Child welfare agency still lacks medical guidance

Seven years ago, after two tragedies, State House investigators identified a major flaw in the Massachusetts child-protection agency: It lacked medical expertise to help caseworkers sort out the complicated conditions affecting children under its watch. The findings led lawmakers to approve reforms, but today, very little has changed.

The position of physician medical director was funded by the Legislature but never filled by the agency. A plan to set up a standing panel of pediatric specialists to offer consultations on medically complex cases went unheeded by top state officials. To this day, if staffers within the agency need advice from medical experts, they are often left scrambling to find help on their own.

“They have not set up a system to bring in the strong expertise that is available in the Commonwealth,” said Dr. Robert Sege, a pediatrician and child-abuse specialist at Boston Medical Center. “It’s a shame.”

The Department of Children and Families’ lack of medical expertise emerged this year as an issue in an emotionally charged case involving a 15-year-old girl who has been at Boston Children’s Hospital for the past 10 months, most of it in the locked psychiatric ward. According to a two-part series in The Boston Globe earlier this week, hospital doctors filed charges of “medical child abuse” last February shortly after seeing Justina Pelletier in the emergency room. Within three days, they concluded that the girl’s parents had wrongfully subjected the child to treatment for a rare metabolic disorder and were blocking psychiatric treatment that she badly needed.

When the parents from West Hartford, Conn., threatened to discharge the girl and take her to see her doctor at Tufts Medical Center, Children’s filed a complaint and the state took emergency custody. The parents, Lou and Linda Pelletier, say they are victims of a Massachusetts child-welfare system that fails to objectively referee complex cases and is overly deferential to Children’s, given the Harvard-affiliated teaching institution’s high standing in pediatric medicine.

Only after Justina had been hospitalized for six months did the child-protection agency bring in a pair of expert consultants, a pediatrician and child psychiatrist, who were not employed by Children’s or Tufts. A juvenile court judge, who has heard testimony over the past month, is expected to rule on the case on Friday. The parents hope Judge Joseph Johnston will return custody of their daughter to them.

The medical staffing at the state agency had long consisted of a few nurses in the central office. But that level of resources came under scrutiny after two high-profile cases in 2006 in which parents managed to manipulate the medical system while under the agency’s watch.

A 4-year-old Hull girl, Rebecca Riley, was killed by an overdose of psychotropic drugs, and an 11-year-old Westfield girl, Haleigh Poutre, nearly died of overlooked long-term physical abuse.

After public outrage over these cases, two blue-ribbon panels proposed a raft of reforms aimed at giving the agency a fresh start.

Among those was a name change from the Department of Social Services to the Department of Children and Families. Lawmakers also approved, among other things, about $1 million in state funding for a beefed-up Health and Medical Services Team at the agency. A key component was hiring a physician medical director. Although that position was initially conceived to be part time at roughly $75,000 a year, the job came with high expectations, including setting up a comprehensive system to provide high-quality medical advice from both in-house and outside experts.

“We thought it was really important to have an MD be the lead,” said Susan Getman, who was deputy commissioner of the state agency when the reforms were proposed.

Getman said having a physician at the helm of the medical team would establish credibility for the agency, especially when it is asked to intervene with doctors in complex cases.

“You have someone who is medically objective and someone who is on your home team,” said Getman.

The position proved more difficult to fill than expected, given the low salary and high pressure, she recalled.

“You have to be willing to be in the eye of the storm,” Getman said.

However when Getman left the agency around the same time as Commissioner Harry Spence departed in 2007, she still thought it was only a matter of time before the agency filled the medical post.

About one-third of all states have a medical director for its child-protection agency, according to a national survey by Brandeis researcher Tom Mackie and colleagues published in 2011.

But the initiative to find a physician medical director at the Massachusetts agency may have fallen through the cracks when a new commissioner, Angelo McClain, came in with his own priorities, and the leadership above him in the Executive Office of Health and Human Services also changed.

The Department of Children and Families oversees close to 35,000 children, who have been victims of alleged abuse or neglect. Yet across the entire state, the only staffers with formal medical training consist of one half-time pediatrician, one half-time psychiatrist, and a handful of nurses. The previous administrative head of the team, a nurse, resigned earlier this year from her job. The position that pays up to $112,000 a year has not yet been filled.

While the agency’s current medical team represents a slight expansion from the past, it falls far short of what reformers had envisioned.

Yet in an interview earlier this fall, Jan Nisenbaum, who was then the deputy commissioner overseeing the medical team, said she saw no need to bring a physician medical director on staff because the agency could continue to turn to specialists for free consultations on a case-by-case basis.

“I feel completely comfortable with the access we have,” said Nisenbaum, who was speaking generally about the system during an interview in September.

But the state’s child advocate, appointed by the governor to be a watchdog for children in state care, disagrees.

In her 2009 annual report, Gail Garinger complained about the sluggish pace at which the agency was upgrading its medical services.

“In recent years, DCF has attempted to hire a physician medical director who could oversee the development of a comprehensive system for accessing specialized medical consultation and for delivering healthcare to DCF-involved children; however this effort has been unsuccessful,” Garinger wrote in her report.

Other options for boosting medical expertise at the agency have failed to gain traction.

Dr. Gordon Harper, a child psychiatrist and the medical director for child and adolescent services at the state Department of Mental Health, had been one of the key advocates pushing for the creation of an expert medical panel to assist the child-welfare department. Although many details still had to be worked out, Harper said, most of the pediatric department chiefs from around the state agreed to serve on the panel.

“They all knew in terms of medical expertise, it was amateurville at DCF,” said Harper. “It’s puzzling that all the headway we made was not sustained by the department.”