"We have known this young man for a long time," Rodney Vickers told the social worker, "and he is one of the finest individuals."
That was apparently not the answer the child abuse team was looking for.
Thereafter, Girardet wrote an updated report for child protection services, noting that Tristan's blood tests were negative for clotting disorders that could mimic abuse and concluded that the child's injuries "were indeed inflicted." But the doctor offered more than just her medical opinion. She also warned that Tristan would still be in danger, even after being taken from her parents.
"Grandparents do not believe Tristan was shaken," Girardet wrote, "which means they are unlikely to be protective caregivers." [1
Timmermans was surprised to learn from a reporter that Girardet's work is being funded. by the state agency that oversees Child Protective Services. According to a 2018 grant agreement with UTHealth's McGovern Medical School, Girardet spends 62 percent of her time working on issues related to her medical school's contract with the Texas Department of Family and Protective Services, which funds a corresponding portion of her $ 181,500 university salary.  The doormat in Rodney and Laura Vicker's Houston home. Elizabeth Conley / Houston Chronicle
Salaries and benefit packages from several other Texas-based pediatricians, nurses, and social workers are funded through a similar arrangement, which requires medical teams to review cases of suspected abuse on behalf of a child protection program. is called the forensic network for networks, which Girardet leads.
Child abuse teams across the country often rely on grants to confirm the costs of a medical subspecialty that generally loses money for hospitals. Some programs receive funding from state criminal justice agencies, such as in Virginia or from public health departments, such as in Michigan.
Girardet has defended the Texas event. For example, when a defense lawyer asked about one of the state grants in 2017, she argued that the university would continue to pay her if the money disappeared. And while testifying before the Texas Legislature in March, she said that financial aid does not affect her decision-making.
"I am paid by the University of Texas," Girardet said. "My salary doesn't ever change whether I say the child was abused or not."
But just as crime labs are susceptible to bias when directly monitored by law enforcement, physicians risk losing credibility when they become too closely aligned with Child Protective Services, said Keith Findley, a professor at the University of Wisconsin Law School who founded The Wisconsin Innocence Project and which has defended caregivers accused of shaking babies.
"When you have a subjective analysis that you do from the doctors in these cases of child abuse, you have to go the extra mile to make sure that the person performing the analysis is free of any influence that can lead to congenital bias, openly or otherwise, "Findley said." They appear to have created the opposite in Texas. "
The problem, according to Diane Redleaf, a family law attorney in Illinois who wrote an essay on the testimony of witnesses' testimony in cases of abuse against children, is that some doctors may think of themselves as "part of the team" with child care workers.
As a result, Redleaf said, sometimes doctors' testimonies and comments "cross the border between medical opinion and lawyer." 19659002] A review by Chronicle and NBC News of dozens of court transcripts revealed several examples of pediatricians abusing children presenting their opinions with absolute certainty while at others The traps share views that seemed to go beyond their role as medical experts. In some cases, they offered advice on what the state should do with children they thought had been abused.
A doctor told a judge in 2015 that she did not believe Child Protection Services would return a child to parents she suspected of medical neglect, even according to a security plan, where I say: "I do not trust them to do what they says they will. ”In a 2017 case, pediatricians for child abuse in court recommended that a mother she suspected of abuse be allowed only supervised visits with her daughter – if not at all.
Another doctor, 2011, said "yes" when asked in court if she considered research suggesting that most rib fractures in young children are assigned as "evidence of a reasonable doubt" that a specific infant with such injuries had
And during a criminal trial in March, Dr. Marcella Donaruma, pediatrician at Texas Abuse, repeatedly testified that she was "100 percent sure" that bleeding and swelling in a child's head – as well as other injuries, including bruises and a healing femur fracture – was the result of abuse.
"She is an abused child, and now she is safe," Donaruma testified at one point, seemingly to support the state's earlier decision to place the infant in foster care.
A neurologist who testified on behalf of the defense said he reached a different conclusion about the child's head injuries after examining medical records, and the child's father was found not guilty.  Few medical opinions can be 100 percent safe, experts say, especially in cases where doctors are asked to diagnose not only a child's condition but also what caused it. There is no laboratory test to confirm that a child has been intentionally shaken or proven to have caused a child's burning burns.
Donaruma refused to be interviewed for this story. Dr. Mark Kline, the physician who is the head of Texas Children's & # 39; s, initially told reporters in an interview that "anyone who says 100 percent about something is immediately suspicious of me."
But after getting more information about the specific example, He said that such statements are justified in some cases, especially when it is obvious that the child has been harmed.
"When there are extreme signs of abuse," Kline said in a statement, "it is perfectly understandable and appropriate for the physician to ensure 100 percent confidence in the diagnosis."
Depending on doctors
Child protection services do not always take children from their parents when a doctor warns of abuse.
In a high-profile example in 2017, Dr. Suzanne Dakil, pediatrician at pediatrics at Children's Medical Center in Dallas, warned, protective services that a 3-year-old gir I, Sherin Mathews, had suffered from several cracks that Dakil said applied, but in that case Child Protection Services left the child in the care of their parents. Seven months later, the girl was found dead in a culvert, and her adoptive father was charged. He later pleaded guilty to a lesser charge.
Thereafter, the state child welfare bureau changed its internal policy and instructed the shipowners to give even greater importance to the opinions of state-funded pediatric pediatricians.
Ultimately, state child welfare agencies are left with the difficult task of determining when the risk to a child's safety is significant enough to take her from her family.
When a referral comes in from a hospital, a caseworker shows up to hear the family's explanation for the injury and see if it is square with what the doctors see. After talking to the hospital worker and reading medical records, workers confer with supervisors before deciding how to handle the case.
It is a process designed to include input from all involved, but current and past Child Protective Services employees said in the subgroup of cases that deal with medical findings, opinions of pediatric pediatricians are paramount.
Rhonda Carson, a former chief of security services, said that a common refrain in the agency was: "We are not doctors."
"They stop looking at something when a doctor has given their opinion," she said.
Sherry Gomez, who oversees child welfare state investigations in Texas, said workers are conducting thorough investigations after receiving reports from child supervisors. To some extent, we have to rely on our experts in that field. "
Faced with a constant flow of new cases, workers said they have little time to criminalize a child's complete medical record or seek further opinions from doctors. Two dozen current and former security service employees described an overloaded agency struggling to keep up with a constant flow of new cases.
On an average day, Child Protective Services receives reports of about 800 children who may have been abused or neglected. one of the state's 2,100 investigators reports of abuse from hospitals account for a small fraction of the cases and are often among the most complicated.
Texas officials have sought to reduce the number of cases assigned to each worker since a four-year-old death in 2016 in a Dallas suburb whose caseworker, saddled with 70 cases, never visited his home. In order to attract and retain more workers, salaries increased wages and decreased training requirements, resulting in a decrease in average caseloads.
Texas reduces daily caseloads
The average number of open cases assigned to each child protection investigator in Texas has decreased in recent years.
But there is continued pressure to move cases through the system quickly, said current and former employees, told of direct orders to do so and threats of disciplinary action if they failed. Two provided internal emails – which extend over a year – from supervisors who repeatedly set quotas for daily closure, a practice that experts say could stimulate speed.
"If you have 17 or higher, I need the following," a supervisor wrote in an email shared with reporters. “The two cases you are closing today. The two cases you finish tomorrow. "
Patrick Crimmins, a city council spokesman, said that any pressure to close cases is simply the result of the constant flood of new referrals and does not mean workers are taking shortcuts.
Course managers are expected to handle a specific caseload – that means closing cases regularly, "Crimmins said. "We acknowledge that there is pressure to close cases as new ones will come in."
Even when protective services conclude that a child is probably safe, an opinion from pediatricians for child abuse can tip the scales to parents.
a 2017 Houston case, a judge refused to return a boy to his mother, even though Child Protective Services had determined that she posed no danger to him. The court-appointed attorney representing the child still objected to returning the boy, citing the severity of the injuries described in the doctor's report.
The judge would not even consider the possibility of returning the boy, according to a transcript, saying if children were returned and later injured, "Your name would not be in the newspaper. Mine would. "
Ann Marie believes she was across town, met Tim's lawyer, the first time Tristan laughed. It was June 2016, a few weeks after child welfare services had taken care of.
The child was with her grandmother and giggled at a goofy face that she did. Ann Marie pretended to be excited when her mother shared the news that afternoon, but in fact she was heartbroken.
It was one in a series of special moments that she says were stolen from her the A year earlier, after losing her job in the oil and gas industry, she had decided to take time off from her career to stay home with her boys.
But now she spent much of her free time at court-ordered meetings and investigate the disputed medical basis for the allegations against her and her husband.
She was surprised to learn that doubts have arisen about the doctors' ability a to definitively diagnose the shaken baby syndrome, which has led the criminal judges to have turned over the last few years and brought some doctors who once made the diagnosis to turn themselves.
For decades, doctors have suggested being able to tell when a child has been shaken, largely based on a signature pattern of internal head injuries, including animal bleeding, brain swelling, and retinal bleeding. Doctors standing at the diagnosis say it has been validated by years of clinical observation, research and confessions from health care providers.
But some biomechanical studies have challenged the notion that a person can shake a child with the power needed to cause the pattern of internal symptoms without also causing serious injury to an infant's neck or other injuries. . Other studies have pointed to underlying conditions, such as bleeding disorders, which can lead to similar injuries.
Pediatricians for child abuse say that they are aware of these conditions and do everything to exclude them before drawing their conclusions. Some of the doctors have denied that there is any significant disagreement about science. While testifying at a 2017 criminal trial, for example, Girardet said no one in the medical community disputes the evidence of shaken baby syndrome. When pressed, she said that only a few "unscrupulous doctors" had questioned it.
Still, some legal experts have called on the National Academy of Sciences to investigate the validity of the diagnosis. And in a 2016 report on problems with other types of forensic analysis, the President's Advisory Council on Science and Technology wrote that concerns over the scientific validity of shaken baby syndrome required "urgent attention."
However, according to legal experts, skepticism about the diagnosis has not been lost to many family law courts, where child protection services are not required to prove their case beyond a reasonable doubt, as in criminal cases, but must only show that a person with "usual caution and caution "Would end up with a child probably in danger before executing an emergency.
Often, the only physician called to testify at family court hearings is the physician who first made the abuse assessment, in part because many families cannot afford to hire experienced attorneys or outside physicians.
Timmermans was happier. The Harris County Sheriff's Office investigated but did not file any criminal charges. Tristan was not placed in foster care, despite doctors' warnings that his grandparents might not protect him. And, perhaps most decisively, Timmerman had the money to defend himself.
They borrowed from the family and dropped savings accounts to pay for high-powered lawyers and a medical expert to review their cases. Two other doctors provided opinions at no cost.
The three external doctors – each of whom has written articles challenging the shaken baby diagnosis – concluded that there was ample reason to doubt that Tristan's injuries were inflicted. All three noted a drastic peak in Tristan's head size in the weeks before the incident that received his hospital visit. At a well-visited child just one week earlier, the boy's primary pediatrician noted that his main circumference jumped into the 99th percentile.
Extreme head growth during the first months of life is evidence of benign external hydrocephalus, the medical experts wrote, a condition where fluid accumulates between the brain and the inside of the skull, increasing pressure and, according to some case studies, potentially leading to the types of internal bleeding usually associated with shaken baby syndrome.
Dr. Marvin Miller, professor of pediatrics at Wright State University in Ohio, said it was "very unlikely that Tristan Timmerman was a victim of child abuse because there is a probable medical explanation for the finding."
Dr. Julie Mack, a Pennsylvania State University radiologist, said: "There is nothing about the imaging results that indicate significant or violent trauma."
And Dr. Joseph Scheller, pediatrician and pediatric neurologist in Baltimore, said Tristan had developed "A very small venous blood clot that caused a seizure, and he recovered from this quickly and has no remaining brain damage."
Slowly, it seemed as if the state's case against Timmermans was beginning to crumble.
In July, two months after Tristan's removal, a judge ordered Child Protective Services to return Tristan to Ann Marie after stating that it was in his best interest to be with his mother. Timmermans had to take Tristan home, but Tim still could not be around the child without supervision.
Four months later, the Timmermans court petitioned to restore its rights as well, arguing that the state had no evidence against him either. At a hearing, Ann Marie described what she had learned from some of the medical experts.
Girardet was not called to testify at the hearing, and a few weeks later, Child Protective Services filed a motion to dismiss the case. Seven months after quitting, there was "reason to believe" that Timmermans had abused and neglected his child – and after the couple spent more than $ 200,000 to defend themselves – the state left.
A judge signed a decision that formally dismissed the case
The following spring, the child welfare service reviewed all evidence in the case and agreed to reverse its original investigation results. The employee accused of reviewing her document said she had seen too many cases like Tristans, according to Timmermans and two attorneys who were present.
When a state aid for child abuse is involved, the worker explained, there is no "There are always enough checks to protect parents.
Tristan, now 3, has fully recovered from brain haemorrhage and has not had any serious health bills. But now, Ann Marie hesitates to take her boys to the doctor after minor injuries, for fear that another doctor may see the allegations of child abuse, which are still prominent in Tristan's medical chart, and urge the authorities to investigate.  Despite the state's move to clear his record, Tim lost his job as a farmer at a Houston oil and gas company the months after the case ended, though he eventually found work elsewhere. He had been afraid to tell his bosses that he is being investigated for child abuse and as a result he had collected too many unexplained absences while he participated in state claims and court hearings.
"The idea that I would hurt my child, my child, is ridiculous," Tim said recently. "All it took was a doctor's opinion, and it almost destroyed my family."