential for Preventing Abuse

Earlier this month, a Florida appellate court struck down a more than $200 million judgment against John’s Hopkins All Children’s Hospital in St. Petersburg stemming from a now infamous case involving Maya Kowalski.

As a young child, Maya had been diagnosed with a rare pain disorder, for which her parents had sought treatment involving high daily doses of the anesthetic ketamine. However, in 2016, when Maya’s parents brought the then-ten-year-old to the Emergency Room at All Children’s complaining of severe pain, doctors questioned the diagnosis, suspecting that she was actually a victim of medical child abuse at the hands of her parents—a case of Munchausen syndrome by proxy.

The doctors reported her case to child protective services. A child abuse pediatrician agreed with their assessment, leading to the state removing Maya from parental custody. After 87 days of separation, her mother committed suicide. In 2018, Maya’s father sued All Children’s for false imprisonment, infliction of emotional distress, and wrongful death, among other complaints.

Media coverage, including the 2023 Netflix documentary Take Care of Maya, leans toward portraying the case as a tale of health and child-welfare authorities railroading innocent parents. This coverage, unfortunately, has played a pivotal role in turning the public against both mandated reporting of child abuse by medical professionals and the particular subfield of Child Abuse Pediatricians (CAPs), both of which remain essential for preventing and responding to child abuse.

Experts, by contrast, remain divided over whether Maya’s parents were guilty of abuse. Ronald Richter, former head of the Administration for Children’s Services in New York, tells me that “Munchausen cases are rare, very rare.” But, of the Kowalski case, he says, “this is one of them.” According to Richter, there is “no question that the parent loves the child. But the parent’s mental illness interferes with their ability to act rationally.”

Andrea Dunlop, an independent journalist and author of The Mother Next Door: Medicine, Deception, and Munchausen by Proxy, tells me that the reports made by the doctors “are the reason Maya Kowalski is still with us today.”

The recently released New York Times podcast The Preventionist advances the theory that CAPs are to blame for what it calls a rash of false reports of child maltreatment at a hospital in Lehigh Valley, Pennsylvania. The narrative such reporting pushes is that, when you’re trained as a hammer, every problem looks like a nail.

But the opposite is true. According to a 2009 study, when comparing second opinions of CAPs in which a non-CAP initially diagnosed abuse, the CAP said it was “not abuse” 44 percent of the time. When there was disagreement between the CAP and non-CAP, 80 percent of the time the CAP said that it was not abuse.

Not only are CAPs blamed for incorrect diagnoses; they are also blamed when Child Protective Services decides to remove children from their parents’ custody. But those decisions are not made by doctors. They can only be legally made by CPS, with the approval of a court.

CPS usually intervenes before a CAP does. A 2023 study looked at aggregate data from a dozen or so children’s hospitals around the country with CAP teams. It found that 68 percent of the time, CPS was called prior to CAP involvement. And 43 percent of those consultations resulted in an assessment of “not abuse.”

None of these facts have stopped journalists from telling heart-rending stories about supposedly false allegations of abuse. And in many cases, child welfare agencies or hospitals cannot correct the record since privacy protections prevent them from discussing the specifics of these cases.

One telling detail mentioned by The Preventionist is that several of the cases it covered have resulted in criminal prosecution. Only a small fraction of cases that come to the attention of child welfare agencies ever meet the evidence threshold necessary for a prosecutor to go to court. That alone suggests there is much more to these cases than the podcast reveals.

Doctors and hospitals must also remain quiet about these cases to guard against the risk of medical malpractice litigation. A doctor at one large medical facility told me his clinic now has a full-time staff member to schedule doctors’ appearances at court proceedings in suspected child-abuse cases (a substantial number of which involve accused parents suing doctors).

Even worse, a sustained campaign of intimidation is now underway against many of these CAPs. Stephen Boos, a professor of pediatrics at UMass Chan Medical School–Baystate, says he has CAP colleagues who have had “to put in security systems because they are receiving threatening calls or posts on social media.” There are only about 400 of these child-abuse pediatricians in the country, Boos tells me, and many are “old or leaving.” Fewer CAPs means that doctors with less experience and knowledge of the signs of abuse will be diagnosing these cases. (Just like calls to defund the police often lead better, more experienced cops to exit the profession, so attacks on child-abuse pediatricians will create the same incentives.)

Andrea G. Asnes, head of Child Safety, Advocacy & Healing at the Yale School of Medicine, says there “have to be immunity protections for people who suspect, report, and evaluate child abuse. If there aren’t, there will be underreporting and missed cases of serious abuse and harmed kids.”

Lawsuits against medical providers who report suspected child abuse, even when unsuccessful or overturned, have a “chilling effect,” says former Texas detective Michael Weber, who has worked on a number of these cases. He calls the appeals court’s reversal of the Kowalski judgment “a big victory for future victims of child abuse.”           

More than 2,000 children in this country die each year at the hands of their caregivers. Richter, Asnes, and everyone involved in these kinds of cases acknowledge that mistakes will be made in reporting and diagnosing abuse. Such mistakes may be a parent’s worst nightmare, but for abused children, the nightmares are darker still.

Photo: Oliver Helbig / Moment via Getty Images