When Kelly Turner was arrested and charged with killing her daughter after allegedly claiming the girl had a serious illness for five years, it raised questions about how doctors could have missed any signs that the child was mistreated.

Olivia Gant, 7, died in August 2017 after Turner asked the Colorado Children’s Hospital to remove her nutrition and send her to hospice care. Turner was charged with murder more than two years later, after police alleged that she lied about another girl’s medical history and investigators questioned whether Olivia had really been terminally ill.

Medical child abuse, also known as Munchausen by proxy or factitious disorder by proxy, involves deception to obtain unnecessary medical care for a child. Parents’ actions can range from exaggerating a child’s actual symptoms to illness through poisoning or other means.

Experts have said that while they cannot comment on Olivia’s death, medical child abuse is one of the most difficult things for a pediatrician to diagnose.

It’s rare. There isn’t a single test to diagnose it. And the behavior of abusive parents is not always very different from that of well-meaning parents faced with the stress of raising a critically ill child.

And even if a doctor or nurse suspects that a parent might be abusive, some are reluctant to report it to their state’s child welfare agency if they are not sure, for fear of breaking the law. trust their patients and provoke a brutal response.

At least one doctor who treated Olivia felt that reporting suspicions to the Social Services Department was a high-stakes decision – one that could take her away from her mother – that required some degree of certainty about the abuse from the start.

Distrust of the child welfare system – which both in Colorado and across the country has been deeply flawed – is not unusual, and it can influence whether a person reports suspected abuse, said Dr Benjamin Levi, pediatrician, founding director of Penn State’s Center for the Protection of Children and director of iLookOut for Child Abuse, a program to train child care providers on mandatory reporting.

“This is a common attitude for anyone familiar with the child protection system,” he said.

Reasonable suspicion of abuse

Levi has done extensive research into what medical providers consider a “reasonable suspicion” of abuse, a phrase used in the mandatory reporting laws of many states to define the threshold at which a commissioned reporter must alert officials. authorities. Because the standard is so ambiguous, doctors are “ubiquitous” about when they would report abuse, he said.

In one survey of 1,200 pediatricians as to how certain they were before they had a reasonable suspicion of child abuse, the most common response was 50% certain – but only about one in six agreed this was the appropriate level. About one in ten said they would have a reasonable suspicion if they were 10% certain, and one in 25 said they would need to be 90% sure.

“It’s basically a Rorschach test on the person,” Levi said, “that has to do with his knowledge of child abuse… and it depends on what you think of the value of reporting.”

The Cleveland Clinic estimates approximately 1,000 of the 2.5 million cases of child abuse reported in the United States in a typical year involve medical abuse of children, meaning it is considerably rarer than physical or sexual abuse.

This is also true in Colorado, according to data provided by the Department of Human Services. In 2020, the agency corroborated more than 10,000 cases of neglect and approximately 1,100 cases of physical abuse across the state. The agency only corroborated 152 cases of medical negligence or abuse.

Usually, medical negligence cases involve parents failing to seek medical care for a child or leaving a hospital against a doctor’s advice, said Joe Homlar, division director for child protection. . It is unusual to see accusations that a parent is seeking unnecessary care, he said. Colorado statistics lump the two together in part because medical abuse is so rare.

Some providers at the children’s hospital felt that Turner was not manifestly inappropriate and that the abuse allegations would be difficult to prove in part because Olivia’s condition was so complex. Some of Olivia’s suspected symptoms were also relatively difficult to refute. According to a 2020 article in Pediatrics in Review, abusive parents are more likely to report these harder-to-find symptoms, such as difficulty feeding or seizures.

Adding to the difficulty of finding it, some potential warning signs can also resemble how parents of legitimately ill children behave. For example, a mother may push back a doctor’s conclusions because she wants to hurt the child, but she is more likely to think that the real needs are not being met – and she may be right.

“It’s kind of like looking for a needle in a haystack,” said Dr. James Metz, head of the child protection team at the University of Vermont Children’s Hospital.

Signs of medical child abuse include:

• Symptoms that don’t make sense or are seen only by a parent
• Childhood illness does not respond to treatment
• Parent reports worsening child’s condition, but providers see no evidence
• Child’s symptoms improve in hospital, but worsen after returning home
• More than one child in the family is treated for a rare disease
• Samples of the child’s body fluids show signs of contamination, such as unexplained chemicals
• Parent insists on invasive procedures and is not relieved if tests reveal the child does not have a particular disease

Of course, some families have more than one child with a rare disease, and not all conditions respond to treatment as expected. Rare disease patient advocacy groups have argued that hospitals may be too fast identify parents who seek child care as potentially violent.

A rare and difficult diagnosis

According to the Pediatrics in Review article, cases of medical child abuse are usually discovered when a doctor or other person reviews the child’s medical records and finds that they do not match what the parent is saying. Some hospitals have also secretly recorded parents injuring their children or tampering with urine or blood samples. But filming patients without their consent raises ethical issues.

Doctors are more likely to identify medical child abuse if the child’s treating physician stays involved and everyone communicates, Metz said. When a child sees many specialists and no one is responsible for overseeing all of their care, it decreases the chances of anyone identifying inconsistencies and putting the pieces together, he said.

Pediatricians are trained to trust and work with parents, and that’s almost always the right approach, Metz said. But it makes it harder to identify the rare instances where parents are untrustworthy, as there may not be clear red flags, he said.

Trust “is kind of the basis of the doctor-patient relationship, and when it breaks down it causes significant problems,” he said. “Looking back, coming back, reading the files, it may become more obvious that things have been missed.”

The healthcare system is not designed to catch deception because doctors do not have easy access to a patient’s records from other practices and hospitals, Metz said. Parents who medically abuse their children can take advantage, swinging between doctors, so that no one has a full picture of the child’s health, he said.

Medical child abuse is particularly difficult to diagnose because it is so rare, Metz said. The signs are also much less noticeable than when a child arrives with a fractured bone as a result of physical abuse, he said.

“It’s not often in the first five things, the first 10 things, or even the first 20 things” on a doctor’s mind when seeing a patient, he said.