How Faint Bruises on Baby Ava Nearly Destroyed Her Family

Proposed federal legislation would move overstressed child protection systems in the wrong direction.


A few days before she turned one, Ava took her first steps. A much-desired baby who arrived after eight years of fertility treatments, her parents, Mike and Debbie King (not their real names), called Ava their "little miracle." Careful and protective, Mike and Debbie were utterly unprepared to become targets of a child abuse investigation.

At Ava's routine one-year checkup, her pediatrician saw several faint, small bruises on Ava's chest, belly, and inner thigh. The pediatrician instructed Mike and Debbie to promptly take Ava for blood tests for bleeding disorders or liver disease. They went to the nearest emergency room the same day. 

Ava's initial blood tests showed no obvious signs of a medical disorder. But given that the Kings couldn't say how Ava's bruising had occurred, an emergency department staff member decided she had to call the child protective services (CPS) hotline to report suspected child abuse. 

Unexplained bruises like Ava's are considered early warning signs of possible abuse. And when abuse is genuinely suspected, calling CPS hotlines is mandated under current law.

It makes sense for doctors who see odd bruises to order tests to rule out medical conditions. It also makes sense for them to ask the parents about possible causes, and to look for more signs of injuries. But even the most attentive parents sometimes can't account for every small bruise on their active infants and toddlers. In those cases, the rush to call an abuse hotline, while intended to protect children, can actually put kids like Ava in harm's way.

And yet such calls have become routine.

An estimated one-third of children in the United States have been investigated for some type of child abuse or neglect. Among African American families, the number is one out of every two children.  

Yet some doctors and policymakers would like to see more hotline calls. Two pending bills introduced on April 3—S.B. 1009, proposed by Sens. Tammy Baldwin (D–Wisc.) and Bill Cassidy (R–La.), and H.R. 2076, proposed by Reps. Kim Schrier (D–Wash.) and Steve Stivers (R–Ohio)—seek $10 million in funding to increase reporting, reporter training, and investigation of unexplained bruises to CPS authorities.

Though well-intended, this measure is riddled with misplaced assumptions. If enacted, it will traumatize innocent families and redirect child welfare resources away from the real cases of serious abuse. These bills wrongly assume that the science of diagnosing abuse from faint marks is well-developed, when in fact it is only in its infancy and requires much more research.

Ava's Story

After the staffer placed the hotline call about Ava, a CPS caseworker quickly came to the hospital, examined the girl, and expressed surprise that her bruising was barely noticeable. He allowed Debbie and Mike to take their baby home, with a plan to continue his investigation. 

The next day, Ava's pediatrician insisted that the Kings should have taken Ava to a different hospital that had a child abuse medical team. When the Kings balked at the added expense, and at the prospect of another long day at a hospital for no good medical reason, the CPS caseworker now threatened to take custody of Ava if they refused.

Once there, the child abuse pediatric team entered orders for two separate rounds of full body x-rays for Ava. While the examining doctor at the new hospital saw no necessity for these scans, he did not countermand the order.

Debbie usually could calm Ava quickly following shots and well-baby exams, but the x-rays were different. Ava wailed while the technicians pulled on her arms and legs. Debbie tried in vain to calm her through her own tears. To Debbie, it felt like she was witnessing abuse that she was powerless to stop.

The scans showed no further injuries. Still, the family was directed to come back for a second scan to see if any broken bones showed up that were too recent to be detected that day.

With the seed of suspicion planted by the hotline call and the demand for a full child abuse workup, the state began working against the Kings. Soon after the suspicion was anchored in the minds of the investigators, confirmation bias made it increasingly difficult to un-ring the abuse alarm.

A police detective assigned to the Kings' case stood up for the family. When Detective Matthew Sandoval made an initial visit to their home, Debbie and Mike showed him Ava's high chair and explained how she often attempted to wrestle her way out. In his report, the detective noted several times that the high chair's harness buckles corresponded to the baby's sites of bruising. He also reported the child's recent prescription for steroids, which would increase her susceptibility to bruising. It was clear that the detective did not believe Ava had been abused.

Sixteen days after the hotline call, the child abuse team convened at the children's hospital. This team included not just the child abuse doctors and social workers from the hospital but police, CPS investigators, and assistant state's attorneys. While called "multidisciplinary," the team did not include any specialists—such as hematologists, orthopedists, neurosurgeons, or radiologists—who diagnose and treat children's medical conditions that can cause bruises.

At the meeting, the detective stated his opinion that there was no evidence of abuse, mentioning the highchair's harness and Ava's recent steroid treatment. No one from the child abuse medical team sought to examine the chair themselves, nor did they credit the steroid explanation. The meeting became contentious, with the two child abuse pediatricians arguing with Sandoval.

The team concluded that the parents should not be allowed to be with Ava except when supervised. They also decided to open an investigation against Ava's day care owner as a possible abuse perpetrator. But Debbie and Mike remained the prime "suspects." 

In order to comply with the new restrictions, Debbie's parents had to come from Indiana to move in with Debbie and Mike to supervise all their contacts with Ava. The Kings were initially told that any unsupervised contact with Ava would cause her to be immediately taken from them and put into foster care with strangers. (A week later, when Debbie's parents told the CPS caseworker that they had to return home, the government relented and let the couple have unrestricted contact with their daughter.)

Eventually, though the child abuse pediatricians had never met the Kings or examined Ava's bruises for themselves, they declared abuse the best explanation, discounting all the alternatives. Relying on this opinion, the CPS agency listed Debbie and Mike as child abusers in the Illinois child abuse registry. This registry can be accessed by employers, doctors, child care agencies, schools, and others authorized to run background checks. CPS then closed its case.

No court case was ever filed. Baby Ava remained home. Several doctors and even the caseworker told the Kings, privately, that they didn't think they had abused their daughter, but they didn't speak up to stop the abuse registry against them. This was supposed to be comforting to the Kings.

It wasn't.

And now they still faced a huge legal hurdle: Getting their names off the child abuse registry.

To do this, Debbie and Mike had to secure legal counsel at their own expense for a registry removal hearing. (In all but a handful of states, registry decisions are made with no prior judicial review, with the burden on the registered person to request review to get off.)

That's how I came to meet the Kings myself. They had reached out to the nonprofit I headed at the time, the Family Defense Center, which helped families navigate the treacherous child protection system.

The Kings had located an out-of-state pediatrician, a specialist with decades of experience in child abuse and emergency medicine, who made a compelling witness. Her conclusion was that there was no abuse and no reason to suspect either Debbie or Mike. Indeed, if the child abuse pediatricians had been correct that "blunt force trauma" had caused the marks on Ava, internal injuries or broken bones would have been found too. 

After she submitted her medical opinion, the CPS concluded that the agency's case was too weak to take to a hearing. And so the registered abuse finding against the Kings was voluntarily expunged.

It had taken a year and a half to get the Kings' names off the state's child abuse registry. 

The toll of the wrongful allegation was substantial. For one thing, Mike and Debbie had spent considerable sums on legal and medical fees. But the greatest trauma was the family's deep new sense of vulnerability. At a time when they should have been experiencing the joy of watching their firstborn learn to toddle, their sense of security and privacy was shattered. The experience left them fearful long after the bruises had faded.

There is an increasing belief—fueled by mandated reporters' liability concerns— that making a hotline call is the "safest" course of action. There seems to be little awareness of how abuse allegations hang like a cloud over the heads of innocent parents, many of whom lack the resources to fight back. Outnumbered and outgunned, few parents can escape unscathed. That holds true even when, as in Ava's case, there is ample evidence in the parents' favor.

Making the Problem Worse

S.B. 1009 and H.R. 2076—along with H.R 2. 2480, an umbrella bill that would reauthorize federal child abuse prevention and treatment funding—call for increasing CPS investigations of minor marks on children. The bills lack any acknowledgment that medical science is not advanced enough to distinguish abusive from non-abusive marks in the absence of other evidence of abuse.

The bills' advocates rely on a 2012 study that found that a quarter of infants under a year old who were eventually identified as victims of physical abuse had medical records noting past bruising. These earlier bruises were considered "sentinel injuries" whose early assessment might have prevented continued abuse.

That certainly supports the importance of identifying truly abusive bruising early on. But the same study found bruising in substantial numbers of the control group too. Moreover, this retrospective study only demonstrates a correlation: It does not provide diagnostic or predictive guidance as to when faint marks like Ava's signal real danger.

The proposed bills should raise special concerns for families of children with rare medical conditions and disabilities, who are disproportionately affected by CPS hotline calls. Marks like Ava's occur in dozens of unusual conditions. CPS involvement can cause physicians to step back from voicing their own medical opinions supporting parents, in an effort to avoid entanglement with police and CPS. If these bills become law, any parent who has a baby with a bruise—regardless of whether it's from a medical condition, or even from learning to crawl—could get entangled in a months-long battle to maintain custody.

Indeed, the Kings were better positioned than most families who face a wrongful allegation of abuse. If Debbie or Mike had worked with children, they likely would have lost their jobs. Registry decisions against parents often ruin careers.

Federal courts have ruled these registry systems unconstitutional in New York, Illinois, and California, raising the question of how often parents are erroneously labeled child abusers. These rulings have cited staggering error rates in registering findings of abuse—and a lack of any meaningful due process for parents trying to challenge them. When parents lose their jobs as a result of being wrongly placed on an abuse registry, they lose their ability to provide for their family. This doesn't make children safer. Quite the opposite.

Health care professionals should of course act on a genuine, reasonable suspicion of abuse. But families' stability and security are put into jeopardy when official child abuse investigations begin without first reviewing medical records, consulting with objective physicians, and confirming essential information with other available caregivers.

Infants' own bumps and tumbles can generate bruises that parents don't always notice or recall when questioned by medical, CPS or police authorities. Rough handling by siblings, interactions with pets, falls off furniture, and other such accidents can easily result in a bruise. It is simply untrue, as some child abuse pediatricians proclaim, that "children who don't cruise don't bruise"—in other words, that kids who are too young to start walking can't possibly get bumped or bruised.

Restoring Balance

Ava remained in her parents' care with no further injuries—except that Ava's grandmother observed the same bruising pattern again a few months later, after she placed Ava in the same high chair while the parents were away.

In medicine, misdiagnosis is often rooted in the failure to consider alternative explanations. This is no different in the field of child abuse. In fact, the still-quite-new field of child abuse pediatrics (which became a certified subspecialty in 2009) creates a fertile ground for misdiagnoses as there are not yet clearly established objective measures for the accuracy of abuse diagnoses.

Instead of a prosecutor's wish list, Congress should pass a much more balanced measure that will help practitioners differentiate between bruises caused by medical issues, accidental injury, daily life, or abusive trauma. Instead of flooding the overstretched child abuse system with investigations of every unexplained boo-boo, Congress should take steps to ensure that the medical system for investigating child abuse first does no harm.

NEXT: The Republican Party’s Retirement Problem

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  1. Guilty till proven innocent!

    True in taxes!

    True in child care!

    Next: Will be true when hurting anyone’s baby feelings with no-longer-free speech!

  2. “…an emergency department staff member decided she had to call the child protective services (CPS) hotline to report suspected child abuse. ”

    As a “mandated reporter” myself, we are encouraged to report any and everything of a suspicious nature, if only to cover our asses. Of course if they didn’t actually do anything wrong, it will come our right, right?

    Once that ball gets to rolling, its going to run it’s course, no matter how ill informed or equipped the deciders may be. Just another outcome of removing practitioners from exercising judgement; if you see [have reason to suspect] something you have to say something; that takes the onus off of the individual and leaves it to government to decide in the end.

    Of course I must literally hate children to even think this way.

  3. Truly a sad story.
    It seems incredibly wrong that being placed on this registry doesn’t require more due process than just the word of a pediatrician.

    1. They should have gotten the lawyer the minute any allegations were brought up and not after the fact. When suspected of a crime, lawyer up!

  4. Parents who allow the state to abuse their children in this manner, do not deserve to have children. Take them away because they went along with the investigation, I say! People shooting up freaking garlic festivals when you have entire bureaucracies full of child abusers. Americans are scum. We all are. Some of us know it.

    1. Yeah… good luck with the “don’t cooperate with the investigation” strategy. That one works great.

      Actually… if you ever had a mind to avoid paying for and taking care of your kids….. hmm… You may actually be on to something here….

  5. even the most attentive parents sometimes can’t account for every small bruise on their active infants and toddlers.

    All the more reason to mandate omnipresent Telescreens.

    1. Scotland was thinking of putting an observer in every home with children. I wonder if they followed through with that idea. Its the only way to be sure in fact I think the idea should be extended to people taking care of the elderly and maybe even gun owners. Heck lets just put observation in every home we can call them Alexa or Siri some unique harmless sounding name

      1. Orwell’s 1984, huh?

  6. I had this happen to my family (in Indiana as well).

    We were accused twice of abusing our son. First time was after he had a seizure. He had a high temperature and they wanted to do a CT scan.

    Now, he was almost two at the time and the idea of having his head locked in place for several minutes while having a high temp and while still out of it from the seizure…he didn’t cooperate. I had to try to hold his head still.

    The nurse came back an hour later and asked if we dropped him on his head. We then went through a bunch of fun for the next two hours with a very grumpy under two year old who thankfully was improving from the meds he was given for his high fever and his seizure.

    The final result? Another radiologist looked at it and asked “was the kid moving during the CT Scan?”

    Grumpy nurse came in and told us we could go home.

  7. Though well-intended, this measure is riddled with misplaced assumptions.

    Speaking of misplaced assumptions, what makes you think this isn’t anything more than attention-whoring and virtue-signaling by attention-whores and virtue-signalers?

    The toll benefits of the wrongful allegation was substantial. For one thing, Mike and Debbie had spent considerable sums on legal and medical fees. But the greatest trauma was the family’s deep new sense of vulnerability. At a time when they should have been experiencing the joy of watching their firstborn learn to toddle, their sense of security and privacy was shattered. The experience left them fearful long after the bruises had faded.

    And mission accomplished. Fucking plebs better learn their place and respect the authoritah of their superiors. We’re all the property of the state.

  8. I noticed a couple of words missing from this very lengthy and thorough article.

    Libel. That word was nowhere to be found. Same goes for Slander. Another fine word that seems really appropriate to the subject matter.

    These doctors who published a finding that they were child abusers… I wonder what the standard is. Because there’s no way in hell they met the actual medical standard of care to actually make such a finding. That is, if there is such a standard. But something makes me suspect that this is exactly similar to bite mark forensics (and even other areas of forensic science) where “opinion” masquerades as scientific finding.

  9. The findings of these doctors and their committee brings to mind the preschool child abuse panics of the late 80’s / early 90’s.

    In those cases you had “experts” who were consulted and offered opinions and guidance that couldn’t have been more inaccurate and damaging. In the Little Rascals case a social worker actually berated kids and called the liars until they told her what she wanted to hear. Questions like “show me where he touched you” were the least leading questions asked.

    In the end these “experts” presented findings like children were repeatedly raped with butcher knives – but without any physical evidence. Findings that are laugh-out-loud impossible were not only offered, but received in all seriousness and treated as scientific fact by the courts.

    They were in the same category as Mississippi’s Dr. Hayne’s famous finding that he could tell from the trajectory of a bullet that two people were holding the gun as it was fired at the victim across the room – complete fantasy.

    Which makes me wonder: Why are we so dangerously susceptible to completely implausible or even absolutely impossible testimony in these situations? And why do we continue consulting these “experts” once they have proven themselves to be wildly unreliable?

  10. Part of the problem is created at the federal level by an unconstitutional programme that sends HUGE amounts of money to local CPS agencies to “fund” foster care programmes. For every child the CPS agency places in foster care, some astoundingly large sum of money per month is sent to the CPS agency. From this pile of money that ONLY comes in when kids are stolen from their parents and farmed into the foster care system, the foster home operators (whether a commercial outfit or individual families “volunteering” ) is paid a monthly stipend per child being cared for. That amount is a small fraction of the new FedBux stream for that same child. In short, this is an YUGE windfall of FedBux for the CPS agency.

    Thus it is no wonder CPS are all about finding and inventing ways or reasons to “intervene” and thus increase their caseloads, and the number of chidren in their district into foster care.

    It would be sort of equivalent to taking your car in to the mechanic and it would fall to the MECHANIC to decide what all needed done and who would do it.

    THIS programme needs to end, now. FedGov have NO business meddling into local government or children.

    1. Can you tell us what this programme [sic] is called?

      1. Title IV-D is for child support, which is why the higher earning parent usually loses primary custody. I am not surprised there’s a CPS equivalent.

  11. No. More. Immunity.

    Not for cops who shoot dogs (and people). Not for social workers who invent child abuse. Not for anybody with any kind of official authority.

    From now on, if they fuck up, then they pay the consequences. If that makes their jobs harder and more stressful, and they perhaps hesitate to bring down the wrath of the state, we all win.

  12. Any allegation of child abuse is an allegation of a crime and the very first thing a family should do is hire an attorney. It should be done from the hospital before any other tests are done. It’s one thing to say, “I don’t want that procedure” and quite another to say, “I’m waiting to hear back from lawyer before I agree to a procedure.”

    It always surprises me when families don’t get legal representation. If the state came to you and said we suspect you of the crime of theft/murder/assault, you’d get a lawyer. If they come to you and say we suspect you of the crime of assaulting your child, why wouldn’t you get a lawyer?

  13. I agree this is a problem, but I don’t like how Reason keeps ignoring the real cause; the regulatory environment that puts doctors, nurses, and other staff in legal peril if they DON’T report something that could (maybe) be interpreted by someone as abuse. You really think those are the slavers? Nah, it’s CPS, the bureaucrats, Congress, etc.

  14. The pediatrician telling the parents that they needed ‘tests’ a the hospital was punting. He had a hunch, and did not want his name, office address, and family drug into a DFS report. So he let the hospital do the dirty work. Order some blood work that would be normal, leaving the implication that the only remaining explanation for bruises must be criminal.

    On any given day I have several bruises on my body, of different stages of healing. It is rare that I have any idea where most came from. People bump into stuff. Kids bump into stuff. If I cannot figure out where my bumps came from , how am I to know where all of my kid’s bumps came from.
    Hey nice CPS lady, where did you get that bruise; has your husband stopped beating you yet? Gosh, I’m a mandatory reporter too….

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