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History of Child Abuse in the United States (#NCAPM)

This is the first installment of a six-week National Child Abuse Prevention Month (#NCAPM) blog series about child abuse and how we are working to prevent it. Dr. Skinner is a child abuse pediatrician who has practiced for more than 30 years, nine of them at the Children’s Center. She is currently a medical consultant for the Child Advocacy Center of Jackson County and now serves on Children’s Center’s Board of Directors.

Guest Post by: Sue Skinner, MD and Children’s Center Board Member

In 1874, 10-year-old Mary Ellen McCormack was adopted from a New York orphanage. After her adoption, her father passed, and her overwhelmed mother started physically abusing Mary Ellen daily.  Neighbors complained and Mary Ellen was assigned a caseworker, but in the 19th century there were no child protection laws.  The caseworker approached the American Society for the Prevention of Cruelty to Animals (ASPCA) for help.  The ASPCA approached a lawyer to argue the case before the NY Supreme Court that Mary Ellen should be removed from her home.  Mary Ellen testified before the judge, she was removed, and her adoptive mother was charged.  Later that year, the New York Society for Prevention of Cruelty to Children was founded. Mary Ellen was eventually adopted by her caseworker and lived a long life.  This landmark case, however, did not initiate immediate change in national policy.

In the mid twentieth century, the first national conference on child abuse was held and the nation’s first child abuse multidisciplinary team (MDT) was established.  This team in Denver was comprised of hospital-based professionals from different disciplines who met regularly to discuss cases where there were concerns of abuse.  Today, the MDT is the standard on how we work to keep children healthy and safe.  By meeting together as an MDT, we acknowledge that the sum of our collective knowledge is greater than the individual parts.

In 1962 a landmark paper, “The Battered-Child Syndrome”, was published in the Journal of the American Medical Association.  The lead author, pediatrician Dr. Henry Kempe, presented two children with head injuries and unexplained fractures, speculating the injuries were nonaccidental and the children had suffered abuse by their caregivers.  Surprisingly, responses were mixed, with some professionals thanking Dr. Kempe for exposing the realities of abuse, whereas others chiding him, stating they didn’t know where he got his information as they had never seen such a case of abuse.  To many at the time, the possibility that parents might harm their own children was unthinkable.  In retrospect, we now understand why this paper is considered one of the best pediatric research articles in the past 150 years, as more than 80% of abused children are abused by caregivers.

In 1974 the federal government established the Child Abuse Prevention & Treatment Act (CAPTA). This not only created a federal definition of child abuse, it also created a structure and plan for how the federal government provided funding to states for child abuse assessment, investigation, treatment, prosecution, and prevention.  This legislation provided an office at the federal level for education, research, grants, and projects related to child abuse. Now all 50 states have mandatory reporting child abuse laws.

Continuing with his expertise and passion, Dr. Kempe gave a talk at a national pediatric conference in 1977 called “Sexual Abuse: Another Hidden Pediatric Problem”. Prior to this, sexual abuse (especially within families) was felt to be very rare; Dr. Kempe acknowledged how common it actually was and also called out the medical profession, stating they had responsibility to keep children safe, instead of viewing sexual abuse as a “family” or “social services” problem.

In response to research, recognition of professionals, and federal legislation, the 1980’s demonstrated an explosion of Child Advocacy Centers (CACs), MDTs across the country and also the founding of the National Children’s Alliance (NCA), the membership organization which serves and accredits the (now) more than 900 CACs across the US.

In 1998, a paper was published regarding a CDC-Kaiser study led by Dr. Vincent Felitti and Dr. Robert Anda: “Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults:  The Adverse Childhood Experiences (ACE) Study”.  More than 17,000 adults had answered a questionnaire about the childhood trauma they experienced.  This was a groundbreaking public health study and has been called one of the most significant public health papers of the century. Conclusions demonstrated a strong association between the degree of childhood trauma one experienced and adverse physical and mental health outcomes in adults.

As Dr. Kempe’s work had been essentially a “call to action” for the medical profession, in 2009 the American Board of Pediatrics approved a subspecialty certification:  Child Abuse Pediatrics.  That year, 191 pediatricians across the nation took and passed the exam.  This began a new era of medical knowledge, commitment, and expertise in the health and safety of children.

Using the foundations established by the ACE study, the 21st century has demonstrated increased research and knowledge in understanding how adverse experiences of childhood impact our adult physical and mental health.  The scientific community has gained a better understanding of the different types of stress children endure, and how toxic stress activates the body’s stress response mechanisms.  Over time, prolonged toxic stress has the ability to disrupt brain architecture and other organ systems, increasing the likelihood of stress-related disease and cognitive impairment.  As a result of research in this area, we have all gained more knowledge of terms such as cortisol, fight-or-flight, and the potential long-term impact of prolonged childhood adversity.

It has been nearly 150 years since Mary Ellen talked of her abuse to a New York judge. We recognize that responding to abuse and neglect is not a choice but a necessity, and the impacts of not acting have the potential for lifetime adverse consequences for children.  We also recognize that it takes a team of professionals to protect children.  Working together, we bring our collective expertise and we demonstrate respect to each other and to those who are often not heard.  Of course, that doesn’t mean our work is done.  In many ways, we have just begun, but our path is clear.

– Sue Skinner, MD

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