ATLANTA — Bumps, falls, bruises, marks, illnesses, and scars.
They're injuries most people will experience at one point in their lives - including children. While their causes are mostly known - what happens when the person injured is an infant who can't explain what happened?
Nearly two dozen Georgia families 11Alive Investigates spoke to for its investigation, Help that Harms said they sought out medical professionals for help to find out why their children were ill. They were blindsided when doctors accused them of causing the problem - either through neglect or abuse.
Some felt, however, the problem isn't child abuse pediatricians, or CAPs, themselves. It's the enormous authority law enforcement, Georgia's Division of Family and Children Services (DFCS), and others give to their their diagnosis.
Former DFCS director Tom Rawlings says he believes abuse is under reported and wishes the state had more child abuse pediatricians. But he adds, their role needs to be an element of the investigation, not the sole opinion.
"They really are a wonderful first line of defense to make sure that children who have been abused are receiving proper safety and are getting cared for," Rawlings explained. "So to me, the question is not dismissing the great work of child abuse pediatricians, but is how do we make sure that when a diagnosis has been made medically, that we are also doing a full and thorough review in the legal system to make sure that we are giving them [the parents] the opportunity to defend themselves?"
What are child abuse pediatricians?
While all medical professionals are required to report suspected child abuse, CAPs have specialized training to evaluate injuries or symptoms that may be associated with abuse or neglect.
The subspecialty in medicine was first established by the American Board of Pediatrics (ABP) in 2009.
Child abuse and neglect was federally defined by 1974 in the United States with the Child Abuse Prevention and Treatment Act (CAPTA). The passing of CAPTA ultimately formed mandatory reporting, among other safety nets for child abuse awareness.
Those who are found guilty of failing to report suspected abuse in Georgia may face a misdemeanor charge.
How many child abuse pediatricians exist?
In 2009, the CAP subspecialty was established certifying nearly 200 child abuse pediatricians.
The field has grown slowly since.
As of June 2023, there were still fewer than 350 certified CAPs in the U.S., according to national data reported on ABP's website.
Although higher compared to other years, only 31 medical professionals completed an initial year of certification in child abuse pediatrics in 2022, according to data provided by ABP.
Earlier this year a new report published on ABP's website, titled, "Child Health Needs and the Child Abuse Pediatrics Workforce: 2020–2040" outlined the CAP work force challenges. It includes fewer fellows entering the field, decreased financial compensation for the subspecialty and workforce retention issues.
As of last year, Georgia had five CAPs certified.
Currently, Children's Healthcare of Atlanta and Emory University School of Medicine offer a three-year fellowship program in child abuse pediatrics, approved by the Accreditation Council for Graduate Medical Education (ACGME).
All of the families featured in 11Alive's investigation said they interacted with Children's Healthcare of Atlanta during their journey, and while they may not have known it until they appeared in court, a CAP was involved in their case.
"Approximately 1,900 suspected victims of abuse and neglect are evaluated annually through our three freestanding hospitals, two outpatient clinics and telemedicine services," Children's Healthcare of Atlanta states on its website.
In March, 11Alive requested to meet with a Children's representative, or CAP, to discuss the medical subspecialty, its fellowship program and more.
The interview request was declined and, instead, a spokesperson offered this statement on March 21:
Children's Healthcare of Atlanta child abuse pediatrician statement
Child abuse pediatrics is a subspecialty of pediatrics that focuses on the diagnosis and treatment of child abuse and neglect. These are highly trained pediatricians who, following their medical school and general pediatrics residency training, participate in an additional three-year fellowship program, approved by the Accreditation Council for Graduate Medical Education (ACGME), with training specific to child abuse. Upon completion of the fellowship program, these pediatricians are eligible to take the subspecialty board examination in Child Abuse Pediatrics.
Child abuse pediatricians utilize a medically-led, multidisciplinary approach when evaluating and diagnosing any form of suspected child abuse, including sexual, physical and neglect, as well as diagnosing accidental injuries and injuries that mimic abuse. They provide medical guidance to Georgia authorities, including law enforcement and Georgia Division of Family and Children Services (DFCS). DFCS determines any next steps with respect to a child’s placement if needed.
For more information on the Child Abuse Pediatric fellowship program, we recommend you contact The American Board of Pediatrics.
How many children are impacted by abuse?
An estimated 558,899 U.S. children were victims of maltreatment in fiscal year 2022, 60,644 of them were from Georgia according to the latest report issued by the Children's Bureau at the Department of Health and Human Services (HHS).
According to Georgia's Child Welfare Data, 418 children that year were removed for allegations of physical abuse.
Children under the age of one represent about 18% of children reported to the state for maltreatment, far more than any other age group.
But 11Alive wanted to go deeper into the data, requesting to know how many infants were reported for physical abuse by a medical professional. The answer, according to the National Data Archive on Child Abuse and Neglect, is that in the past five years 326 children under the age of one reported suspected abuse to DFCS. Seventy nine percent of those accused were parents and 45 percent of those infants were removed from their custody.
While HHS' reports reveal a steady decline in the total number of estimated children neglected or abused, ABP points out that those declines may be impacted by other factors, such as the COVID-19 pandemic.
Why Georgia families are speaking out
11Alive Investigates reviewed nearly two dozen Georgia cases for its investigation. The parents and medical professionals sought for an independent evaluation, believe the injuries that brought their child to the hospital were medical - not abuse.
Still, the families said their attempts to seek help for their children and the swift decisions made by CAPs ultimately caused them the greatest harm.
"If I had it my way, I'd have a stack of cards right there in those rooms for these parents because it doesn't matter what they say - it's a catch-22," Darice Good, an attorney representing families fighting against abuse and neglect allegations, said.
Many of the parents still face, and are actively fighting, criminal charges alleged against them, like child cruelty and aggravated battery.
Tarilyn and Tyler Alexander, Georgia parents who originally took their son to the hospital because they noticed he had a swollen leg, now face 360 years in prison for 18 criminal charges -- a count of child cruelty and battery for each fracture a CAP said they found.
Tarilyn Alexander says three doctors that have conducted an independent review of her child's medical history believe those injuries were caused by infantile rickets and a possible genetic disorder, Ehlers Danlos Syndrome. Despite their medical opinions, the CAP involved in their case stands firm on the diagnosis of abuse.
As a result, the Alexanders haven't seen their oldest son in three years and a baby boy born a year later was also taken by DFCS and adopted to a family member for care.
Good is not involved in the Alexander's case, but has represented several families like them.
In her opinion, "it doesn't necessarily come down to the fact that they're [CAPs] wrong. It's the fact that they're insufficient - they're consistently relying upon the same people, the same records. They're not relying on a lot of these specialists who have had years in their fields. I just think that they're lacking all the information that would make a good evaluation of the client."
CAPs do work with other medical professionals to make their diagnosis, but Georgia families say it is too often made within hours of arrival and does not take the child's entire medical history into account. Once labeled with abuse, other doctors appear hesitant to contradict the claim.
Parents say they want access to a second, independent medical opinion before the allegation of abuse is formalized. They also want more education and better oversight about the weight initial CAP findings have on agencies, like law enforcement and DFCS.
"If they can explain it, they'll say the explanation isn't sufficient to explain the injuries. If they can't explain it, then they'll say it was abuse," Good said. "So, there's no winning for these parents in these situations."
11Alive requested an on camera interview with the American Board of Pediatrics. They declined, offering to only respond to questions in writing. We also reached out to the Helfer Society, an honorary group for physicians working to protect children from abuse and neglect. The organization never responded to our calls or emails.
11Alive Investigator Rebecca Lindstrom has been looking into the Help That Harms. Follow her investigation on demand via our streaming app 11Alive+ Available on Roku, Apple TV and Amazon Fire TV.