Helping Children – and Families – Through the Darkest Days
When so much is at stake—when a child may be taken from parents or left in an abusive environment—special expertise matters. Columbia's Jocelyn Brown, MD, is among a small number of pediatricians in the US trained to evaluate potential child abuse patients.
“The idea is not to find abuse but to protect the child,” says Dr. Brown, whose team at Columbia is tapped when potential child abuse victims arrive at the medical center. She and her colleagues use their training and experience to diagnose injuries caused by child abuse, but also interview parents and caregivers and to piece together the story behind the injuries.
They also appear frequently as expert witnesses in criminal and family court and confer with police detectives, the district attorney’s office, and child protection officers.
Over her decades in practice, and through her research, Brown has been integral to the evolution of her field. In the beginning, doctors lacked standards for physical findings of abuse and protocols for interviewing and reporting. Today the set of practices is well-delineated and evidence-backed. Pediatricians entering the child abuse pediatrics now receive training in orthopedics, radiology, and injury mechanisms, in how to work with outside investigators and attorneys, and in how to testify in court. For the past 14 years, child abuse pediatrics has been a recognized subspecialty with board certification.
That expertise, encouragingly, leads to fewer abuse cases brought against caregivers. “Studies have shown that cases that are reviewed by child abuse pediatricians and pediatric radiologists tend to have fewer findings of abuse than when a pediatrician or hospital does not have access to those specialists.”
Columbia as first responder
Columbia is a key first responder for child abuse victims in New York City. Children and adolescents who arrive at NewYork-Presbyterian Morgan Stanley Children’s Hospital’s pediatric emergency department, or who are admitted to the hospital with suspected or confirmed physical or sexual abuse, neglect, or medical child abuse, are connected with Dr. Brown and her team and for medical evaluation and psychosocial assessment. Dr. Brown also directs the Columbia program serving the Manhattan Child Advocacy Center, the designated referral center in the borough run by Safe Horizon, a national victim assistance organization that operates programs across the city.
Child abuse is all too common, affecting at least 1 in 7 children in the US in past year. The most common form of child abuse, accounting for 70 percent of reports, is not physical or sexual abuse, but neglect. Signs that alert teachers and others that a child is suffering neglect include missed appointments and school days, wearing the wrong clothes in winter, or when a mother declines mental health services for the child, says Dr. Brown. Through the HEARS (Help, Empower, Advocate, Reassure and Support) Family Line—a new NYS Office of Children and Family Services initiative created to prevent calls based on race and poverty to the State Central Registry of abuse and maltreatment—pediatricians are now able to connect families directly to services without having to make a report. Parents can also contact HEARS (1-888-554-3277) to access services including food, clothing, housing, medical and behavioral health care services, parenting education, and childcare.
Physical abuse is most common in very young children, and those who are disabled. Many cases of abuse go unreported until a child is brought to the emergency room with a serious injury. Because children who come in with certain types of bone breaks and bruises have likely been abused before, their exams include a full body x-ray looking for prior fractures characteristic of abuse.
The medical team’s aim is to rule out other explanations for injuries. Fractures, for example, can be caused by a vitamin deficiency, metabolic disorder, or other medical condition, so Dr. Brown might bring in a pediatric endocrinologist or a geneticist to rule out other conditions, and would test the child’s vitamin D levels to rule out rickets. “We do a differential diagnosis and look for everything else that it could be before we can say there's no explanation other than abuse. It's so important to be at a children's hospital for this work,” Dr. Brown adds. “We rely on the expertise of our pediatric radiologists or geneticists and other specialists to help us interpret radiological findings and think about other causes.”
Diagnoses of sexual abuse are based on disclosures made by a child or a teen, she says, and all disclosure of this kind should be taken seriously. “Social media has really changed the landscape and given kids access to chatrooms, pornography, and very sexualized materials. Teenagers, especially those who are at risk, who are bullied, lonely, depressed, will go and meet someone, and can be assaulted.”
After assessing a child, Dr. Brown, usually accompanied by a social worker, meets with the parents or caregivers. “That first assessment should be done as quickly as possible so parents don't have time to change their story. And again, the idea is not to find abuse or to trick parents, but to think carefully about what happened,” she says. “I tell them, ‘I can see that you are a concerned parent because you are here. I am a specialist in trauma, and want to help. I want to protect your child, and make sure this doesn't happen again, so I have questions.’ This is one of the challenging parts of this job: We have to put the pieces of the story together like a puzzle.”
Once Dr. Brown has gathered all of the information, her team communicates everything to the detective, case worker, and prosecutor. When cases are later brought against a parent or caregiver, they are tried in family and/or criminal court, and Dr. Brown is likely to be subpoenaed about why she believes the child has been abused.
Through a follow up clinic Dr. Brown continues to see children for a couple of years whose cases she’s been involved in. “If a young child is abused and has had trauma, you really don't know the impact of the injuries until they're old enough to talk or walk,” she says. “So I usually continue to see them. And when I testify, it can be a year after the reported incident. I like to have that perspective on the case and sometimes I get additional insights, or a parent might confess.”
Drop in abuse cases during COVID pandemic
Many people in the field thought that the COVID pandemic would lead to a spike in child abuse cases, since the abusers would be in the home with the children, and children would not be monitored through schools. Instead, most data indicate that abuse has decreased. “All of the emerging literature shows that cases of neglect are linked to poverty. And during COVID we were helping families with their basic needs,” she says.
These findings support a growing movement in child welfare to rethink how neglect and abuse cases are approached—a “mandate to support” rather than “mandate to report.” “We’re now thinking about how can we help families before they are really not able to take care of their kids,” Dr. Brown says. “Child Protective Services is creating systems to support families by linking them to services rather than investigating them. Of course, if the child is abused, is shaken, is sexually abused, those cases deserve investigation and the child needs to be protected and possibly removed.”
In preparing an article for The Lancet, Dr. Brown has been reviewing the literature on universal healthcare and universal pre-K and daycare and how these relate to rates of neglect, she says. “The data is amazing. In places where there are more services, families’ basic needs are met and fewer children are removed from their homes. It is time to develop a less punitive, less biased system, and to help families upstream, before maltreatment occurs.”