I'm curious about the connection between COVID-19 and the number of cases of child abuse. In the United States, have the numbers gone up or down?

We know the numbers of reported cases have gone down, but what we've seen across the United States is an increase in the severity of physical abuse. What we think is happening is the children are isolated, not going to school, not going to daycare. So the reports aren't happening earlier where we can prevent more severe abuse, and it's not actually coming to our attention until it's severe enough where they have to present to the hospital into the emergency rooms for medical intervention.

In terms of child abuse, we think about physical abuse or sexual abuse, but there are other forms of child abuse. Can you go over the different types?

In the United States, the most common form of abuse is neglect. That can be anything from failing to provide food and shelter to not providing appropriate supervision. Children that may be too young and left home alone, not providing educational resources for them, or even not providing the necessary medical treatment they need. And that really accounts for three-fourths of child maltreatment in United States. Of course you have physical abuse and sexual abuse, but then there's also emotional abuse and that's probably the one that's most difficult to prove. This is some action by the caregiver that impacts the child's growth or development or psychological functioning. This can be extreme forms of punishment, not physical punishment, but emotional punishment, such as putting them in a dark closet, that's going to make the child very fearful, belittling the child, where they feel rejected and unloved. So those are all forms of emotional abuse as well. 

In terms of the protocol for reporting child abuse, what are the requirements?

It really is the responsibility of everyone who has access to children to intervene and report if needed. In Texas, everybody's a mandated reporter, especially people that are responsible for children, such as doctors and teachers and medical professionals. 

Does that mean that you're able to call in anonymously and confidentially? I'm sure some people might be afraid to speak up if you suspect something, but you're not quite sure.

The laws in my state (Texas) say if you have reasonable suspicion, you're a mandated reporter. There is an 800 number that we call. Child protective services cannot tell the parent who made the report. They can't tell the family, it is confidential. When you call in a report, you don't have to give your information, but obviously, it's very helpful for the investigators to know who made the report so they can talk to you about your concern. So we always encourage people to give their information.

During COVID-19, what can we do as a community to prevent these cases? We see some horrific cases, there was a recent case here in Korea that made the headlines. What do we need to do?

I think it's a matter of understanding that even if it's not your family, that child is still your business. That it is your responsibility to step in and help protect that child. And the only way we can do that is to report and hopefully report before it gets to the point of a child losing their life or having severe injuries. Of course, even better would be the preventive services for families to help keep them healthy. But it's everybody's business to stand up for children because they can't do it themselves. It's also better for us as a society because then we can intervene, hopefully provide services for that family to reunite them and keep that child in the home, but in a healthy home where that child is loved and nurtured. And then that child will then grow up to be a productive adult. We know when we don't intervene in these cases of abuse, there can be really severe longterm, physical and mental outcomes with these children that we all as a society pay.

In The Media

At 2 p.m. CST on Tuesday, Jan. 8, 2019, Jamye Coffman, M.D., will be a featured expert on Munchausen Syndrome by Proxy on 'The Dr. Oz Show.' The episode will explore the case of Gypsy Rose Blanchard, whose mother (Dee Dee Blanchard) claimed she was terminally ill and wheelchair-bound since childhood. Blanchard pleaded guilty to second-degree murder in the death of Dee Dee and is serving a 10-year prison sentence.

Anyone who has ever heard of Munchausen syndrome by proxy has probably asked themselves the same questions:

Why in the world would a mother want to hurt her own child?

And how does a child end up receiving unnecessary medical procedures? Don’t doctors know when a patient is really sick?

The answers are complicated. But each year, experts in Tarrant County get a little better at understanding how to spot these abusers and bring them to justice.

What is medical child abuse?

You may have heard about the HBO documentary ‘Mommy Dead and Dearest’ about the 2015 murder of Dee Dee Blancharge. Her daughter, Gypsy Rose, pleaded guilty to second-degree murder and is serving a 10-year sentence for her death. The trial uncovered a number of unknowns about the relationship between Dee Dee and Gypsy.

To everyone who knew Gypsy, she was believed to have been wheelchair bound and have a myriad of medical problems. It turns out those issues were largely fictitious and now, at 25 years old, Gypsy is arguably one of the most notorious victims of medical child abuse.

Medical child abuse is the diagnosis given to a child whose parent or guardian is suspected of lying about their medical history, leading to unnecessary treatments and procedures. This condition was formerly known as Munchausen syndrome by proxy. The abuser has what’s known as factitious disorder imposed on another.

“Anyone who has worked in pediatrics for very long has run across these kids. The question is whether or not you recognize it because it is so difficult to diagnose,” said Jamye Coffman, M.D., medical director of the Child Advocacy Resources and Evaluation (CARE) team at Cook Children’s. “We call it medical child abuse because in all of the other names, abuse is nowhere in it. But it’s abuse. And it’s medical, because we are the weapon.”

Few people may realize just how experienced experts in Tarrant County have become with this disturbing crime.

Since January 2009, the Tarrant County District Attorney’s office has investigated 19 reports of medical child abuse. Of the eight prosecutable cases, five were reported to Child Protective Services (CPS) by attending physicians at Cook Children’s. In each case, the abuser was the child’s mother.

“Tarrant County is pretty good at identifying and handling these cases,” said Michael Weber, a Tarrant County investigator who specializes in medical child abuse. “We have a system in place that is better than most counties in America.”

That system heavily relies on information provided by the medical community.

They’re using us to harm their child

In the medical field, the Hippocratic Oath is sacred. At the beginning of a physician’s career, they make a promise to ‘do no harm.’ But when a parent gives a doctor false information, they may unintentionally end up breaking the oath by providing procedures the child did not really need.

“The most common unnecessary surgery is placement of a feeding tube, or G-tube,” said Dr. Coffman. “That’s because there are very few tests that tell us if a child needs a G-tube. We are dependent on a history showing a failure to gain weight.”

The inability to gain weight is one of the top symptoms in medical child abuse cases. The abuser may withhold food and water from the child to make it seem as though there is a medical issue preventing weight gain. Besides inducing symptoms, abusers may also exaggerate and even fabricate symptoms.

“The parent may say their child threw up seven times in 12 hours, but they really threw up once. Or, if they are fabricating symptoms, they may say a child threw up seven times but there was never any vomiting at all,” said Dr. Coffman.

The severity of these cases can vary, and some symptom fabrications that seem mild may actually end up being life threatening.

For instance, a parent may tell a physician their child has been diagnosed with sleep apnea. Due to the Health Insurance Portability and Accountability Act of 1996 (HIPAA), physicians cannot access another hospital’s records unless they have written permission from a parent or guardian. Without approval to access information protected by HIPAA, the physician has no way of knowing if the parent is being truthful about the apnea diagnosis. Once admitted to the hospital, the parent may actually suffocate their child in order to set off alarms, thus inducing symptoms.

“We’ve seen kids in wheelchairs who said they could not walk, even though there was no problem with their ability to walk. We’ve had parents tamper with lab tests and falsify records. Abusers have even gone as far as injecting feces into a feeding tube or IV line to make a patient septic,” said Dr. Coffman.

“In most cases, the abuse has been going on for many, many years. It’s psychological manipulation, physical manipulation and total control of the child by the parent,” said Weber.

It may seem baffling that children, who would be perfectly healthy otherwise, end up in these situations.

“You have to remember that ninety-nine point nine percent of our parents are good parents giving us accurate information,” said Dr. Coffman. “But if all an abuser has to do is say their child is vomiting and they’re secretly withholding food from them, how are we supposed to know that? We are depending on parents to tell the truth.”

Hiding in the spotlight

Identifying medical child abuse cases can be difficult for a number of reasons. The medical team is usually being lied to by the abuser, patients may be too young to speak for themselves or they may have been conditioned to lie as well.

Also challenging is the fact that the person harming the child is often the last person anyone would suspect.

“You may have a mother who seems like the best parent ever. The medical staff loves them, they are extremely concerned about their child, and they have a lot of medical savvy,” said Dr. Coffman. “We used to think these people had a medical background, but now with the internet, that’s not necessarily the case.”

According to Weber, Google and social media are key to the investigation.

“When we are building a case, we take all of the child’s medical records and dump it into a spreadsheet with social media posts and internet search history. When arranged by date, we can see the abuse pattern, and the lies,” said Weber.

He says in one case, a mother falsely told a doctor that she took her child to an emergency room the night before. Then later, she made posts on her Facebook page about her child being admitted to the hospital, though that never happened.

“She had numerous Facebook posts that were all lies,” said Weber. “Social media is a huge part of these cases.”

When the hero is the villain

One of the biggest mysteries surrounding medical child abuse cases is ‘why.’

For Dr. Coffman, that’s not something she spends time worrying about.

“We don’t have to know the reason why. Just like I don’t understand why a pedophile is sexually attracted to a child, I don’t have to understand why a parent is doing this.”

Instead, she says she needs to know if a parent is exaggerating, fabricating or lying about a child’s symptoms. Then, a report can be made to CPS.

“I do believe it’s a compulsive behavior that creates some sort of internal gain for them. They like to be the hero,” Dr. Coffman said.

That doesn’t mean they can’t control their actions, she said.

“They know what they are doing, and they know it’s wrong. It’s premeditated.”

Both Dr. Coffman and Weber say anyone who suspects a child is being subjected to unnecessary medical care should report their concerns to CPS.

“If you suspect it, report it,” says Weber. “It’s no different from physical or sexual abuse.”

They just didn’t know exactly how or for how long.

Inside the hospital, nurses and security guards were on high alert. The 2-month-old boy the Shiras were on their way to pick up was under a security watch. He had a broken femur and doctors were certain his injury was no accident. The longest and strongest bone in his body had been snapped in half. On top of that, he was suffering withdrawals from methamphetamine. Child Protective Services (CPS) acted quickly by taking the baby into their custody and beginning the search for a foster family.

“We got a call saying they were ready to discharge this baby and we decided to drive to Fort Worth to pick him up. We didn’t know much, but were told to find a specific nurse and give her a code,” said Katie Shira. “When we first arrived, the staff was very guarded. They weren’t going to let us see him until they figured out we were the foster parents. I was really impressed because they were doing everything to protect him.”

The baby, now known as Jett, was in a Pavlik harness. The full-body contraption kept both of his legs from moving. Katie and Chas listened as nurses explained how they should care for Jett. They had to handle him with extreme caution as the slightest adjustment could cause the baby pain.

When they left the hospital that night, the Shiras had no idea what life had in store. While they both wanted to provide love and support to a child in need, they never imagined the child would be in such a severe state.

“Sometimes I didn’t know if he was crying because his leg was broken or if he was withdrawing from meth,” said Katie. “It was so hard. He would shake and have tremors. His jaw would quiver. It was scary to watch and very sad.”

It took about six months for Jett’s addiction to subside. Slowly, his withdraws faded away and at the same time his leg was healing fast. He was soon able to ditch the harness and begin walking on his own. In many ways, things were looking up, but there was still a tough road ahead.

Jett’s biological family was fighting to get him back. They denied allegations of abusing the little boy and wanted full custody.

After 18 months of Jett living in the Shira’s home, the case finally went to trial. Katie describes the months leading up to that point as some of the most difficult she’s experienced.

“It’s a very odd feeling to have your life in the hands of 12 strangers,” she said. “I was struggling emotionally for two to three months before trial. I couldn’t sleep. I couldn’t eat. The anticipation of what was about to happen was so daunting.”

Katie and Chas both feared that Jett would be taken away from them. Even worse, they were scared he would be placed back into the care of the people who hurt him.

“When the trial began, the attorneys for the biological parents were arguing that his broken leg was an accident,” said Katie. “It got pretty ugly. Dr. Jamye Coffman was on the stand for 3 or 4 hours. She testified that there was no way this was an accident and his injury could have only been the result of abuse.”

Jamye Coffman, M.D. is a child abuse pediatrician and the medical director of the Child Advocacy Resources and Evaluation (CARE) team at Cook Children’s. She saw Jett soon after he arrived at Cook Children’s and followed his journey back to health and into a new home. It would be great to say that Jett’s case was one of the few Dr. Coffman became involved in that year, but the truth is her office saw 1,520 child abuse visits in 2015.

For the Shira family, having Dr. Coffman and the CARE team on their side was a game-changer. After seven days in court and two hours of deliberation, the jury came back with a decision. The Shiras were granted full custody of Jett.

“It’s funny because I feel like she has no idea what she has done for us. She changed the entire dynamic of the trial,” said Katie with audible emotion in her voice. “I get teary thinking about her because I believe she is an angel walking among us.”

For Dr. Coffman, knowing the outcome of cases like Jett’s help her stay motivated.

“Sometimes we don’t know if what we’re doing is really making a difference in a particular child’s life,” Dr. Coffman said. “Knowing that we helped a child is what keeps us going.”

Jett is now 2 years old and was officially adopted by the Shiras in January. Katie says there are days when she still can’t believe he’s theirs.

“It’s still kind of surreal that we don’t have to worry about his safety and well-being. He can just live with us forever,” she said.

In addition to becoming an official Shira, Jett is about to take on a new role. Katie and Chas are expecting their first child in May meaning Jett is about to become a big brother.

“We always wanted to have our own children, but we really wanted to adopt first,” Katie said. “We realized there are kids out there who don’t have the convenience of waiting until we have our perfect family. There are kids at the CPS office right now who just need someone to say yes.”

Adopting Jett Video

About the CARE Team

Led by pediatricians who are board-certified in child abuse medicine, the Cook Children's Child Advocacy Resources and Evaluation (CARE) team provides medical evaluations, psychosocial assessments and preventive education. Most CARE team examinations are conducted following a referral from Child Protective Services, a law enforcement agency or a medical provider.

The team provides medical evaluations for:

• Sexual abuse
• Physical abuse
• Other forms of child maltreatment
• Neglect
• Drug exposure
• Medical child abuse

Find more information by clicking here.