Introduction
In the United States, the first recorded organizational response to child abuse was made by the American Society for the Prevention of Cruelty to Animals (ASPCA). Responding to the now famous case of Mary Ellen in 1873, the ASPCA recognized the responsibility of organizations to prevent and intervene in cases of child abuse. However, child maltreatment was typically not an interest of health care professional organizations prior to the early 1960s. Over the last 45 years, several organizations either have added child maltreatment issues to their priorities, or have been formed primarily to respond to those issues. This has created new interest in clinical practice, scholarship, research, and advocacy to address the continuing problems of child abuse and neglect.
Many organizations deserve recognition for their important contributions to collaborative efforts to reduce and respond to the problem of violence and abuse. Those making important medically focused contributions serve as the focus of this chapter.
The American Academy of Pediatrics
The American Academy of Pediatrics (AAP) is the premier association whose mission is to improve the health and well-being of all children. The AAP was founded in 1930 in response to the need for an independent pediatric forum to address children’s needs. Since its inception, the AAP has made a huge impact on advocacy, research, and practice in pediatrics in general and in the field of child abuse and neglect. The issue of child abuse and neglect was first addressed by the AAP Committee on the Infant and Preschool Child in 1962 when the AAP’s Executive Board advised the Committee to address the issue of “the battered child syndrome” at the national level, working closely with the Children’s Bureau, the National Council of Juvenile Court Judges and other agencies in the field. In the mid-1970s, the AAP’s Task Force on Child Abuse and Neglect was established to visit health-based centers to discuss child abuse and neglect under a contract with the U.S. Department of Health Education and Welfare’s Health Resources Administration. The Task Force reported their findings to the government agency, which in turn passed on the report to physicians, hospitals, and state and local welfare authorities. The Task Force developed a Self-Instructional Program in Child Abuse and Neglect as an educational tool for communities. With the sun-setting on the Task Force, the Committee on the Infant and Preschool Child established a Subcommittee on Child Abuse and Neglect. The Subcommittee worked with Academy staff and the Task Force on a contract to prepare a manual on child abuse; The Visual Diagnosis of Non-Accidental Trauma and Failure to Thrive by Barton D. Schmitt, which was published in 1979.
With a lack of dedication to child abuse and neglect by the now combined Committee on Early Childhood, Adoption and Dependent Care, the Task Force on Child Abuse and Neglect was once again established. A resolution was proposed to appoint a committee to address the widespread problem of child abuse and neglect and the dramatic increase in sexual abuse of young children. The new Task Force met for the first time on May 18-19, 1986. The Task Force became a Provisional Committee in 1988, and in 1990 it became a full standing Committee.
At the same time the Committee became official, the Section on Child Abuse and Neglect (SOCAN) was founded. The SOCAN, a special interest group of AAP members who have an interest in child abuse and neglect, provides an educational forum for the discussion of problems and treatments relating to child abuse and neglect as well as prevention. With education as its main goal, the SOCAN has developed a number of educational resources since 1990 including the current third edition of the valuable teaching resource Visual Diagnosis of Child Abuse on CD-ROM and the now retired Guide to References and Resources in Child Abuse and Neglect. The Guide provided lists of articles and selected annotations, as well as resource lists to help the pediatrician chart a path through the child advocacy system. Information on programs providing diagnostic and treatment services in the United States and Canada was also included in the manual. A revised version of this is now posted on the Section’s web site: http://www.aap.org/sections/scan/medicaldiagnostic/medicaldiagnostic.htm . The SOCAN also sponsors educational sessions at the AAP National Conference and Exposition (NCE) and at the annual conference of the Pediatric Academic Societies. The SOCAN has grown to about 600 members since its creation and includes other health care professionals as affiliate members.
In 2003, members of the AAP COCAN and the SOCAN approached the AAP to support a proposal for federal funding of university-based centers of excellence, which would provide child abuse education, research, and services in a more organized manner across the United States. The Health Child Abuse Research Education and Services (Health CARES) Network proposal, based on the successful federally funded University Centers of Excellence in Developmental Disabilities, was further refined with the assistance of AAP staff and approved by the AAP Board of Directors in the spring of 2004. Shortly after, the Boards of the American Academy of Child and Adolescent Psychiatry (AACAP) and the National Association of Children’s Hospitals and Related Institutions (NACHRI) endorsed the proposal. In addition, a supportive resolution was passed at the American Medical Association (AMA). Staff in the AAP Department of Federal Affairs dedicated time to advocate for support and funding of the proposal, including arranging meetings with federal agencies to gain support of the Health CARES Network. Having a long successful liaison relationship with the COCAN, the Centers for Disease Control and Prevention (CDC) Division of Violence Prevention enthusiastically expressed support of and interest in housing the Health CARES Network within their agency. Currently, AAP staff, COCAN and SOCAN members are advocating for appropriation funding of the Health CARES Network, and the CDC has provided funding for development of a report on the current status of child abuse programs providing medical services in the United States.
Over the past 18 years, AAP’s support of efforts in the field of child abuse and neglect has grown tremendously. Since the creation of the COCAN and SOCAN, approximately 30 state-level committees have been organized through AAP chapters. These chapters and their respective districts have contributed greatly to advance this field through submission of resolutions in the AAP Annual Chapter Forum. These resolutions have encouraged additional research and support of child abuse prevention programs. The AAP has also been able to make great strides in child abuse research and prevention with Federal and foundation funding. Through a grant from the Agency for Healthcare Research and Quality (AHRQ), the AAP conducted a study on the child abuse recognition and reporting behaviors of pediatricians through their Pediatric Research in the Office Setting (PROS) program. The results of this study, which showed that pediatricians are not reporting 27% of the injuries they highly suspect are caused by child abuse, are leading the way to additional efforts by the AAP to support pediatricians in their difficult but crucial role in protecting the child from abuse, including sponsoring a multidisciplinary conference to identify strategies to reduce or eliminate barriers to reporting and hence improve the health and well-being of these extremely vulnerable children and their families. The results were published as a supplement to Pediatrics in 2008.
Important progress has been made in the field of child maltreatment prevention. The AAP served as an important participant in a 1999 conference sponsored by the CDC to develop a plan for CDC’s work on child maltreatment prevention. The AAP and the CDC continue to have a strong relationship, and in 2005 the CDC provided a grant to the AAP through a competitive application process to enhance pediatricians’ ability to prevent sexual violence. As a result of the funding, the AAP published an educational toolkit for health care professionals to assist them in incorporating sexual violence prevention messages into the health care they provide to children, adolescents, and young adults.
Shortly after the CDC Child Maltreatment conference in 1999, through funding from the Doris Duke Charitable Foundation (DDCF), the AAP sponsored a conference in collaboration with Prevent Child Abuse America to determine the best approach for pediatricians to prevent child maltreatment in the office setting. Additional funding ($1.5 million) from DDCF supported the development of material to use in pediatric offices to enhance anticipatory guidance and improve screening of children ages 0 to 3, and to prevent child maltreatment. In spite of these efforts, there is much work left to be done collaboratively with other organizations and federal agencies.
The American Board of Pediatrics
The American Board of Pediatrics (ABP) was founded in 1933. As one of the 24 certifying boards of the American Board of Medical Specialties (ABMS), the ABP certifies pediatricians who meet all credentialing requirements in general pediatrics and in approved pediatric subspecialties. The ABP strives to “… continually improve the standards of its certification (and to) advance the science, education, study, and practice of pediatrics.”
A new pediatric subspecialty, Child Abuse Pediatrics, has been developed, with initial certificates issued in 2010. Following several years of planning and preparation, representatives of the evolving subspecialty in Child Abuse Pediatrics, sponsored by the Ray E. Helfer Society and with support from the AAP, applied to the ABP for recognition as a pediatric subspecialty. After receiving approval from the ABP, the subspecialty was subsequently recognized by the ABMS, a subspecialty board was established, and work on the certifying process began. An important part of the process of establishing a new subspecialty is working with the Accreditation Council for Graduate Medical Education (ACGME) to set accreditation standards for the 3-year fellowship eventually required by all applicants for subspecialty certification. The ACGME is a private, nonprofit council established in 1981 when the academic medical community agreed about the need for an independent accrediting organization to evaluate and accredit medical residency and fellowship programs in the United States. The mission of the ACGME is to “… improve health care by assessing and advancing the quality of resident physicians’ education through accreditation.”
The Subboard of Child Abuse and Neglect first met at the ABP headquarters on December 12, 2006. The seven subboard members and a medical editor were selected from the leadership of the AAP’s COCAN and SOCAN as well as from the Helfer Society. The subboard developed requirements for certification in the new subspecialty and first offered the certification examination in November, 2009.
The purpose of the new Board certification is to create a pediatric response to child abuse and neglect by subspecialty-trained pediatricians active in research, education, and clinical service. Subspecialty recognition will encourage young physicians to continue research and scholarly activity, bring credibility to forensic testimony, and enhance multidisciplinary discourse focused on the prevention, intervention, and remediation of child abuse. By imposing standards for certification and recertification, only pediatricians who develop and maintain excellent skills and who possess the requisite cognitive knowledge base will be recognized as being certified in Child Abuse Pediatrics. In addition, certified subspecialists will be available to promote appropriate curricula in medical schools, residency programs, and continuing medical education programs. An important role will be to serve as consultants and referral sources for other physicians confronting possible child abuse or neglect cases in their practice.
The Ray Helfer Society
The Ray Helfer Society was founded in 1999 and incorporated in 2001 as an honorary society of physicians seeking to enhance the prevention, diagnosis, and treatment of child abuse and neglect. Initially, a small group of physicians with a special interest in child maltreatment met in Philadelphia to begin the discussions that led to the formation of the Society. Discussion focused on promoting education and training in the medical aspects of child abuse and neglect, and improving medical evaluation and care for children who are victims of child abuse and neglect. Other objectives of the Helfer Society are to advocate for improved resources for research in order to strengthen research and scholarly activity in the field. Society members agree it is important to promote high ethical standards for both clinical and forensic practice and research, to develop collaborative relationships with other professional organizations, and to emphasize the importance of the health consequences of child abuse and neglect. Acceptance into the Helfer Society is meant to honor an individual physician’s contributions to the physical and emotional health of victims of child abuse and neglect. The Society sponsors candidate members, usually younger physicians in Child Abuse Pediatrics fellowship training or in other related disciplines such as emergency medicine, public health, child psychiatry, pediatric radiology, or preventive medicine.
The Helfer Society sponsors an annual educational meeting open to regular members, candidate members, and guests. This meeting serves as a networking opportunity, a forum for state-of-the-art research presentations, and provides workshops on education, clinical guidelines, court issues, fellowship development, and other topics important to the field. Because the Society’s meetings have become the principle gathering of certified subspecialists, members are working on issues related to curriculum and scholarly activities, and other important issues related to fellowship training in Child Abuse Pediatrics.
American Professional Society on the Abuse of Children
The American Professional Society on the Abuse of Children (APSAC) is a national organization whose mission is to enhance the ability of professionals to respond to children and families affected by abuse and violence. APSAC primarily fulfills this mission through providing education and other sources of information to professionals who work in the child maltreatment and related fields. Among the resources that have made a significant contribution to the field is their journal Child Maltreatment .
International Society for Prevention of Child Abuse and Neglect
In 1977, C. Henry Kempe, MD assembled a group of child abuse professionals from around the world to found an international organization that would support and advance their work, the International Society for Prevention of Child Abuse and Neglect (ISPCAN). Today the mission of the ISPCAN remains the same. It is the only multidisciplinary international organization that brings together a worldwide cross-section of committed professionals to work toward the prevention and treatment of child abuse, neglect, and exploitation globally. ISPCAN’s journal Child Abuse and Neglect is a preeminent publication in the field of child abuse and neglect. ISPCAN’s biennial International Congress has attracted as many as 1000 professionals from 88 counties.
American Medical Association (AMA) National Advisory Council on Violence and Abuse (NACVA)
In 1991, the AMA founded the National Advisory Council on Violence and Abuse to support physicians in dealing with violence in America’s communities. The Council’s mission was (1) to identify, develop, and promote practices and policies that enhanced the physician’s capacity to recognize and identify the presentations and consequences of violence and abuse in all their forms; (2) to ensure that physicians are capable of providing appropriate responses when these issues are identified; (3) to educate the medical community to play an appropriate role in the prevention of violence and abuse; (4) to encourage other health care organizations to identify and work toward similar goals of violence prevention; and (5) to provide leadership, advocacy, support, and guidance to other related organizations that shared their goals. In the mid 1990s, the Council published a series of eight monographs on various issues of violence, abuse, and sexual violence: Diagnostic and Treatment Guidelines on Child Sexual Abuse ; Mental Health Effects of Family Violence ; Domestic Violence ; Child Physical Abuse and Neglect ; and Strategies for the Treatment and Prevention of Sexual Assault . Recently the AMA dissolved the NACVA due to financial cutbacks. The former AMA NACVA Council has formed a Transition Working Group (TWG) to develop a new organization and continue the work of the NACVA. The Family Violence Prevention Fund (FVPF) is providing an interim home and limited staff support to help the TWG determine appropriate next steps. During this transition, the organization’s name is the National Health Collaborative on Violence and Abuse (NHCVA), without reference to or use of the AMA’s name.
The Academy on Violence and Abuse (AVA)
Members of the American Medical Association National Advisory Council on Violence and Abuse developed the concept for the AVA when its members realized that increasing exposure to curricula focusing on violence and abuse in the core education of physicians, nurses, and other health care providers was an immediate necessity. In order to accomplish this goal, a professional membership organization was needed to give credence to this discipline. In addition, the Institute of Medicine, in its 2001 report, Confronting Chronic Neglect: the Education and Training of Health Professionals on Family Violence , suggested such an organization was needed to improve the infrastructure necessary to support this training. The mission and vision of the AVA is to “… advance health education and research on the recognition, treatment, and prevention of the health effects of violence and abuse. By expanding health education and research, the Academy will integrate knowledge about violence and abuse into the training of all health professionals, promote the health of all people, protect the most vulnerable, and advance health and social policy that promotes safe families, safe workplaces and safe communities.” In 2008, the AVA released its first comprehensive report, “Building Academic Capacity and Expertise in the Health Effects of Violence and Abuse: A Blueprint for Advancing Professional Health Education.” The report is available from the AVA through its web site http://avahealth.org/ .
Family Violence Prevention Fund
Although technically not a membership organization for professionals, the Family Violence Prevention Fund (FVPF) has made significant contributions to the health care field in an effort to prevent child maltreatment. The FVPF, whose mission is to work to prevent violence in the home and the community and to help those who have been devastated by violence, has a number of initiatives to protect children including programs aimed at improving father’s roles in their child’s lives. Of most significance to the health care field is their National Consensus Guidelines on Identifying and Responding to Domestic Violence Victimization in Health Care Settings, which is recommended by the AAP to prevent child maltreatment.
Advocacy and Research
Organizations play an important role by advocating for children, especially those that have been abused. For nearly four decades, the legislative staff in the AAP Department of Federal Affairs (DOFA) has worked to place and sustain children’s health on the national agenda. Through lobbying, coalition building, and raising public awareness, DOFA has cemented the Academy’s credibility and visibility on national child health issues. On issues related to child abuse, the AAP has played an instrumental role urging Congress to reauthorize the Child Abuse Prevention and Treatment Act (CAPTA) and to pass bills such as the Safe and Stable Families Act. The AAP has played an even larger role at the state level with the advocacy efforts of their Chapters. For example, because of the advocacy of the Oklahoma Chapter, physicians and child advocacy centers are able to receive compensation from the state for child abuse investigations through a special state fund created by raising the fee for filing a law suit. The Illinois Chapter worked with others in the state to get reimbursement from Medicaid for pediatricians who screen for maternal depression.
Organizations can play an increasingly important role in developing research in the field of child maltreatment. With the subspecialty of Child Abuse Pediatrics sponsored by the Helfer Society with the support of the AAP, and accepted by the ABP and the ABMS, a new generation of scholars will be created through accredited fellowships. Many studies in child abuse and neglect will benefit from collaborative, multisite projects. Organizations focused on the health consequences of violence and abuse, like the AVA and the AAP, will work to affect political policy decisions leading to funding for research. The organizations mentioned in this chapter, along with the many others focused on child maltreatment issues, can assist in the movement to recognize the critical public health consequences of all forms of violence and abuse, including child maltreatment.
Summary
Education of health professions, public awareness of the health consequences of maltreatment, and influencing of political processes can all be accomplished by dedicated professionals and staff through national organizations. When addressing the issue of child maltreatment, organizations lend credence to the magnitude of the problem and the need for intervention. Groups of individuals organized around specific issues can have a greater effect. In addition to those mentioned here, organizations such as Prevent Child Abuse America, the National Center for Shaken Baby Syndrome, Children’s Healthcare is a Legal Duty, and others help create forums for the advancement of knowledge, policies, and advocacy, all important to the eventual curtailment of child maltreatment.
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