News All - Florida Forensic Science

Tampa State Attorney Speaks on Field Test Kits

December 2, 2016/in Attorney, Chemistry News, News /by Steve

A Tampa prosecutor speaks to the advantages of field test kits. Read more.

Ecstasy Tablet Test Kits

December 2, 2016/in Chemistry News, News /by Steve

Field test kits are not only used by law enforcement.Ecstasy tablets are notorious for containing a variety of drugs. Users will sometimes have tablets tested to see what they contain. Read more about it here…

Doughnut or Methamphetamine?

December 1, 2016/in Chemistry News, News /by Steve

An Orlando was arrested for what Orlando Police Department thought was methamphetamine. Further testing revealed the suspected meth was doughnut icing. Read more about it here…

An Interview with the Chemist who Invented Scott’s Reagent

December 1, 2016/in Chemistry News, News /by Steve

An Interview with the Chemist who Invented Scott’s Reagent

Which Personality Disorders are in Cluster B?

November 30, 2016/in Ask an Expert, Medical Trauma /by Forensic Competency

Courtesy of Godoy Medical Forensics

Cluster B personality traits are dramatic, emotional and attention seeking. They include:

Antisocial Personality Disorder
Borderline Personality Disorder
Histrionic Personality Disorder
Narcissistic Personality Disorder

The following is an example of how an individual with a cluster B personality disorder may require the services of a criminal attorney:

John is a 25-year-old construction worker who was arrested for stealing from his employer. His attorney learned that John had a chaotic home environment when he was a child. His father was a violent alcoholic who physically abused John and his mother. His school records showed that he achieved passing grades, though he was frequently truant. His teachers described him as a bright student who did not work up to his potential. He bullied other students and was frequently involved in fights. He was evaluated by a school psychologist who diagnosed him as having a conduct disorder. John quit school at age 16 and joined a gang. He was arrested as a teen for stealing a car and drug possession. He spent time in a juvenile detention center. John denied any prior criminal history when he met with his attorney. He also said that he did not steal from his employer. He insisted that the employer gave him money to buy building supplies and equipment and was now changing his story.

Antisocial Personality Disorder

John from our case study is a fictional example of a client who has an antisocial personality disorder, demonstrating a pattern of disregard for the rights of others. He meets the criteria of having a conduct disorder with onset before age 15. An individual must also meet three of the following criteria to be diagnosed with an antisocial personality disorder:

Repeatedly performing acts that are grounds for arrest;
Deceitfulness, repeated lying or conning others for personal profit;
Impulsivity;
Disregard for the safety of self or others;
Irritability or aggressiveness;
Consistent irresponsibility;
Lack of remorse.
(American Psychiatric Association, 2013)

Individuals who have an antisocial personality disorder become involved with the legal system due to traits of aggression and irresponsibility. They are rarely able to delay gratification. It is important for the attorney to maintain clear professional boundaries when representing clients who have ASPD. These clients can be difficult to work with because they may not trust their attorney and use manipulation to meet their needs. They can be initially charming but can become verbally and physically abusive if they are frustrated. These individuals may abuse drugs and alcohol which can exacerbate their symptoms. Not everyone who has antisocial personality disorder is a criminal. Some individuals are successful in a career that is compatible with the competitive, risk-taking aspects of their personality, such as professional sports, politics, military, or business professions.

Borderline Personality Disorder

Individuals with a borderline personality disorder demonstrate a pattern of unstable and intense personal relationships. They experience frequent life crises. These individuals have difficulty tolerating being alone and may react to feelings of abandonment with anxiety, depression, and unhealthy behaviors, such as rage, suicidal gestures, and self- mutilation. The character played by Glenn Close in Fatal Attraction is an example of someone with a severe borderline personality disorder. Clients with BPD may have a history of physical, emotional, or sexual abuse and may have an additional diagnosis of PTSD. Clients with BPD may become involved with the criminal justice system because of poor impulse control or difficulty managing anger. They may idealize, then devalue their attorney. They may also be manipulative. This manipulation is to gain nurturance, rather than for profit or power, as compared to an individual with antisocial personality traits. Attorneys need to be aware that their clients with BPD are at risk for self-harm due to intense feelings of anxiety and depression that are difficult for them to manage in addition to poor impulse control. Suicidal threats should be taken seriously and appropriate action taken to protect the client.

Histrionic Personality Disorder

An individual with histrionic personality disorder has a pattern of attention seeking and overly emotional behavior. They need to be the center of attention and may be sexually inappropriate. It may be difficult for the attorney to obtain accurate and detailed information from their client with a histrionic personality because they tend to be superficial and exaggerate. They can be inconsistent and unpredictable. These clients may demand constant attention from their attorney. Unlike clients with antisocial traits, they don’t need to feel superior. They may be willing to be fragile and helpless in order to gain attention.

Narcissistic Personality Disorder

Clients with a narcissistic personality disorder are self-centered and unable to empathize with others. They are grandiose and require admiration. They may experience depression if they experience criticism or failure. Individuals who have a narcissistic personality are not usually self-destructive, impulsive, and do not have abandonment concerns, as do other cluster B disorders. These individuals believe that they are superior and only the most successful attorney can represent them. They may wish to act as their own attorney. It is important to monitor your own emotional reactivity when working with these clients and avoid taking their behavior personally. It can be helpful to direct them to goals that will benefit them.

Don’t miss the Godoy Medical Forensics newsletter! Topics covered are:

Assault / Trauma
DUI / General Medical
Child & Elder Abuse / Neglect
Mental Health / Toxicology
Sign up here.

Which Personality Disorders are in Cluster A?

November 23, 2016/in Ask an Expert, Medical Trauma /by Forensic Competency

Courtesy of Godoy Medical Forensics

The American Psychiatric Association organizes personality disorders by clusters. Cluster A is a category that describes individuals who are withdrawn and may engage in odd or eccentric behavior. The diagnoses include:

Paranoid Personality Disorder

An individual with this disorder suspects that others are exploiting, harming, or deceiving him or her. They often suspect without justification that their spouse or sexual partner is unfaithful. They may imagine threats or hidden meaning in communication from friends or co-workers. A client with a paranoid personality disorder may not be willing to trust and confide in his or her attorney.

Schizoid Personality Disorder

Individuals who have schizoid personality disorder have a pattern of detachment from relationships, even with family members. They prefer solitary activities, such as computer games. They may appear to be emotionally cold and detached. They may not respond to anger if provoked. They are indifferent to the praise or criticism of others. An individual with a schizoid personality may not respond appropriately if questioned by police.

Schizotypal Personality Disorder

Individuals with this disorder have symptoms that are similar to those of schizophrenia. They tend to be socially isolated and their behavior and appearance can be odd and eccentric. Their thinking may be positive for unusual beliefs and bizarre fantasies. An individual with schizotypal personality disorder could be suspected of drug abuse due to odd behavior and speech.

Case Study

The following is a fictional case study about a client who is arrested and has been diagnosed with a personality disorder. As you read the case, think about what the diagnosis might be and the most effective way for the attorney to communicate with this client.

John is a 40-year-old divorced man who lives in a rural neighborhood with his dog. His closest neighbors are a family of two parents and three teenage boys. John reported to the police that his neighbors poisoned his dog. The investigation was concluded quickly after a call to the veterinarian who said that the dog was 12 years old and appeared to have expired from natural causes. John would not accept this conclusion. He called the police a few weeks later to report that his teenage neighbors were entering his house when he was at work. He said that nothing was missing but insisted that objects inside the house had been moved. When one of the boys chased a ball into John’s yard he shouted at him that he was trespassing. When the boy’s father walked over to the yard, John confronted him with a rifle and fired a shot into the air. John was arrested. His blood alcohol was 0.15. John met with his attorney and stated that he was being set up by the neighbors. He stated that he had been treated unfairly all of his life and this was another example.

Legal Implications

The legal nurse advised the attorney that the best way to communicate with John was to be calm and matter-of-fact. She told the attorney that a warm and friendly approach would be likely to cause suspicion. She also advised the attorney to avoid joking and whispering in his presence.

An assessment was done by a psychologist who concluded that John had a paranoid personality disorder and wrote a report that was presented to the court. Mandatory counseling that included substance abuse treatment was ordered.

Don’t miss the Godoy Medical Forensics newsletter! Topics covered are:

Assault / Trauma
DUI / General Medical
Child & Elder Abuse / Neglect
Mental Health / Toxicology
Sign up here.

What are the Criminal Implications of Munchausen Syndrome by Proxy?

November 16, 2016/in Ask an Expert, Medical Trauma /by Forensic Competency

Courtesy of Godoy Medical Forensics

Munchausen Syndrome by Proxy was first described in 1951 by a British physician, but it was not until 1977 that the condition was labeled “Munchausen Syndrome by Proxy” by pediatrician Roy Meadow. The syndrome was defined as “a condition in which a parent or other caretaker persistently fabricates symptoms on behalf of another, causing that person to be regarded as ill.” Dr. Meadow was the first to describe this behavior as abuse and is still considered a form of abuse by the American Professional Society on the Abuse of Children. Currently, in the United States the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM–5), the syndrome is termed Factitious Disorder Imposed on Another (FDIA).

The Victim

According to the literature, boys and girls are equally victimized in Munchausen’s Syndrome, and 77 to 90 percent of the time, the perpetrator is the child’s biological mother. In addition, 29 percent of perpetrators have symptoms of Munchausen Syndrome themselves.

What the victim might look like:

Failure to thrive due to nutritional neglect;
Child has a history of multiple hospitalizations;
Is usually less than age five at the time of symptom onset;
Has a deceased sibling or a sibling with a complicated medical history;
Testing completed does not match the clinical picture of the child;
Worsening of the symptoms reported by the caregiver, but not seen by the medical providers;
May also exaggerate symptoms to obtain caregivers attention;
Symptoms worsen upon discharge.

The Offender

What the caregiver might do to mimic illness in the child:

Adding chemicals to the child’s urine or stool;
Withhold food so the child looks like they are anorexic;
Make up lab results to be abnormal;
Give the child drugs to make the child throw up or have diarrhea and abdominal pain;
Infect an intravenous line (IV) by adding feces or saliva to the IV site;
Applying fecal matter to wounds or rubbing dirt and coffee grounds into orthopedic pin sites;
Injecting urine into the child;

What the offender may look like:

Usually is a parent and is typically the mother of the child, but can be the father;
May also be a health care professional;
Is very friendly and cooperative with the health care providers;
Appears quite concerned or overly concerned about the child or designated patient;
Is even willing to have the child undergo painful or risky procedures and/or operations in order to get the sympathy and special attention given to people who are truly ill;
Utilizes many different medical providers and facilities as a way to earn praise from others for their devotion to the child’s care
Tends to be quite “fluent” in the medical jargon and able to explain medical details easily;
Will not usually leave the child alone with the medical provider.

Criminal Implications

Munchausen’s Syndrome is considered a form of medical child abuse in terms of physical abuse and medical neglect. This type of abuse is considered to be premeditated. Medical providers are considered a mandatory reporting entity, but many do not recognize the syndrome or get “sucked into” the sympathy for the caregiver. “Even when fabricated illness is reported to child protective services, many children are not protected from further harm. In a 2-year surveillance study in the UK, approximately one-third of the children (46 of 119) were allowed to return home. Approximately one-quarter of the children still had signs or symptoms of abuse at follow-up. Only one-third of the children were placed in caregiving arrangements outside the control of the alleged offending parent.” (American Academy of Pediatrics, 2013)

Estimates suggest that about 1,000 of the 2.5 million cases of child abuse reported annually are related to Factitious Disorder Imposed on Another (FDIA) or Munchausen’s Syndrome by Proxy. “This disorder can lead to serious short-and long-term complications, including continued abuse, multiple hospitalizations, and the death of the victim. Research suggests that the death rate for victims of FDIA is about 10 percent.” (Cleveland Clinic, 2014).

Monsters in the Closet: Munchausen Syndrome by Proxy

Materia Medica is a brief review of current literature in medicine relevant to criminal law designed to help prepare you for your next case.

Monsters in the Closet: Munchausen Syndrome by Proxy by Laura Criddle, RN PhD, ACNS-BC, CCRN, CCNS

This article discusses Munchausen’s Syndrome by Proxy (MSBP) and states that it is underrecognized and underreported. Some points in the article to be brought forward for defense attorneys are:

“…there is likewise no standardized definition of the disorder.”
- This ambiguity allows the defense attorney to question the medical diagnosis.
“Although the condition is often characterized as ‘rare,’ lack of a standardized definition and centralized reporting repository make it difficult to quantify the incidence of MSBP. Expert estimates range from 1 in a million children to 2.8 in 100,000 children.”
- The only consensus is that it is a rare disease. There is little literature that defines its incidence. Rarity alone supports a defense case.
“…if this fabrication does not garner sufficient interest from medical providers, abusers are driven to increase the stakes.”
- The disorder is considered an escalating disorder. It is beneficial to review past medical history of the child and determine if there were previous incidences of potentially mild symptom fabrication, such as claims of apnea or ataxia.
“Mothers, and other women in a guardian role, are by far the most frequently reported perpetrators (93%), but Sheridan’s large scale review found that fathers were primarily responsible approximately 7% of the time.”
- This is relevant for both male and female defendants. Defense may postulate that the male defendant is an unlikely suspect, or that the female is not the exclusive perpetrator in this condition.

What is a Personality Disorder?

November 9, 2016/in Ask an Expert, Medical Trauma /by Forensic Competency

Courtesy of Godoy Medical Forensics

The American Psychiatric Association (2013) defines a personality disorder as an enduring pattern of inner experience and behavior that deviates markedly from the expectations of an individual’s culture. The personality traits are pervasive and inflexible. These individuals have difficulty with adaptation and relationships. Personality disorders usually appear in adolescence or early adulthood. They are stable over time. An individual can learn to use more adaptive coping skills but the basic personality does not change. This means that there is no “cure” for a personality disorder.

The diagnosis of a personality disorder requires an evaluation of the individual’s long-term pattern of functioning. A single interview, without sufficient history may not be enough for a clinician to make an accurate diagnosis. Many neurological or other medical conditions can cause personality changes. Examples are brain injury or tumor, epilepsy, HIV, substance abuse, cerebrovascular disease, and lupus with brain involvement. Personality changes that follow exposure to trauma or extreme stress may be related to PTSD.

Don’t miss the Godoy Medical Forensics newsletter! Topics covered are:

Assault / Trauma
DUI / General Medical
Child & Elder Abuse / Neglect
Mental Health / Toxicology
Sign up here.

How is Schizophrenia Treated?

November 2, 2016/in Ask an Expert, Medical Trauma /by Forensic Competency

Courtesy of Godoy Medical Forensics

Case Scenario

The police were called to a busy intersection of the city because a man was standing in traffic, shouting, and stopping cars. He was a white male in his early 20s with an unkempt appearance. When the police questioned him, he stated that he was an undercover FBI agent. He said that his job was to direct traffic and find terrorists. The police ordered him to get out of the road and he refused. He became combative when the officers tried to escort him. He was tased by one of the officers and fell, hitting his head on the street. He was unconscious and transported to the emergency room, where he was diagnosed with head trauma and admitted to the intensive care unit. Emergency room personnel recognized him and referred to him as a “frequent flyer” who had a diagnosis of schizophrenia and was admitted to the acute psychiatric unit on a regular basis. The case is likely to receive media attention and the community may state that the police officer acted inappropriately by using a Taser on an individual who was unarmed and mentally ill. A lawsuit may be filed against the police department by the family of the injured man, potentially leading to both criminal and civil proceedings.

Symptoms and Diagnosis

There is currently no diagnostic test for schizophrenia. The age of onset is usually between the late teens and early thirties. Diagnosis is based on an individual’s history and presenting symptoms. Positive, negative, and cognitive symptoms are identified. Positive symptoms are delusions and hallucinations. Sometimes, people confuse these two symptoms. A delusion is a belief that is not based in reality. In the scenario presented, the individual believed that he was an undercover FBI agent. Delusions often have themes involving religion, sex, or the government. An individual who has schizophrenia may have paranoid delusions—believing that a person or group will harm him or her. Hallucinations involve the senses. They can be auditory, visual, tactile, olfactory, or gustatory. The most common are auditory hallucinations, sometimes referred to as “voices.” An individual who is hearing voices may appear distracted, be slow to respond, or appear to be listening or laughing inappropriately. Initially, the voices can be comforting or amusing but this changes as the disease progresses. The voices can become very critical and derogatory.

Approach Considerations

Individuals with schizophrenia may sleep excessively or use alcohol or other substances to diminish the voices. Command hallucinations are the most serious and can be dangerous. The voices may command an individual to harm themselves or others. The person may feel that they must obey. It is helpful to ask someone who experiences auditory hallucinations if they are in control or the voices are in control. They will respond best to a low stimulation environment if experiencing psychotic symptoms. Examples would be low lighting, minimal people and a low noise level. Only one person should speak to the psychotic individual and requests should be direct and brief. Whispering and laughing can be misinterpreted and should be avoided. Orienting the individual to reality, such as using his or her name, is recommended. The focus when working with a person who has schizophrenia is to decrease anxiety and build trust.

The negative symptoms of schizophrenia involve a loss of function. Examples are a loss of verbal fluency, loss of energy and motivation, loss of the experience of pleasure, and loss of emotional expression. Personal hygiene and social skills may be lacking. These symptoms may seem less dramatic than positive symptoms but they are just as debilitating. When a person with schizophrenia is being interviewed, he or she may respond with one word answers and seem to have no expression on their face. This presentation could be mistaken for low intelligence or depression. Cognitive symptoms can involve memory and language deficits. The individual may be slow to process information. They may be slow to respond to questions. Individuals with schizophrenia may lack insight and awareness of their disorder. They may resist treatment for this reason. Social skills training, anxiety management, and education about the illness and medications is also helpful. Insight-oriented psychotherapy is less effective.

Medical Treatment Options

The primary treatment for schizophrenia is anti-psychotic medication. It can help individuals to manage their symptoms, but it is not a cure. The older anti-psychotic medications—called “first generation”—were effective for positive symptoms and had serious side effects. Some side effects, such as tardive dyskinesia can be irreversible. Neuroleptic malignant syndrome is a rare, but life-threatening, side effect. Examples of first generation anti-psychotics are: Thorazine, Haldol, Stelazine, and Prolixin. Haldol is still used in emergency situations because it can be given by injection and is fast acting. The older medications may be prescribed because of lower costs, but the newer anti-psychotic medications are generally considered safer and more effective. First prescribed in the 1990s, they are effective for both positive and negative symptoms. Geodon, Seroquel, Abilify, and Risperdal are examples. These newer medications—called “atypical” or “second generation”—can also cause significant side effects, but less frequently. There is a high risk for weight gain and type II diabetes with the newer medications. Compliance with treatment is often a problem for people who have schizophrenia. They may not have insight about their need for treatment as noted in the previous section. They are usually unable to maintain employment in jobs that have insurance benefits. When faced with a choice between medication and food, because of inadequate finances, they will choose food. Side effects—such as obesity, sedation or restlessness, dizziness, and sexual dysfunction—can discourage people from taking their medication. When individuals stop taking medication they experience symptoms that can lead to hospitalization or legal problems.

How Does Drug Use During Pregnancy Affect a Fetus?

October 26, 2016/in Ask an Expert, Medical Trauma /by Forensic Competency

Courtesy of Godoy Medical Forensic

Causes of Still-Born Births

The incidence of still-born births in the United States is 1 in every 160 pregnancies. The diagnosis of fetal demise is usually completed via ultrasound to confirm the absence of the fetal heart beat. Autopsy is generally recommended, along with diagnostic testing in an attempt to provide causation.

Common causes of fetal demise are:

Birth defects;
Placental issues;
Poor fetal growth;
Infection;
Chronic health conditions of the mother;
Umbilical cord accidents; and
Trauma.

Not all causes can be identified on autopsy, nor are all causes determined. In a recent study, African-American females were found to have a two-fold increased risk of still-born births without any correlating cause. External causes are difficult to definitively correlate with fetal demise, but there are higher incidences of still birth associated with drug use. For example, cigarette smoking is the most common identifiable preventable cause of stillbirth with an odds ratio of 1.6.

Drug Effects on the Fetus

The consumption of many substances can cross the placental barrier and affect the fetus. Not only is this true for everyday substances we consume throughout the day, but for legal and illegal drugs, as well. The consumption of illicit drugs during pregnancy is harmful to the mother and to the fetus. Drugs such as marijuana, cocaine, and heroin will cross the placental barrier, and may affect the growth and development of the unborn child. Illicit drugs can cause miscarriage, low birth weights, premature labor, placental abruption from the uterus, and fetal demise.

Legal Implications

In some states, the criminal justice system is attempting to prosecute mothers of still-born babies if the child resulted positive for illicit drugs on autopsy. In 2007, a young Mississippi woman was indicted by a grand jury for “depraved heart murder” which is defined as an act that results from the gross negligence of an individual. The indictment reported she had “unlawfully, willingly, and feloniously” caused the death of her child from smoking crack during her pregnancy. Although, at birth, it was noted the umbilical cord was wrapped around the baby’s neck. One article on the case can be viewed here.

The controversy in that case is whether her drug use caused or contributed to the death of the unborn child. In truth, there are no individuals that can say for certain which was cause of death as both are correlated with fetal demise and both have resulted in a viable and even healthy child outcome. For certain, using illicit drugs during pregnancy is detrimental to the child.

It has long been discussed if the unborn child had, or has, any rights. In some states, such as Alabama, the Supreme Court has determined the definition of a “child” would include the unborn fetus. In other states, such as Tennessee, women that abuse drugs while pregnant could be criminally charged for harm done to their babies. This holds ramifications for everyone involved. New definitions will need to be put in place regarding what constitutes harm,gestational age qualifications, and a clarification of when harm is permissible (e.g. narcotics are commonly used during labor to ease the pain of the mother).

Disclaimer: Heightened emotions arise when discussing the rights of women and what they are permitted to do with their body versus the rights of children before they are born. This blog post is in no way a stance related to either side, but simply a commentary on a rising issue in the criminal system.

What Are the Effects of Magic Mushrooms?

October 19, 2016/in Ask an Expert, Medical Trauma /by Forensic Competency

Courtesy of Godoy Medical Forensics

Users can come to the attention of the legal system due to possession, intoxication, or criminal behavior that occurred after ingestion of the mushrooms. The active drug in these mushrooms is called psilocybin, which is chemically related to Lysergic Acid Diethylamide (LSD). It has a long history of being used in religious rituals in Mexico and Central America. Users are typically teenagers and young adults and it is not known to cause physical dependency. Many users attempt to gather mushrooms themselves, leading to dire results as misidentification of mushrooms can have serious consequences. In this way, poisonous mushrooms have been mistakenly ingested by users resulting in illness and death.

Consumption

Psilocybin is taken orally. It can be ingested in food, dried, eaten fresh, or brewed in tea (National Institute on Drug Abuse, 2009). The drug produces psychotic symptoms similar to those seen in schizophrenia. The user may feel that they are in a dream state; their sense of time is distorted. Perceptions—such as sight, sound, and touch—may seem to blend together. Thinking is impaired and the user cannot distinguish fantasy from reality. Of particular interest to criminal attorneys is that users do not have the ability to act with intention or determine right from wrong when in a psychotic state induced by psilocybin ingestion. Users have been known to act violently towards themselves or others after using psilocybin.

“Bad Trip”: Psilocybin Adverse Reaction

When someone uses a hallucinogen and experiences anxiety, paranoia, and a panic reaction, it is called a “bad trip.” It is difficult to predict who will have a “bad trip” because individual response to drugs vary and can be dose-dependent. A group of people may be partying with psilocybin and some may have a bad reaction while others do not. The best predictor of who will have an adverse reaction is a history of having a “bad trip” in the past. Treatment of an adverse reaction is usually supportive, with a quiet, low-stimulation environment. Sometimes, medications (benzodiazepines) may be administered to control extreme agitation or seizures (National Institute on Drug Abuse, 2009).

How is Methamphetamine Made and Hidden?

October 12, 2016/in Ask an Expert, Medical Trauma /by Forensic Competency

Courtesy of Godoy Medical Forensics

This illegal drug was once produced in vast quantities in the U.S. using easy-access medications and chemicals until the Combat Methamphetamine Epidemic Act of 2005 was incorporated. This act bans medications containing pseudoephedrine, ephedrine, and methamphetamine from being sold over the counter. Now meth is classified as a Schedule II stimulant under the Controlled Substances Act—meaning that it is highly addictive and can be obtained only by a non-refillable prescription. Now users “smurf”, or accumulate small but multiple doses of these medications, in order to acquire the necessary amount to manufacture meth in “meth labs.” These meth labs are very volatile because the chemicals used in combination with the medications are toxic and explosive. Oftentimes, the one producing the meth in the lab is a user with an already compromised mental status.

Because the U.S. has placed such stringent rules and regulations on the prescription medications, the illicit drug is often imported in large quantities from Mexican cartels. Both American and Mexican users and producers are always looking for new and innovative ways to get around laws and law enforcement. Users may “body-pack” or “body stuff” bags of meth internally to avoid detection by law enforcement. However, the new and upcoming form of an even stronger form of meth is “liquid meth.” Solid meth is dissolved in liquid and transported via common containers, such as liquor bottles or vehicle gas tanks, in order to avoid detection during traffic stops or at border crossings. The liquid is then either burned off back into its solid state or applied to paper that users then tear off into pieces and ingest.

What is the Responsibility of IHSS Caregivers Concerning Abuse and Neglect?

October 5, 2016/in Ask an Expert, Medical Trauma /by Forensic Competency

Courtesy of Godoy Medical Forensics

For elderly and disabled persons to live independently in their home, they often seek aid from family or hired assistants. Sometimes this involves live-in caregivers, and other times, the caregiver comes in for a few hours at a time. The support provided typically involves the activities of daily living (ADL), such as cleaning, cooking, and bathing. At higher levels, care may involve assistance with medical tasks, such as injections for diabetics or dressing changes for wounds. Unless the caregiver is an independently hired nurse, the medical aspects of care are very limited.

Most states provide support to eligible applicants based on age or disability. For example, the program in California is through the Department of Social Services and is called In-Home Supportive Services (IHSS). Under this program, a non-medical person will come into the home of the recipient and assist them with common household duties, such as cooking, cleaning, and shopping. There are some mild “paramedical” tasks that may be authorized, such as checking blood sugar or giving injections, but training is required before they can be provided. California’s list of non-medical authorized tasks can be reviewed here and information on paramedical services is here. For more information on your state, a keyword search online is necessary. Family members may apply to become IHSS providers for reimbursement by the state.

Reporting Requirements

Whether training is required for the IHSS provider varies from state to state. If you take a moment to peruse the training content, you will see that it requires a high level of reading comprehension and much of it is in legal jargon/penal codes. I am sure the IHSS providers are of a wide variety of educational backgrounds but my sense is that most of them are not going to be able to read and understand a penal code. Even the definition of neglect and self-neglect under “Types of Abuse and Neglect” is at a 14-15th grade reading level. There are YouTube videos on how to fill out your timesheet, but none on any of the tasks expected, or on abuse or neglect.

So what is the responsibility of IHSS caregivers when it comes to abuse and/or neglect? Obviously, they should be reporting anything they see that is suspicious of abuse or neglect. Whether or not it is mandated will vary from state to state. In California, caregivers are mandatory reporters. Family members not under the umbrella of the IHSS program are not mandatory reporters, but under social etiquette, they should report any suspicions they have. Whether they are aware of how to report is an issue of training and education. In most cases, they will rely on medical providers to guide them when the patient is taken in to the doctor or hospital.

Can Sudden Infant Death Syndrome (SIDS) Be a Sign of Child Abuse?

September 28, 2016/in Ask an Expert, Medical Trauma /by Forensic Competency

Courtesy of Godoy Medical Forensics

What is SIDS?

The sudden, unexpected, and unexplained death of a seemingly healthy infant under one year of age is known as sudden infant death syndrome (SIDS). The age at peak incidence is 2 to 4 months, with 90 percent of cases being less than seven months of age. SIDS is a diagnosis of exclusion—meaning it is only diagnosed after a thorough death scene investigation, interviews of caregivers, a complete review of clinical and social history, and a complete forensic autopsy. SIDS should not be used as an emergency department diagnosis. Instead, sudden unexpected infant death (SUID) is a more accurate diagnosis when there is no clear evidence to suggest another cause of death.

SIDS can be difficult to distinguish from other types of SUIDs—particularly unintentional suffocation in an adult bed. However, when SIDS is identified as the cause of death, modifiable environmental factors may have been noted to contribute to the death. Some of these factors include sleeping on the stomach, bed-sharing with an adult, or maternal smoking.

The typical presentation begins with an infant being put to bed after feeding and subsequently found dead, usually in the same position in which he or she had been placed. Most infants are apparently healthy; however, there have been reports that babies had diarrhea, vomiting, and listlessness within the two weeks prior to death.

Causes and Risk Factors

Sudden Infant Death Syndrome is typically associated with a period of sleep, and in most cases no signs of distress are apparent.

Some of the causes of SIDS include low birth weight, recent respiratory infection, side or stomach sleeping, sleeping on a soft surface, hyperthermia, and sleeping with parents. Research examination of the brain stems of babies who died of SIDS showed a delay in the development of serotonin-binding nerve cell pathways in the brain. Delayed development of these pathways could prevent the infant from arousing from sleep if the mouth and nose became obstructed during sleep.

Some risk factors include infants in the second and third months of life; being male; being African American, American Indian, or Eskimo; babies who have had siblings or cousins die of SIDS; secondhand smoke; and being premature. Mothers also have risk factors that increase risk, including age younger than 20, cigarette smoking, drug and/or alcohol use, and inadequate prenatal care.

Physical/Autopsy Findings

Three common autopsy findings in the pathophysiology of Sudden Infant Death Syndrome are unclotted blood in the heart, intrathoracic petechiae (small red spots inside the thoracic cavity caused by bleeding), and fluid-filled heavier organs.

Other findings that are consistent with SIDS include the following:

Serosanguineous watery, frothy, or mucous-like drainage from the mouth or nose;
Reddish-blue mottling of the fact and dependent portions of the body;
Marks on pressure points of the body;
Well cared-for appearance with no significant skin trauma;
No environmental contribution, like an unsafe sleeping environment.

Considering Abuse in SIDS

Findings that raise suspicion for abuse include malnutrition or neglect and injuries to the skin, such as bruising, traumatic lesions, and abnormalities of the head and/or body. In the American Academy of Pediatrics’ Policy on Distinguishing SIDS from Child Abuse Fatalities, it is stated that the death of an infant may be attributed to SIDS when all of the following are true:

A complete autopsy is done, including cranium and cranial contents, and autopsy findings are compatible with SIDS;
There is no gross or microscopic evidence of trauma or significant disease process;
There is no evidence of trauma on skeletal survey;
Other causes of death are adequately ruled out, including meningitis, sepsis, aspiration, pneumonia, myocarditis, abdominal trauma, dehydration, fluid and electrolyte imbalance, significant congenital lesions, inborn metabolic disorders, carbon monoxide asphyxia, drowning, or burns;
There is no evidence of current alcohol, drug, or toxic exposure; and
Thorough death scene investigation and review of the clinical history are negative.

Methamphetamine: What Triggers a Drug Screen?

September 21, 2016/in Ask an Expert, Medical Trauma /by Forensic Competency

Courtesy of Godoy Medical Forensics

Methamphetamine use has physical manifestations that heighten suspicion of use and lead to a drug screen. The category of stimulants, which includes methamphetamine, methylphenidate, and cocaine, all produce dilation of pupils and the pupils appear abnormally large. Unlike sedatives, stimulants do not cause gaze nystagmus (jerky eye movements that become apparent when a person looks to the side). Methamphetamine can cause rapid heart rate, sweating, elevated body temperature, tremor, and twitching. Research on the ability of standard field sobriety tests to detect amphetamine found that low levels of stimulants did not impair performance on the standard tests (Silber, 2005). An observer may see signs and symptoms strongly suggestive of stimulant use, but it is not possible to definitively identify stimulant use without a chemical test.

Screening

Methamphetamine is typically detected through urine and blood screens that offer positive or negative (“qualitative”) results. A positive result on a screen often leads to a confirmatory test that will use more sophisticated laboratory tests which can quantitate the concentration of the drug and drug metabolites.

Interpreting screening and confirmatory testing results can be complex as a result of test cut-offs and patterns of use. Urine is most frequently used for screening because it is less invasive to obtain than blood samples. Also, the kidneys filter and concentrate chemicals during the excretion process. As a result, urine tests can detect substances that may have much lower concentration in the blood.

Concentration and Metabolites

Blood concentrations for methamphetamine use as a prescribed medication are typically in the range of .02-.05 mg/L for a person taking methamphetamine prescribed for attention deficit disorder, weight loss, or narcolepsy. Drug abuse with methamphetamine yields blood levels as low as .01 mg/L and 2.5 mg/L. Levels above 3.0 mg/L have been documented and are associated with significant risk of toxicity. Some laboratories report drug concentrations using different units such as micrograms and milliliters. Online search engines offer converters that will automatically convert units and allow for direct comparisons of levels.

As the liver attempts to clear the body of methamphetamine, 5 of 7 percent of the drug is metabolized to create the metabolite amphetamine. As a result, screening tests positive for methamphetamine can also be positive for amphetamine. Although it is possible that a methamphetamine user also used amphetamine prior to the test, the vast majority of the times, the presence of amphetamine is a simply by-product of the parent drug methamphetamine.

Amphetamine levels are lower than methamphetamine and appear later, with peak levels 12 hours following methamphetamine use. The presence of amphetamine is a marker that some time has elapsed since methamphetamine use started. Methamphetamine users can repeat drug use several times in a day and may binge over a period of days or weeks. Multiple doses of methamphetamine interfere with interpreting amphetamine levels to estimate timing of methamphetamine use. In order to avoid a false positive test for methamphetamine as a result of prescribed stimulant medications, some employers specify that a screening test be positive for amphetamine in addition to methamphetamine.

Detection Time

Compared to cocaine, methamphetamine’s effects can be more intense and last longer. The half-life for methamphetamine (the time period required for the body to decrease the blood level of methamphetamine by 50 percent) ranges from six to twenty hours.

The time window for detecting methamphetamine will depend on both testing factors and individual factors. All screening and quantitative tests have a lower limit, or cut-off, for detection. This limit varies for tests and among labs. If a person had used methamphetamine many hours prior and the concentration was very low in the blood or the urine, a qualitative test may come back as negative. Quantitative tests may also result in negative results if the amount in the sample was below the lab threshold for a positive report. Very sensitive tests, with much lower cut-offs for concentrations, will detect the presence of methamphetamine and amphetamine sooner and for a longer period of time than less sensitive tests. Laboratories will inform you of the lower limits by either including the cut-off level on the written report or through a personal communication.

The method by which methamphetamine is consumed will also impact detection time. Intravenous use will have almost immediate detectable methamphetamine in blood samples and in the first void after use. Oral ingestion of methamphetamine requires absorption through the GI tract and requires a longer period to detect the drug. Peak blood levels occur three hours after an oral dose. Urine tests may require 12 to 24 hours to test positive.

The duration of detectable of methamphetamine and amphetamine in blood or urine can vary due to several factors. The half-life will be shorter if a person has acidic urine; the kidneys will clear the drug faster when urine is acidified. This has led to the marketing of acidifying products, such as vitamin C supplements, to people anticipating a urine drug screen.

An individual may have impaired liver function or take medications that block the metabolism of methamphetamine by enzymes in the liver. Medications that inhibit the liver’s P450 enzyme system and slow the metabolism of methamphetamine to amphetamine are called P450 inhibitors and include common over the counter and prescribed medications such as the antidepressant Prozac and the sleep and allergy aid diphenhydramine.

Don’t miss the Godoy Medical Forensics newsletter! Topics covered are:

Assault / Trauma
DUI / General Medical
Child & Elder Abuse / Neglect
Mental Health / Toxicology
Sign up here.

How Reliable is Forensic Science?

September 20, 2016/in Attorney, News /by Steve

Not all forensic science seen in the courtroom is equal. Read more.

Can Someone Consent After a Head Injury?

September 14, 2016/in Ask an Expert, Medical Trauma /by Forensic Competency

Courtesy of Godoy Medical Forensics

Many times, a police officer will interview a defendant after a fight or a car wreck where the person being interviewed has suffered head trauma. What the police officer may not understand is that even mild Traumatic Brain Injury (mTBI) can affect a person’s ability to comprehend the questions being asked and the ramifications of the answers he is giving. From the officer’s perspective, the patient may not demonstrate any outward signs of compromised capacity. A mental health expert is best suited to assess the patient’s ability to consent at the time of the interview.

The ability to consent and make informed decisions is affected in all patients with Traumatic Brain Injury. However, this is not an either/or issue. It is, rather, one that falls into a spectrum. In some cases, the ability to make decisions is obvious, as in those with severe TBI and neurological compromise. In patients with mild or moderate TBI, it may not be so clear:

A case study presented by Dr. Catherine Marco (2003) discusses a gentleman with a simple cut to his head who was mildly intoxicated but “alert and aware.” However, he became agitated when the doctor wanted to run a CT scan. Agitation is a sign of a more severe internal cranial bleed. Thus, the doctor had to make the decision of whether to run the diagnostic tests against the patient’s will, or let the patient leave against medical advice and risk progressing into a coma from a possible bleed.
A study published in Neurology (2012) assessed the treatment consent capacity of patients across a range of TBI severity. Even patients at the lowest level of TBI demonstrated a compromise of their capacity to appreciate or understand the questions being asked. At the next level in severity, where the patient demonstrates small injuries to the brain on CT scans, the patients demonstrated capacity compromise in all three areas assessed (understanding, reasoning and appreciation).

In summary, an interview performed in the setting of any level of head trauma should be taken with caution and may not hold up in court.

Don’t miss the Godoy Medical Forensics newsletter! Topics covered are:

Assault / Trauma
DUI / General Medical
Child & Elder Abuse / Neglect
Mental Health / Toxicology
Sign up here.

How Can Life Experiences be Used in Mitigation?

September 7, 2016/in Ask an Expert, Medical Trauma /by Forensic Competency

Courtesy of Godoy Medical Forensics

Among the life experiences that are linked to adult problems, childhood adversity is the best studied and has the most compelling data. In study after study, early life adversity is linked to medical, mental health, and other problems including substance abuse and involvement with the criminal justice system. The negative effects of early life experience are additive. For example, if a person experiences multiple forms of abuse and neglect as a child, his or her risk of developing a substance use disorder later in life increases several-fold. All types of child abuse and neglect put a person at greater risk for arrest later in life.

The Adverse Childhood Experience Scale and other tools systematically assess abuse, neglect, household dysfunction, and other childhood problems. Summarizing and discussing the cumulative impact of childhood adversity using published research evidence is a powerful way to link early life problems with adult problems.

Can Tolerance Be Used as a Defense for a Marijuana DUI?

August 31, 2016/in Ask an Expert, Medical Trauma /by Forensic Competency

Courtesy of Godoy Medical Forensics

Medical marijuana is becoming more and more visible as it makes its way through the various steps of legalization and post-legalization changes and amendments. The ability to defend a person charged with DUI of medical marijuana poses new challenges to defense attorneys everywhere. A good understanding of what medical marijuana is prescribed for and the side effects—both desired and inevitable—is necessary in order to defend a person’s right to function in society while recovering from a painful and sometimes terminal disease. One defense strategy might be to argue that a high tolerance due to the chronic ingestion reduces the effect of the medication on the brain.

California is one of 14 states that have legalized marijuana for medical uses. The federal government, however, still holds marijuana illegal for any purpose. The law in California became effective November 6, 1996, and is allowed only in certain quantities and for certain conditions. According to CNBC, those conditions are “AIDS, anorexia, arthritis, cachexia, cancer, chronic pain, glaucoma, migraine, persistent muscle spasms, including those associated with multiple sclerosis, seizures associated with but not limited to epilepsy, severe nausea” (CNBC, 2010).

The first factor is, of course, to determine that the person was using the marijuana according to the state’s guidelines. Once that is determined to be valid, there are two factors that can affect the outcome of a DUI charge in regards to medical marijuana: potential side effects and the driver’s tolerance to them. The known side effects of marijuana include light-headedness, paranoia, anxiety, and loss of coordination. External physical symptoms include tachycardia and dilation of the pupils. Therefore, a field sobriety test (FST) may come out as abnormal if administered correctly. The desired side effects when used for medical purposes include decreased nausea and vomiting, increased appetite, and general analgesic effects (pain relief).

Users of medical marijuana may, however, not be susceptible to the side effects that affect their ability to drive if they have been taking the marijuana consistently for a period of time. One study indicated that tolerance can begin after only four to five days and that the tolerance applies to some, but not all, of the side effects and symptoms. (Jones, Benowitz, & Herning, 1981).

The idea is that just because someone is tolerant to some of the side effects does not necessarily mean that (1) they will increase the amount they ingest; or (2) that they are not receiving the desired effect of the medication. According to the Le Dain Cannabis Report, “[s]elf-administration of increased doses would not ordinarily be expected unless tolerance had developed to those specific aspects of the drug reaction which were reinforcing or rewarding its use. Tolerance or adaptation to some effects of a drug might occur independently from those responses which are sought by the user.” (Canadian Government Commission of Inquiry into the Non/Medical Use of Drugs, 1972)

In summary, as the policies and laws change in regards to the use of medical marijuana, we must keep ourselves current on potential defenses for charges relating to and including the intoxication of marijuana in persons who are permitted to use marijuana for medical purposes. This not only applies to the laws themselves, but to the potential uses, side effects, and symptoms of marijuana. More studies will be coming out to support and hinder our theories on tolerance. The potential of using tolerance as a defense for a DUI charge for a medical marijuana user may include that he or she had a tolerance to the less desirable side effects of the medication, but was still receiving the therapeutic benefit of the drug.

How Can Bruising and Fractures Be Used to Determine if Child Abuse Has Occurred?

August 24, 2016/in Ask an Expert, Medical Trauma /by Forensic Competency

Courtesy of Godoy Medical Forensics

The purpose of these newsletters is to aid criminal defense attorneys in early recognition of cases that should be investigated further by medical experts. Regardless, no case should simply be written off as child abuse until every alternative explanation can be ruled out.

Child abuse comes in many forms: sexual, physical, and emotional. It also has many associated phrases: abusive head trauma, shaken baby syndrome, neglect, failure to thrive, molestation, Munchausen’s Syndrome by proxy, and several others. It is the responsibility of the persons involved in the child’s care and the referring agencies, such as Child Protective Services in California, to fully investigate the injuries before charges are filed. It is unfortunate that many times charges are brought before a full medical evaluation has been done to rule out other causes of the injuries or the condition of the child. There are many “mimics” or other contributing factors that could explain why the child was flagged as a possible abuse victim, such as bruising and bone fractures.

Bruising

There are many reasons why children get bruises that are not related to abuse. Blood and other disorders should be investigated and ruled out before that child is considered an abuse victim. Some of the things to look for are hemophilia, sickle cell disease, some types of anemia, Vitamin K Deficiency in combination with hypoprothrombinemia, Hermansky-Pudlak Syndrome (standard blood tests are normal in this disorder), and Scurvy (see more below). Also, many medications cause a tendency to bleed, such as ibuprofen (Advil, Motrin, etc.) and Prednisone. Other medications that pass through the breast milk may cause bleeding in an infant, such as Warfarin.

Bone Fractures

There are several classifications of fractures that are considered highly suspicious of abuse, including metaphyseal lesions, posterior rib fractures, scapular fractures, fractures of the spinous process, spiral fractures (humerus or femur), and ternal fractures. There are also increased concerns over multiple fractures, especially when they are of different ages or on both sides of the body (Alexander, 2010).

Fractures in children can often be explained away by the caregiver’s story. It is the case in which the fracture cannot be explained or the explanation doesn’t seem to fit the injuries that enters into the legal system. In these cases, criminal defense attorneys must seek out other potential causes.

Below is a brief description of a few of the mimics and what to look for:

Osteogenesis Imperfecta (OI): Also known as Brittle Bone Syndrome, this is actually a disease of the connective tissue commonly associated with weak bones. It was previously thought to be solely genetically inherited. It is now recognized that new mutations can cause the disorder. There are four types in which two are classified into sub-types, making a total of six potential classifications of OI. The birth incidence is approximately one case in 20,000 births.
Rickets/Vitamin D Deficiency: Rickets is a disease of growing bone that is unique to children and adolescents. Vitamin Deficiency rickets occurs when the metabolites of vitamin D are deficient. Less commonly, a dietary deficiency of calcium or phosphorus may also produce rickets. Natural sources of Vitamin D are limited to fatty, ocean-going fish and natural sunlight exposure. Cow’s milk in the United States is fortified with Vitamin D. Therefore, the children at highest risk of Vitamin D Deficiency Rickets are infants who are solely breastfed and children who are fed a vegan diet, especially those with dark skin. Except in pediatric patients with chronic malabsorption syndromes or end-stage renal disease, nearly all cases of rickets occur in breastfed infants who have dark skin and receive no vitamin D supplementation.
Scurvy: Scurvy is a dietary deficiency of Vitamin C that results in impaired collagen synthesis. It is most commonly associated with sailors in the Renaissance era. It has been recognized in infants that had heated formula, pasteurized milk, and a lack of orange juice in their diet. Hemorrhaging is a hallmark feature of scurvy and can occur in any organ and lead to bruising. Hair follicles are one of the common sites of cutaneous bleeding. Bone involvement is also common in infantile scurvy. Bruising and fractures together make Scurvy highly suspicious in abuse cases when unrecognized. Although scurvy is uncommon, it still occurs and can affect adults and children who have chronic dietary vitamin C deficiency. Infants and children on restrictive diets—because of medical, economic, or social reasons—are at risk for scurvy. Occurrence of scurvy is uncommon in those younger than seven months old. Most cases of infantile scurvy occur when the infant is aged 6 to 24 months old.

Contact Our Office