# Chapter 2

When our Zoom screen went dark, an oppressive silence filled the room. The gravity of our task weighed heavily on us, and the stakes were high. Each of us felt the weight of the responsibility that lay ahead. We were a team that embodied unwavering integrity, and now we had to dig into a case that could potentially alter lives.

As I looked around the table, I saw the faces of my seasoned team, each one reflecting a mix of determination and concern. Nanton Johns, my steady right-hand man and Deputy Controller, sat back in his chair, hands behind his head, his calm demeanor hiding a sharp intellect. Joe Buck, our sharp-eyed Senior Auditor, leaned forward, his expression serious and thoughtful. Our unflappable Operations Manager, Michelle Hobel, sat with a notebook open, ready to take meticulous notes. Nanton was known for his unwavering dedication to detail, meticulously marking up audit reports until every nuance was clarified. Joe brought a personable nature that put outsiders at ease during audits, and Michelle's organizational prowess transformed data chaos into comprehensive, structured spreadsheets.

Nanton broke the silence with a resigned sigh. "I’m not sure if there’s anything we can do for them. We don’t have the authority to examine individual cases from Children and Youth Services. All that information is private."

Joe leaned forward, his face intense. "Do we need the individual details? Sure, it would be ideal if we could pinpoint exactly how much each case costs, but if we’re trying to figure out if this is a systemic issue, maybe the individual details aren’t as crucial. Our first step should be mapping out the entire process. We should create a flowchart of what happens once Childline is called. I imagine there are several complex steps and procedures Children and Youth Services initiate immediately."

The conversation continued for some time, each of us contributing our thoughts and concerns. Ultimately, we decided that some preliminary research before engaging in a full audit would make the most sense. The team resolved that I should investigate the issue and craft a comprehensive plan.

"You know the initial challenge will be gaining access to the necessary information," Nanton said, glancing at me with a knowing smile. He knew how much I despised navigating the maze of bureaucratic red tape, and I had a knack for ruffling feathers. Within the county, people weren’t exactly fond of a Controller who saw his job as more than just conducting routine audits. Whenever I tried to address other areas of concern, folks immediately put up brick walls to keep me from peeking over.

"I get it," I said, rolling my eyes. "But we need to get to the bottom of this, no matter how many walls they try to put up."

When done correctly, an audit demands meticulous planning and a clear objective. Our goal was to ensure we would be equipped with the necessary information to conduct a thorough and quality audit, embodying the diligence and integrity required for such an undertaking. This was not a task to be taken lightly but one that called for careful preparation and thoughtful consideration. Michelle and I became the point people to do the initial research and report back to the group.

Over the next few days, Michelle and I dove into a mountain of research papers and contacted experts. Reading studies and talking to specialists helped us better understand what was happening. I researched medical child abuse and Munchausen Syndrome by Proxy (MSBP), trying to understand the nuances of these complex issues. I also looked into the doctor involved, finding out she had faced problems in the past. Additionally, I examined the procedures and processes of Children and Youth Services to understand how they handled such cases.

Munchausen Syndrome by Proxy revealed its unsettling reality. One must first fool a doctor to succeed at faking a child's illness. If an individual could deceive medical professionals, they might also be able to mislead auditors. This possibility was particularly concerning for our audit team. If MSBP was at play, the mom we investigated might be masterful at masking her deception.

Beth Maloney sent over her book, "Protecting Your Child." Beth, a seasoned lawyer and passionate advocate, dives deep into the child protection system, revealing its flaws through meticulous research and personal stories. I immersed myself in her book, taking notes along the way. It offered valuable insights during this phase of our investigation. Each chapter thoroughly walks you through a CPS case, from the initial inquiry to the complex maze of legal procedures, answering critical questions about parental rights and various CPS scenarios.

These insights were further expanded upon when I delved into Maxine Eichner’s paper "Bad Medicine." Eichner critiques the broad application and diagnostic criteria of Medical Child Abuse (MCA), which evolved from Munchausen Syndrome by Proxy (MSBP). Her analysis exposes how legal and medical paradigms can fail families, highlighting the dangers of overdiagnosis and the potential for professionals to abuse these medical theories, leading to wrongful accusations against parents. Eichner's call for a thorough review of child protection policies is both urgent and compelling.

We wouldn't hear the full extent of family stories for several weeks, but the snippets we got were enough to keep us going. Many families lost their children to the government, and their kids ended up in foster care or kinship care. Here is a condensed version of one such story from a mom that I met:

Our audit into the cluster of medical child abuse diagnoses began like any other audit. We first established the financial aspects and procedures we needed to review, developing spreadsheets primed for analysis. We identified two main areas for research: the costs associated with placing a child in foster care—including kinship care, legal bills, therapy, and caseworker time—and gaining a deeper understanding of the affected families and the diseases being misdiagnosed.

We faced a pivotal decision that could shape the future of our investigation. The primary issue at hand was deciding which type of audit to conduct. For the uninitiated, audits come in various forms, each with its unique approach and focus. A financial audit, for instance, is like a meticulous examination of a complex puzzle, ensuring every piece fits perfectly. It's detailed, structured, and immensely time-consuming. Given my upcoming re-election, I worried that embarking on such a rigorous audit might take too long to complete before the year's end. The thought gnawed at me – if I lost the election, there was no certainty my successor would continue the audit. The potential waste of all our efforts and the trauma endured by the individuals involved was unacceptable. We couldn't risk letting the families down.

Ultimately, we opted for a more flexible approach that allowed us to be thorough without the constraints of a financial audit. This way, we could continue our work diligently and ensure that the investigation would proceed regardless of the election's outcome. This decision ensured that our work would be completed efficiently and with the seriousness and diligence it deserved but did not have to follow the format laid out by the U.S Government.

The "Yellow Book," formally known as the Generally Accepted Government Auditing Standards (GAGAS), is a comprehensive guide created by the U.S. Government Accountability Office (GAO). It sets the standards for audits of government organizations, programs, activities, and entities that receive government funds. The Yellow Book provides a framework for conducting high-quality audits with integrity, objectivity, and independence. It is used by federal, state, and local government auditors, as well as by CPA firms that audit governmental entities.

The journey was far from over, but this pivotal moment marked a turning point. We had navigated the uncertainty and emerged with a clear plan. And as I looked around the room at my team, I knew we were ready to face whatever challenges lay ahead.

At the outset, the documents and procedures we needed to review laid the groundwork for our investigation. We approached data collection methodically, developing comprehensive spreadsheets for detailed analyses. This quantitative phase was the foundation upon which we built our understanding of the issue.

Our investigation into the prevalence and impact of medical child abuse misdiagnoses was both meticulous and comprehensive. We approached this issue from two angles: a thorough statistical analysis and a deep dive into the human stories behind the numbers. Many of my employees are parents, with children ranging from young ones to adults. The potential for a single doctor's actions to cause families to lose their children deeply concerned them. As a result, my staff was highly motivated to ensure that we, as a county, were taking the right steps.

As we sifted through the initial information, the cold data failed to capture the human stories. It became evident: no array of figures or probability charts could adequately convey the intricate realities hidden within the numbers. So we embarked on a parallel path, making sure we pursued the living stories pulsing beneath the data. Every decimal contained a kernel of human anguish crying for recognition—a parent's cry of injustice stifled by a physician's bias...or a child's sob muffled under a pediatrician's determined but misguided diagnostic efforts. It was the qualitative research that brought depth and color to our investigation. This phase involved interviewing families who had experienced misdiagnosis and understanding the journey the families had to endure.

As we spoke to families we would hear the quiet cries of families shattered by hasty diagnoses. We heard woman say they would have done anyting to get their child back including killing themselves. We would meet parents who had drained their savings accounts, borrowed against their 401k, and liquidated money meant for their child's college. Their money was spent fighting off accusations of medical child abuse—accusations.

Each interview was approached with sensitivity and profound respect for shared personal stories. These interviews were conversations, often emotional, always significant. They provided insights that numbers alone could not. We did not kid ourselves, we knew that we could be interviewing child abusers that were posing as victims. But the overlap of the stories between families was very consistent. The things the doctor would say. They way they were treated. There was a pattern that could be clearly seen, and it looked like these families had been wronged.

We spoke with many lawyers and therapists around our area. They were all familiar with the doctor. Many were concerned about her but were unwilling to speak up.

As I delved deeper into the complexities of MCA for my investigation, the significant influence of media and popular culture became increasingly evident. Sensationalist media portrayals often skew public understanding by focusing on extreme cases, leading to misconceptions and heightened fears about the prevalence and nature of these abuses. To fully grasp the complexities of this issue, it's essential to examine how sensationalist portrayals and investigative journalism shape societal perceptions. One such incident involved the case of Justina Pelletier, a teenager whose medical and custody battle received extensive media attention.

The narrative began in 2013 when Justina was taken to Boston Children's Hospital with flu-like symptoms. Doctors at the hospital quickly diagnosed her with somatic symptom disorder, a mental condition contradicting her previous diagnosis of mitochondrial disease from Tufts Medical Center. The clash between the two hospitals led to Justina being placed in state custody, as her parents were accused of medical child abuse.

The media frenzy that followed was intense. Headlines often painted the Pelletiers as either victims of a medical system gone awry or perpetrators of abuse, depending on the outlet. The emotional appeals were palpable, with news segments featuring tearful pleas from Justina’s parents and footage of protests outside the hospital. Public reaction was swift and polarized, with hashtags like #FreeJustina and social media ablaze as people rallied for the family or the medical professionals involved.

Investigative journalism played a pivotal role in bringing the nuances of Justina's case to light. Reporters delved into medical records, legal documents, and interviews with experts to uncover a story of systemic failure and bureaucratic overreach. These journalists highlighted how the hospital's decision, albeit intended to protect Justina, led to significant trauma for her and her family.

The long-term effects on the Pelletier family were profound. The public exposure exacerbated their ordeal, with the family enduring the legal battle to regain custody of Justina and the scrutiny and judgment of a divided public. Eventually, Justina was returned to her parents, but the emotional and psychological scars remained.

Beyond the sensationalism, this case prompted broader discussions about the role of child protective services and the need for clearer guidelines in diagnosing and handling medical child abuse. It also underscored the importance of media in both highlighting injustices and influencing public policy.

Educational efforts have since been amplified, with documentaries and public awareness campaigns aiming to inform the public about the complexities of medical child abuse. These initiatives strive to strike a balance between vigilance in protecting children and safeguarding families from wrongful accusations.

By examining cases like Justina Pelletier's, we see how media coverage can both illuminate and distort the realities of medical child abuse. This broader context provides a deeper understanding of the stakes involved and the urgent need for systemic reforms.

To further illustrate the profound impact of media on public perception and policy, we can look at another major scandal: the Sandusky scandal at Penn State. This seismic event forever changed Pennsylvania's approach to child protection. Jerry Sandusky, once revered as a trusted mentor and assistant football coach at Pennsylvania State University (Penn State), was at the center of one of the most egregious and shocking sexual abuse scandals in American sports history. The scandal broke in 2011, but the abuse had been ongoing since the 1990s, hidden in plain sight within the hallowed halls of Penn State.

Sandusky’s heinous acts involved sexually abusing numerous young boys, many of whom were part of his charity, The Second Mile. This organization, ironically dedicated to helping at-risk youth, became his hunting ground. The abuse frequently occurred at Penn State facilities, where Sandusky had unfettered access to his victims. As the investigation unfolded, it became evident that several university officials had known about Sandusky’s predatory behavior but failed to act, prioritizing the institution’s reputation over the safety of children.

In 2012, the law caught up with Jerry Sandusky. He was convicted of 45 counts of sexual abuse and sentenced to 30 to 60 years in prison. His conviction, while bringing some measure of justice, could not undo the profound damage inflicted on his victims. The fallout from the scandal was widespread and severe. Penn State’s once-sterling reputation lay in tatters. The iconic head football coach, Joe Paterno, was fired, and several high-ranking university officials resigned in disgrace. These actions began significant legal and organizational reforms at Penn State.

The scandal’s ripple effects extended far beyond the university. It spurred Pennsylvania lawmakers to revise the state’s child protection laws. One of the most significant changes was the introduction of mandatory reporting laws. These laws required certain professionals to report any suspicion of child abuse to authorities, with severe penalties for non-compliance. While these stricter rules aimed to protect children, they also brought new challenges, including the risk of innocent parents being unfairly accused.

During our investigation, the shadow of the Sandusky scandal loomed large, highlighting the delicate balance between vigilance and fairness in child protection. Parents of children with complex medical needs found themselves in an especially precarious position, caught in a relentless tug-of-war between ensuring their children received the necessary medical care and avoiding the ever-present suspicion of abuse. This delicate balance was further strained by a society quick to judge and slow to understand the intricacies of such medical and psychological conditions.