The case

A thirty-five-year-old female presents to the emergency department on a weekend afternoon with the following chief complaint: “I want to give up custody of my son.”

The patient is well dressed — and so is her four-year-old son, who is sitting comfortably on the bed playing a video game on his mother’s cell phone.

According to the patient, she is a single mother with no support system. Her son’s father deserted them shortly after his birth, and the patient has only distant relatives in another state with whom she is not currently in contact. She states that she has lost multiple days of work because she can’t find affordable child care, and she is concerned because lately she has not had enough money to put food on the table. She doesn’t know where else to turn, so she came to the emergency department for assistance.

Further questioning reveals the patient is adamant about giving up custody of her son. She understands that because of her limited income she will not be able to provide adequate care for the boy. She is on the verge of losing her job because she has missed multiple days of work due to her inability to find child care for her son, and she cannot afford to lose her only source of income.

You offer to contact social services, but she declines. She has thought for a long time about her decision to give up custody and has finally come to terms with it. She is certain this is the best course of action.

Discussion

In my ten years working in the emergency department, I had never encountered anything like this. Neither had the physician directly involved in the case, nor any of the dozen people who eventually became involved.

At first glance, this may seem straightforward. The mother is giving up custody of her son. This constitutes neglect, so CPS should be notified and the child should be taken away. Furthermore, the mother should probably be fined, reprimanded, or jailed for not considering other options.

As it turns out, this is not technically neglect. And as difficult as it may be to believe, the woman seemed like a loving mother. The boy was well educated and well behaved. The patient came to the emergency room because she had nowhere else to turn. She was desperate, and she was convincing in her argument that her son would be better off living with another family.

So where do we turn from here? How do we handle a desperate mother trying to do what she deems best for her son by resorting to the ER for advice and help?

Like all complicated cases, we needed to break down the main issues.

Establish capacity

Mental illness is rampant in our society. It is estimated that 3% of the general public currently suffers from some kind of psychosis, which can take on a variety of forms. The causes of psychosis can be functional (i.e., schizophrenia, bipolar with psychotic features) or organic (tumors, infection, drugs). In this particular case, a diagnosis of brief reactive psychosis (BRP) due to an acute personal stressor was considered. However, BRP is due to specific events, like the death of a family member, and usually only lasts a couple of days.

This was not the case with this patient. The woman had no organic or functional pathology. Her vital signs and physical exam (including a thorough neurological and psychiatric exam) were completely normal. She did not present with any signs of psychosis. She had no flight of ideas, hallucinations, or delusions. She seemed to verbalize her decision in a rational manner.

Rule out child abuse

According to Childhelp, five children die every day as a result of child abuse in the United States. Up to 60% of child fatalities due to child abuse are not recorded as such on death certificates. More than 90% of child sexual abuse victims know the perpetrator in some way, and 70% are abused by family members.

We did not suspect physical or sexual abuse in this case. The physical exam of the child also revealed no evidence of injury. But neglect also constitutes child abuse. According to ChildWelfare.gov, neglect is defined as “the failure of a parent, guardian, or other caregiver to provide for a child’s basic needs.” It can take on many forms:

• physical = the failure to provide shelter, food, or appropriate supervision
• emotional = the failure to provide psychological care (e.g., allowing a child to ingest alcohol or drugs would be considered a form of emotional abuse)
• education = the failure to provide adequate schooling
• medical = the failure to provide the necessary medical or mental health needs

The mother of this boy was not guilty of neglect, as she was providing for all her son’s basic needs. In addition, the purpose of her ER visit was to ensure that her son would continue to have all the above needs met by another family.

What about abandonment?

According to safe haven laws, a parent can drop off an unharmed newborn in a designated area, such as a police station or an emergency room, and not be arrested for abandonment. In this case, though, the child is older than thirty days, so the safe haven laws do not apply.

Therefore, is this woman technically abandoning her child?

Child abandonment, which is a felony, occurs when a caretaker deserts the child without regard to the child’s mental or physical welfare. Such inattentiveness can lead to the child suffering serious harm. Leaving a child somewhere without provision or support constitutes abandonment.

Again, the mother in this case had not abandoned her son. She had come to the emergency department seeking help to ensure the child would be looked after.

Child protective services

Whenever the care of a child is in jeopardy, child protective services (CPS) must be notified. It is mandatory for physicians to report any suspicion of child abuse, even if the facts are equivocal. Our job as physicians is to recognize potential abuse and report it. That’s it. CPS takes care of sifting through the details and determining what other measures need to be taken. In this case, there were plenty of reasons to get CPS involved.

Although governments in what is now the United States have been involved in the care of victims of child abuse through its principle of parens patriae since the 1690s, it wasn’t until 1974 that Child Protective Services was established. This was a direct result of the “Child Abuse Prevention and Treatment Act,” which provided funding for a wide array of research on and services for victims of child abuse and neglect. But the real catalyst for the birth of CPS was the public outcry resulting from “The Battered-Child Syndrome,” an article written by C. Henry Kempe et al. and published in JAMA in 1962. This landmark article was the first time members of the medical community attempted to identify and recognize the prevalence of child abuse in the United States and describe the atrocious acts in detail.

CPS provides multiple services, including assessing the home for a child’s safety, intervening to protect the child from harm, and providing shelter for the child if the caretaker is deemed unfit or dangerous.

In this case, CPS interviewed the mother and agreed that they did not believe the child had suffered from physical, sexual, or emotional abuse. The fact that the mother had come to the ER for help proved that the child had not been neglected or abandoned — at least not at that time. They offered the mother free food stamps and child care, but the mother declined, stating that she knew these were only temporary measures and that, eventually, she and her son would be back in the same predicament.

The two CPS social workers recommended that the police be notified since they had never encountered a case like this and were not sure what course of action was required. In the meantime, they contacted their supervisor and scheduled a home assessment.

Police Involvement

Police should be involved in all cases where the welfare of a child is at stake. In this case, the officers on the case were equally baffled. In their years on the force they hadn’t encountered a parent actively seeking to give up custody of her preschooler.

At that point in time, the child’s mother wasn’t breaking the law, and she wouldn’t be unless she left her son in the ER and walked away. But that wasn’t her plan.

Because the police also were not sure what to do, the state district attorney got involved.

Summary of the case

Ultimately, the mother was arrested for abandonment and her son was taken away. According to the district attorney, the mother’s expressed interest to give up custody of her four-year-old son constituted abandonment. She was charged with a felony and jailed.

When CPS did further research, they found out that the woman lived with a roommate who described her as “spoiled” and “unfit for parenting.” Although the woman’s roommate stated she had never witnessed an incident of physical or sexual abuse, she gave ample examples of how neglectful the woman had been with her son during the previous months.

Although this was a very unusual case, the teaching point is clear: Our job as physicians is to recognize potential child abuse and report it. We are mandated to do so. In many instances findings are equivocal, and we hesitate to get CPS and the police involved because we fear getting an innocent parent in trouble. But this fear should not complicate our task, which is to protect our pediatric patients from potential harm.

Most physicians are comfortable with managing difficult medical conditions, while the myriad social issues prevalent in our everyday practice are often the most challenging. Luckily, most emergency departments are equipped with resources to help us navigate through such cases. In addition, CPS and the police are usually easily available to provide assistance.

But what about those of us who work in smaller emergency departments with no access to CPS and only limited access to law enforcement agencies? If neither CPS nor the police were available in a timely manner, what could be done? What roles do the emergency physician and nurses, the emergency department, and the hospital play in such cases? What’s our liability?

Regardless of where we work, it is imperative that we all familiarize ourselves with our current state laws and practices. Guidelines for dealing with difficult cases, like questionable child abuse, abandonment, rape, or domestic violence, should be clearly delineated so the entire ER staff knows what pathway to follow.

There is no doubt the practice of medicine in the United States is changing rapidly. It’s likely that the emergency department will continue to serve as a place of refuge or security for all sorts of individuals in need of social assistance. Therefore, it is imperative that we discuss such cases and prepare ourselves for these challenges. The welfare of our patients depends on it.

Alberto Hazan is an emergency physician and author of Dr. Vigilante and The League of Freaks series.