1

ROY L. MORRIS, ESQ.

! PO Box 100212

! Arlington, VA 22210

! 202 657 5793

! 509 356 2789 (Fax)

! Roy_Morris@alum.mit.edu

Dr. Alison M. Jackson, MD, MPH

Director

Children’s Hospital

Child and Adolescent Assessment Center

111 Michigan Ave., NW

Washington, DC 20010

Fax: 202-476-3790

May 29, 2009

Re: Mandated Reporters-Based Investigation of Ariana-Leilani King-Pfeiffer DOB 05/07/03

(MR#020787632)

Dear Dr. Jackson,

On April 24 2009 the DC Child and Family Services Agency presented Ariana-Leilani King-Pfeiffer for

an evaluation of “sexual abuse.” That evaluation was brought about by three experts reporting suspected

medical neglect and sexual abuse directly to the Child and Family Services Agency of Washington DC on

April 21, 2009. I represent Dr. Ariel King, the mother of Ariana-Leilani and who is her legal parent.

Based on the medical records we have received regarding that visit, Ms. Ashley D. Gardella, LICSW and

Dr. Deyes received statements of fact from the father, Dr. Michael H. Pfeiffer, the suspected abuser.

Much of that information was clearly inaccurate and misleading, such that it would necessarily have an

impact on the impressions of the evaluators at the Child and Adolescent Assessment Center at CNMC.

We understand that the Children and Adolescent Evaluation Center staff works hard to give your young

clients that best service possible in our nations capital. I am sure you would agree that the best evaluation

requires full and accurate information and disclosure of information – and in situations of alleged abuse,

information should not be gathered from that alleged abuser, but instead either objective sources, if

available, or parties other than the alleged abuser. In this case, where mandated reporters who are

experts in their fields originated the case (not the mother, who is the non-abusing parent, as reported in

the CAC intake record), the information those experts originally provided to CFSA should certainly be

considered. Based on the intake medical records we have been provided thus far by Children’s, your

staff was not afforded this information. The highlights of points of misinformation on the official record

that are corrected by the attached letters, affidavits and medical record are below:

1. Contrary to the Childrens’ intake form, the DC CFSA complaints were not reported by the Mother, but

were reported orally and by written reports by from Dr. Joy Silberg (of Sheppherd-Pratt Psychological

Hospital who reported both abuse and neglect), Dr. Robert Sklaroff (a board certified

hematologist/oncologist who reported problems with the medical neglect of the child), and Justice for

Children (which follows serious abuse cases throughout the United States) (See, Attached Reports):

2. Contrary to the Childrens’ intake form, the suspected herpes was not reported by the Mother, but

instead by Dr. Abu-Gosh of Georgetown University Hospital. (See, October 22, 2008 medical report of

Dr. Abu-Gosh).

2

3. Contrary to the Children’s intake form, CFSA has represented that CNMC has done a complete

evaluation of sexual abuse (including an interview with the child) and medical neglect – both of which

were clearly not done because CFSA specifically did not ask that they be done. In addition, neither the

suspected herpes found by Georgetown University’s Dr. Abu Gosh nor the possible use of drugs by Dr.

Pfeiffer which could be a likely cause of the severe neutropenia whose cause had been undiagnosed for

over a year, appear to have been investigated because of CNMC’s constraints on CNMC.

4. Contrary to the medical notes, there is no permanent no contact restriction between the mother and

child, instead the father has isolated her and opposed any contact, not only with the mother, but her

grandmother and others who she has known and loved for years....not even a telephone call.

5. CFSA allowed the child to be brought into CNMC by the Father, and be present, thus eliminating any

possibility of the child feeling free to speak without retribution by the suspected abuser.

6. Ms. Magnuson, the CFSA worker who accompanied the child to the CNMC, had already concluded on

the evening of the April 21, 2009 that the reports by the experts were “unfounded” and appeared to be

trying to guide CNMC in that direction to avoid an inconsistent result. In addition, she made no note of

physical injury of the child – even though the CNMC indicated a head injury occurring earlier that day.

7. The German School is under a legal obligation to provide medical and educational information to both

parents, including Dr. King, and even as of the most recent correspondence with Dr. King, they did not

mention any incident where Ariana-Leilani was injured or fell off a bike on April 21, 2009 (the same day

that the expert’s reported the abuse and neglect, and the same day that the child was seen by Ms.

Magnuson who did not report any injuries on the evening of April 21, 2009, and thus claimed that reports

of abuse were unfounded).

I would appreciate it if you would keep me informed of any developments, including the follow-up

therapy and evaluations that were recommended in the CNMC medical record. In that vein, please

forward records from the planned follow-up on 4/30/2009, per the “Intake Form Ambulatory Treatment

Record.”

On behalf of Dr. King, she thanks you for your caring and concern for her daughter.

Please review completely the attached material and incorporate it into your evaluation and medical

records. The experts who originated the CFSA investigation that are mandated reports are willing to

consult with you to discuss the materials, as is Dr. King.

Sincerely,

Roy L. Morris, Esq.

cc: Linda Matthews, Esq., Risk Management, Children's National Medical Center

Tel: 202-471-4862, Fax: 202-471-4870, Email: LMatthew@CNMC.org

Documents included:

Dr. Joy Silberg, DC CFSA, 21 April 2009 Report

Dr. Robert Sklaroff, DC CFSA, 21 April 2009 Report

Eileen King, Justice For Children, 21 April 2009 Report

Letter (hand-written) from Kerstin Rae Magnuson of CFSA, LICSW CPS SW, 21 April 2009

Dr Abu Ghosh, Georgetown University Hospital, October 22, 2008

Dr. Scott Meyer, Georgetown University Hospital, January 9, 2009

04 /21 /2009 11 :47 4109385072 TRAUMA DISORDERS

Childhood Recovery Resources

PAGE 02 /12

Dr. Roque R. Gerald Interim Director, CPS 444 North Capitol St., NW Suite 515 Washington, DC 20001 Email: ioque.gerald@dc.gov Fax: 202-727-7279

Dear Dr. Gerald:

I am a. clinical psychologist licensed by the State of Maryland, and I am internationally recognized as an expert on child abuse and the protection of children. My CV is attached.

As a mandated reporter, I am writing to report my suspicion that the child Ariana-Leilani, King-Pfeiffer currently residing at 4836 Reservoir Road, Apt. 3, Washington, DC 20007 is a victim of sexual abuse, and physical and medical neglect. I fear the situation is critical and believe strong protective action should be taken.

Dr King, the child's mother, 11725 Greenlane Drive, Poto~nae, M,D 20854, Tel: 202-730-51 11, has been engaged in efforts to protect her child from abuse for almost a year. Unfortunately, the alleged abuser has convinced multiple jurisdictions not to take these claims seriously and no adequate investigation has been done. She has been prevented from contact with her child for 1 1 months.

T have extensively interviewed Dr. Ariel King, spoken with two of her evaluating psychologists, and reviewed numerous psychological and medical records regarding the minor child Ariana-Lcilani.

Tn addition, I have reviewed a DVD taken by a private investigator from February and March of 2009. In this video, Ariana-Leilani appears to be sick, is wearing poorly fitted and mismatched shoes, and does not appear to be receiving attentive and appropriate care.

In addition, recent medical records indicate that the child is suffering from neutropoenia and has not been receiving adequate treatment as documented in an affidavit by Dr. Robert Sklaroff. Additional medical documentation indicates a possible diagnosis of genital herpes.

Based on my review of these documents, the recent medical records and the DVD, ray interviews with Dr. King and her evaluators, and my extensive experience in the area of child safety, it is my professional opinion that Ariana-Leilani continues to be at risk in her current environment of both physical and medical neglect, and likely sexual abuse, hi

Joyanna Silberg 6501 N. Charles St. P.O. Box 6815 Baltimore. MD 21285-681 5 410-938-4974

04 /21 /2009 11 :47 4109385072 TRAUMA DISORDERS

Childhood Recovery Resources the past, she has disclosed "bail touches," and seeing a "po-po" that "gets harder and harder." None of this information has been adequately investigated.

There is 110 evidence in any of the materials that T reviewed or from my extensive interview with Dr. King or with her evaluating psychologist that Dr. King has coached or manipulated any information from her child.

I urge you to do whatever is in your power to help protect this child. Additional professionals are sending their own letters and documentation, as this situation has reached a critic,al level and there is a broad base of concern for this child's welfare from physicians and psychologists.

We have alerted several United States Congressmen of this ongoing issue, and I will work to provide any cooperation you might need. Please let me know if I can offer any other assistance.

Joyanna Silberg 6501 N. Charles St. P.O. Box 6815 Baltimore, MD 21285-6815 41 0-938-4974

TRAUMA DISORDERS PAGE B4/12

CURRICULUM VITAE

March 3"', 2009

Jovanna Lee Silber~. Ph.D.

Psychologist 6501 N. Charles Street, P.T 136 P. 0. Box 6815 Baltimore, Maryland 21285-6815 (410) 938-4974

Licensed as a psychologist by the Maryland State Board of Examiners, April 1982.

EMPLOYMENT:

Current Position: Consulting Psychologist - The Sheppard Pratt Health System, November 1,997 - Present. Coordinator Trauma Disorders services for children, researcher, and therapist

Private Owner: Childhood Recovery Resources: Consulting, therapy, forensic evaluation for children and adolescents, with specialization in family court issues, tramna and dissociation.

Senior Associate Editor, Journal of Child & Adolescent Trauma.

Past Positions: Haworth Press, Co-Editor, Trauma Books, 2005-2007 Senior Psychologist, Sheppard Pratt Hospital, Coordinator of Trauma Disorder Services for children. 1994 - 1997.

Clinical Coordinator of School Consultation Program, 1988 - 1997.

Consultant to McDonough School, Key School, Friends School, Bryn Mawr

Coordinator of Psychological Testing - Responsible for coordination ofhospital- wide testing, supervision of technicians and psychologists, staff training in testing issues. Responsible for psychological and ncuropsycliological assessment and coordination of testing related research.

Coordinator of Child and Adolescent Programs. Program included Custody Evaluation program, eating disorder program, underachiever program, 1982- 1989.

Slieppard Ptatt experience includes inpatient short-term adolescent treatment, participation in, special education Level V school, staff training on treatment plan development.

TRAUMA DISORDERS PAGE B5/12

EDUCATION:

Graduate: The Ohio State University, Columbus, Ohio Fall, 1974 - Spring, 1979 Clinical Child Psychology and Developmental Psychology

Ph.D., March 1979 - Psychology General Cornprehensivc Exams, May, 1977 MA., ~ecember 1976, Psychology

Undergraduate: University of Maryland, College Park, Maryland 1970 - 1971 and 1972 - 1973 B.A., August 1973, Psychology

Hebrew University, Jerusalem, Israel 1971 - 1972

POSTDOCTORAL FELLOWSHIP:

Postdoctoral Fellowship in Child and Adolescent Psychology, The Sheppard and Enoch Pratt Hospital, Towson, Maryland July 1980 - July 1982. Two year, half-time appointment.

Supervised experience in individual therapy, psychological evaluations and behavioral consultations with severely disturbed outpati,ent and, inpatient population, neuropsychological evaluations.

Internship in, Pediatric Psychology, University of Maryland Baltimore, Maryland, July 1978 -July 1979.

Experience in a broad range of psychological services in a pediatric setting, including evaluations of children, adolescents, and families; individual, group, and family therapy; parent training, staff education and consultation: research.

TEACHING EXPERIENCE:

Faculty, Post-Doctoral Institute on Trauma, Maryland Psychological Association 2006-2008.

Faculty, Dissociative Disorders Psychotherapy Training Program, sponsored by the International Society for the Study of Trauma and Dissociation, Teacher of year long course for mental health professionals, October 2006 -June 2007.

Presenter, national and international conferences on treatment and assessment of 2

TRAUMA DISORDERS PAGE 06/12

traumatized children, 1990 -present.

Faculty, National Center for Human Development

Presentations on child and adolescent development, psychopathology, attention deficit disorder to public and professional audiences. 1983 - 1984

Supervisor, Postdoctoral fellows, 1985 -present.

Instructor, Ohio State Univcrsity, 1975 - 1978.

Substitute teacher, Roarnokc, Virginia. Experience in elementary, junior high, and high school. October 1973 -February 1974.

UPCOMING AND RECENT PRESENTATIONS:

Treatment of Dissociative Symptoms and Disorders in Childrcn and Adolescents: Maryland Psychological Association, September 26,2008

Childrcn as Pawns, Police Academy of Baltimore County, Training on Domestic Violence and Custody, June, 2008, Frederick Comity SherrifFs Office, October 2008.

Diagnosis and Treatment of Traumatized and Dissociative Children, Bergen Norway, May 8-9,2008

Healing the Child Survivor: How Trauma Hurts Children's Brains and What We Can Do, Allegheny County Department of Human Services, May 2,2008

Trauma-Informed Care: Lessons Learned in Protecting Children In Family Court, January 2008, Thc Battered Mothers Custody Conference

Assessing Allegations of Abuse, DV LEAP Conference, George Washington Law School, Dcccmber 7,2007

The Treatment of Traumatized Children and Adolescents, Workshop in Assen, Netherlands, March 21-22,2007.

Custody Evaluation in Cases Involving Violence, half day workshop sponsored by New York Psychological Association, April 15,2007.

Healing the Child Survivor: Treatment of Dissociative and Traumatized Youth, Widener University, Plenary, June 12,2007.

Child of hicest: Child of Trauma: All day workshop on 1:reating effects of incest on children, for therapists sponsored by Jewish Family Services of Dallas, February 15, 2007.

Myths About Abuse, May, 2006, Judicial Training, New York Suprcnie Court Judges. 3

TRAUMA DISORDERS PAGE 07/12

Assessment and Treatment of Traumatized and Dissociative Children, Maryland Psychological Association, Workshop, March 2005.

Child Custody vs. Child Protection: A Clash of Core Values, Presentation at the International Family Violence Conference, San Diego, September, 2004.

The Voice of the Child in Family Court: Presentation to Israeli Bar Association, March 17, 2004, Tcl Aviv, Israel.

Child Abuse and Domestic Violence for Custody Cases: Presentation to Maryland Volunteer Lawyer's Association, GAL Training Day, February 19, 2004.

Ethical Binds and Ethical Solutions for Psychologists in Custody Disputes where Abuse i s Alleged. Nova Southeastern University, Ft. Lauderdale, March 2004.

Treatment of Dissociative Cliildren, Invited Workshop, National Sexual Abuse Resource Center, Oslo, Norway, October 2003.

Thc Ten Biggest Mistakes Made in Protecting Children in Family Court, Judicial Training, sponsored by Maryland Coalition Against Sexual Abuse and Administrative Office of the Court, March 13, 2003.

A Developmental Perspective on the Treatment of Childhood and Adolescent Dissociative Symptoms and Disorders, at Allegheny General Hospital, November, 2002.

Complex Management of Complex Tra-uma in Children and Adolescents, Silberg and ~erentz, ISTSS, I 8"' Annual Meeting in Baltimore, November, 2002.

The Assessment and Treatment of Traumatized Children, International Family Violence Conference, San Diego, 2006,2005,2004,2002.

Diagnosis and Treatment of Childhood Dissociation, New Zealand, 2002, presentation to child trauma workers of New Zealand.

Diagnosis and 'beatmcnl of Childhood Dissociation, Finland, 2001, prcscntation to child trauma workers of Finland.

Workshop on Dissociation and Child Abuse: German Society for the Study and Prevention of Child Abuse, March 2000

Diagnosis and Treatment of Child and Adolescent Dissociative Disorders. APSAC Colloquium, San Antonio, 1999; Chicago, 1998.

An Integrative Developmental Model of Childhood Dissociation: Symposi~lm, American Psychological Association Convention 1999; International society for the Study of Traumatic Stress, Miami, 1999.

B4/21/2BB9 1 1 : 4 7 41B93B5B72 TRAUMA DISORDERS PAGE m / 1 2

Cross-cultural Case Studies in Dissociation, Stockholm, 1998, International Association for Child and Adolescent Psychiatrists and Allied Professionals, International Congress.

Dissociative Children: Impact on Learning and Behavior, Trauma Counseling Center, University of Wisconsin, March, 1998, one day workshop. Diagnosis and Treatment of Child Dissociative Disorders, November, 1998, Dutch-Flemish Society for the Study of Dissociation, two-day workshop.

Constructing Consciousness in Dissociative Children, Plenary speech,, May, 1999 ISSD UK International Conferences, Manchcster, England.

PARTICIPATION ON TASK FORCES, SUMMITS, SPECIAL PROJECTS

Representative 017 Think Tank on Abused Children and the Family Court co- sponsored by Our Children, Our Future, and the Family Violence and Sexual, Assault Institute, September, 2000.

Representative on day long retreat, Childrcn's Issues in Family Court, Family Violence and Sexual Assault Institute, September 2001.

Participation in the Massachusetts Citizens for Children, Summit on Children and the Courts: Improving Court Responses to Child Victims of Intrafamilial, Violence and Sexual Abuse, October 2002.

Department of Justice, Office of Victims of Crime, Contributor to Child Treatment Guidelines for Child Victims of Crime, published, January 2003,

AWARDS AND HONORS:

Four-year University Fellowship awarded by Ohio State University Fall, 1974 -- Spring, 1978,

General Honors and High Honors awarded upon graduation from University of Maryland, 1973.

Walter P. Klopfer Award, 1992. for outstanding research paper on assessment awarded by the Society for Personality Assessment.

Cornelia Wilbur Award, 1992, for outstanding clinical contribution, International Society for the Study of Dissociation.

GRANTS RECEIVED:

Sidran Foundation Research Grant, 1992 - 1994.

TRAUMA DISORDERS PAGE 09/12

Samuel Novey Memorial Fund, Research Grant. Sheppard Pratt Hospital, 1994 - 1995.

RESEARCH PROJECTS:

The Dcvcloprnent of Pronoun Usage in Psychotic Children, Master Thesis.

The Development of Pronoun Usage among Psychotic Children and its Relation to Three Cognitive-Linguistic Skills. Doctoral Dissertation.

Patterns of Thought Disorder on Psychological Testing: Implications for Adolescent Psychopathology (co-author of article, Journal of Nervous and Mental Diseases, Vol. 184, No. 8,448-456.

The Rorschach Test for Predicting Suicide in Depressed Adolescent Inpatients. Journal of Personality Assessment, (1992).

Factors Association with Positive Therapeutic Outcomes, Research published in The Dissociative Child: Diagnosis. Treatment and Manasement.

Dissociative symptomatology in children and adolescents as displayed on psychological testing. Journal of Personality Assessmcnt, (1 998(.

Normal and Pathological Fantasy in Traumatized Children, paper presented at ISSD Inteniational Conference, 1997.

Factitious Disorder by Proxy and Dissociation, paper presented at International Society for the Study of Traumatic Stress, 1998.

Dissociative Features of Traumatized Teenagers, Ongoing, 2004 - 2007.

PUBLICATIONS:

Silberg J. L. & Dallam, S. (2009) Out of the Jewish Closet: Facing the Hidden Secrets of Child Sax Abuse - and the Damage Done to Victims In Neustein, A. Tempest i,n the A, Bmdeis University Press. (113, press, publication date, March, 2009.)

Silberg, J. L. & Dallam, S. (in press). Dissociation in Children & Adolescents: At the Crossroads, in Dell, P. F. & O'Neill, 1. (eds.), Dissociation: DSM-V and Beyond.

Dallam, S. & Silberg, J . L. (in press). Can children consent to sex with Adults7 In Walker, L. & Gold, S. Handbook or Sexual Abuse Treatment.

Dallam, S. J. & Silberg, J. L. ( J d F c b 2006). Myths that place children at risk during custody disputes. Sexual Assault Report, 9, (3), 33-47.

04 /21 /2009 11 :47 4109385072 TRAUMA DISORDERS PAGE 1 0 / 1 2

Silberg, J. L. (2004). The treatment of dissociation in sexually abused children, from a familyJattachment perspective. Pwchotherapy; Theory, Research, Practice & Training, 41,487-496.

Silberg, .T. L. (2003). Drawing conclusions: Confusion between data. and theory in the traumatic memory debate. Journal of Child Sexual Abuse, Vol. 12 (2) 2003, 123- 128.

Whitfield, C., Silberg, 1. L. & Fink, P. J. Ed. (2002) Misinformation on Child Sexual Abuse and Adult Survivors, Binghamton, N.Y.: Haworth Press.

Silberg, J. L. (2001). Treating maladaptive dissociation in a young teenage girl. In H. Orvaschel, J. Faust & M. Hersen (Eds.), (pp. 449-474). Handbook of .Conceptualization and Treatment of child Psycho~atl~ology. Oxford, UK: Elsevier Science LTD.

Dallam, S., Gleaves, D. Cepeda-Benito, A., Silberg, J. L.. Kraeiner, H., Spiegel,, D. (2001,). The Effects of Child Sexual Abuse: An Examination of Rind, Tromovitcb and Ba~isennati (1,998). The Psychological Bulletin, Vol 127, 6, 715- 733.

Silberg, J. L. (2001). A presidents' perspective: The human face of the diagnostic controversy. Journal of Trauma & Dissociation, 2 (I), 1-5.

Silberg, J. L. (2000). Fifteen years of dissociation in maltreated children: Where do we go from here? Child Maltreatment. 5, 1 19-1 36.

Silberg, J. L. (1997). Dissociative Disorders in Childhood. In J. Noshpite (ed,.), gandbook of Child and Adolemx~.t P s y w . Volume 11, (pp. 278-2$1), Jolm Wilcy & Sons.

Silberg, J. L., Stipic, D., Tagl~iza.dch, F., (1997). Dissociative Disorclcrs in Children and Adolescents. Invited Chapter for Noshpitz, J. (ed.), Handbook of Child and Adolescent Psychiatry. Volume 111. (329-355). John Wiley & Sons.

Silberg, J. L., (1998). Dissociative symptomatology in children and adolescents as displayed on psychological testing. Journal of Personalitv Asscssrnel~t, 71, 421-439.

Silberg, J. L. (ed.), (1996). The Dissociative Child: Diagnosis, Treatment and Management. Baltimore: The Sidran Press.

Silberg, J. L. (ed.), (1998). The Dissociative Child: Diagnosis, Treatment and Management. 2nd edition, Lutherville, MD: The Sidran Press.

Silberg, J. L., (1,998). Afterword, In J. L. Silberg, (ed.) The Dissociative Child: Diagnosis, Treatment and Manag-. 2nd edition, Lutherville, MD: The Sidran Press.

04 /21 /2009 11 :47 4109385072 TRAUMA DISORDERS PAGE 1 1 / 1 2

Silberg, J. (1996). Interviewing Strategies for Assessing Dissociative Disorders in Children and Adolescents, in Silberg, L. (ed.) The Dissociative Child: D&g~osis, Treatment and Manag-, pp. 47-62, Lutherville, MD: The Si,dran Press.

Silberg J. (1996). Psychological Testing with Dissociative Children and - - - Adolesce~i~s. ii, s ~ I L ? ~ , (cd.) The Dissociative Child: Ui%r~osis~;I:reat~~ie~~t gmJ yf.'ina~?eiiieni, pp. 8.5 lo?. I.iithci~~~lle, VD: Tlic Sidran Press.

Silberg, J. (1996). The Five-Domain Crisis Model: Therapeutic Tasks and Techniques for Dissociative Children, in Silberg, 1. (eel.), The Dissociative Child, pp. 113- 134. Lutberville, MD: The Sidran Press.

Silberg, J. & Waters, F. (1996). Factors Associated with Positive Therapeutic Outcome, in Silberg, J. (ecl.). The Dissociative Child, pp. 103-1 12. Jdutherville, MD: The Sidran Press.

Waters, F. & Silberg, J. (1996). Therapeutic Phases in the Treatment of Dissociative Children. In Silberg, J. (ed.), The Dissociative Child, pp. 135- 166. Lutherville, MD: The Sidran Press.

Waters, F. & Silberg, 1. (1996). Promoting Integration in Dissociative Children, in Sill>erg, J. (ed.), dissociative Child,, pp. 167-190, Luthei~ille, MD: The Sidran Press.

Silbcrg, J. L. Kishton, .I. M. Thrower, S. A., Mathews, W. D. and Smith, M. P. Instmctor7s Manual for Ed~~cational Psy-, Boston, Allyn and Bacon, 1978.

Armstrong, J., Silberg, J., Parents, F. (1986). Patterns of Thought Disorder on Psychological Testing: Implications for Adolescent Psychopathology, Journal of Mental, Diseases, Vol. 174, No. 8,448-456.

Silberg, J. & Amstrong, J. (1992). The Rorschacli Test for Predicting Suicide in Depressed Adolescent Inpatients, Journal of Personality Assessment.

Silberg, J. L. (1 978). The development of pronoun usage in the psychotic child, Journal of Autism and Childhood Schizophrenia, 8 (4), 41 3-425.

SPECIAL INTERESTS:

Community education regarding mental health Preventative interventions Behavioral correlates of psychological test variables Psychological trauma and dissociative disorders Child abuse and Family court Traumatic stress in children

TRAUMA DISORDERS

PROFESSIONAL ACTIVITIES:

President, International Society for the Study oFDissociation, 2000-2001 Executive Vice-President, Leadership Council on Child Abuse & Interpersonal, Violence (1998 -present) Member APSAC, American Professional Society on the Abuse of Children Member, A.P.A., American Psychological Association Mcmbcr. M.P.A., Maryland Psvcl~ological Association -. ~ounder'of city-wide study group on Dissociative Disorders in Children and Adolescents Reviewer, Journal of Nervous and Mental Disease Reviewer, Journal of Trauma Practice Reviewer, Journal of Trauma. and Dissociation

PAGE 12/12

1

Affidavit of Dr. Robert Sklaroff, MD CONCERNING HEALTH AND WELFARE OF

ARIANA-LEILANI KING-PFEIFFER

I, Dr. Robert Sklaroff, on oath, under penalty of perjury depose and allege:

1. I am Board-Certified in Internal Medicine (1977) and Medical Oncology (1979), and there has been no interruption in my active license to practice medicine in Pennsylvania.

2. I am fully aware of the prevailing professional standards of care that

pertain to providing medical services (diagnostic and therapeutic) under like and similar circumstances as those encountered in this case. I have no financial interest in the outcome of this case.

3. My practice includes patients with the medical conditions that are the

subject of this case—assessment of severe leukopenia/neutropenia, both diagnostic and therapeutic—and I have experience treating similar patients during the past 28 years of private clinical practice. None of my opinions has ever been disqualified in a legal proceeding. I have written hundreds of reports such as this affidavit, I have been deposed on 60+ occasions, and I have provided in-court testimony on 30+ occasions; thus, sworn testimony has been rarely required.

4. Unless evidenced otherwise, I routinely rely on clinical information

[including medical records, nursing records, lab reports, diagnostic tests and images, consulting physician reports and other patient data] which are the type of data routinely employed by physicians and paraprofessional clinical staff who provide (inpatient and outpatient) patient care. I have worked with medical office and hospital staff, including medical technologists and nurses.

5. I graduated medical school at the Thomas Jefferson University

(1974). I completed an Internal Medicine internship/residency program at the Henry Ford Hospital (1977); I then completed Hematology/Medical-Oncology Fellowships at the Memorial Sloan-Kettering Cancer Center (1979) and Hahnemann University (1980). I have been licensed in the Commonwealth of Pennsylvania (and have been in continuous practice) since 1979.

6. I am a Fellow of the American College of Physicians. I have had 27+ years' experience in practicing medicine in office settings, hospitals and others (e.g., summer-camp doctor, private clinic, locum tenens for brief time-periods). Regarding assessment of the issues in this case, my specialty is similar to that of the practitioners who were involved therein.

7. I am familiar with the applicable (outpatient and inpatient) medical standards of care. The minimum medical standard of care for the assessment, diagnosis and treatment of patients with similar signs, symptoms, and conditions as were harbored by this patient (at-issue in this case and serving as the basis of this report) applies to internists and hematologists nationally (/'A, it does not differ greatly by community); nevertheless, specifically, I'm familiar with hospitals in Washington, D.C. and neighboring Virginia.. . and their environs.

8. I was a leader (at multiple levels) of Organized Medicine's Hospital (later "Organized") Medical Staff Section and was President of a Medical Staff. Thus, I have participated in development and use of protocols, policies and procedures for the care of patients with myriad medical conditions including those experienced by this patient, and I am familiar with Joint Commission for the Accreditation of Healthcare Organizations standards.

9. I have composed hundreds of reports, have been deposed on 60+ occasions, and have provided in-court testimony on 30+ occasions. I have never been disqualified as an expert witness, and none of my opinions has ever been disqualified in any administrative forum, court of law, or other legal proceeding. I have never been found guilty of fraud or perjury in any jurisdiction. I have no financial interest in the outcome of this case.

10. I have been advised that the definition of Negligence is as follows:

Negligence, when used with respect to the conduct of 8 physician means failure to use ordinary care, that is, failing to do that which a physician of ordinary prudence would have done under the same or similar circumstances or doing that which a physician of ordinary prudence would not have done under the same or similar circumstances.

11. 1 have been advised the definition of Proximate Cause is as follows:

That cause which, in a natural and continuous sequence, produces an event, and without cause such event would not have occurred. In order to be a proximate cause, the act or omission complained of must be such that a health care provider, using ordinary care, would have foreseen that the event or some similar event might reasonably result therefrom. There may be more than one proximate cause of an event.

12. I have reviewed additional medical records ["Exhibit A" appended] from Georgetown University Hospital [I 0/22/2008 - 4/9/2009].

13. I again observe the following as to the assessment of infection-risk:

a. Neutropenia occurs when the circulating neutrophils in the peripheral blood decreases to a point whereby the absolute neutrophil count (ANC) is less than 1500 cells per mm3. [The! ANC is calculated by multiplying the percentage of bands and neutrophils (segmented neutrophils or granulocytes) on a CBC differential times the total WBC count.]

b, Because many modem automated instruments generate the ANC by calculation, reports of granulocytes may combine neutrophils and bands. Thus, if the band number is reported separately, it must be added to the granulocyte number.

c. The severity of neutropenia is categorized as "mild" when the ANC is 1000-1500 cells per mm3, "moderate" when the ANC is 500-1000 cells per mm3, and "severe" when the ANC is less than 500 cells per mm3. The risk of bacterial infection is related to both the severity and duration of neutropenia.

d. Possible causes of Neutropenia include: i. infection, ii. drugs, iii. problems with the immune system (e.g., leukemia,

HIViAIDS, etc), and iv. autoimmune and myeloproliferative disorders.

e. Assessment of a bone marrow (via aspiration, biopsy and cytogenetics) is often considered to be helpful when assessing the aforementioned differential diagnosis; this would permit the detection of such findings as an intrinsic marrow defect (such as arrested maturation) and could be invoked to support such clinical findings as congenital neutropenia, fungal infection, and a vitamin B-12 or folate deficiency.

f. In such patients, consideration is often given to instituting prophylactic measures such as:

i avoiding exposure to large numbers of school-children, ii. eliminating drugs that could contribute to neutropenia, iii. altering her diet (perhaps, to avoid fresh vegetables), iv. protecting her from cuts, and v. administering a stool softener,

14. I reaffirm the points made in my Affidavit prepared in October, 2008 regarding the hematologic assessment of this five-year-old child, Ariana-Leilani R, King-Pfeiffer [B.D. 5/7/2003], and It shocks the conscience that these problems and uncertainties persist.

15. These conclusions included the following {as rephrased and distilled}:

a. It is critical to determine the cause of neutropenia in cases (such as this) which persist for at least several months,

b. Neutropenia developed between 2006 and May 2008,

c. Neutropenia persists (per the most recent CBC),

d. Since June 18, 2008, there has been unnecessary delay in acquiring a full hematological work-up for this child by a trained hematologist to determine the cause of the Neutropenia,

e. This work-up often includes examination of the bane marrow, although to-date this procedure has not been performed.

f. Since at least as early as last May, the child has been at-risk to develop (suddenly) a major infection, but consideration has not been given to imposing any prophylactic measures, and

g. Giving the child a full panel of vaccines when her ANC was known to be below 1500 risked both compromise of her ability to be immunized (as intended) and development of infections.

16. The clinical data provided in follow-up depicts events that transpired following the 10/10/2008 visit (mandated by Child Protective Services of Washington DC), justifying ongoing concern with the child's status.

17. There have been four clinical encounters (10/22/2008, 1/9/2009, 3/27/2009 and 4/9/2009), information about which has been acquired belatedly (and immediately conveyed to this physician, for critique).

18. These data have served to reinforce concern that this child has been neglected, a conclusion that the child's mother wishes to convey promptly to any physician who can be encouraged to intervene.

19. This physician was contacted as a direct result of these concerns, recalling that the aforementioned ORDER resulted (in part) following a direct, professional conversation between CPS and this physician.

20. The child's father (Dr. Michael Pfeiffer) returned with the child on 10/22/2008, due to detection of oral and groin lesions, to wit:

Father states child began developing shallow based ulcers yesterday on her lower lip which have spread into her oral mucosa. States child has been tolerating PO liquid and solids well, playing, and only told him that something was in her mouth in passing. Denies fever, NIV, sore throat, ear pain. Also states she has multiple circular, pruritic, dry lesions in her grain area without any drainage. Dad only noticed them yesterday. States that he came today because Dr. Myers told him to come to clinic immediately if he notices any signs of mucositis.

21. The child was found to have corroborative physical findings, to wit:

b. One (2-3 x 1 cm2) erythematous ulcer on lower [lip] with yellow crusting and swelling [sic],

c. Four-to-five shallow based erythematous ulcers on oral mucosa and right buccal mucosa,

d. Four-Five (1 cm2) bilateral groin popular lesions, and

e. Hyperpigmented region (3 x 3 cm2) on right thigh.

22. The ANC was 1100, but additional studies (e.g., lesion cultures for possible Herpes Simplex) were not obtained.

24. The child was given Bacitracin and mouthwashes.

25. On 1/9/2009, during a routine follow-up visit, the child was said to be asymptomatic; persistent oral physical findings [see 21. (a-c)] were noted, and the child's ANC was back down to 480 (with 14 blood- parameters significantly out-of-range). The doctor's impression was benign cyclic neutropenia (despite the absence of documentation of any "cyclic" component thereof and despite the oral abnormalities).

26. Again, no work-up or testing of persisting oral lesions was ordered, not even (infectious disease, dentistry, dermatology) consultation.

27. The child was provided "common sense" neutropenic precautions, including good hand-washing and avoiding sick-contacts and large confined crowds; yet, she was allowed to attend school.

28. This advice appears to have been oxymoronic (particularly noting the absence of any bone marrow interpretation, previous or immediate); it can reasonably be anticipated that a school is a site comprised, in part, by the presence of the "sick-contacts and large confined crowds" that it was advised the child explicitly eschew.

29. The plan to employ G-CSF if a neutropenia-associated infection were to arise, also inexplicably, was not invoked in the presence of the persisting possibly-Herpetic lesions (recognizing that they can spread regionally and systemically in patients with compromised immunity).

30. On 3/27/2009, the ANC was 576, reflecting severe neutropenia.

31. On 4/9/2009, the child was not taken to a scheduled appointment.

32. A review-article illustrating the complexities of this overall situation (and the assumptions that have been made regarding the diagnosis) exists [httl~://emedicine.medsca~e.com/article/204821-overvie~.

33. This article [under "Procedures"] cites bone marrow assessment, among a number of infection-related samples.

34. It appears that a pattern of "neglect" exists, if for no other reason than to note the fad that the patient has now not been reassessed for a persistent oral infection (on 10/22/2008 and 7/9/2009) because her father did not take her for follow-up (on 4/9/2009).

35. I harbor continued concern that the child's father continues to avoid ensuring that the child receives timely, high-quality follow-up care; determining the cause of her neutropenia presages the capacity to plan proper ongoing manaaement (of the hematologic and infectious concerns) for, absent treatment, neutropenia can cause (and will cause, if left untreated) severe and irreparable harm to the child.

36. A full evaluation at an independent tertiary institution is required immediately to insure the life and safety of this child.

37. The child needs to be placed in the custodial care of someone who will assure that the proper independent medical evaluation and treatment is obtained immediately.

[The rest of this page has intentionally been left blank.]

All of the information and facts contained in this AFFIDAVIT are true and correct to my best knowledge and belief.

Date ' Signature *'

Sworn to and Signed before me this April 15, 2009 In Montgomery County, Pennsylvania ,,.,

. .̂r?0/\3 \/̂A* Commission Notary Publid~fficiai and Title

04/23/2008 14:51 FAX 2024280657 RUBIN WINSTON DIERCKS HA

F@R CHILDREN N BOARD OF DIRECTORS

Jill B. Deal P m e r

Venable. LLP

James P. Gillece, Jr. p&er

Whiteford, Taylor &Preston. LLP

Dr. Roque R,Gerald Interim Director DC CFSA 444 Notth Capitol St., NW Suite 515 Washington, DC 20001 Email: roque.gerald@dc.gov Fax: (202) 727-6505, Fax: (202) 727-7279 (ACSF)

April 21,2009

c o u k e ~ Alston & Bid, LLP

Katie Bornq Moose Author

LaKesha P. Pope, M.A. National Alliance to

End Homelessness

Max Riederer von Paor Partner

Rubin, Winston, Diercks, Harris & Cookc, LLP

Eileen King Regional Director

Washington W.C. Chapter I I55 Connecticut Ave., N.W.

St@. 600 Washington, D.C. 20036

202-462-4688 81.5-301-5516 Fax

&n~~iusticeforchlldren.or~

Shelley Rubin, LICSW Staff

Eliot Nelson, BA Staff

J a m s A. Sl~ields Executive Director

National Headqunrier8 2600 Southws~ Freeway

Suite 806 . ... Houston, Texu 77098

713-225-4357 Fax 713-225-2818

jshields~usticcforchildr~n,org ww.justic~f~rchildrcn,org

In the interest of Ariana-Leilani M.A. King-Pfeiffer, DOB May 7,2003

Dear Dr. Gerald:

Justice for Children (JFC) is a national child advocacy organization with headquarters in Houston, Texas and ofices in Washington D.C. JFC was founded in I987 by Randy Burton, a former Chief Prosecutor of the Family Offenses Section of the Hartis County (Texas) Dishict Attorney's office, and a group of concerned citizens within the community in response to the inadequacies and failure of child protective systems to protect abused and neglected children.

JFC's mission is to provide legal advocacy for neglected and abused children and to develop and implement collabotative solutions to entrenched pfoblems impeding the quality of life for these children, as well as to raise consciousness ab'out the failure'of governmental agencies to protect victims of child abuse,,~hildren are 0uy2,~@?irst and oyly priority. JFC works together with Child Protective Services and other agenci'es for themwelfare of these children, and, when appropriate, opposes coutt or agency actiin that threklens to compound the abuse already suffered by these helpless , yictims. , ,! .:', . . ,!, ,.., ... :

, #

JFC's expert opinion is recognized and valued by local a d national media, legal and' medical professionals, child abuse experis,'and other children's rights organizations~ JFC has appeared as amicus curiae in numerous appellate cases throughout the counhy., JFC was the lead amici',for,'the ,Wilkins v Ferguson case,(l$trict of Columbia Court of Appeals) conhibuting to~~the~ucce~sful appellate decision'i$ ;29?7'that protected a young child who had been sexuali$itiused by her father. : ~ # , , , i ;,; , ' , , , , ,, , : 8 ,, :.,. . ' t ' 1. .' ,, , t

. : , , , , , ,

Our work has been featured on ABC's Primetime Live, ABC's Primetime documentary entitled "Crimes Against Children," a PBS documentary entitled "Boy Crying, Baby Crying," as well as Good Morning America, Donahue, the Discovery channel's %stice Files." and on HBO.

, , , , . , # . , , ' , , ,, ; > ,!,; , ,.,.'?'

Most recently, Eileen King, J F C - D ~ S , ; R ~ ~ ~ ~ ~ ~ I , ~ D I ~ ~ C ~ O ~ ~ ,w& interviewed on W S A Channel 9 regarding the case of Le%ieGi~ver . ,;,,;,.I?,.,,, , : , h ,.,, ~$o&.,bod.yyas , F :,. s..! ,found,in a creek, allegedly placed there by her own mother. ~ex~~'s;manp,Bespefate,bries .,,,.,.,,,),.,,,,I . , ~ fo;%lp were ignored by both CPS and law enforcement in Virginia, resultirig,~h , , , lier.mgic , . , and preventable death.

, .. , , , , ,

In Ariana-Lei1ani7s case, we are houbled r ~ ~ a ; d i " ~ the inadecyte follow-up care for this child's neuhopenia as documented in an affidavit by RoBeti Sklaroff, M.D., who has

RUBIN WINSTON DIERCKS HA

thoroughly reviewed the available medical records. We understand that Dr. Sklaroff has sent you his affidavit which states his concerns,

In October 2008, Ariana-Leilani presented with oral mucosal ulcers and papular lesions bilaterally in her groin area. The medical notes from Georgetown University Hospital state that the oral lesions were suspicious For herpes and the source of the groin papular lesions were unhown. A culture was ordered for both conditions but the results of the cultures are (oddly) unavailable from Georgetown University Hospital records department. We are concerned as to whether the cultures were actually completed, since if they were indeed done, there should be no problem accessing this information. The culture results are vital in assessing whether the causes of the ulcers and lesions were benign or if they arose fiom serious medical conditions in which symptoms may appear at various intervals and then disappear.

Ariana-Leilani has also disclosed (as Joy Silberg, Ph.D. writes in her letter) "'bad touches,' and seeing a 'PO-PO' fiat 'gets hmder and harder.' None of this information has been adequately investigated." The child has also disclosed that her father (allegedly) sleeps in her bed at home. In the opinion of Justice for Children, this information should he cause for serious concern and ought tn be immediately and thoroughly investigated.

All of this information creates a picture of a child who is falling through the cracks. The fac t that her father is a physician (neurologist) may provide false reassurance, deflecting attention from Ariana-Leilani's need for adequate follow-up treatment as well as a thorough investigation of her disclosures of (alleged) inappropriate touching.

We urge that DC Child and Family Sewices Agency intewene and conduct a thorough medical evaluation as well a5 child sexual abuse investigation for this child.

Sincerely yours,

Eileen King, Regional Director Justice for Children Washington, D.C. Chapter I I55 Connecticut Ave. NW Ste, 600 Washin@on, D.C. 20036 202-462-4688 direct line

Georgetown University Hospital ¡-- Lombar& Comprehensive Cancer Center

The Children's Cancer Foundation Pediatric Hematology Oncology Clinic Department of Pediatrics Division of Pediatric/Hematology/ Oncology, Blood and Marrow Transplantation

3800 Reservoir Road, NW Washington, DC 20007-2 1 13 Phone: 202 444 2224 * Fax: 202 444 88 17

MedStar Health

Patient Name: King-pfeiffer, Ariana R MRN: 641 2380 DOB: May 07,2003

PEDIATRIC HEMATOLOGY- ONCOLOGY FOLLOW-UP VISIT

INSTITUTION: Georgetown Pediatric Hematology Oncology

PATIENT: Ariana R King-pfeiffer MRN: 6412380 DATE OF BIRTH:May 07,2003

DATE OF VISIT: Oct 22, 2008

PHYSICIAN: Amal Abu-Ghosh, M.D.

REASON FOR VISIT: 5 year old with history of neutropenia presents today with oral mucosal ulcers for one day.

HISTORY OF PRESENT ILLNESS: Interim History: Father states child began developing shallow based ulcers yesterday on her lower lip which have spread into her oral mucosa. States child has been tolerating PO liquid and solids well, playing, and only told him that something was in her mouth in passing. Denies fever, NIV, sore throat, ear pain. Also states she has multiple circular, pruritic, dry lesions in her groin area without any drainage. Dad only noticed them yesterday. States that he came today because Dr. Myers told him to come to clinic immediately if he notices any signs of mucositis.

HPI: Ariana is a five year old, healthy female who presents to the hemelonc clinic for a consult regarding her persistent neutropenia since May of 2008. Ariana was seen by her pediatrician on May 2, 2008 for a WCC, and a routine CBC was

Electronically signed by: Arnal Abu-Ghosh, M.D.

Patient Name: King-pfeiffer, Ariana Visit Date: Oct 22, 2008 Page: 2

performed: WBC 4.6, granulocyte count 26%, ANC 1200, Hb 12, platelets 315. The pediatrician did not find any significant physical findings at this WCC (only some shotty cervical lymphadenopathy). Prior to this WCC, Ariana had been feeling well, but did have a hx of very mild URI symptoms (clear to yellowish rhinorrhea and intermittent cough) since November 2007. These symptoms never caused her to miss school, she remained energetic (as usual) with a good appetite and she did not have any fevers, palllor, or abnormal bruisinglbleeding. In light of this slightly decreased ANC of 1200, Ariana was re-evaluated on May 25, 2008, with a CBC at that time showing: WBC 4, granulocyte count IS%, ANC 600, Hb 10.9, platelets 346. Ariana was still essentially asymptomatic at this time. After this follow-up, Ariana was referred to Dr. Rubio (ID) on May 30, 2008 for further evaluation, at which time Dr. Rubio believed Ariana's neutropenia to be secondary to viral myelosuppression (ANC at this time 500).

On June 1 1, 2008 Adriana was hospitalized at Montefiore Medical Center in New York for 'neutropenia', although Dad states that this was a 'social admission', as the staff was not comfortable releasing Adriana home with her mother. While at Montefiore, Adriana was tested for EBC, CMV, HIV, Toxo, Parvo and ANA, all of which came back negative. During the course of this hospital admission, she remained afebrile and asymptomatic, with her ANC ranging from 120 to 373. Her peripheral smear was WNL. The hemlonc service saw Ariana during this admission, and diagnosed her with idiopathic neutropenia, likely post-viral. She was discharged on June 17, 2008.

Following this admission, Adriana has been following up with Dr. Maria Marquez at Georgetown to track her ANC's, which initially increased to 880, but again decreased to 560 on Sept 23, 2008. Ariana's father is not overly concerned about her neutropenia, but she is here today for a second hemelonc consult for 'social reasons'.

ROS negative for fever, abdominal pain, chest pain, shortness of breathlwheezing, rashes, bleedinglbruising, mouth sores, diarrhea, constipation, urinary problems, or headaches. Ariana has no hx of otitis media, UTI's, sinus infections or pneumonia, mucositis, and her father does not believe that she has ever been on abx.

Ariana is currently living with her father in Washington, DC, where she attends kindergarten. She did not receive her immunizations at the recommended ages but she is currently almost caught up with all of her vaccines.

PAST MEDICAL/FAMILY/SOCIAL HISTORY: No History components were reviewed during this visit.

MEDICATIONS: There is no information available for Current Medications - Treatment. There is no information available for Current Medications - Patient.

Allergies: This patient has no documented allergies.

REVIEW OF SYSTEMS:

Constitutional Normal - No loss of appetite, weight changes or fatigue; no fever, chills or sweats.

Allergic/lmmunologic Normal - No complaint of allergies. Head Normal - No trauma or headaches. ENMT Abnormal - Clear rhinorrhea present. No hearing impairment, tinnitus or ear pain.

No ulcers, swollen gums, dental problems or change in taste, no sinus pain or epistaxis.

Eyes Normal - No visual difficulties. No diplopia. Neck Normal - No pain or dysphagia.

Electronically signed by: Amal Abu-Ghosh, M.D.

Patient Name: King-pfeiffer, Ariana Visit Date: Oct 22, 2008 Page: 3

Integumentary

Breasts

Abnormal - Hx of dermographism. No rashes, lesions, inflammation, purpura or pruitis. Normal -

Cardiovascular Normal - No chest pain or shortness of breath at rest or during exercise. Respiratory Abnormal - Mild intermittent cough, no dyspnea on exertion, no wheezing Gastrointestinal Normal - No nausea, vomiting, diarrhea, GI bleeding, or constipation. No

heartburn, change in appetite or bowel habits. Genitourinary (F) Normal - No abnormal genital masses. No hematuria, hesitancy, incontinence,

vaginal bleeding, discharge or other problems with urination. Normal sexual function. No frequency, urgency, dysuria, hematuria, bladder or flank pain.

Musculoskeletal Normal - No fractures, joint pain or back pain. Neurologic Normal - No headache, blurred vision, and no areas of focal weakness or

numbness. Normal gait. No sensory problems. HematologicILym phatic Normal - No bleeding or easy bruising. No enlarged nodes.

PHYSICAL EXAMINATION:

Vital Signs: Performed on Oct 22,2008 08:55 BMI 17.04 BSA (derived) Pain (Faces) 0.00 BP Height 111.00 cms Pulse Temperature 36.00 C(L0W) Weight

Performance Status: 100% - Full active, normal. (Lansky)

Constitutional

Head Eyes

ENMT

Neck

Integumentary

Cardiovascular

Respiratory

Abdomen

Normal - Alert, cooperative, oriented; mood and affect appropriate. Appears developmentally appropriate for age. Normal - Normocephalic, atraumatic Normal - Conjunctivae and sclerae are clear and without icterus. Pupils are reactive and equal. Extraocular muscles intact. Abnormal - Moderate amount of clear rhinorrhea present. Sinuses are nontender. 1x2-3 cm erythematous ulcer on lower with yellow crusting and swelling; 4-5 shallow based erythematous ulcers on oral mucosa and right buccal mucosa. Oropharynx clear. Tongue normal. Good dentition. TM's normal. No fluid Normal - Supple without masses or thyromegaly. Some shotty, mobile, non- tender cervical lymphadenopathy present Abnormal - No rashes, petechiae or bruises. Left thigh hyperpigmented area (- 3x3 cm) Normal - Regular rate and rhythm; no murmurs, gallops; rubs or ectopy. Capillary refill less than 2 seconds. Pulses palpable and equal bilaterally in all four extremities. Normal - No tachypnea or nasal flaring. Clear to auscultation bilaterally with good aeration. No crackles or wheezes. Normal - Non-tender, non-distended, no masses, ascites or hepatosplenomegaly. Good bowel sounds. No guarding or rebound tenderness.

Electronically signed by: Amal Abu-Ghosh, M.D.

Patient Name: King-pfeiffer, Ariana Visit Date: Oct 22, 2008 Page: 4

No pulsatile masses. GenitaliaIGroinlButtock (F) Abnormal - 4-5 1 cm papular lesions bilaterally in groin area; non-indurated, non

erthymetaous, no fluctulance Normal female external genitalia.

Extremities Normal - No visible deformities, no cyanosis, clubbing or edema. Pulses 4+ and equal bilaterally.

BackISpine Normal - No evidence of scoliosis or kyphosis. Musculoskeletal Normal - No tenderness or swelling, normal range of motion without obvious

weakness. Psychiatric Normal - Appears to be well adjusted. Hematologic/Lymphatic Normal - No bleeding or bruising. No palpable lymph nodes in supraclavicular,

axillary or inguinal areas.

LABORATORY: Most recent lab results are not available for this patient.

RADIOLOGY:

IMPRESSION: 5 year old female with history of neutropenia, currently with mouth ulcers of recent onset suspicious for a viral infection (Herpes). CBC today showed an ANC of 1 107/ul.

PLAN: 1. LABS CBC: WBC 4.1 ; HgbIHct 1 1.3133.8; platelet 350. ANC 1 107

2. Cultures of oral lesions are pending.

3. RTC in 3 months to recheck CBC or earlier if mouth lesions or skin lesions worsen.

4. Discussed with Dr Rubio as well who recommended Bacitracin to skin lesions.

cc: Dr. Scott N Myers, M.D., M.P.H. No 'Providers' exist for this patient. Maria L Marquez, M.D.

Electronically signed by: Amal Abu-Ghosh, M.D.

Georgetown

Hospital @ ~ombardi Compt'ehensive Cancer Center

The Childrop's Cancer Poundation Pediatric Hematology Oncology Clinic Department of Pediatrics Division ofPediatric/Hematologyi Oncology, Blood and Marrow Transplantation

3800 Reservoir Road, NW Washington, DC 20007-21 13 Phone: 202 444 7.224 * Fax: 202 444 88 17

MedStar Health

Patient Name; King-pfeiffer, Ariana R MRN: 6412380 DOE: May U /, 2003

PEDIATRIC HEMATOLOGY- ONCOLOGY FOLLOW-UP VISIT

INSTITUTION: Georgetown Pediatric Hematology Oncology

PATIENT: Ariana R King-pfeiffer MRN: 641 2380 DATE OF BIRTH:May 07,2003

DATE OF VISIT Jan 09,2009

PHYSICIAN: Dr. Scott N Myers, M.D,

REASON FOR VISIT: 5 year old with history of neutropenia presents today for scheduled follow-up.

HISTORY OF PRESENT ILLNESS: Interim History: Ariana was in clinic with her father again today who is pleased to report that she has been doing well. The oral ulcer which Dr. Abu-Ghosh saw her for 10/22/08 resolved in a few days, treated with only bacitracin topically and mouthwash (as per Dr. Rubio's recommendation). She tias had no intercurrcnt mucosal or skin lesions of any kind. She has had no fever or any symptoms of illness. She is gaining height and weight, meeting her developmental milestones with no signs of delay. She is doing well in kindergarten. She is on no medications. ROS negative for fever, abdominal pain, chest pain, shortness of brealhlwheezing, rashes, bleedinglbruising, mouth sores, diarrhea, constipation, urinary problems, or headaches. Ariana has no hx of otitis media, UTI's, sinus infections or pneumonia, rnucositis, and her father doas not believe that she has ever been on abx.

Electronitially signed by: Dr. Scott Myem, M.0

Patient Name: King-pfeiffer. Ariana Visit Date: Jan 09.2009 page. 2

Hlo persistent neutropenia since May of 2006. Ariana was seen by her pediatrician on May 2, 2008 Tor a WCC, and a routine CBC was performed: WBC 4.6, granulocyte count 20%, ANC 1200, Hb 12, platelets 315. The pediatrician did nut find any significant physical findings at this WCC (only some shottycervical lymphadenopathy). Prior to this WCC, Arlana had been feeling well, but did have a hx of very mild URI symptoms (clear to yellowish rhinorrhea and intermittent cough) since November 2007. These symptoms never caused her to miss school, she remained energetic (as usual) with a good appetite and sne did nul have any fevers, palllor, or abnormal bruisinglbleeding. In light of this slightly decreased ANC of 1200, Ariana was re-evaluated on May 25, 2008, with a CBC at that time showing: WBC 4, granulocyte count 15%, ANC BOO, Hb 10.9, platelets 346. Ariana was still essentially asymptomatic at this time. After this follow-up, Ariana was referred to Dr. Rubio (ID) on May 30, 2008 for further evaluation, at which time Dr. Rubio believed Ariana's neutropenia to be secondary to viral myelosuppression (ANC at this time 500).

On June 11,2008 Adriana was hospitalized at Monteftore Medical Center in New York for 'neutropenia', although Dad states that this was a 'social admission', as the staff was not comfortable releasing Adriana home with her mother. While at Montefiore, Adrhra was tested for EEC, CMV, HIV, Toxo, Parvo and ANA, all of which came back negative. During the course of this hospital admission, she remained afebrile and asymptomatic, with her ANC ranging tram 120 to 373. Her peri~heral smear was WNL. The hemlonc service saw Ariana during this admission, and diagnosed her with idiopathic neutropenia, likely post-viral. Sue was discharged on June 17, 2008.

Following this admission, Adriana has been following up with Dr. Maria Marquez at Georgetown to track her ANC's, which initially increased to 880, but again decreased to 560 on Sept 23, 2008. Ariana is now followed by our hemfonc service for the chronic neutropenia.

Ariana is currently living with her father in Washington, DC, where she attends kindergarten. She did not receive her immunizations at the recommended ages but she is currently almost caught up with all of her vaccines.

Allergies: This patient has no documented allergies.

REVIEW OF SYSTEMS:

Constitutional

Allergio/lmmunologic Head ENMT

Eyes Neck Integumentary

Cardiovascular Respiratory Gastrointestinal

Musculoskeletal Neurologic

Normal - No loss of appetite, weight changes or fatigue; no fever, chills or sweats. Normal - No complaint of allergies. Normal - No trauma or headaches. Normal - No rhinorrhea present. No hearing impairment, tinnitus or ear pain. No ulcers, swollen gums, dental problems or change in taste, no sinus pain or epistaxls. Normal - No visual difficulties. No diplopia. Normal - No pain or dysphagia. Abnormal - Hx of dermographism. No rashes, lesions, inflammation, purpura or pruitis. Normal - No chest pain or shortness of breath at rest or during exwclse. Normal - Mild intermittent cough, no dyspnea on exertion, no wheezing Normal -No nausea, vomiting, diarrhea, GI bleeding, or constipation No heartburn, change in appetite or bowel habits. Normal - No fractures, joint pain or back pain. Normal - No headache, blurred vision, and no areas of focal weakness or numbness. Normal gait. No sensory problems. Normal No bleeding or easy bruising. No enlarged nodes.

Electronically ti'igned by: Dr. Scott Myors, M.D

Patient Name: King-pfeiffer, Ariana Visit Data: Jan 09,2008 Page: 3

PHYSICAL EXAMINATION:

Vital Signs: stable, see Aria

Constitutional

Head Eyes

ENMT

Neck

Integumentary Cardiovascular

Respiratory

Abdomen

Extremities

BacK/Spine Musculoskeletal

Psychiatric Hematologic/Lymphatic

Normal -Alert, cooperative, oriented: mood and affect appropriate. Appears developmentally appropriate for age. Normal - Normocephalic, atraumatic Normal - Conjunctivae and sclerae are clear and without icterus. Pupils are reactive and equal. Extraocular muscles intact. Normal - Moderate amount of clear rhinorrhea present. Sinuses are nontender. 1x2-3 om arythematnus ulcer on lower with yellow crusting and swelling; 4-5 shallow based erythematous ulcers on oral mucosa and right buccal mucoaa. Oropharynx clear. Tongue normal. Good dentition. TM's normal. NO fluid Normal - Supple without masses or thyromegaly. Some shotty, mobile, non- tender cervical lymphadenopathy present Normal - No rashes, petechiae or bruises. Normal - Regular rate and rhythm; nu murmurs, gallops; rubs or ectapy. Capillary refill less than 2 seconds. Pulses palpable and equal bilaterally in all four extremities. Normal - No tachypnea or nasal flaring. Clear to auscultation bllatwally with good aeration, No crackles or wheezes. Normal - Non-lender, non-distended, no masses, ascites or hepatosplenornegaly. Good bowel sounds. No guarding or rebound tenderness. No pulsatile masses. Normal - No visible deformities, no cyanosis, clubbing of edema. Pulses 4+ and equal bilaterally. Normal - No evidence of scoliosis or kyphosis. Normal - No tenderness or swelling, normal range of motion without obvious weakness. Normal -Appears to be well adjusted. Normal - No bleeding or bruising. No palpable lymph nodes in supraclavicular, axillary or inguinal areas.

LABS; CBC today showed an ANC of 480 Iul. Pit count WNL at 294k. Hgb 11.5g/dL. No evidence of leukemia on blood smear ANC was 11 00 /ul on 1 O)Â¥/Â¥i/O

IMPRESSION: 5 year old female with history and labs consistent with chronic benign neuliopenia, currently asymptomatic.

PLAN: CBC today as above. RTC in 3 months to recheck CBC or earlier if any neutropenic symptoms, which I reviewed again today with her father. G-CSF and antibiotics may be necessary if any neutropenic infection occurs Her father will call with any new symptoms.

Electronically si~ned by: Dr. Scott Myers, M.D.

Patient Name: King-pfeiffer, Ariana Visit Date: Jan 00,2009 Page: 4

They will pursue "common sense" neulrupenic precautions, including good hand washing and avoidance of sick contacts and large confined crowds (as much as possible). It is QK for Ariana to attend school. Ariana's father will continue to communicate with her teacher's regarding the importance of enforcing good hand-washing in the classroom, and trying to keep Ariana away from sink contacts when possible.

Note ernaiied to father at michaelhpfeiffer@netscape.net. ANC called to father cell at 202-4274009.

cc: Maria L Marquez, M.D. Tom Rubio, MO

Electronically signed by: Dr Sent* Myers, M.D.