Assumptions About Shaken Baby Syndrome Now Being Questioned
Yadira Ramos and Mauricio Perez burst through the emergency room doors of Paradise Valley Hospital with their unconscious 13-month-old son early one evening, late in the summer of 2009.
Mauricio Jr.'s small body was stiff, his teeth clenched. His head was swelling and it seemed to his parents that he was struggling to breathe. His mother feared the worst as ER doctors whisked the child away. The young parents — Ramos 19, Perez 21 — paced the waiting room for about an hour before hospital officials told them the baby was being transferred by medical helicopter to Phoenix Children's Hospital.
Ramos climbed inside the chopper next to her son, who was strapped down to a stretcher, still unconscious, with a small oxygen mask covering his face. The whirling blades cut through the night air, rushing toward a team of specialized pediatricians.
Assumptions About Shaken Baby Syndrome Now Being Questioned
As surgeons operated on her son to relieve pressure on the brain, Ramos explained to hospital officials that the baby had fallen off the bed in the two-bedroom apartment in East Phoenix she and Perez shared with five other people. An interpreter was attempting to translate, but hospital and court records show the Spanish interpreter and, thus, doctors had trouble understanding the Guatemalan immigrant's dialect.
Perez joined Ramos at Phoenix Children's Hospital after he briefly stopped at the apartment, gathered extra diapers, clothes, and formula and dropped them off with them a family friend who was watching their 2-month-old daughter, Kimberly.
Later that night, police arrived at the hospital and started questioning the couple separately. Ramos told them the same thing she'd told doctors — that her son fell off the bed. She said Mauricio Jr. might have hit a dresser on his way down, but she said she wasn't sure; she hadn't seen him fall because her back was to the bed he was laying on with his dad. She had been lying with them, watching the 5 p.m. news on Univision, but got up when Kimberly started fussing in her bed. It was a tight fit. The queen-size bed occupied most of the small room; a two-drawer dresser about two feet from the bed doubled as a TV stand. Kimberly's small, white bassinet took up the remaining space.
Perez was on the phone talking to his uncle in Guatemala. He said he didn't see the baby fall, either.
Ramos told police she heard a thud on the tile floor. She scooped up her son and screamed when his body stiffened and he stopped breathing. She recalled that his arms froze at 90-degree angles, as if he were a plastic doll.
"My baby's dying!" she cried, handing him to Perez so she could call 911.
The dispatcher didn't speak Spanish. Ramos couldn't wait. She hung up, and she and Perez banged on their roommates' doors and asked for a ride to the hospital, about seven miles away from the apartment.
On the way, Perez tried to administer mouth-to-mouth and massaged his son's chest. He didn't have any training.
Ramos and Perez told the same story to hospital social workers, state child-welfare advocates, and the police detectives investigating their son's injuries. In fact, their story was the same in all the records New Times reviewed, and even years later during half a dozen interviews, their story doesn't change.
Both consistently describe an accidental fall — not discipline or shaking.
But even as they were in the midst of recounting the events on the night it happened, a pediatric specialist examining the baby scribbled into his medical chart "shaken" and what appears to be the word "severe."
Pediatricians found a skull fracture and a triad of symptoms — subdural hematoma (blood pooling between the skull and the brain), retinal hemorrhage (bleeding of the eyes), and brain swelling — that signaled to them that the injuries were intentionally inflicted.
Shaken baby syndrome. It's a condition we've all heard of — the stuff of Lifetime TV movies and Law & Order episodes. First diagnosed in the 1970s, it has led to hundreds of prosecutions and helped medical and law enforcement personnel better reveal cases of child abuse.
Or has it?
Phoenix police detectives who investigate abuse believed the accounts of the cooperative parents and the roommates who were in the apartment when the baby was injured. They determined that the event was an accident and never pursued criminal charges.
But doctors and social workers — and, later, state child welfare workers — weren't convinced. They repeatedly urged Ramos and Perez to come clean about what had really happened.
"Why do they want us to make something up?" Ramos tells New Times. "We told them what happened. He fell off the bed. We didn't hurt him."
Either way, it's all but certain that Yadira Ramos and Mauricio Perez will never see either of their children again.
Yadira Ramos journeyed alone to Phoenix in May 2007 from Tajumulco, one of the municipalities of San Marcos in Guatemala, Mexico's southeastern neighbor. She was only 17 years old, and it was a difficult trek. But life was far better here in the United States, where she found work as a maid and left behind the abject poverty she knew in her village.
"There are no jobs there, and the food is expensive," she says of her rural hometown. She says she would cross the border into the neighboring Mexican state of Chiapas to work as a waitress, a job that earned her 350 pesos (roughly $27) a week.
She knew of Arizona because her uncles had come to Phoenix "to make money, and they stayed a few years before returning home."
When she arrived, she moved into an apartment with other Guatemalan immigrants. Shortly thereafter, she met Mauricio Perez, a young man also from Tajumulco. Perez had arrived in Phoenix a year before Ramos, when he was 18. He was working as a landscaper.
Perez was raised by his grandmother and, like Ramos, came to the states to make a better living. He says that in Guatemala he earned 40 quetzal (about $5) a day working in the fields chopping crops with machetes.
"I came here to get my family ahead," he says.
But he soon found himself with a new family to support.
Perez and Ramos moved in together in September 2007. She gave birth to their first child, Mauricio Jr., a year later, and Kimberly about a year after that.
Six years later, they speak nearly no English. And neither appears to understand that their young family's fate was sealed when Mauricio Jr.'s examination revealed signs of shaken baby syndrome.
Mauricio Jr. was a happy, healthy baby who learned to walk when he was about 11 months old, his mother says. He shared a bedroom with his parents and sister but had the run of the apartment when everyone was at work. He watched cartoons and played with his toys, especially a plastic yellow fire truck and black sports car.
Perez was working full-time while Ramos stayed home taking care of their children. She liked to swoop her son's mop of hair into a baby faux-hawk so it was just like his daddy's hair.
They made ends meet by living a simple life and sharing the apartment with five other roommates.
By all accounts, life was good until the evening of August 24, 2009.
Almost two years after the night Ramos and Perez handed their injured son to ER doctors, a Maricopa County Superior Court judge severed their parental rights to both children. That means Ramos and Perez no longer have any legal right to see them, let alone ever again have custody.
In Arizona, a growing number of children are being separated permanently from their parents.
Between April and September 2006, CPS records show the courts agreed to terminate parental rights for 360 children. By comparison, during the same six-month period in 2012, there were 1,609 parental rights severed.
All told, during those seven years, New Times' analysis shows, nearly 12,000 parental rights terminations were granted.
The Arizona Child Safety Task Force, created by Governor Jan Brewer in 2011 in response to several high-profile child abuse cases, recommended that the agency "establish greater involvement of law enforcement in investigating reports of abuse."
Greater law enforcement involvement, the task force reported, will help to alleviate parental fears of children being capriciously pulled from the home and will help to preserve family rights.
"CPS is about protecting a child and keeping it with its family, if it can. But they really don't do that," says Laura Knaperek, a former state GOP lawmaker with a long history of involvement in child-welfare issues. "They're in foster care panic, removing more and more kids. But there are federal laws and guidelines for state agencies that removing a child should be the last resort."
Knaperek, now a political consultant and lobbyist, believes child removal is a way to manage the agency's image following high-profile cases in which children died at the hands of their caregivers after CPS, which was involved with those cases, did not remove the children from the homes.
"There needs to be more oversight of the agency," Knaperek tells New Times. "And you can't put your finger on anyone in particular because the whole system is so complex. And on top of that, they don't have enough foster homes, enough case workers."
The agency may get some relief in the coming years.
Brewer's 2014 state budget earmarks $69.1 million for child welfare and protection services and includes money to hire 200 additional CPS caseworkers and support staff.
Karin Kline, a former CPS worker, is now a program manager at the ASU Center for Applied Behavioral Health Policy and oversees several child welfare initiatives at the center.
She says the agency, mandated by the feds in 1970, is fairly young.
"There is still so much to learn, and it's evolving as a profession," she tells New Times. "The struggles its workforce faced every day change, but there are always struggles, whether it's limited funding, not enough employees. It's a hard job, and it's always going to be a hard job."
Initially, the feds required states to operate a hotline for reports of child abuse. Since then, Kline says, there are so many more expectations.
"Before [the agency was established], families, churches, and schools addressed the issues of child abuse, but along the way, so many more demands have been shifted on the state agency," she says.
Even with so many reforms, it's not clear justice was done in the case of Mauricio Jr.
Perez and Ramos' court-appointed attorneys — each parent was assigned separate legal representation — were unable to convince the state that the couple had not harmed their son.
It didn't matter that Ramos and Perez passed police-administered polygraph exams and weren't charged with any crime. Or that psychological evaluations of each revealed no mental illness, or that police records showed no history of domestic violence or drug use. There were no signs of abuse — healed fractures, old bruises — on either child. No one cared, apparently, that Ramos and Perez completed all court-ordered parenting programs and counseling sessions.
The couple the loss of their children contested to the state Court of Appeals. They lost. They tried to push their case to the Arizona Supreme Court, but the court declined to hear it.
This is surprising, because though it is obvious that those who sought to keep the parents and children apart were convinced Mauricio Jr.'s case is one of shaken baby syndrome, it's not so obvious that it actually is. In recent years, members of the medical community have begun to doubt that symptoms such as those seen in this case always result from shaking, as opposed to, for example, an accidental fall from a bed about two feet off the ground.
Neither the courts, social workers, nor the pediatricians gave meaningful weight to the controversy surrounding shaken baby syndrome, even though doubt about the diagnosis has moved appellate courts to overturn child abuse and murder convictions in similar cases in Arizona and across the country.
The account in this story is the result of a several-month investigation, based on New Times' review of more than a thousand pages of police, medical, and court records (some obtained by Ramos through public-records requests); dozens of studies supporting and refuting abusive head trauma; and in-depth interviews with Ramos, Perez, and medical and legal professionals. CPS officials declined comment.
Questions about the longstanding assumptions regarding shaken baby syndrome have been raised even by Dr. Norman Guthkelch, the British pediatric neurosurgeon who authored a report in 1971 that linked unexplained brain injuries in infants to shaking.
New Times tried repeatedly to reach 97-year-old Guthkelch to ask him to review Mauricio Jr.'s case. The retired doctor lived in Tucson for several years but moved to the Chicago suburb of Evanston shortly after his wife died in 2011. He now lives in a retirement home. New Times unsuccessfully reached out to him through family members and the fellows at Northwestern University's Medill Innocence Project, one of the many organizations that sought out Guthkelch to review shaken baby syndrome cases they were examining.
But during several media interviews, including one with National Public Radio, and in a four-page "swan song" written in November 2012 on the subject — linked on the website of one of the many innocence projects that have taken on SBS — Guthkelch made clear his concerns about how the medical and legal communities commandeered his decades-old research paper into a blueprint for proving child abuse.
In his final reflection, the near-centenarian wrote that there have been instances in which "both medical science and the law have gone too far in criminalizing alleged acts of violence" when the only proof of violence was the child's clinical state.
"For me, the triad may legitimately be classified as a syndrome," he wrote. "But it is not necessarily the result of shaking or abusive behavior."
The medical and scientific underpinnings of shaken baby syndrome actually have nothing to do with babies. The discovery dates back more than four decades to studies using monkeys to determine whether whiplash could cause brain damage.
In 1969, Ayub K. Ommaya, a prominent neurosurgeon at the National Institute of Neurological Disease and Blindness in Bethesda, Maryland, conducted, along with others, experiments on monkeys to observe the effects of simulated rear-end collisions on the brain and neck. His study determined, among other things, that brain injuries occurred even when the monkey's head didn't strike anything.
In the early 1970s, Guthkelch was one of two pediatric specialists who independently cited that study as evidence for a new medical theory — that violent shaking without impact could cause brain damage in infants.
"One must keep in mind the possibility of assault in considering any case of infantile subdural hematoma, even when there are only trivial bruises or indeed no marks of injury at all," he wrote in his 1971 research paper. He said there should be an inquiry as to "whether perhaps the baby's head could have been shaken."
Despite the contention that now surrounds that diagnosis, it was an important finding, because in those days, particularly in northern England where Guthkelch practiced, shaking was a socially acceptable form of "correction" for unruly or rambunctious children.
Guthkelch's work raised awareness among parents and guardians who had not realized the potential damage they could cause with an otherwise stern, even violent, jostle to snap a child into attention.
Shaking a baby is much more serious than shaking an adult, medical professionals say. The National Institute of Health explains on its website that when an infant or toddler is shaken, the brain bounces back and forth against the skull. It can bruise the brain or create swelling, pressure, or bleeding. Or the large veins outside the brain may tear, leading to further bleeding, swelling, and increased pressure. The shaking also can injure the eyes, neck, or spine.The medical theory is that an injury like Mauricio Jr.'s occurs when a parent or caregiver — trying to quiet or punish a child — grips its torso and violently shakes it with the same force a child would endure in a fall from several stories. Sometimes, the injury is exacerbated when the shaken baby's head strikes another object — a wall, the floor, or even something as soft as a mattress.
Yet, as Guthkelch reflected on the four decades of studies and research projects premised on his medical theory and reviewed criminal prosecutions of shaken baby syndrome that resulted in long prison sentences, he was struck by the obviously inadequate inquiries doctors were making into other possible causes for the child's injuries.
Turns out, a syndrome thought to be such a valuable tool when it was first diagnosed has been the centerpiece of a debate between legal volunteers from "innocence" projects who advocate for caregivers accused of abuse and child-welfare workers who speak for the suspected victims, and it's playing out in the healthcare community, in courtrooms, and in the arena of social justice.
In reviewing the case of an Arizona man who has spent 10 years in prison for shaking to death his girlfriend's 4-month-old son, Guthkelch told NPR during a 2011 interview that he "wouldn't hang a dead cat on the evidence of shaking as presented."
In interviews and his end-of-career musings, Guthkelch reiterates that he isn't raising questions now to excuse child abuse or authorities' failure to investigate it. But his present-day doubts about the legal use of shaken baby syndrome are supported by a growing body of literature published in medical and legal journals that points to alternative causes — falls, diseases, and infections — that mimic the trio of symptoms found in non-accidental head trauma.
At the very least, they create reasonable doubt about a diagnosis at the center of a public firestorm. But "reasonable doubt" is only a legal standard in criminal cases — not in family court, where Ramos and Perez's fate was decided.
In that court, there only needed to be "clear and convincing" evidence.
"For the first time, a court examining the foundation of SBS concluded that it has become sufficiently eroded that a new jury probably would have a reasonable doubt as to the defendant's guilt," Deborah Tuerkheimer, a law professor at DePaul University College of Law in Chicago, wrote regarding the case of Wisconsin woman convicted for the death of a 7-month-old girl she was babysitting. (See sidebar at www.phoenixnewtimes.com.)
Tuerkheimer authored "The Next Innocent Project: Shaken Baby Syndrome and the Criminal Courts," published in 2009 in the Washington University Law Review.
In 2001, John Plunkett, a retired forensic pathologist in Minnesota, documented 19 cases in which children suffered fatal head injuries as a result of short-distance falls — some falling from about the same distance as Mauricio Jr. fell.
Plunkett tells New Times he became involved in studying children's deaths from short falls because, 15 years earlier, he worked such a case. One physician told him a child's death couldn't have been caused by a short fall because short falls can't kill.
"I said, 'Wait a minute. What's that based on?' Plunkett recalls. "And they said, 'Well, we never see it.' And it was obvious immediately that that is circular argument."
He says his views remain unchanged since his paper was published in the American Journal of Forensic Medicine and Pathology. He was one of the first to question SBS; today, he's hardly alone.
"We're just going to keep on destroying families until somebody wakes up?" asks Plunkett, who weighed in as an expert witness on behalf of Ramos and Perez at a court hearing to sever their parental rights.
He speculates that pediatricians and child-welfare providers are resistant to change because they've been "saying something for 20 or 30 years that has resulted in untold numbers of families . . . destroyed, finances and reputations that have been destroyed, and people in prison."
He continues: "And all of a sudden, you're shown that what you believe to be true is not and has resulted in all of this mischief. I think the natural human response is to circle the wagons, to try to protect your prior belief."
Plunkett says that instead of "reappraising" what they believe, doctors "get busy in trying to disprove what someone else says."
Not everyone agrees with Plunkett.
Gregory Schmunk, chief medical examiner in Polk County, Iowa, a forensic pathologist, and chairman of the National Association of Medical Examiners, believes that doubt regarding diagnosis of non-accidental head trauma has been created by self-proclaimed medical experts who testify for defense attorneys.
They "aren't looking at scientific evidence. Instead, they're looking at case reports — isolated incidents — and drawing inappropriate conclusions," Schmunk says.
Schmunk tells New Times that Plunkett's article on deaths from short-distance falls was severely criticized and that in every one of those cases he cited, there were "other things involved . . . that made it fairly clear" the children were victims of abuse.
He says there also are other articles out there, some that contain "gross miscalculations" but get published in journals that are not peer-reviewed and then end up getting cited in courts.
Sandeep Narang, a Houston doctor who specializes in child abuse pediatrics, noted in an analysis on abusive head trauma published in the Houston Journal for Health Law and Policy in 2011, that there are more than "700 peer-reviewed clinical medical articles, comprising thousands of pages of medical literature, published by over 1,000 different medical authors, from at least 28 different countries" that support the scientific theory behind abusive head trauma.
"It is virtually unanimous among national and international medical societies that [abusive head trauma] is a valid medical diagnosis," Narang wrote. "Amongst clinical practitioners, from pediatricians to radiologists, from the American Academy of Pediatrics to the World Health Organization, the validity of AHT as a medical diagnosis is unquestioned."
Plunkett doesn't refute that suspected abuse should be reported, but "the responsibility ought to be on the physicians to prove abuse. Not to say, you didn't tell us how it really happened, so it must be abuse."
Which is exactly the quandary in which the young immigrants Ramos and Perez found themselves.
Yadira Ramos remained at Mauricio Jr.'s bedside for nearly two weeks at Phoenix Children's Hospital. She took showers at the hospital, changing into clean clothes Perez brought for her. She ate her meals in the room and slept on a recliner next to her son.
She watched as doctors tended to him and was grateful when she learned that the swelling in his head was going down. He had seizures, but those, too, waned. She held him when she could.
One of the pediatricians wrote in Mauricio Jr.'s critical care progress chart: "On exam this morning, he awakens with a light touch and he looks very appropriate in his mom's arms."
By the time Mauricio Jr. was released from the hospital, the state already had taken temporary custody of Ramos and Perez's children. Kimberly was placed with family friends for a short time, but when they moved to California, the little girl went into foster care.
Medical records and case notes filed by Child Protective Services social workers showed that Mauricio Jr. had recovered well and did not show signs of long-term medical or physical problems.
In the year and a half that followed, Child Protective Services arranged for the parents to have supervised visits with their children a couple of times a week, each visit lasting about two hours. CPS ordered Ramos and Perez to take parenting classes, get counseling, and see a psychologist.
At one point, Ramos says, CPS officials threatened to have her deported if she didn't tell them the truth about her son's injuries. She says they told her that she would go to jail. She stuck to her story: Mauricio had fallen off the bed.
Ramos says that CPS social workers also told the couple that if they complied with the agency's conditions, they would get their children returned.
Ramos and Perez apparently did everything but offer a different explanation for the baby's injuries. Obviously, that was the only thing that mattered to the state.
On a typical visitation day, Ramos packed a bag with clothes, diapers, and toys. The couple got a ride or took the bus and usually were waiting at the CPS office when a state-certified parent aide arrived with the children.
Ramos sat on a sofa and cuddled with her babies before feeding them. Maurico got rice and beans, or beef and vegetable soup, or a homemade tamale. She poured watered-down juice in a sippy cup for him to drink. She fed Kimberly baby cereal while Mauricio Jr. played with his dad and the toys she brought for him.
Just before each visit was over, she would tell Mauricio it was time to clean up and he'd gather up the toys. She would change the baby's diaper.
One parent aide noted that when Mauricio Sr. left the room to go to the bathroom, his son became agitated and started looking for him. When Dad returned, the aide noted, the boy smiled and returned to his toys.
At the end of each visit, the parents kissed and hugged their children, walked them to the aide's car, and buckled them into their car seats.
For a short time, when the supervised visits were moved to the couple's new apartment, Ramos says, it felt as though they were a family again.
But then, the visits started getting postponed. Seven, eight, nine visits here and there and the children never showed up.
Ramos' attorney argued that she had a right to see her children — that even if the state was planning to take them away, it hadn't yet. She asked for the visits to resume, but they never did.
It was confusing, Ramos says, because she believed they were doing everything that was asked of them.
Child Protective Services documents obtained by New Times do reveal that Ramos and Perez were told that they would be reunited with their children. The initial goal was to have the children — who were removed in September 2009 — back home by March 2010.
"[Case manager] explained [to the parents] that the case had been discussed and it was determined that it would be appropriate at this time to begin the transition of the children home," Amy Kromer, the assigned CPS case manager wrote in the case notes on June 4, 2010. "The parents were very happy to hear this news."
Yet peppered throughout the case documents were social workers' notes stating that "explanations of the parents provided for the injury is not consistent with the injury."
On the first page of one report, CPS officials note five times on a page that the medical professional who treated Mauricio say the parents' explanation does not match the extent of his injuries.
Based on the recommendation from Child Protective Services and the doctors involved with Mauricio Jr.'s treatment, the state filed a motion in December 2010 with the Maricopa County Superior Court to sever Ramos and Perez's parental rights.
The agency told the court that it "feels that the children are not safe in the parent's care until an explanation that matches Mauricio's injuries is provided," according to a CPS report.
Most parent aides who supervised visits with the children and the parents recommended the children be reunited with their parents. They commented on Ramos' patience with the children, noting she was able to keep them entertained for a four-hour visit. (Another parent aide did describe Perez as "angry, agitated, and intolerant" and Ramos as "frustrated" toward the children, but that was an unusual comment in hundreds of pages of case notes.)
The psychologist working with the parents also said the children should be returned to their mother and father.
One note in the family's file describes Ramos' attorney telling CPS during a meeting that "the parents have done everything that was requested of them" and that nothing had changed since the case started when the goal was returning the children.
That nothing had changed "was precisely the problem," the case manager wrote. "The [doctors] who treated Mauricio are stating that his injuries were inflicted and that no matter what services were done this was always going to be the issue."
Several court hearings took place during the spring of 2011, most with testimony from doctors involved in Mauricio's care who couldn't say with 100 percent certainty his injuries weren't caused by a fall as his parents said. But, they insisted, symptoms such as these were extremely rare in a case involving a simple fall.
By July, Maricopa County Superior Court Judge Peter A. Thompson, who was presiding over the case, made his ruling.
From his decision, it's obvious that Thompson was moved by the parents' plight, but was persuaded by doctors.
"That the parents dearly love and are devoted to their children is evident by their diligent attendance at all services throughout this case," Thompson wrote in his decision to terminate the parents' rights to the toddlers. "If the depth of a parent's love and sincere regret were the standard for the decision, perhaps this case would be decided differently."
The parents appealed that decision to the Arizona Court of Appeals, which upheld the lower court's ruling. The couple borrowed money from friends and employers to hire an attorney to file another petition for appeal to the Arizona Supreme Court.
The Supreme Court declined to hear their case.
Ramos and Perez don't know where their children are anymore. But Ramos says she isn't going to stop trying to find out.
She frequently calls English-speaking friends who are helping her search for an attorney who will take a look at her case and perhaps find a way to reunite her with her son and daughter.
If Mauricio Jr. and Kimberly have been adopted — and that adoption has been finalized for a year or more — the parents' continued fight may be futile.
Arizona state law indicates that after one year from the date the adoption decree is finalized, no one can come back and challenge the adoption based on "any irregularity" or attack the validity of the adoption.
Even if the children are still in foster care, the parents' chances of reuniting with them are not significantly better. In the eyes of Arizona state law, the parents are like strangers to the toddlers. If they want parental rights "restored," they would have to qualify as adoptive parents and adopt their own children.
And given that the state already has removed the children from their care — and the courts have not been swayed by their appeals — it's unlikely the couple would qualify.
Sitting on the edge of a couch in her new apartment and sharing her story with New Times earlier this summer, Ramos says she just doesn't understand how two years have managed to pass without her being allowed to hold her babies. Her eyes get watery.
About a half-hour into the interview, there's a knock on the door. It's Perez, wiping sweat off his forehead. He rode his bicycle to Ramos' apartment on this warm July evening.
The stress of losing their children took its toll on the couple; they separated in October 2011.
They agreed to remain friends.
"We kept arguing and blaming each other," says Perez, who looks just like the boy in his son's baby pictures. "She was blaming me, saying I should have been paying attention. I was blaming her for getting up. We just knew that we couldn't keep living together when we were so unhappy. It just wasn't a happy home anymore."
They did vow to keep searching for ways to reunite with their children.
"Just too much time has passed," Perez says, his face hard, brows furrowed. "This isn't right. It's time for the children to come home."
He says he is worried that his son and daughter will forget them or never know how hard they fought to be a family again.
Neither parent plans on having more children.
"How can I hold another baby in my arms when I know my son and my daughter are out there somewhere?" Ramos says. "I couldn't."
Ramos walks into the bedroom, where she keeps the items she hasn't been able to throw or give away. She pulls a small suitcase off the top shelf in her bedroom closet and places it on her bed. Soft rays of sunlight from an uncovered window wash over the bag.
She unzips the bag, revealing a pile of baby clothes and a white stuffed dog with a red ribbon tied around its neck.
"Kimberly loved this toy," she says, holding it up. "It was her favorite."
She smiles while digging through the tiny T-shirts and shorts that belonged to Mauricio Jr. and the frilly pink outfits and white onesies she outfitted Kimberly with when she was just a few months old. The clothing is loosely packed as if it were frequently rummaged through. None of the items would fit the children today.
"Mauricio will be 5 years old in just a few days. And Kimberly, she's already 4 years old," she says.
Every day and every night, Ramos wonders where her babies are — who they're with, whether they're safe, whether they're being loved. She wonders whether Mauricio is living with Kimberly and whether he's taking care of his little sister.
Ramos runs her fingertips over the small T-shirts before she zips up the suitcase and returns it to the closet shelf. She walks to a narrow coat closet in her living room and reaches for a clear plastic bag full of toys and oversized plastic cars.
She couldn't quite reach, and asks Perez for help. Only slightly taller than her, he stretches his arm and pulls it down.
"Mauricio loved playing with this one," she says as she pulls a chunky yellow firetruck from the sack. "I just can't get rid of these. I want them to be here when the kids come home. I want them to know I never forgot them."
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