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News / Health / Health Wire

When child abuse is a misdiagnosis: WA doctor pushes back on questionable cases

By Nina Shapiro, The Seattle Times
Published: September 24, 2023, 6:05am

SILVERDALE, Kitsap County — The infant’s doctor visit was supposed to be a routine wellness check. Mother Emily Massaro had a list of questions, one of them about bluish gray marks that looked to her, and then the pediatrician, like bruises. Massaro explained the 2-month-old boy recently fell off a bed, something she had told another doctor at the time.

But this pediatrician was suspicious. Massaro and her husband, Dan, soon found themselves at the center of an abuse investigation — one that intensified when the doctor directed them to an Everett hospital, which said X-rays showed one or possibly two healing fractures to a rib and leg.

The Massaros said they didn’t know how such fractures could have occurred.

Police and a state social service worker arrived, informing the couple their son would be taken away. The parents handed over their infant, blanketed in his dad’s sweatshirt, in the hospital parking lot.

“I collapsed on the ground,” said Dan Massaro. “I was bawling.”

Then, Dr. Niran Al-Agba got on the case.

A second-generation pediatrician in the Kitsap Peninsula town of Silverdale, operating a thriving practice out of a split-level office she designed with her father, Al-Agba has become a vital part of the defense of many parents who say they were wrongly accused. Typically, she becomes involved in cases where other medical providers have reported or diagnosed abuse in an evaluation for the state.

She is referred to parents’ lawyers through the state Office of Public Defense, one of only a few on the agency’s list of pediatricians located in Washington. As such, she plays a key — and, to at least one pediatrician long relied on for abuse consultations, unwelcome — role as the state faces calls to move more cautiously in separating children from their parents.

While Al-Agba never categorically says abuse didn’t occur, she’s found more likely explanations for a child’s condition in 47 of the 61 cases — 77% — she consulted on as of late August. She tends to review the most questionable cases, in defense lawyers’ eyes. Even so, her findings underscore longstanding complaints from parents and defense attorneys who claim the state regularly makes abuse allegations on the basis of doctors’ insufficiently vetted suspicions.

“She’s an essential component to our system right now,” said Tacoma family law attorney Chris Torrone.

In her office overlooking a row of plum trees, Al-Agba examined the 2-month-old with bluish gray marks, entrusted to a grandmother last May after a night in foster care. “The moment I looked, I said: ‘Those are Mongolian spots,’” the pediatrician recalled.

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The so-called bruises were in fact birthmarks, as later confirmed by a hospital provider consulting with the Department of Children, Youth and Families, according to a DCYF document obtained by The Seattle Times, along with other records in the case.

It was the beginning of the end of the state’s “dependency case,” requesting custody from a court. The reported fractures remained a mystery. No breaks turned up in a second set of X-rays Al-Agba ordered, though she said the hospital’s earlier films might indicate a birth injury.

The state dismissed its custody request in July, citing no ongoing safety concerns, and sent letters to the couple saying its abuse allegations were unfounded. Even so, the couple said they were left traumatized and distrustful of health care providers.

Al-Agba says such cases have changed her views of medicine.

“If you asked me five years ago would I be doing this work, I would have said no,” she said, talking in characteristic rapid fire. Doctors would never wrongly accuse someone, she thought.

She has come to believe doctors too often jump to suspicion of abuse without fully exploring other possibilities. While this can affect all demographic groups, Al-Agba finds people of color are particularly hard hit. Black, Native American and multiracial people make up roughly 12% of the state’s population but constitute one-third of last year’s requests for state custody.

“These are people who as a general rule do not have resources,” Al-Agba said of many parents accused of abuse. “We always seem to believe they’re bad parents. And sometimes that’s true. Sometimes, someone has hurt the child. But actually, my experience is that more often than not, they haven’t.”

A brewing backlash

Two years ago, DCYF Secretary Ross Hunter told The Seattle Times he sought to halve the number of kids in foster care, then at 7,400. A rethinking of the child welfare movement was afoot, with some calling for supporting families rather than breaking them apart.

In July, a state law took effect that raises the standard for removing children from their homes from “serious threat of substantial harm” to “imminent physical harm.”

Meanwhile, child poverty — strongly correlated with involvement in the foster care system — dropped nationwide as families received federal relief benefits. DCYF officials say that’s a big reason the number of Washington children placed outside the home as of June 30, just below 6,000, is the lowest it’s been since the agency began keeping track in 1979.

Child poverty jumped back up when the benefits expired, so the decline in foster placement may not hold.

It’s also unclear whether the state’s rethinking of separating families will affect abuse cases triggered by health care providers. DCYF, declining an interview request, said in a statement it relies on medical professionals, including consultants contracted to review cases, to help protect children. The agency, balancing competing pressures, faces heavy criticism when it ignores red flags.

“Child safety is our paramount concern, and when we receive reports of alleged child abuse or neglect, we exercise precaution to protect the child, while also assessing new information as it arises,” DCYF said.

Critics say the doctors the agency relies on — many of whom built careers on identifying abuse and may not have broad pediatric experience — make mistakes.

While all physicians do, Amelia Watson, a supervising attorney with the state public defense office, said she’s been shocked by what seems to her like a high error rate of doctors reporting abuse. She’s judging by what she’s heard about case resolutions; her office doesn’t keep statistics.

A state law allows for a second opinion by a doctor of parents’ choosing, but DCYF doesn’t usually tell parents that, and the agency often takes children away before the parents are aware of their rights, according to Watson and several defense attorneys.

Further, some critics say DCYF doesn’t fully grasp the gravity of what abuse allegations mean for parents and their children.

“The harm of removal and destruction of families is simply not appreciated and understood by those who have no follow up responsibilities or accountability for errors and lack of judgment,” said Rae Lea Newman, a Puyallup nurse who reviews cases for parents’ attorneys.

A backlash is brewing.

A dozen parents filed a federal lawsuit in November accusing Dr. Elizabeth Woods, formerly of Mary Bridge Children’s Child Abuse Intervention Department and an expert state witness, of providing “false, incomplete, and/or unsupportable evidence” as a basis to remove children from their homes. The parents also filed a parallel state lawsuit against DCYF for relying on Woods.

DCYF and the doctor, who left the Tacoma children’s hospital in 2021, deny the allegations.

The lawsuits follow a King County judge’s 2019 ruling, in a case highlighted by an NBC News and KING 5 investigation, that Woods made allegations against one mother mostly “without supporting factual basis” and that a consulting Seattle Children’s physician “was factually mistaken at times and at other times did not support her opinion with the underlying facts.”

Steve Fogg, a lawyer representing Woods, said the Tacoma pediatrician stands by her judgments and made them in consultation with other doctors.

Mary Bridge spokesperson Kalyn Kinomoto said a subsequent independent review of its abuse intervention department found it to be high-performing but suggested “strengthening peer review and adding additional leadership.”

A Seattle Children’s spokesperson didn’t respond to specific questions but sent a statement saying health care providers are required to report what they believe to be child abuse or neglect.

The hospital’s Dr. Kenneth Feldman refuted criticism more forcefully.

Feldman is a member and former medical director of Seattle Children’s Safe Child and Adolescent Network, a team devoted to identifying abuse and neglect for the children’s hospital and Harborview Medical Center. It also consults on cases for other medical facilities and DCYF.

SCAN members look at all possibilities for children’s injuries, communicating with doctors around the hospital on every case, he said. “It’s not us as the lone ranger.”

Feldman recently reviewed his own determinations in cases over a five-year period and calculated he diagnosed abuse in 40% of them — lower than the 50% rate in roughly two dozen similar programs around the country, according to a study conducted by a SCAN fellow.

In 40 years of doing this work, he said he could think of only a handful of cases where he’s been wrong.

In Feldman’s view, Al-Agba’s arrival on the scene hasn’t been a positive development.

“Basically, the consultations I’ve seen are totally incompetent,” he charged, saying Al-Agba has “no training in abuse beyond her medical school and residency” and that judges believing her findings “got the wool pulled over their eyes.”

Al-Agba has become “a professional witness,” he added. “She’s making quite a bit of money from that.”

The Silverdale pediatrician said she earns about as much from her case reviews, $400 an hour, as she does seeing patients. She makes $500 an hour for court testimony. (Feldman says he earns $300 an hour for testifying in cases that don’t involve Seattle Children’s or Harborview.)

As for Al-Agba’s training, she said she agreed with Feldman. “I’m not a child abuse expert. What I am is a general pediatrician. And my job is to properly diagnose children with diseases.”

She does this work, she said, because “this is justice to me.”

‘Heartbreaking’ assumptions

In many ways, Al-Agba, 48, exemplifies a small-town doctor. She was born in the county where she now sees some 4,000 patients, and Central Kitsap Reporter readers recently voted her the region’s best pediatrician.

With a University of Washington medical degree, she returned to the area in the early aughts after a Colorado residency, joining her father’s practice.

Dr. Saad Al-Agba was the kind of a pediatrician who once promised a patient a watch if the teen got straight A’s. He practiced until he had a heart attack at 81, then died soon after in 2017.

It was a rough period for Al-Agba, dealing with her dad’s illness and taking over his patients on top of her own. Patients’ families rallied.

“I would be three hours behind and coming to the exam room and be like, ‘I’m so sorry.’” Those waiting for her would not only be understanding but ask: “Did you eat today? Let me buy you lunch.”

She wrote a column for the Kitsap Sun about their kindness. It drew so many readers, she said, that the paper asked her to contribute regularly.

She had written a previous opinion piece or two, including about what she saw as a worrisome trend toward health care consolidation. With a twice-monthly column, she covered all sorts of topics: racism, immigration (her dad had emigrated from Iraq) and her experience with a patient’s family DCYF had accused of abuse after one of its physician consultants, Woods, evaluated a bruise.

Fogg, Woods’ attorney, said by email the Tacoma pediatrician had a narrow role in the case and was asked by DCYF, on the basis of a photo, to “give her preliminary medical opinion as to whether the concerning marks could be the result of non-accidental trauma (not whether abuse had in fact occurred).”

Al-Agba had seen the bruise herself and believed it consistent with the mother’s explanation that the toddler had fallen while climbing over a baby gate. In the 2019 column, Al-Agba questioned “overzealous child abuse pediatricians.”

Dr. Elizabeth Meade, then-president of the state chapter of the American Academy of Pediatrics, objected in a letter to the editor. “Anecdotal stories … do not provide a balanced look at the systems we have in place to keep children safe,” she wrote. “They do not shed light on the countless lives saved by pediatricians who use their training to recognized signs that children are being hurt.”

But Al-Agba’s view resonated with others, leading to her role on behalf of parents.

Her presence in Washington allows her to physically examine allegedly abused children instead of just looking at records, as consulting physicians on both sides of cases sometimes do. In many instances, the Office of Public Defense taps out-of-state doctors, as it’s difficult to find local physicians willing to subject themselves to complaints known to come from child abuse pediatricians whose judgments were questioned.

“In at least one of our cases, the court commented on the fact that the only doctor who had seen the child in person was saying that this was not abuse,” recalled Seattle defense attorney Elena Trebaol. “That was pivotal.”

Al-Agba likens her work to solving a puzzle. For the many professionals looking at a case, definitive conclusions aren’t always easy to piece together. Family situations can be complicated. Domestic violence may be involved. DCYF and other authorities often have to make quick decisions.

In the aftermath, Al-Agba sorts through the medical clues. For example: She looked at lab results during one infant’s hospital stay and suggested a diagnosis of a rare liver disease — one that can cause poor weight gain, as well as easy bruising and fractures — before the diagnosis was officially confirmed.

“There is something terribly wrong,” Al-Agba wrote in an email to the mother’s lawyer, urging her to ensure the child be brought to a specialist immediately. The child is now being treated for the disease, and DCYF eventually dropped its request for custody.

In another case, Grace and Sam Wilkinson took their 7-month-old to an urgent care facility last February because the baby was holding her arm unusually while nursing. A doctor manipulated the arm in an attempt to solve what he thought was the problem, and ordered X-rays, which showed an elbow fracture, according to a King County judge’s ruling.

The family was referred to Seattle Children’s, where the girl had surgery and the SCAN team raised suspicion not only about her elbow but other possible fractures, as well. DCYF placed the child in protective custody with a grandmother.

But were there actually fractures? Al-Agba, one of several doctors the Wilkinsons consulted, testified she didn’t see evidence of any, with the possible exception of the elbow injury. It was hard to tell because of the surgery.

If there was an elbow fracture, it could have been caused or exacerbated by the urgent care doctor’s manipulation, she and another doctor suggested, according to the ruling. Al-Agba also noted babies occasionally fracture their elbows while rolling from their stomach to their back.

All the doctors offering second opinions made abuse seem unlikely, and Judge Nicole Gaines-Phelps was persuaded. In her March ruling, she said the case, first reported by Fox 13, was emblematic of “how the medical community often reaches decisions based on conscious and unconscious bias.” Sam Wilkinson is Black; Grace Wilkinson is Filipino and Puerto Rican.

The judge called out a doctor’s note provided to DCYF. “Bio-dad not involved at this time due to physical abuse concerns,” it read.

In fact, Sam Wilkinson, then a maintenance supervisor for an apartment complex company, didn’t come to the agency-mandated checkup because he was working.

“The assumptions that were made are just heart-breaking,” said the judge. “A note like that … could change somebody’s life.”

She ordered the child be returned to her parents, who later received DCYF letters saying the abuse allegations were unfounded.

The Seattle couple — $75,000 in debt, largely over medical costs — did get one thing out of the ordeal: a new pediatrician. They found Al-Agba to be so knowledgeable and compassionate that they now trek to her Silverdale office for their daughter’s care.

“We don’t trust any other pediatrician,” Grace Wilkinson said.

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