Children's Crusader
>> Like any big city medical center, the U of C Children's Hospital daily encounters cases that may-or may not- involve abuse. Jill Glick and the Child Protective Services group have the demanding job of recognizing abuse and intervening for the good of the child.

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THE 13-YEAR-OLD GIRL-CALL HER MARIA-has been in the University of Chicago Children's Hospital for seven days. She was admitted after swallowing a toxic overdose of her mother's seizure medication, and although she denied attempting suicide, doctors and social workers are concerned. The mother has refused to let her daughter undergo psychological assessment, a worrisome sign. Equally worrisome, the girl has revealed that she likes to have a few beers with her father when he comes to visit, as he does frequently.

Two days ago, a "risk of harm" report was filed with the Illinois Department of Children and Family Services (DCFS) and an appointment was set up for the girl's mother with a mental-health screening agency. Is this a case of child abuse? Probably, concludes the hospital's Child Protective Services group (CPS, in hospital shorthand) after reviewing the case. But the question vexing the group at this week's "rounds" on a late winter afternoon is: What's to be done to put the girl out of harm's way? As the discussion unwinds, it appears that the question is one for which they don't yet have answers.

An easier call for the group seated around an oblong conference-room table is the case of a 3-year-old boy we'll call Daniel who was hospitalized seven days ago for severe burns of the feet, legs, and buttocks. The incident was reported by another local hospital as possible abuse-immersing children in scalding liquid is an all too common form of abuse.

But Jill Chapman Glick, the slim, dark-haired, sometimes intense U of C physician who presides over these CPS weekly rounds, thinks the parents were telling the truth when they said that the boy accidentally tipped over a pan of hot grease as he raced through the kitchen. The pediatrician's conviction grows out of careful medical assessment. To make her case, she unpacks a Macintosh laptop, hooks it to a projector, and shows a series of photos of the boy's feet and legs. There are ugly blisters on the tops of the feet, but the skin between the toes and on the soles is clear and healthy. There are small secondary burns near large, raw ones on the boy's legs and buttocks, a pattern consistent with splashes of hot grease.

The photos are convincing: It was an accident, not abuse, and CPS now possesses the forensic evidence that will keep this child and his family together.

The most difficult case this week involves a 3-month-old infant we can call Herman. He was admitted two days ago for swelling of the head and intracranial bleeding. That alone raised suspicions of abuse, but there was more. A computerized tomography (CAT) scan showed a fracture of the baby's clavicle; how fresh a fracture, it's difficult to discern. Sitting in on today's rounds is an intern who examined the infant on admission and who finds the combination of injuries ominous. But the medical evaluation is not yet complete-Herman is undergoing a magnetic resonance imaging (MRI) scan this very afternoon.

Glick cautions her colleagues not to leap to an abuse conclusion. She points out that the baby was a vacuum-delivery child, and she reminds them that vacuum- and forceps-delivery infants often experience intracranial trauma. What's more, clavicle fractures are known to occur during difficult births.

While that doesn't rule out abuse, it suggests caution. Let's wait for the MRI pictures, Glick says. And the group moves on to the next case.

Jill Glick is something rare in contemporary medicine: a forensic pediatrician. And the CPS group she works with at the Medical Center is, if not quite rare, at least not common. In the city of Chicago, there's a similar unit at Cook County Hospital and another at Children's Memorial, and two pediatricians trained by Glick at the U of C have started units at Rush Children's and Mount Sinai Hospitals.

The U of C unit is alerted whenever an emergency room doctor or an admitting physician spots signs of possible abuse. First to respond usually is Penny Rivers, a social worker who serves as the CPS coordinator. She in turn notifies Glick and Veena Ramaiah, an emergency-medicine pediatrician with a clinical interest in abuse cases. All three are present at today's rounds. Their backup includes anywhere from seven to ten social workers on the hospital staff, plus medical personnel assigned to the suspected victim.

As CPS coordinator, Rivers does the intake work on child maltreatment cases and acts as liaison to staff members working on the cases, the CPS team, and, when necessary, the police and the Department of Child and Family Services. "We try to gather and verify information," she says. "We try to put a bubble around the child in terms of information flow. If the police come in, we provide a CPS consultant to serve as the go-to person. Our opinion has a lot of clout with police and the welfare system because we supply medical evidence."

Much of that medical evidence is gathered by Glick and Ramaiah. "Most primary-care physicians don't know how to diagnose child abuse," says Glick, "and when DCFS is called in, they don't have a physician to give them a clear answer." She cites a recent case in the Chicago suburb of Lombard in which a 29-day-old infant died of head injuries that were initially blamed on a dog stepping on the baby's head; it wasn't until a postmortem that the real cause of death was identified: head trauma inflicted by shaking. "That's classic child abuse," says Glick, "and primary doctors-especially critical-care doctors and neurosurgeons-need access to medical expertise that can help them diagnose it."

Shaking babies hard enough to cause injury or death is common enough to have a clinical name: Shaken Baby Syndrome. "Kids die of this every week," says Penny Rivers. "It produces abusive head trauma, with impact and shearing injury to the brain." Shaken Baby Syndrome hit U.S. and British news media a few years ago when British au pair Louise Woodward was convicted of murdering 8-month-old Matthew Eappen in Boston by shaking him and slamming his head. The conviction upset many people in this country and England who were unconvinced by the prosecution's case, but Glick had no doubt that justice was done. After the trial she wrote a letter to the Boston Globe defending the jury's verdict: "Media publicity…has led to considerable sentiment that [Woodward] was convicted despite allegedly irrefutable scientific evidence presented by the defense that the infant's injuries had occurred days to weeks earlier…. But infants simply do not suffer massive head injury, show no significant symptoms for days, then suddenly collapse and die."

Like the Woodward case, incidents of abuse uncovered at Children's Hospital often end up in a courtroom, and when they do Glick is almost invariably the CPS member who testifies. "I spend a tremendous amount of time in court and preparing for court," she says. "It's one of the most stressful parts of my job, because the justice system is very adversarial and very abusive-they try to impeach you and demean you. But I think that's appropriate, because you want medical experts presenting scientifically based opinion."

Still, it would be a rare medical colleague who might offer to trade places with her on the witness stand. "Very few physicians, with our egos, are willing to be attacked like that, or threatened, so most physicians walk away and say, I don't need this," she says. "When I go to court, I make sure that my opinion is based on current medical knowledge, and I won't testify unless I can make a scientifically clear statement."

Getting to that point is labor-intensive. It begins with a subpoena from the state attorney's office regarding one of the CPS cases. Although the law requires this to be delivered seven days before a trial, typically it arrives with only five days to spare. "I work with both the criminal and child protection division attorneys, and usually they want to prove abuse and have the child removed from the home. I will only testify as to what is medically supported, so I'll teach them all about skeletal trauma, the mechanisms, the evaluations, the imaging procedures, and I'll explain how I make my decisions." That can take up to three hours, and if there's a deposition it can mean another three hours. "Then there will be court, which usually takes all afternoon. Of course, to prep for court I have to pull out all my notes and the imaging film, and I have to fax them my c.v. If you add all this up, I'll spend 13 to 15 hours dealing with a single juvenile court case."

There were 35 such cases last year, Glick estimates, and she insists the state is getting a bargain because, as a consultant in the hospital, she can be subpoenaed at no cost to the state. "If I could charge, say, $200 an hour-and that's a low figure-these services would cost $60,000 a year," she likes to point out. "Plus, I save the primary doctor on the ward from coming in to testify."

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JILL CHAPMAN GLICK earned her undergraduate and M.D. degrees at the University of Illinois and followed with a pediatric residency at the University of Chicago. "I went into pediatrics without knowing my long-term future," she says, "but I was very interested in chronic disease in adolescents, and I was attracted to pediatric emergency medicine, which was then a growing subspecialty." Early in her residency, she noticed an increase in kids with injuries that could have been the result of abuse, but there was no system in place to evaluate them forensically-that is, to look for evidence of a crime rather than merely making a medical diagnosis.

She learned her forensic skills the old fashioned way-on the job. "There's really no forensic training available and no board certification," she says, "though there's now a handful of fellowships. For me it's all been by learning at the bedside and reading. As an emergency room doc, you see so many injuries that after a while you know what's normal and what's not. It takes a couple of years in ER to understand what the abuse patterns are."

Those patterns can include burns and broken bones stemming from physical abuse; evidence of sexual abuse; and psychosocial signs of emotional abuse. The DCFS defines abuse as the mistreatment of a child under the age of 18 by a parent, a caretaker, someone living in the home, or someone who works with or around children. The mistreatment must either cause or put the child at risk of injury. Neglect happens when a parent or responsible caretaker fails to provide adequate supervision, food, clothing, shelter, or other basics for a child.

Illinois law mandates that workers in certain professions file a report whenever they have reasonable cause to suspect abuse. Along with teaching, child-care, and law-enforcement personnel, the law covers physicians, residents, interns, pathologists-in short, anyone involved in the care or treatment of patients. In 1999 the Illinois child abuse hotline clocked more than 100,000 reports of abuse, nearly half involving children under five years of age. Natural parents were the most common abusers, followed by stepparents, grandparents, babysitters, siblings, and aunts or uncles.

Nationwide there were an estimated 903,000 child victims of maltreatment in 1998, according to the National Clearinghouse on Child Abuse and Neglect Information, an agency of the U.S. Department of Health and Human Services. More than half of the cases involved neglect, and almost a quarter of the children suffered physical abuse. Nearly 12 percent of the victims were sexually abused. The highest victimization rates were for the infant-to-3 age group. More than four-fifths of the victims were maltreated by one or both parents. The most common pattern of maltreatment was a child neglected by a female parent with no other perpetrators identified.

Glick has noted that five children die every day from abuse and neglect, most of them under two years old. For children over four, homicide is the third leading cause of death. Those statistics arouse in her indignation and a strong desire to see justice served. "These are people who have committed terrible crimes, and I think our society has to deal with them. At the same time, I recognize that incorrect decisions-calling something abuse that isn't-are as harmful as missing a child-abuse case. We must truly try to make the best decisions. But I also feel we need to acknowledge that doctors are not trained in this area, and we need citizens to demand that the DCFS employs scientifically based decisions about abuse."

Lynn Kahana, a professor of clinical medicine who heads the pediatric intensive care unit at Children's Hospital, shares Glick's passion. Too many children die of abuse, she laments. "We take pride in our medical advances, but if we could just stop the violence." Kahana is an unabashed booster of the CPS unit. "This is an essential service, as important as having a cardiac surgeon," she says. "I can't imagine being in a city hospital in this generation and not having this service."

But the truth is, forensic pediatrics is uncommon both in hospitals and in clinical practice. Recognizing this, the director of the Illinois DCFS, Jess McDonald, AM'73, and House Republican Leader Lee Daniels have funded a task force to develop a state model for child-abuse investigations; Glick is one of its members. The task force's short-term goal, according to Ed Cotton, deputy director of child protection for DCFS, is "to get better immediate medical diagnoses and second opinions in Shaken Baby Syndrome cases and then expand into other areas of child abuse." The long-term goals are to establish centers staffed by experts in diagnosing and treating abuse, and a video network that lets practitioners throughout the state consult the centers' experts.

Cotton has high regard for Glick and her U of C team. "She is totally dedicated to keeping kids safe, and she works very well with our staff," he says. "She is one of four pediatricians in Chicago that our workers call all the time." Cotton shares Glick's desire to see more doctors trained in forensic pediatric medicine, and he acknowledges that this will require physician training. Glick is convinced doctors will accept forensic training if peer review can be built into the process and if the state helps fund the programs.

Glick has a pretty fair track record when it comes to attracting funds. She found external funding for CPS overhead, and she's attracted a grant from the Lloyd A. Fry Foundation that underwrites a tracking system for high-risk children. Managed by Steve Bollinger, a social-work student in the School of Social Service Administration, the program-called Linkages-tracks children who have come under the scrutiny of the CPS team to ensure that they get needed medical care after they leave the hospital. "When a family has a history of missed appointments, or when the CPS team feels a child needs extra follow-up, these cases are referred to me," says Bollinger. "I send a letter to the family explaining the program and then arrange an appointment with a primary caregiver. The day before the appointment, I contact the family by phone as a reminder. If transportation is a problem, I recommend services or resources. And I also provide the doctor with information about the child."

Glick calls Linkages a novel program. "I don't know if anybody else does it. Many of the cases we see are not clear abuse-the mom who hasn't bonded well with her child, the teenage mom who's somewhat depressed-yet we have concerns about medical neglect or lack of compliance." If the family still ignores follow-up care despite Bollinger's efforts, she adds, "We've laid a template down, so when we call DCFS we have documentation."

Around her forensic work Glick manages to juggle teaching duties and frequent invitations to speak at regional and national conferences. The assistant professor of medical pediatrics teaches core curricula to residents in the pediatric rotation and offers an elective in advocacy medicine to residents and to medical students in their clinical year. This spring she taught a course in forensic pediatrics for medical students. Among students at Pritzker, she has a reputation as a teacher who's patient with students but sets high standards. Her popularity was demonstrated a year ago when, at the initiative of some of her students, she was elected a faculty member of Alpha Omega Alpha, an exclusive academic honor society comprising the top 3 percent of medical-school graduates.

Although colleagues tend to use the word "intense" when describing her, they quickly soften the adjective. Says Cotton: "She's so full of energy, I don't know when she sleeps." When interviewing parents of children who might have suffered abuse, says Rivers, Glick is forthright but not abrasive, careful with her language, and aware that she's talking to frightened people who are caught in a crisis. "She doesn't whitewash stuff," says Rivers. "She has a good understanding of family dynamics."

That understanding may owe something to the fact that family is part of Glick's own life. She keeps photos of her two children, a 9-year-old son and a 12-year-old daughter, next to the two computers on her office desk in the faculty section of Children's Hospital. The Glicks are an athletic family. Both children are state-level swimmers. Mom's sport is running, though she laughs that she's a middle-of-the-pack racer. She has aspirations to sample her husband's sport and attempt a triathlon. This spring the Glick family relaxed with a trail-biking expedition in the Canyonlands, one of Utah's more remote and wild corners.

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BACK AT THE weekly round sessions, the Child Protective Services unit continues to wrestle with tough decisions. Rounds involve freewheeling discussions among a highly focused group of specialists, and no one is shy about offering information or an opinion. Members drift in and out of the room depending on the case under discussion, and the small conference room sometimes runs out of chairs. Occasionally a pager beeps, sending someone hustling out the door. Among today's attendees are Penny Rivers, whose comments clearly carry special weight with Glick, and Laurie Druse, AM'94, coordinator for the DCFS-sponsored task force. Ellen Rosendale, head of social work, normally attends but is not in the room today. Neither is Linkages manager Steve Bollinger; he's a couple of floors down bringing order to a chaos of debris left by a recent CPS move into new quarters. Usually, a representative from DCFS sits in. Rounding out today's group are Ramaiah, an intern, and a third-year pediatric resident. Glick doesn't think of CPS as a fixed entity; she encourages anyone connected with a given case to attend the weekly deliberations and be part of the process.

Another of today's cases is a 3-month-old boy who came to the emergency room in respiratory distress. The medical diagnosis was not complicated: bronchiolitis. But there's a "risk of harm" hotline entry on record for this infant, and his siblings are in DCFS custody. For the moment, the group must await a DCFS assessment now in progress before it can act. That could take weeks.

Next case: a 3-year-old girl who was admitted to the hospital with shigella, a stubborn form of diarrhea, and pancreatitis. There are six siblings in the toddler's family and her mother is eight months pregnant. An anonymous phone call alleging parental neglect has set off alarms. But after family interviews, the CPS team has determined that parenting capacity is adequate and recommends that the infant be sent home when she's medically ready to leave the hospital.

Advocacy, as the CPS members view it, extends not only to the children but also to families. Calling in DCFS or police triggers events that are unpleasant and disruptive, and Glick wants to spare innocent families that ordeal if she can.

Late in the afternoon, today's rounds still on her mind, she muses aloud about Herman, the infant whose intracranial bleeding may be the result of birth trauma. "We're just not sure if this is abuse," she says. "We weren't able to do a bleeding time test-which determines how long it takes for the blood to clot-because the parents refused permission, and that missing element in the workup has long-term ramifications for the baby."

The presenting problem in this case, an unusually large head, first raised suspicion of the medical condition known as hydrocephalus, an increase of intracranial pressure caused by abnormal accumulation of cerebrospinal fluid in the brain. After the CAT scan ruled that out, a neurologist opined that the bleeding was most likely due to birth trauma. If today's MRI confirms his opinion, it will rule out Shaken Baby Syndrome as well. "This is an example of our process," says Glick. "We have not just medical sophistication but also medical collaboration."

Two weeks ago, she adds, there was a case that a neurologist refused to believe could possibly be abuse. He wouldn't call in CPS, says Glick, and "wouldn't do the perfunctory suspected-child-abuse workup. He said, There's no way the mom did this, it's birth trauma. And that could have been true, but there were no findings to substantiate his opinion."

Even the best forensic clinician occasionally encounters almost impenetrable ambiguity. "We deal with a lot of unsolvable problems," Glick concedes, "but I don't think there's anybody in this hospital who doesn't respect our work-there's a real collaboration here. I try to put everything through a scientific sieve. I try to get the social workers during rounds to understand the boundaries upon which we base an opinion. It's not enough to say, 'I like the parents' or 'they present themselves well.'"

When Glick formed the CPS team in 1994, there was some adverse reaction from physicians who suspected her of second-guessing them. One orthopedic surgeon who was initially critical of the CPS work called it inappropriate science. "In fact," Glick admits, "there are a lot of inappropriate opinions made on both sides without scientific data, and that enrages me. Now we work together, and he realizes I'm very careful about diagnosing true abuse."

Returning to baby Herman, a case that won't leave her mind until the MRI report comes in, she says, "I kind of jumped on the intern today, but this child had a clavicular fracture sustained from a difficult birth-classic birth trauma. Why would we think someone intentionally caused that injury? Why do we jump to this conclusion in low-suspicious injuries and think a parent would do that? I'm a child-abuse doctor, but there I was, trying to defend those parents. And I do that a lot."

A short time later, an aide informs Glick that Herman's MRI examination is complete, and she hurries off to radiology. The MRI has turned up nothing Glick does not already know about the intracranial bleeding. "We found that he had a rather large head and one side of it was flattened," she says. "I reviewed this with the neurosurgeon, who felt that this child was probably born with some increased fluid around the brain and that he was more likely to bleed from birth trauma. As a team we are rather relieved at this news."

It's good news as well for Herman's family. It means their baby, his bleeding now stopped, can come home.

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Walton R. Collins, editor emeritus of Notre Dame Magazine, is a freelance writer whose most recent University of Chicago Magazine article was a report on autism ("Living Life at Arm's Length," February/99).