From Courtroom to Clinic: Child Advocacy in Action

One of the most important roles of a physician is that of patient advocate. This role is widely considered a professional obligation in medicine and holds such importance that formal advocacy training has been a requirement of pediatric residency programs for over twenty years and is now being incorporated into graduate medical education curricula across several other specialties.^1,2 The authors are husband and wife, both fourth year medical students pursuing careers in primary care. We developed a passion for advocacy through our work as a Court Appointed Special Advocate (CASA) team.

A CASA is a trained community volunteer appointed by a judge to advocate for children who are in the family court system due to abuse and/or neglect. We each spent 30 hours in training learning about types of child abuse and neglect, how to communicate with the various parties involved in the care of these children, and the intricacies of the family court system. As CASA volunteers we are responsible for advocating for these children to receive essential therapeutic, educational, and medical services in addition to advocating for safe permanent placement. While these responsibilities align with that of Missouri’s Department of Social Services–Children’s Division, caseworkers are overwhelmed, having on average 25–plus cases while the recommended case load is 13 to 15.³ Case turnover rates for caseworkers are up to 60%, reflecting the temporality of their relationship to cases. CASA volunteers are in a unique position to stay on cases until closure and focus on being the voice for their assigned children by championing these responsibilities. As we entered our clinical rotations in Rolla, Missouri, we quickly saw how advocacy in the courtroom translates to advocacy in the clinic.

Advocacy training for CASA volunteers and physicians alike include topics such as child development, warning signs of child abuse and neglect, cultural competency, and the impact of adverse childhood events such as domestic violence, poverty, and substance abuse. Both are also trained to complete appropriate documentation. In many ways, the court reports we write for our CASA cases parallel the SOAP (Subjective, Objective, Assessment, and Plan) note format used by medical professionals. In both instances, we are tasked with gathering the history, investigating the story we are told, determining facts, analyzing data, and developing an assessment and plan. This serves as a guide in making a recommendation reflecting the best interest of the child. When advocating in both the courtroom and the clinic, we must take into consideration the immediate and long–term impact of any interventions. The ultimate goal is to help families establish safe environments for their children to thrive as well as addressing preventative measures to ensure brighter futures.

MSMA Alliance Leaders Share CASA Experiences

Mary Shuman, BSN

MSMA Alliance Past President

An attorney affiliated with Children’s Mercy Hospital in Kansas City was the featured speaker. His topic was abused children. The horrific photos were of children with third degree burns from being thrown on hot grills and burning coals, tossed in scalding water—all at the hands of their parents. A woman in the audience shared that she was the director of an organization that advocated for abused and neglected children. I introduced myself to her. I was all in and I still am. I am a CASA.

Sammy Jo was one of my earliest cases. She was four years old. Mom and dad’s parental rights had been terminated. Sammy Jo was placed in multiple foster homes. She was always the new kid in countless schools. I kept a ‘Sammy box’. I saved her school papers, photos, essays, and poetry. We agreed that the box would stay with me, for safe keeping, until she had a place of her own. She graduated high school from a juvenile detention center. I was there to cheer her on. Her diploma went into the Sammy box. She was released from juvie. She had aged out of the children’s division system. She was on her own.

I helped her enroll at the local university. Late one night she phoned me from CVS. She was hysterical. She was wearing her only pair of jeans and her period had started. She didn’t have money to buy tampons. I met her. We shopped for that and other essential needs like toothpaste and shampoo. Giddy teen girls worried if they would be asked out on a date. Sammy Jo worried where she would stay—she was homeless. She got caught up with a dangerous crowd. She was sentenced to prison. Monthly, I would visit her at Chillicothe Women’s Correctional Center.

March 18, 2020, the Kansas City Police Department released the name of a 27 year–old woman who had been identified as the victim of a deadly shooting. It was Sammy Jo.

I attended her funeral. I still have the Sammy box filled with memories. She was a gifted writer—poetry was her favorite.

November 17, 2022, the 5th Circuit Court of Missouri presented me a 25–year service award. I can’t retire—I have six active cases.

The United Nations human rights system has a mandate that focuses on preventing torture of prisoners. Vulnerable children should be so lucky. Underpaid and overworked children division workers come and go. CASA stays.

Whether advocating for permanent placement, tutoring, therapy, or medical services, we have discovered one of the most important aspects of this work is including both the child and the caregiver in the conversation. Children may not appreciate the intricacies of their circumstances, but educating them and their caregivers in a simplified, understandable manner is essential to ensuring success. In an unfortunately similar way, the recommendations made in the best interest of the children and patients we care for are simply that—recommendations. A unique mutual barrier exists in these two environments; buy–in of third parties. For parents and court systems alike, recommendations only go as far as the cogency of the argument. In these situations, a decision–maker may ask, “Does this child really need this intervention?” Going beyond mere suggestions is the crux of advocacy. Putting forth effort to defend a recommendation through education, clear expectations, attainable goals, and clear definition of how the recommended interventions will improve the long–term outcome for the child is fundamental in effective advocacy.

All in all, our experiences in the courtroom have provided a stark parallel and instilled a deep appreciation for the gravity of the recommendations we will make as future physicians. Purposefully advocating for the best interests of each patient is paramount. Physicians especially must fulfill the role of advocate in order to provide the highest quality patient–centered care. We would like to encourage fellow student doctors and other medical professionals to seek out opportunities to practice advocacy outside of medicine alone through opportunities such as CASA. Every child in the foster care system can benefit from the constant support of a trusted adult as they navigate the family court system. The need for CASA volunteers is great, with nearly 700,000 children becoming victims of abuse and neglect annually and only about 250,000 of them having CASA volunteers.³ For more information on becoming a Missouri CASA volunteer, we encourage readers to visit MoCASA.org.

MSMA Alliance Leaders Share CASA Experiences

Sue Ann Greco, BSN, MSN

MSMA and AMA Alliance

Past President

My road to becoming a CASA actually started in 2001 when I began studying for a certificate in Legal Studies. During student introductions in my very first class, one of the students described how she was going through classes to become a Court Appointed Special Advocate. I had never heard of this position before and was very intrigued as I had been a pediatric nurse and had a little bit of familiarity with the foster care system. However, this was not the time for me as I was venturing out on a path to become a legal nurse consultant.

In 2010 I was between jobs and heard a public service announcement about CASA by Missouri’s First Lady, Mrs. Jay Nixon. It reminded me that this was something I had wanted to do. Ironically, I had spent the last year volunteering at a Catholic Charities social work agency that provided case work for abused and neglected children. My task was to copy and organize case files. After reading some of the files, I knew that becoming a CASA was what I needed to do. I applied and began the training and received my first case that spring.

As a new CASA I was asked what type of case I would like. Since my background was in pediatric nursing, I said I would be willing to take on a case where the child had health issues. I was given a case where the child had multiple health issues and handicaps. I have been told several times that not many CASA workers would have taken on such a case, but for me it has been very comfortable and rewarding. I am still on the same case 12 years later. The most rewarding aspect of having been on this case is that I am the person on the team who has been on the case the longest. We have gone through multiple social workers and placements. It is very rewarding to me to be able to have the history with this child that I do.

Over the years I have spoken to many CASA volunteers. Everyone I know finds this volunteer position to be challenging but rewarding. Case work can take anywhere from 4 hours to 15 hours a week. We are required to complete 12 hours of continuing education credit each year. It is a great position for someone who is retired and looking for something rewarding to do. Some of the CASAs I have met have been CEOs of companies. However, you do not need to have any particular background, you just need to have a heart.