Child Abuse Pediatrics: A new pediatric subspecialty

Abstract

Child abuse and neglect has been characterized as a “national emergency.”1The U.S. Advisory Board on Child Abuse and NeglectChild Abuse and Neglect. U.S. Government Printing Office, Washington, DC1990Google Scholar In 2003, there were 2.9 million reports and an estimated 906,000 children who were victims of abuse and neglect, representing an incidence of 12.4 per 1000 children in the United States and including 1500 deaths.2U.S Department of Health and Human Services, Children’s BureauChild maltreatment 2003. U.S. Government Printing Office, Washington, DC2005Google Scholar According to the 1993 National Research Council’s report entitled Understanding Child Abuse and Neglect: “The consequences of maltreatment can be devastating. [They] affect the victims themselves and the society in which they live.”3National Resource CouncilUnderstanding child abuse and neglect. National Academy of Sciences Press, Washington, DC1993Google Scholar Over the last several years, a group of pediatricians focusing on clinical, educational and research work in the field of child abuse and neglect has evolved into a subspecialty group, the Helfer Society, named after the late Ray E. Helfer.4Runyon D.K. Child Abuse Negl. 2001; 25 (Letter): 199-201Crossref Scopus (6) Google Scholar These physicians serve as a resource to children, families, and communities by accurately diagnosing abuse, consulting with community agencies on child safety, providing expertise in courts of law, treating consequences of maltreatment, directing child abuse and neglect treatment and prevention programs, and participating on multidisciplinary teams investigating and managing child abuse cases. In June 2005, the American Board of Pediatrics (ABP) accepted a petition from this group to begin a new pediatric subspecialty, board certified by the ABP. The evolution of this new subspecialty sprouted roots in 1962 when C. Henry Kempe and colleagues defined the “battered child syndrome,”5Kempe C.H. Silverman F.N. Steele B.F. Droegmueller W. Silver H.K. The battered child syndrome.JAMA. 1962; 181: 17-24Crossref PubMed Scopus (1882) Google Scholar evolved to an honorary subspecialty society through the Helfer Society, and will be finally accepted as an official subspecialty with the anticipated approval by the American Board of Medical Specialties in 2006. Certification will be offered when accreditation and examination details are completed.The 2 most compelling reasons for the development of a subspecialty in child abuse and neglect are the need for more and better research and the burgeoning core knowledge in the field. Currently, more than 16,000 citations are found on PubMed for child abuse and more than 15,000 for child neglect. There are about 30 published primary textbooks or monographs, and additional resources appear each year. Several journals are devoted to child abuse, and articles from the field now appear in all major pediatric journals. Yet many important research questions remain. While more than $20 million in funded research in the field has been recently identified, this level of funding falls significantly behind other pediatric issues of similar magnitude. To address this, a group of physicians working through the Helfer Society and the American Academy of Pediatrics has developed a plan for federal support. Health CARES (Child Abuse Research, Education, and Service) is a proposal for federal investment in a national health care infrastructure to reduce the health harms resulting from child abuse and neglect. Although the proposal faces an uphill battle with the current trying budgetary issues faced by the President and Congress, it would create collaboration between medical school pediatric departments and cooperative agreements among those departments and other community resources focused on child abuse and neglect issues.A second reason for the establishment of the new subspecialty is the growing body of knowledge and expertise in the field, which are not routinely taught during medical school and residency. Surveys indicate pediatric residents receive insufficient training in the evaluation of child abuse and neglect.6Giardino A.P. Brayden R.M. Sugarman J.M. Residency training in child sexual abuse evaluation.Child Abuse Negl. 1998; 22: 331-336Crossref PubMed Scopus (22) Google Scholar, 7Botash A.S. Galloway A.E. Booth T. Ploutz-Snyder R. Hoffman-Rosenfeld J. Cahill L. Continuing medical education in child sexual abuse cognitive gains but not expertise.Arch Pediatr Adolesc Med. 2005; 159: 561-566Crossref PubMed Scopus (20) Google Scholar In 2005 we know that several hundred hours of training and experience are required to master the new knowledge and skills needed to provide expert care for children alleged to have been abused. Child sexual abuse evaluation in particular has become a sophisticated area over the last 20 years, with new techniques (colposcopy) and new knowledge about anogenital anatomy and sexually transmitted infections. New insights into the presentation and differential diagnosis of physical abuse are also continually being developed. These include the biomechanics of fractures (type and location), the physiology and biomechanics of abusive head trauma, distinguishing abusive and inflicted burns from accidental trauma, recognizing patterns in skin injuries, identifying some poisonings as intentional, and differentiating the rare but important homicide appearing otherwise to be a sudden, unexpected “natural” death. A greater understanding, definition, and response to child neglect are also rapidly becoming an important focus of this developing subspecialty. And while all physicians can offer expert opinion in courts of law, fair and reasonable testimony by Child Abuse Pediatricians can greatly assist the community in doing what is right for children and families in a small but important proportion of contentious cases.8Palusci V.J. Hicks R.A. Vandervort F.E. You are hereby commanded to appear pediatrician subpoena and court appearance in child maltreatment.Pediatrics. 2001; 107: 1427-1430Crossref PubMed Scopus (32) Google ScholarThe presence of a child abuse subspecialty does not minimize the continuing role of the generalist pediatrician. It is certainly within the scope of practice for the generalist pediatrician to suspect, diagnose, and manage a case of child abuse, and it is important to the field of pediatrics that this new subspecialty will complement rather than detract from the value of generalist pediatricians. But when the going gets tough, especially with critical, challenging diagnoses and related court appearances, the availability of a subspecialist in the field for consultation or case referral is preferred by many. The child abuse subspecialty field should be able to serve the generalist pediatrician similarly to other subspecialists such as a pediatric cardiologist, endocrinologist, or gastroenterologist. Increasing the numbers of Child Abuse Pediatricians will undoubtedly enhance access to expert care for children for whom it was often previously unavailable while professionally supporting the generalist pediatricians who will continue to provide front-line assessments.While there are 15 to 20 1- and 2-year child abuse fellowship positions at any given time available across the United States, the development of the specialty will be aided by the development of full 3-year fellowships. These are critical to developing the next generation of medical school faculty in this field, since subspecialists in departments define the core skills and knowledge that medical students and residents need to master. It is equally critical to train a cadre of physicians to serve as leaders in children’s hospitals, as these hospitals and the National Association of Children’s Hospitals and Related Institutions develop plans to incorporate the expertise of these services within their hospitals, and, in collaboration with communities, to prevent and manage cases of child maltreatment.9Child Abuse Medical Advisory Group, National Association of Children’s Hospitals and Related InstitutionsDefining the children’s hospital role in child maltreatment. National Association of Children’s Hospitals and Related Institutions, Alexandria, VA2005Google ScholarA third objective, research building, can best be accomplished through traditional fellowship preparation and research mentoring as required in other fields by the ABP. Another objective will be the development of a pool of trained, knowledgeable, and ethical expert witnesses for legal proceedings. Overall, a fellowship can also increase and maintain interest in the field of child abuse and neglect in an institution, as well as increase clinical experience, which will improve overall care for children and their families. A small number of fellowship-trained Child Abuse Pediatricians already provide the key leadership and motivation for a small but growing number of Centers of Excellence throughout the U.S., which serve as the hubs for growing networks of pediatricians and others who provide care within the hospital and community.How many Child Abuse Pediatricians will be needed? It has been roughly estimated on the basis of current experience that the U.S. needs at least 1 Child Abuse Pediatrician for every 1 million population. In addition, there should be at least 1 in each medical school. Thus, with a population of 250 million and 125 accredited medical schools, the United States needs at least 375 Child Abuse Pediatricians to meet the educational, research, and service needs in this newly recognized subspecialty. Both department Chairs and community programs sponsoring clinicians will need to grapple with the reality that although the services provided by Child Abuse Pediatricians are critical, funding and reimbursement for those services are often difficult to find. It will be important to parlay the value of a new subspecialty into recognition by state Medicaid programs, insurance providers, state and local governments, foundations, and private philanthropists, so that adequate support for physicians and their programs can be guaranteed.The Helfer society began in 1997 when a small group of interested physicians gathered in Philadelphia to begin discussions about the need for specialized focus in the field of child abuse and neglect. Seventy-five physicians attended the second meeting in 1998. In 1999, the American Academy of Pediatrics Section on Child Abuse and Neglect submitted an initial application for specialty recognition which was not accepted.10Jenny C. Application to the American Board of Pediatrics from the American Academy of Pediatrics Section on Child Abuse and Neglect for Establishment of Subspecialty Boards in Child Abuse and Forensic Pediatrics. 1999Google Scholar At the beginning of the process, the field struggled to find a name, and the term “forensic pediatrics” was developed to recognize the critical role pediatricians dealing with child abuse played in the courts. However, that term was rejected by the ABP, leaving leaders in a naming quandary. Since 2001, the Helfer Society has presented annual conferences emphasizing organizational activities, education, fellowship development, advocacy, quality improvement, research and clinical information. Many Helfer presentations and discussions were titled, “Paedikatachromiology,” a tongue-in-cheek reference to a very loosely translated Greek term for the science and study of child abuse. Alternative terms, including Child Abuse Pediatrics, are all awkward in some ways, and everyone can think of another name which is equally less than ideal. However, it is not the name but the work that is being accomplished that is important. As we work to turn the tide of this “epidemic,” abused and neglected children, families, health care professionals, and many others will benefit from this new subspecialty of Child Abuse Pediatrics. Child abuse and neglect has been characterized as a “national emergency.”1The U.S. Advisory Board on Child Abuse and NeglectChild Abuse and Neglect. U.S. Government Printing Office, Washington, DC1990Google Scholar In 2003, there were 2.9 million reports and an estimated 906,000 children who were victims of abuse and neglect, representing an incidence of 12.4 per 1000 children in the United States and including 1500 deaths.2U.S Department of Health and Human Services, Children’s BureauChild maltreatment 2003. U.S. Government Printing Office, Washington, DC2005Google Scholar According to the 1993 National Research Council’s report entitled Understanding Child Abuse and Neglect: “The consequences of maltreatment can be devastating. [They] affect the victims themselves and the society in which they live.”3National Resource CouncilUnderstanding child abuse and neglect. National Academy of Sciences Press, Washington, DC1993Google Scholar Over the last several years, a group of pediatricians focusing on clinical, educational and research work in the field of child abuse and neglect has evolved into a subspecialty group, the Helfer Society, named after the late Ray E. Helfer.4Runyon D.K. Child Abuse Negl. 2001; 25 (Letter): 199-201Crossref Scopus (6) Google Scholar These physicians serve as a resource to children, families, and communities by accurately diagnosing abuse, consulting with community agencies on child safety, providing expertise in courts of law, treating consequences of maltreatment, directing child abuse and neglect treatment and prevention programs, and participating on multidisciplinary teams investigating and managing child abuse cases. In June 2005, the American Board of Pediatrics (ABP) accepted a petition from this group to begin a new pediatric subspecialty, board certified by the ABP. The evolution of this new subspecialty sprouted roots in 1962 when C. Henry Kempe and colleagues defined the “battered child syndrome,”5Kempe C.H. Silverman F.N. Steele B.F. Droegmueller W. Silver H.K. The battered child syndrome.JAMA. 1962; 181: 17-24Crossref PubMed Scopus (1882) Google Scholar evolved to an honorary subspecialty society through the Helfer Society, and will be finally accepted as an official subspecialty with the anticipated approval by the American Board of Medical Specialties in 2006. Certification will be offered when accreditation and examination details are completed. The 2 most compelling reasons for the development of a subspecialty in child abuse and neglect are the need for more and better research and the burgeoning core knowledge in the field. Currently, more than 16,000 citations are found on PubMed for child abuse and more than 15,000 for child neglect. There are about 30 published primary textbooks or monographs, and additional resources appear each year. Several journals are devoted to child abuse, and articles from the field now appear in all major pediatric journals. Yet many important research questions remain. While more than $20 million in funded research in the field has been recently identified, this level of funding falls significantly behind other pediatric issues of similar magnitude. To address this, a group of physicians working through the Helfer Society and the American Academy of Pediatrics has developed a plan for federal support. Health CARES (Child Abuse Research, Education, and Service) is a proposal for federal investment in a national health care infrastructure to reduce the health harms resulting from child abuse and neglect. Although the proposal faces an uphill battle with the current trying budgetary issues faced by the President and Congress, it would create collaboration between medical school pediatric departments and cooperative agreements among those departments and other community resources focused on child abuse and neglect issues. A second reason for the establishment of the new subspecialty is the growing body of knowledge and expertise in the field, which are not routinely taught during medical school and residency. Surveys indicate pediatric residents receive insufficient training in the evaluation of child abuse and neglect.6Giardino A.P. Brayden R.M. Sugarman J.M. Residency training in child sexual abuse evaluation.Child Abuse Negl. 1998; 22: 331-336Crossref PubMed Scopus (22) Google Scholar, 7Botash A.S. Galloway A.E. Booth T. Ploutz-Snyder R. Hoffman-Rosenfeld J. Cahill L. Continuing medical education in child sexual abuse cognitive gains but not expertise.Arch Pediatr Adolesc Med. 2005; 159: 561-566Crossref PubMed Scopus (20) Google Scholar In 2005 we know that several hundred hours of training and experience are required to master the new knowledge and skills needed to provide expert care for children alleged to have been abused. Child sexual abuse evaluation in particular has become a sophisticated area over the last 20 years, with new techniques (colposcopy) and new knowledge about anogenital anatomy and sexually transmitted infections. New insights into the presentation and differential diagnosis of physical abuse are also continually being developed. These include the biomechanics of fractures (type and location), the physiology and biomechanics of abusive head trauma, distinguishing abusive and inflicted burns from accidental trauma, recognizing patterns in skin injuries, identifying some poisonings as intentional, and differentiating the rare but important homicide appearing otherwise to be a sudden, unexpected “natural” death. A greater understanding, definition, and response to child neglect are also rapidly becoming an important focus of this developing subspecialty. And while all physicians can offer expert opinion in courts of law, fair and reasonable testimony by Child Abuse Pediatricians can greatly assist the community in doing what is right for children and families in a small but important proportion of contentious cases.8Palusci V.J. Hicks R.A. Vandervort F.E. You are hereby commanded to appear pediatrician subpoena and court appearance in child maltreatment.Pediatrics. 2001; 107: 1427-1430Crossref PubMed Scopus (32) Google Scholar The presence of a child abuse subspecialty does not minimize the continuing role of the generalist pediatrician. It is certainly within the scope of practice for the generalist pediatrician to suspect, diagnose, and manage a case of child abuse, and it is important to the field of pediatrics that this new subspecialty will complement rather than detract from the value of generalist pediatricians. But when the going gets tough, especially with critical, challenging diagnoses and related court appearances, the availability of a subspecialist in the field for consultation or case referral is preferred by many. The child abuse subspecialty field should be able to serve the generalist pediatrician similarly to other subspecialists such as a pediatric cardiologist, endocrinologist, or gastroenterologist. Increasing the numbers of Child Abuse Pediatricians will undoubtedly enhance access to expert care for children for whom it was often previously unavailable while professionally supporting the generalist pediatricians who will continue to provide front-line assessments. While there are 15 to 20 1- and 2-year child abuse fellowship positions at any given time available across the United States, the development of the specialty will be aided by the development of full 3-year fellowships. These are critical to developing the next generation of medical school faculty in this field, since subspecialists in departments define the core skills and knowledge that medical students and residents need to master. It is equally critical to train a cadre of physicians to serve as leaders in children’s hospitals, as these hospitals and the National Association of Children’s Hospitals and Related Institutions develop plans to incorporate the expertise of these services within their hospitals, and, in collaboration with communities, to prevent and manage cases of child maltreatment.9Child Abuse Medical Advisory Group, National Association of Children’s Hospitals and Related InstitutionsDefining the children’s hospital role in child maltreatment. National Association of Children’s Hospitals and Related Institutions, Alexandria, VA2005Google Scholar A third objective, research building, can best be accomplished through traditional fellowship preparation and research mentoring as required in other fields by the ABP. Another objective will be the development of a pool of trained, knowledgeable, and ethical expert witnesses for legal proceedings. Overall, a fellowship can also increase and maintain interest in the field of child abuse and neglect in an institution, as well as increase clinical experience, which will improve overall care for children and their families. A small number of fellowship-trained Child Abuse Pediatricians already provide the key leadership and motivation for a small but growing number of Centers of Excellence throughout the U.S., which serve as the hubs for growing networks of pediatricians and others who provide care within the hospital and community. How many Child Abuse Pediatricians will be needed? It has been roughly estimated on the basis of current experience that the U.S. needs at least 1 Child Abuse Pediatrician for every 1 million population. In addition, there should be at least 1 in each medical school. Thus, with a population of 250 million and 125 accredited medical schools, the United States needs at least 375 Child Abuse Pediatricians to meet the educational, research, and service needs in this newly recognized subspecialty. Both department Chairs and community programs sponsoring clinicians will need to grapple with the reality that although the services provided by Child Abuse Pediatricians are critical, funding and reimbursement for those services are often difficult to find. It will be important to parlay the value of a new subspecialty into recognition by state Medicaid programs, insurance providers, state and local governments, foundations, and private philanthropists, so that adequate support for physicians and their programs can be guaranteed. The Helfer society began in 1997 when a small group of interested physicians gathered in Philadelphia to begin discussions about the need for specialized focus in the field of child abuse and neglect. Seventy-five physicians attended the second meeting in 1998. In 1999, the American Academy of Pediatrics Section on Child Abuse and Neglect submitted an initial application for specialty recognition which was not accepted.10Jenny C. Application to the American Board of Pediatrics from the American Academy of Pediatrics Section on Child Abuse and Neglect for Establishment of Subspecialty Boards in Child Abuse and Forensic Pediatrics. 1999Google Scholar At the beginning of the process, the field struggled to find a name, and the term “forensic pediatrics” was developed to recognize the critical role pediatricians dealing with child abuse played in the courts. However, that term was rejected by the ABP, leaving leaders in a naming quandary. Since 2001, the Helfer Society has presented annual conferences emphasizing organizational activities, education, fellowship development, advocacy, quality improvement, research and clinical information. Many Helfer presentations and discussions were titled, “Paedikatachromiology,” a tongue-in-cheek reference to a very loosely translated Greek term for the science and study of child abuse. Alternative terms, including Child Abuse Pediatrics, are all awkward in some ways, and everyone can think of another name which is equally less than ideal. However, it is not the name but the work that is being accomplished that is important. As we work to turn the tide of this “epidemic,” abused and neglected children, families, health care professionals, and many others will benefit from this new subspecialty of Child Abuse Pediatrics.