In 2006, there were nearly one million cases of substantiated child
abuse and neglect in the United States and approximately 1,500 children
were known to have died as a result of maltreatment.[1] The recent article
by Starling, et al describes how in the face of this monumental public
health burden, only 70% of pediatric senior residents feel comfortable,
and somewhat less feel competent, with the diagnosis and management of
this rampant pediatric problem.
By way of vivid contrast, the American Heart Association reports that
about 36,000 children are born with a heart defect each year and a
mortality that varies from 1 to 5 % depending on the condition and care
provided. [2] The American Cancer Society estimates that approximately
10,000 cases of pediatric cancer are diagnosed each year with
approximately 1,500 deaths per year as well; yet these serious medical
conditions receive more emphasis in training programs than child
maltreatment, despite their comparatively lower incidence and similar
mortality. [1,3] By any account, child abuse and neglect is a relatively
large problem but it appears that its socially uncomfortable overtones
create some ambiguity in terms of its place in pediatric training. We get
the sense that we have been here before and would value hearing from Dr.
Starling and her authors what they see as the reasons for this persistent
ambiguity despite the large numbers of children and families affected by
this problem.
In 1975, the phrase “the new morbidity” was coined by Haggerty et al
to describe the effect of maltreatment on child health. [4] Dubowitz first
called for improved physician training and resources in the area of child
maltreatment in 1988. [5] Ten years later, Giardino et al found that a
majority of faculty and residents in pediatric training programs are not
satisfied with the quality of their training in this field. [6] Narayan et
al discovered that the level of resident preparedness for dealing with
cases of child maltreatment was associated with increased clinical
experiences and increased didactic teaching, but more than a third of new
residency graduates categorized themselves as less than well-prepared. [7]
Starling’s study illustrates that the need for further education on child
abuse and neglect topics has persisted relatively unchanged for over
twenty years. Despite the outcry from specialists in the field, child
abuse has remained on the periphery of many residency training programs’
vision for an appropriate curriculum for resident physicians.
In the past, each author hypothesized similar obstacles to the
progress of child maltreatment education: emotional reaction to the child
victims and their families, lack of a formalized curriculum or required
rotation, discomfort with the agency system that manages referrals for
suspected abuse, and limited financial support for a specialty with few
options for reimbursement are all fingered as culprits. Do these same
obstacles exist today? Will we be revisiting the same issues in the
decades to come?
It is essential to improve pediatricians’ skills in identifying child
abuse and neglect in order to reduce its associated morbidity and
mortality, and to ultimately prevent its occurrence. As a medical
community, we must realize that the adverse effects of child maltreatment
may extend far beyond the pediatric years. Education is needed; this point
has been made more than abundantly clear. How much longer must this
“silent epidemic” remain silent?
1. U.S. Department of Health and Human Services, Administration on
Children, Youth and Families. Child Maltreatment 2006 (Washington, DC:
U.S. Government Printing Office, 2008).
2. American Heart Association. Congenital Heart Defects in Children Fact
Sheet. Dallas, TX: American Heart Association. Retrieved Apr 30, 2009
from http://www.americanheart.org/presenter.jhtml?identifier=12012
3. American Cancer Society. Cancer Facts and Figures 2007. Atlanta, GA:
American Cancer Society. Retrieved December 26, 2007, from
http://www.cancer.org/downloads/STT/CAFF2007PWSecured.pdf.
4. Haggerty RJ, Goghmann KJ, Pless IB. Child Health and the Community. New
York: John Wiley & Sons; 1975, 94-116.
5. Dubowitz H. Child abuse programs and pediatric residency training.
Pediatrics. 1988;82(3):477-480.
6. Giardino AP, Brayden RM, Sugarman JM. Residency training in child
sexual abuse evaluation. Child Abuse Negl. 1998;22(4): 331-336.
7. Narayan AP, Socolar RRS, St Claire K. Pediatric residency training in
child abuse and neglect in the United States. Pediatrics. 2006;117(6):2215
-2221.
Conflict of Interest:
None declared
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