The subspeciality of forensic pediatrics focuses on the evaluation, treatment and prevention of child abuse and neglect. National statistics reveal that an estimated 3 million reports of suspected child maltreatment are made to child welfare agencies annually, and nearly 1 million children are found to be victims of at least one form of maltreatment. The US Department of Health and Human Services reports the rate of child victimization was 12.4 victims per 1,000 children in 2003. Neglect accounted for 60.9% of cases, physical abuse 18.9%, sexual abuse 9.9 %, psychological abuse 4.9%, and medical neglect 2.3 %.' A child may suffer from more than one form of child maltreatment.
THE SCOPE OF CHILD MALTREATMENT
An estimated 1,500 child maltreatment fatalities occur yearly, equivalent to 4 children dying each day as a result of child abuse or neglect. The majority of these fatalities occur in children younger than 4 years-of-age. The National Research Council summarized the consequences of child maltreatment in their 1993 report, Understanding Child Abuse and Neglect.
The consequences of maltreatment can be devastating. For over 30 years, clinicians have described the effects of child abuse and neglect on the physical, psychological, cognitive and behavioral development of children. Physical consequences range from minor injuries to severe brain damage and even death. Psychological consequences range from chronic low self-esteem to severe dissociative states. The cognitive effects of abuse range from attentional problems and learning disorders to severe organic brain syndromes. Behaviorally, the consequences of abuse range from poor peer relations all the way to extraordinarily violent behaviors. Thus, the consequences of abuse and neglect affect the victims themselves and the society in which they live.2
In 2004 there were 2,906 children identified as victims of one or more forms of child maltreatment in Rhode Island.3 The Rhode Island Kids Count reports die rate of child victimization was 7.0 victims per 1,000 children in Rhode Island in 2004 Neglect accounted for 71% of cases, physical abuse 17%, sexual abuse 5%, psychological abuse 1%, and medical neglect 2%.4 The cause of the discrepancy between national and Rhode Island data is unknown. However, during the last five years the Rhode Island Department of Children, Youth and Families has redefined criteria for identifying abuse and neglect from "credible evidence" to a "preponderance of the evidence" standard, which may influence the Rhode Island data. The Child Protection Program (CPP), described below, has completed evaluations for the diagnosis and treatment of suspected child maltreatment from every county within Rhode Island, because child maltreatment is experienced across all racial, ethnic and socioeconomic lines.
THE DEVELOPMENT OF THE SUBSPECIALTY OF FORENSIC PEDIATRICS
In 1962, C. Henry Kernpe and colleagues defined the "battered child syndrome," which led to die engagement of pediatrics in a wide range of clinical research about the spectrum of abusive injuries to children.
The knowledge and research in this field has exploded in quantity and sophistication. In 1966, the National Library of Medicine began to offer the Medline medical information system. That year, Medline listed one article under the heading 'child abuse.' By 1996, 662 articles were published in indexed medical and psychiatric journals. Recent simple inquiries through PubMed resulted in over 16,000 hits for the term 'child abuse.'
In a survey of 167 pediatric residency programs, Dubowitz found that the median amount of training in each year of residency in the area of child maltreatment was only seven to eight hours. Half of this time was spent in clinical supervision in the care of the maltreated child.8 In a similar survey of 147 pediatric training programs, 70% of faculty and 63% of residents thought that the time spent in training pediatricians about child sexual abuse was inadequate, and 74% of third year residents estimated that they had evaluated five or fewer patients for suspected sexual abuse during their residency.9
Practicing physicians are not always equipped to complete forensic evaluations for suspected child maltreatment. Although few studies document the knowledge of practicing physicians regarding child abuse, two surveys, in 1986 and 1996, illustrate the lack of knowledge among physicians in regards to examinations for suspected sexual abuse. In the 1986 survey, Ladson and colleagues found that many pediatricians and family practitioners incorrectly identified genital structures of the pre-pubertal female; 40.9% could not identify the hymen on a photograph of a normal child's genial area. When this study was repeated in 1996, the incorrect responses remained at 38.7%, no statistical improvement over the 1986 survey.10
Thus, the ever-expanding body of knowledge required to be a forensic pediatrician is beyond the scope of education offered in a general pediatric residency and typically exceeds the scope of practice of the general pediatrician. Since the establishment of this subspecialty, forensic pediatricians also have developed expertise in sexual abuse, neglect and factitious illness by proxy.5,6
Today's forensic pediatricians diagnose abuse, consult with community agencies on child safety, provide expert testimony in courts of law, treat consequences of abuse and neglect, direct child maltreatment prevention programs, and participate on multidisciplinary teams investigating and managing child abuse cases.7 Forensic pediatrics must have expertise and knowledge in general pediatrics as well as unique medical knowledge in child development, nutrition, biomechanics of injuries, dynamics of abusive families, dermatology, pediatric trauma, orthopedics, genetic/metabolic disorders, gynecology, and forensic pathology. In addition, they must undertand court procedures and expert witness testimony. They require specialized clinical skills, including the collection of forensic evidence, and forensic interviewing. They must be able to recognize a spectrum of rare and common diseases that may mimic child maltreatment.
Specialized training beyond a general pediatric residency is essential for clinicians to acquire that knowledge and clinical skills. There are a handful of Forensic Pediatric Fellowships available across the country. The Fellowship Program in Forensic Pediatrics at Hasbro Children's Hospital and Brown Medical School is recognized as one of the leading fellowship programs in the country.
DESCRIPTION OF THE FELLOWSHIP PROGRAM IN FORENSIC PEDIATRICS AT BROWN UNIVERSITY
The Fellowship Program in Forensic Pediatrics is provided through the CPP at Hasbro Children's Hospital. Established in 1996, the CPP is a comprehensive hospital-based program that resolves child abuse identification and child protection issues. It is dedicated to the identification, prevention and treatment of children victimized by child maltreatment. The program has an extensive network of educational programs and clinical services, including the accurate and timely diagnosis and treatment of child victims throughout Rhode Island and neighboring states. In addition, the specialized training and resources within this program are used to clarify misinterpretations of medical findings that could lead to wrongful accusations of child abuse.
The CPP provides special forensic training to a pediatrician in all aspects of diagnosing and treating child maltreatment. The program actively recruits qualified applicants to complete a two-year academic program of subspecialty training in forensic pediatrics. The fellowship includes the following 5 components:
1) Clinical Component. Clinical training allows fellows to become proficient in the evaluation, care and treatment of child victims of abuse and neglect. The fellows acquire expert clinical skills and knowledge in the field of child abuse and neglect. This ongoing clinical exposure emphasizes the medical aspect of child abuse evaluations, including biomechanics of physical injuries; sexual abuse and sexual assault, including forensic evidence collection, diagnostic methods for sexually transmitted disease (STDs); the epidemiology and forensic significance of STDs; pediatric and adolescent gynecology; failure to thrive; neglect; medical abuse; and the differential diagnosis of conditions that may mimic child maltreatment. Collaboration with other subspecialties broadens the fellows' skills and insights.
An important component is the acquisition of skills for special procedures, including colposcopic documentation of genital injuries, photodocumentation of physical injuries, punch biopsies for genetic diseases, removal of vaginal foreign bodies, and collection and maintenance of forensic evidence. Fellows also learn about the psychosocial aspects of child abuse and family violence. In addition, fellows learn about the dynamics of abusive families and the immediate and long-term consequences for victims and their families.
2) Teaching Component. Forensic Pediatric Fellows develop competency in lecturing to and teaching a variety of professionals, including non-medical personnel. This includes education and training of residents in pediatrics, family practice, emergency medicine, and psychiatry. The CPP fellows ensure that residents training in these specialties acquire the knowledge and skills to complete an initial evaluation for cases of suspected maltreatment.
3) Community Component. Fellows develop the ability to work as an integral part of a multidisciplinary team. They participate in community prevention programs and community outreach activities. Successful child abuse prevention and child protection require the involvement and collaboration of many different systems including child welfare, criminal justice, community-based support, and medical care. Thus, the program offers opportunities for fellows to provide leadership roles within the community.
4) Legal Component. Fellows learn how to provide medical expert witness testimony at court. They learn to create medical work products pertaining to the diagnosis and treatment of child maltreatment that withstand the rigors of the legal process. Fellows receive training in the evaluation of child pornography cases, and work with local, state and federal law enforcement agencies. Fellows participate in didactic lectures provided by local and regional attorneys and law professors. They develop expertise in understanding mandatory reporting laws and other laws, procedures and protocols used to protect the safety and rights of children and families. They obtain knowledge of court procedures in civil and criminal cases. In addition, fellows learn about public policy and legislative advocacy.
5) Research Component. Graduates of the fellowship program take an active role in generating new knowledge through research. During fellowship, they acquire knowledge and skills for critical reading and scholarly writing. They complete clinical or epidemiological research, and are encouraged to publish their work in peer-reviewed journals.
Since the inception of the fellowship program at Brown Medical School, ten pediatricians have completed training and have accepted academic and clinical positions across the country. Those graduates provide teaching and training to improve the diagnosis, treatment and management of child maltreatment in academic medical centers and other practice settings.
CONCLUSION
At present, the number of pediatricians specializing in forensic pediatrics is inadequate to meet the demands for clinical services, teaching and research. Seventeen universityaffiliated fellowship programs exist in Forensic Pediatrics, and the American Board of Pediatrics is considering the recognition of child abuse pediatrics as a boarded subspecialty. Formalized certification and training should lead to increases in the number of pediatricians choosing this rewarding and challenging subspecialty.
REFERENCES
1. US Department of Health & Human Services, Children's Bureau: Child Maltreatment 2003: Reports From the States to the National Child Abuse and Neglect Data System. U.S. Government Printing Office, Washington, D.C., 2005.
2. Panel on Research on Child Abuse and Neglect, Commission on Behavioral and Social Sciences and Education, National Research Council: Understanding Child Abuse and Neglect. National Academy Press, Washington, D.C., 1993, p.208
3. Rhode Island Department of Children, Youth and Families, Rhode Island Children's Information System (RICHIST), 2004.
4. Rhode Island Kids Count Factbook. Rhode Island KIDS COUNT, Providence, R.I., 2005.
5. Bays J, Chadwick D. Medical diagnosis of the sexually abused child. Child Abuse Neglect: InternatJ 1993; 17:91-110.
6. Jenny C, Barron CE, Roelser TA. Munchausen's Syndrome by proxy. AmerAcadPed Update 2002;23.
7. Starling SP, Sirotnak AP, Jenny CA. Child Abuse and Forensic Pédiatrie Medicine Fellowship Curriculum Statement. Child Maltreatment 2000;5: 58-62.
8. Dubowitz H. Child abuse programs and pediatric residency training. Pediatrics 1988;83:805-7.
9. Giardino AP, Brayden RM, Sugarman JM. Residency training in child sexual abuse evaluations. Child Abuse Neglect: Internat J 1998;22:331-6.
10. Ladson S, Johnson CF, Dory MS. Do physicians recognize sexual abuse? Amer J Dis Children 1987;141:411-5.
CHRISTINE E. BARRON, MD, AND CAROLE JENNY, MD, MBA
Christine E. Barron, MD, is Assistant Professor of Pediatrics, Brown Medical School.
Carole Jenny, MD, MBA, is Professor of Pediatrics, Brown Medical School.
CORRESPONDENCE:
Christine E. Barron, MD
Hasbro Children's Hospital Child Protection Program
593 Eddy Street, Potter-005
Providence, RI 02903
Phone: (401) 444-3996
Fax: (401) 444-7397
e-Mail: cbarronl@lifespan.org
Copyright Rhode Island Medical Society Sep 2005
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