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.