Broken bones. Fractured skulls. Burns, bruises and internal bleeding.
Today, when doctors see these sorts of injuries in babies and toddlers, they look for signs of child abuse and act to protect the children if they find them.
That hasn’t always been the case. History, of course, is rife with tales of violence against children: the Biblical tale of the slaughter of the innocents, stories of abandoned babies and foundling hospitals, legends of child sacrifice in the ancient Aztec and Inca cultures.
Physical and sexual violence against children continues in the modern era, but health care providers are seeing the problem in a new light and responding in more proactive ways, says Desmond Runyan, MD, DrPH, a pioneer in child abuse pediatrics with strong ties to the Robert Wood Johnson Foundation (RWJF).
Until the first half of the last century, signs of abuse were often overlooked because health care providers lacked awareness of the problem and the resources to respond to it, Runyan says. The problem was seen as a matter for lawyers and social workers but not for doctors or nurses. “Unexplained injuries and illnesses were never recognized as abuse. There was no disquiet, no discomfort that something else might be going on,” he notes.
But that began to change several decades ago. In its first year of existence in 1972, RWJF gave C. Henry Kempe the money he needed to start a non-profit organization to raise awareness about child abuse and neglect. In the years since, RWJF has supported numerous physician-scientists who have conducted groundbreaking research in the field.
In so doing, RWJF helped create the medical subspecialty of child abuse pediatrics and a new awareness of and response to child abuse in the United States and worldwide. Without RWJF’s support, Runyan says, the specialty may not have come into existence when it did. It certainly wouldn’t be the large and influential field it is today—and many more children would have suffered from undiagnosed and untreated abuse. “The Foundation actually started and nurtured a worldwide movement to end the abuse and neglect of children,” he says. “It’s an effort that has had profound implications for world health.”
Alarmed by ‘Non-Accidental’ Injuries
The story of that movement begins with Kempe, a Jewish immigrant from Germany who fled his native country just before the start of World War II, when he was just nine years old. He grew up to become a pediatrician in the United States and chair of the pediatrics department at the University of Colorado. While there, he became alarmed by the number of children who arrived at the hospital with “non-accidental” injuries and began to demand answers from his peers in the medical community.
Pushing the health care field to explore the issue did not go over well at first, but Kempe persisted, Runyan says. In 1962, Kempe published “The Battered Child Syndrome” in the Journal of the American Medical Association, a landmark paper that gave a medical name to the health effects of child abuse and called on physicians to diagnose, treat and help prevent it.
A decade later, with support from RWJF, Kempe founded the National Center for the Prevention and Treatment of Child Abuse and Neglect, a world leader in the field. Runyan, national program director of the RWJF Clinical Scholars program, was recently named its director.
In the decades since the center was founded, the RWJF Clinical Scholars program has played a “seminal role” in establishing the field, Runyan says. He participated in the program in 1979-1981 and has conducted research in the areas of foster care, social supports and protective services for children, and the health effects of court procedures. Runyan is now conducting a large, longitudinal study of the lifetime effects of abuse in early childhood.
Other Clinical Scholars program alumni who were early pioneers in the field include John Leventhal, MD (1976-1978), who studied bone fractures in children to determine if they were indicators of abuse, and Carole Jenny, MD, MBA (1974-1976), who conducted groundbreaking work on shaken baby syndrome.
“When I first started studying child abuse pediatrics, I really didn’t know anything about it,” Jenny recalls. “I found only three articles about it, and two of those were of terrible quality. So I just started doing research, and figuring it out along the way. The birth and growth of the field has literally happened in my professional lifetime.”
Other RWJF Clinical Scholars made major contributions to the field as well. Fred Rivara, MD, MPH (1978-1980), directed an injury prevention and research center in Seattle; Angelo Giardino, MD, PhD, MPH (1990-1992) served as editor of a major textbook on child abuse; Lisa Amaya-Jackson, MD, MPH (1991-1993) is associate director of the National Child Traumatic Stress Network and a co-founder of a three-university child abuse research and treatment center; and Toni Laskey, MD, MPH (2001-2003) heads the child abuse and neglect committee at the American Academy of Pediatrics and co-directs a family violence center at the University of Utah.
Other prominent Clinical Scholars program voices include Jack Pascoe, MD, MPH (1977-1979), Lolita McDavid, MD, MPA (1982-1984), Molly Berkoff, MD, MPH (2003-2005), Joanne Wood, MD, MSHP (2007-2009), and Andrea Asnes, MD, MSW (2001-2003). David Rubin, MD, MSCE, an associate director of the Clinical Scholars program, is another leading voice in the field.
And coming full circle, Richard Krugman, MD, an alumnus of the RWJF Health Policy Fellows program (1980-1981), who directed the Kempe Center from 1981 to 1990, now chairs the National Advisory Committee of the RWJF Clinical Scholars program.
Federal Support Has Lagged
As a group, Clinical Scholars have conducted a lot of the major research on child abuse, which has helped to make up for inadequate federal funding in the area, Runyan says. They’ve also helped legitimize the field, pushed medical schools to cultivate experts on the topic, and raised awareness about the problem in the United States and abroad.
“Without the Clinical Scholars program there just wouldn’t have been the human capital—the scholars with the skills, credibility and influence in academic circles—to carry the specialty off,” Runyan says.
Jenny agrees: “The Clinical Scholars program primed the pump. It turned out a group of people who were not traditional, people with a broader view of the world, and gave those people the flexibility to take a different path. It gave the field a source of man- and woman-power who could change the health care system and change academic medicine.”
There is now a wide network of program scholars and alumni who focus on child abuse. One recent inductee is Hiu-fai Fong, MD (2012-2014), who is exploring barriers to high quality mental health services for sexually abused children. The expertise in child abuse among Clinical Scholars makes sense, she says, given the program’s emphasis on interprofessional collaboration. “It’s a natural fit,” she says, noting that child abuse pediatricians work with a wide array of professionals in fields such as social service, law enforcement, and policy.
Despite the work of RWJF scholars in the field, child abuse and neglect is a persistent problem. Today, between 5 and 8 percent of children in the United States experience abuse or neglect, according to Runyan. The stigma of abuse still silences victims. And the problem remains largely unaddressed by the federal government, which has yet to fund a major study in the field, Runyan and Jenny say. “It’s very hard for people to actually come to grips with this and to talk about it publicly,” Jenny says. “You think it’s a really rare thing, but it’s actually not all that rare.”
But there are encouraging signs of progress. In the last two decades, the number of scholarly articles in medical journals has exploded, more physician scientists are specializing in the field and, most importantly, there has been a stunning 50 percent decline in rates of child abuse and neglect, Runyan says.
“There was a time in human history where the vast majority of children were maltreated,” Runyan says. “We’ve come an incredible way in the last 50 years alone, and I’m hopeful that we’ll continue down the path toward ending this shameful scourge.”
40 Years of Innovation
The grantees of the Robert Wood Johnson Foundation’s Human Capital portfolio have become leaders in inventing methods of prevention, treatment and research that have greatly advanced health and health care in America. This series, 40 Years of Innovation in the Health Care Work Force, tells their stories.View all