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