Medical child abuse — like that alleged in Olivia Gant case — is rare and hard to identify, experts say

When Kelly Turner was arrested and charged with killing her daughter after allegedly pretending the girl had a severe illness for five years, it raised questions about how doctors could have missed signs the child was being abused.

Olivia Gant, 7, died in August 2017 after Turner asked Children’s Hospital Colorado to withdraw nutrition and send her to hospice. Turner was charged with murder more than two years later, after police allege she lied about another daughter’s medical history and investigators questioned whether Olivia truly had been terminally ill.

Medical child abuse, also called Munchausen by proxy or factitious disorder by proxy, involves deceit to get unneeded medical care for a child. Parents’ actions can range from exaggerating a child’s real symptoms to causing illness through poisoning or other means.

Experts said that, while they couldn’t comment on Olivia’s death, medical child abuse is one of the harder things a pediatrician can be asked to diagnose.

It’s rare. There’s no one test to diagnose it. And abusive parents’ behavior doesn’t always look much different from that of well-meaning parents dealing with the stress of raising a seriously ill child.

And even if a doctor or nurse does suspect a parent might be abusive, some hesitate to report that to their state’s child welfare agency if they aren’t certain, for fear of breaking their patients’ trust and bringing down a heavy-handed response.

At least one doctor who treated Olivia felt reporting suspicions to the Department of Human Services was a high-stakes move — one that could take her away from her mother — that required some degree of certainty about the abuse upfront.

Mistrust of the child welfare system — which both in Colorado and nationwide has been deeply flawed — is not unusual, and it can influence whether a person reports suspected abuse, said Dr. Benjamin Levi, a pediatrician, founding director of Penn State’s Center for the Protection of Children and director of iLookOut for Child Abuse, a program for training child care providers on mandated reporting.

“It’s a common attitude for anyone who is significantly familiar with the child welfare system,” he said.

Reasonable suspicion of abuse

Levi has researched in depth what medical providers consider to be “reasonable suspicion” of abuse, a phrase used in many states’ mandated reporting laws to set the threshold for when a mandated reporter must alert authorities. Because the standard is so ambiguous, doctors are “all over the board” in terms of when they would report abuse, he said.

In a survey of 1,200 pediatricians about how certain they would have to be before they had a reasonable suspicion of child abuse, the most common answer was 50% certain — but only about one in six agreed that was the appropriate level. About one in 10 said they would have reasonable suspicion if they were 10% certain, and one in 25 said they’d need to be 90% sure.

“It’s essentially a Rorschach test about the person,” Levi said, “which has to do with their knowledge of child abuse… and it depends upon what you think about the value of reporting.”

The Cleveland Clinic estimates about 1,000 of the 2.5 million cases of child maltreatment reported in the United States in a typical year involve medical child abuse, meaning it’s considerably rarer than physical or sexual abuse.

That holds true in Colorado as well, according to data provided by the Department of Human Services. In 2020, the agency substantiated more than 10,000 instances of neglect, and about 1,100 instances of physical abuse across the state. The agency substantiated just 152 cases of medical neglect or abuse.

Usually, cases of medical neglect involve parents failing to seek medical care for a child, or leaving a hospital against medical advice, said Joe Homlar, division director for child welfare. It’s unusual to see accusations that a parent is seeking unnecessary care, he said. Colorado’s statistics lump the two together in part because medical abuse is so rare.

Some providers at Children’s Hospital felt Turner was not obviously inappropriate, and that allegations of abuse would be difficult to prove in part because Olivia’s medical condition was so complex. Some of Olivia’s alleged symptoms were also relatively difficult to disprove. Abusive parents are more likely to report those harder-to-find symptoms, like difficulty feeding or seizures, according to a 2020 article in Pediatrics in Review.

Adding to the difficulty of finding it is that some potential warning signs also can look like the way parents of legitimately ill children behave. For example, a mother might be pushing back against a doctor’s findings because she wants to hurt the child, but it’s more likely she believes real needs aren’t being met — and she may be right.

“It’s kind of like looking for a needle in a haystack,” said Dr. James Metz, head of the child protection team at University of Vermont Children’s Hospital.

Signs of medical child abuse include:

• Symptoms that don’t make sense or are only observed by one parent
• The child’s illness doesn’t respond to treatment
• The parent reports the child is worsening, but providers see no evidence
• The child’s symptoms improve in the hospital, but worsen after returning home
• More than one child in the family is being treated for a rare disease
• Samples of the child’s bodily fluids show signs of contamination, such as unexplained chemicals
• The parent insists on invasive procedures, and isn’t relieved if tests find the child doesn’t have a particular disease

Of course, some families do have more than one child who has a rare disease, and not every condition responds to treatment as expected. Advocacy groups for patients with rare diseases have argued that hospitals may be too quick to identify parents who are seeking care for their children as potentially abusive.

A rare and difficult diagnosis

Medical child abuse cases are generally found when a doctor or someone else reviews the child’s medical records and discovers that they don’t align with what the parent is saying, according to the Pediatrics in Review article. Some hospitals also have covertly recorded parents harming their children or tampering with urine or blood samples. But taking video of patients without their consent raises ethical issues.

Doctors are more likely to identify medical child abuse if the child’s primary care doctor remains involved, and everyone is communicating, Metz said. When a child is seeing many specialists and no one is responsible for overseeing all of their care, it decreases the odds anyone will identify inconsistencies and put the pieces together, he said.

Pediatricians are trained to trust parents and work with them, and that’s almost always the right approach, Metz said. But it makes it harder to identify the rare cases where parents aren’t trustworthy, because there may not be clear red flags, he said.

Trust “is kind of the basis for the doctor-patient relationship, and when that breaks down, that causes significant problems,” he said. “In hindsight, going back, reading through the records, it can become more apparent that things were missed.”

The health care system isn’t set up to catch deceit, because doctors don’t have easy access to a patient’s records from other practices and hospitals, Metz said. Parents who are medically abusing their children may take advantage of that, by bouncing between doctors, so no one has a complete picture of the child’s health, he said.

Medical child abuse is particularly hard to diagnose because it’s so rare, Metz said. The signs also are far less apparent than when a child comes in with a broken bone from physical abuse, he said.

“It’s not often in the top five things, the top 10 things, or even the top 20 things” on a doctor’s mind when they see a patient, he said.

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