May 8, 2023
Show Notes:
Rachel Berger and Will Bachman talk about Rachel's journey since graduating from Harvard. Rachel graduated with a degree in biochemistry and moved to New York City to attend Columbia medical school. She moved to Pittsburgh for her residency and ended up staying for 27 years. After completing her residency, she did a fellowship in general academic pediatrics in Braddock, Pennsylvania.
Rachel took a job at the Children's Hospital of Pittsburgh in a new division for child advocacy as a child abuse pediatrician. She eventually became board certified in the field when it became a subspecialty. Rachel then advanced in her career to become a tenured professor in 2016. After nine years as the leader of the division of child advocacy, Rachel stepped down in September of 2022 and is now focusing on clinical research and advocacy for children.
Establishing the Child Advocacy Centre
Child abuse work in the United States has been around since the mid-1970s, when laws were passed which mandated reporting of child abuse but it wasn’t a subspecialty until 2009. Establishing this subspecialty and law to report was in response to the number of children who were abused and sent back into a situation that was often fatal. The Child Advocacy Center was set up at the hospital and employed physicians, nurses, social workers and forensic interviewers to ensure that this would not happen again. The subspecialty combines expertise in pediatric and orthopedic medicine, as well as knowledge in communicating with criminal courts and family courts to help keep children safe. Unfortunately, it is the most underfunded and understaffed of any pediatric subspecialty in the country. However, there are fellowships and other resources available for medical students and residents interested in this field.
Recognising and Reporting Child Abuse
Rachel explains that there are several different paths a child may take to get to see a child abuse pediatrician. These may include being referred by a hospital, Child Protective Services (CPS) if the child turns up at the Emergency room. Schools are a major source of reports, as teachers often have a close relationship with the children they are supervising, and can be more likely to spot possible abuse. Sometimes a family member may reach out. If abuse is suspected, the school or other responsible body can call the child abuse pediatrician to access their expertise.
Rachel talks about how the specialists determine if abuse is taking or has taken place but they put support and services in place that, hopefully, help the children and family. To help recognise whether a child is the victim of abuse, Rachel suggests checking the TEN-4 FACES P mnemonic to identify any signs of abuse that may be serious.
The Prevalence of Child Abuse
While it is difficult to determine the number of abuse cases since most children don’t or won’t talk about it until they are adults, the official data states that around one in seven girls say they have been victim of sexual abuse before they reached the age of 18. She also states that there is a myth that you can “tell” the perpetrators of abuse, and that parents who abuse their children don’t love them. Sometimes, it’s anger control issues, or even discipline gone awry.
Rachel also reflects on the importance of communication between medical experts and child protective services, social workers, attorneys, and police. This can be difficult because they don’t understand the medical information.
She talks about how the subspecialty of child abuse pediatrics had developed to advocate for children in court. It was seen as a combination of different elements, such as the increasing evidence base and the need for experts to advocate for children. However, there was a concern that other pediatrician reporters may become less involved if the subspecialty was created.
There is concern that this could lead to a dangerous precedent where the responsibility for reporting child abuse cases is removed from other pediatricians because they don’t think it’s their job to do so.
The advantages of having a child abuse pediatrics subspecialty is that there has been a growth in high quality research, and that the NIH has now funded a child abuse pediatric research network. However, Rachel is concerned that there are not enough people going into this field and that this could lead to a lack of access to people with expertise in this field. She suggests that the high bar of board certification might be discouraging people from people covering a small area of child abuse. Overall, they believe that the subspecialty has been a benefit to children and research, but that there is still a need for more people in this field.
Rachel has focused her research on how to better identify physical abuse in its early and mildest forms to prevent catastrophic injury. She mentions the Child Abuse Pediatric Research Network (CAP-NET) as a resource for research and noted that it has numerous projects looking into better ways to identify risk, concerning injury, and intervene in cases of physical abuse. Rachel explains how electronic records and machine learning can help track and identify cases of abuse across different hospitals, locations, systems, and services.
Socio Economic Factors in Child Abuse
Rachel discusses policy surrounding child protection and laws established to do so. Research has proven that fatalities from child abuse are far higher than expected and this has led to the need for protective laws to be passed. She goes on to talk about the difficulty of creating laws that protect both the child and the family from maltreatment or misjudgement, and what she offers suggestions on how the systems could be improved.
She cites decreasing childhood poverty as the major factor in reducing abuse. She explains that 30% of kids in the United States are supported by Medicaid, but 70-80% of children involved in child welfare rely on it. While abuse does occur in wealthier families, it is much more common in lower socioeconomic classes, and neglect is the most common form of child maltreatment. To decrease child abuse, Rachel suggests using the earned income tax credit and housing vouchers as two ways to reduce the impacts of childhood poverty.
Rachel shares examples of neglect, such as supervisory neglect, malnourishment, educational neglect, and medical neglect. She discusses physical abuse and sexual abuse, explaining that physical abuse often results in the child being admitted to the hospital for treatment, whereas sexual abuse is seen more often in an outpatient setting. Rachel also noted that sexual abuse often involves someone the child knows and trusts. Overall, the conversation highlighted the prevalence of different forms of child abuse and the need for society to address the issue.
Working on The Obama Commission to Eliminate Child Abuse and Neglect Fatalities
Rachel talks about her position as a research lead on the Obama Commission to Eliminate Child Abuse and Neglect Fatalities and why she was selected for the commission. The commission traveled to 17 places in the United States, including at least one Indian Reservation, and talked to different child welfare agencies, hospitals, police, and child advocacy centers. The commission's report focused on different types of child abuse and how communities respond to these situations. She was shocked to discover that communities were not seeking out information from other communities on how they were dealing with situations of abuse despite reports sent out from newspapers around the country about children who had died or nearly died of abuse. The commission put together a public report at the end, but it wasn't implemented due to the change in presidential administrations. Some of the recommendations from the commission have been implemented by the Casey Family Programs.
Rachel reflects on how powerful the experience was, how it shaped the next step of her career, and how she learned a lot about politics and how it is involved in an area that should be beyond political machinations of the day.
Courses and Professors of Influence
Professors mentioned by Rachel include Doug Melton.
Timestamps:
07:42 Child Abuse Referrals and Prevalence
15:15 Myths Surrounding Child Abuse and Navigating External Systems
15:39 The Challenges of Communicating Medical Information to Non-Medical Professionals
17:51 The Evolution of Subspecialty in Child Abuse Pediatrics
24:41 Research in the Field of Child Abuse Pediatrics
28:46 Potential for Machine Learning to Identify High Risk Kids in Medical Records
31:07 Exploring the Benefits of Electronic Health Records in Clinical Practice
34:28 Policy Changes to Better Protect Children from Abuse
39:19 Socioeconomic Distribution of Child Abuse
45:15 Child Maltreatment and Presidential Commissions
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