How Child Abuse Pediatrics Has Become Embedded in Child Protection Investigations
In order to truly understand the power that child abuse pediatricians (CAP) hold and the subsequent impact on cases like Maya Kowalski's, it's important to examine the history and structure of child abuse pediatrics.
The sub-specialty of child abuse pediatricians became embedded in child abuse investigation teams under federal policy and funding streams due to the Child Abuse Prevention and Treatment Act.
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In 1974, Congress passed the Child Abuse Prevention and Treatment Act (CAPTA). CAPTA has been reauthorized ten times and continues to provide funding to states for their child abuse hotlines, investigations, and child abuse multidisciplinary teams.
Federal funding for child protection investigations also supports the National Children’s Alliance, which is a national non-profit organization which accredits, funds, trains, and sets practice standards for Children’s Advocacy Centers (CAC). In 2022, the National Children’s Alliance reported federal appropriations of $16,757,000. These funding sources include CAPTA and Department of Justice grants. The National Children’s Alliance, in turn, has established a standard of operations that requires any accredited CAC to have a multidisciplinary team (MDT). To receive the highest level of accreditation, a CAC must have a board-certified CAP on staff.
These "multidisciplinary practice” models endorsed by the National Children’s Alliance establish teams of police, prosecutors, child protection agency staff, medical professionals (typically CAPs), victim advocates, mental health providers, and CAC staff who work in partnership on child abuse investigations. The term “multidisciplinary” refers to various functions in child abuse investigation, evaluation, and prosecution, and not to any variety of medical subspecialties that are involved in these investigative and prosecutorial functions. While some hospital-based MDTs do include doctors from specialties other than child abuse, the CAP is envisioned as the person who synthesizes medical opinion across a variety of medical specialties.
CACs perform a wide variety of functions in child abuse investigations, but primarily provide settings in which children are often interviewed in sexual abuse cases, using one-way mirrors. CACs may also be a site for medical exams of children who are alleged victims of physical abuse. It is less common for these centers to play a role in neglect allegation investigations. Child abuse pediatricians may work out of a CAC, but in many states and localities, they work at hospitals or for a non-profit that is not a CAC.
Map of CAC locations in the United States
Image shared from United States Children's Alliance
States typically combine their federal sources of funding with state funds and provide grants and contracts to specific institutions and centers in their state to carry out the investigative roles assigned to CAPs.
The funding of these functions is currently not coupled with any requirements of parental notification as to the CAP specialization and role, consent to access records of a child, other respect for parent rights, or any constraint on the role of the CAP as a prosecution team member or prosecution witness. At the same time, no federal funding is available to parents for obtaining independent medical expert witnesses to objectively evaluate the scientific validity of a CAP’s abuse conclusion.
The level of funding for CAPs is not reported in any national data that is available to the FJRC. In a Texas Public Policy Report in 2019, funding at the level of $5.5 million was reported as appropriated by the state. In Illinois in 2022, at least $1.6 million was appropriated to CAPs and the centers in which they work. The contracts held by CAPs give them explicit authority to conduct medical evaluations of children in physical abuse cases (without specification of parental consent or other legal protections for the child and family).
[Note: the FJRC will include additional information in this toolkit regarding the funding of CAP positions as it becomes available.]
It is clear that federal and state taxpayers are subsidizing the CAP system, and that there are no meaningful legal restrictions on the use of such funding to support a CAP like Sally Smith.
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The Florida child abuse system conferred authority to Dr. Sally Smith to participate in Maya’s hospital care while simultaneously influencing the State’s actions to separate Maya from her family.
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Dr. Sally Smith, child abuse pediatrician
Dr. Sally Smith's role in Maya Kowalski's case was established through policies and practices of Florida's Department of Children and Families and other state departments. Smith's long-time boss, Dr. Robert Alexander, testified that he was Sally Smith's boss from 2004 to 2015 in his position as the statewide Medical Director for the child protection team (CPT) program in the state of Florida. This program, which Dr. Alexander termed "unique" to Florida, is an entity created by state law, first established in 1978.
Both Alexander’s and Smith’s positions were, by law, designed to assist the Florida Department of Children and Families in investigations of child abuse. CPT team members write reports about whether there is child abuse and report their recommendations to Florida’s DCF. They also perform outreach in the community. Alexander testified that there were approximately 100 medical staff in the CPT program with approximately 100 additional positions (social workers, caseworkers, and other health care team members).
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At the time of Dr. Alexander’s testimony, the CPT system was organized into 22 geographic zones throughout Florida, each having its own CPT. These zones were not coextensive with counties or Department of Child and Families regional offices, but had their own geographic boundaries. State funding for CPT child abuse pediatricians came through the Florida Department of Public Health, which in turn created the public-private contracts. The types of specific contractual agents vary—they could be private companies, universities (e.g., the University of Florida administered the program in several zones), or other social service non-profit agencies. Smith reported to Dr. Alexander as the overall program director in her own position as a CPT Medical Director for Pinellas County. Her direct employer was a private company, Suncoast Center, which was the contractual agent for funds paid for her services through the Florida Department of Public Health. The Suncoast Center is also a CAC accredited by the National Children’s Alliance. It is the understanding of the FJRC that JHACH apparently served as the third-party beneficiary of the contract and/or grant funding that came from the Florida Department of Public Health and entities like Suncoast.
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Alexander also described the nature of Smith’s work related to JHACH as "simply performing the function of a 'CPT Medical Director.'" Those duties include advising hospital staff on the making of a child abuse hotline call, working on reports for DCF when a hotline call was accepted, and being available to help with questions. Reporting responsibilities included conducting interviews and exams.
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Dr. Alexander forcefully denied that Dr. Smith bore any role as treating physician for Maya Kowalski or that she served as a member of Maya’s treatment team.
At the same time, however, he did not deny that she: (1) advised JHACH staff on whether the hotline should be called for the concerns relating to Maya and her mother; and (2) provided ongoing advice to treatment team members. He also asserted that when Smith told another doctor to “get [Maya] off as many meds as possible,” this was “advice” and not “treatment.” He clarified that Smith would only be providing “treatment” if she were the one directly removing Maya from medication. Similarly, he asserted that Smith’s direction to remove Maya’s surgically-implanted port was not a treatment directive, but also just “advice.” He stated this direction would only constitute treatment if Smith herself wrote the order for the port’s removal. He testified that Smith’s direction to initiate 48-hour surveillance of Maya without her knowledge was performed as a “CPT physician” who was neither treating the child nor serving as an investigator or prosecutor. He further stated that the child abuse team was “independent of the hospital” and the hospital itself does not have “child abuse teams.” He acknowledged that whether Smith had crossed the line between advice and treatment would be determined by “what the parties [involved in the treatment] would say.” He clearly stated that Smith’s job as a CPT physician was not to provide treatment.
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He further clarified that under Florida law, CPT physicians do not require hospital privileges to see the child, access their records, or perform their role; however, he failed to mention that Florida DCF policy explicitly states a preference for the opinions of CPT Medical Directors, such as Smith, over the viewpoints of treating doctors, as outlined in Chapter 9 of CFOP 170-5.