Statement of Kent Hymel, M.D., Falls Church, Virginia, on behalf of American Academy of Pediatrics

Testimony Before the Subcommittee on Income Security and Family Support
of the House Committee on Ways and Means

May 23, 2006

Mr. Chairman, I am grateful for the opportunity to testify at this important hearing on our nation’s response to our abused and neglected children.  My name is Dr. Kent Hymel, and I am proud to speak on behalf of the 60,000 primary care pediatricians, pediatric medical subspecialists, and pediatric surgical specialists of the American Academy of Pediatrics.  Until recently, I sat on the Academy’s Committee on Child Abuse and Neglect, and I am President-Elect of the Helfer Society, the professional society of physicians specializing in child maltreatment issues.  I serve as Medical Director of the Pediatric Forensic Assessment and Consultation Team at Inova Fairfax Hospital for Children and am Associate Professor of Clinical Pediatrics at the University of Virginia.  I’m a retired Air Force pediatrician, where I was the first US Air Force medical consultant for child abuse and co-founded the Armed Forces Center for Child Protection at the National Naval Medical Center. 

The American Academy of Pediatrics has a deep and abiding interest in the health care provided to children at every stage of the child welfare system.  The Academy has published numerous policy statements, clinical guidelines, and studies regarding child abuse, neglect, foster care, and family support.  In addition, the Academy has recognized the unique challenges faced by children in foster care by designating children in foster care as one of the five issues highlighted in our Strategic Plan for 2006-2007.  A new Task Force on Foster Care will examine these issues holistically over the next three years and craft a multi-pronged strategy for the Academy to improve the health of children in foster care.

Overview of Child Maltreatment

In 2004, an estimated 3 million children were alleged to have been abused or neglected and received investigations or assessments by State and local child protective services (CPS) agencies. Approximately 872,000 children were determined to be victims of child maltreatment.  Over 60 percent of child victims were neglected by their parents or other caregivers, making neglect the most common form of child maltreatment. About 18 percent were physically abused, 10 percent were sexually abused, and 7 percent were emotionally maltreated.  In addition, 15 percent experienced "other" types of maltreatment based on specific State laws and policies.  Some children are victims of more than one type of maltreatment. [1]  

Sadly, these numbers are almost certainly only the tip of the iceberg.  The majority of cases of abuse and neglect go unreported.  In one major study sponsored by the Centers for Disease Control and Prevention, 25% of adults reported having been victims of physical and/or emotional abuse as a child, 28% said they had been physically abused, 21% said they had been sexually abused, and 11% had been psychologically abused.[2]  These numbers have enormous implications for the short- and long-term health of these individuals, in addition to the massive human and economic toll they represent.

At any given time, approximately 540,000 children are in foster care, most of whom have been placed there as a result of abuse or neglect at home.  Compared with children from the same socioeconomic background, children in foster care have much higher rates of serious emotional and behavioral problems, chronic physical disabilities, birth defects, developmental delays, and poor school achievement.[3]  Typically, these conditions are chronic, under-identified, and under-treated, and they have an ongoing impact on all aspects of their lives, even long after these children and adolescents have left the foster care system.[4]  Some of these conditions are a direct result of the abuse or neglect they have experienced. 

As a result of all these factors, children in the child protection system warrant special attention in all aspects of their health care.  Some require immediate health attention due to abuse or neglect.  Many have never received regular well-child care, such as immunizations.  A growing body of research indicates that the majority would benefit from targeted, long-term interventions directed at their individual health care needs.  A modest investment of resources at the earliest possible stages can often avert the need to spend far more later, not only in health care dollars, but also in education, law enforcement, and supportive services.

Science is beginning to quantify the long-term effects of child maltreatment in stark terms.  The Adverse Childhood Experiences study, sponsored by the Centers for Disease Control and Prevention and Kaiser Permanente, has examined the connection between childhood trauma and adult poor health status among over 18,000 middle-class adults.  The results of this study are nothing short of shocking.  Among those adults who had experienced the highest levels of childhood trauma – such as having been a victim of abuse or neglect, having had a parent die, or living in a home with mental illness or substance abuse – those individuals were:

• 5 times more likely to have been alcoholic;
• 9 times more likely to have abused illegal drugs;
• 17 times more likely to have attempted suicide;
• 3 times more likely to have an unintended pregnancy;
• 2.5 times more likely to develop heart disease; and
• twice as likely to be obese.

Based on these statistics, childhood trauma may be the leading cause of poor adult health in our nation.  When childhood trauma goes unaddressed by society, children and youth may turn to self-medication in the form of drugs, alcohol, tobacco, promiscuity, or food.  Each of these can produce a short-term improvement in an individual’s perception of their mental state, but all have devastating long-term health consequences.[5]  The cumulative costs to government and society likely exceed hundreds of billions of dollars.

Role of the Pediatrician

Pediatricians are uniquely positioned to prevent child maltreatment.  Pediatricians see most children on a regular schedule of well-child visits.  The typical well-child schedule dictates visits at the ages of 1, 2, 4, 6, 9, 12, 15, and 18 months, as well as annually after the age of 2 years.  This provides numerous opportunities to examine children thoroughly and observe their interaction with one or both parents, even if some visits are missed.

In addition, pediatricians already discuss with parents many of the most common “triggers” for abusive events.  Pediatricians talk to parents about how much their infant cries and offer strategies for coping.  Many parents appreciate information about the developmental stages and needs of their children.[6]  A parent may punish a toddler for “willfulness” without understanding that the child does not yet comprehend the “if-then” consequences of their actions.  The privacy of the doctor-patient relationship allows parents to discuss problems and issues with a physician that they might be reluctant to raise with a family member, neighbor or teacher.

Pediatricians and the Child Protection System Today

Today, pediatricians tend to exist on the periphery of the child protection system.  The average pediatrician reports suspected cases of abuse or neglect, but receives little or no feedback from the child protection system.  At the same time, pediatricians have little input into the structure or activities of child protective services.  Not only is this situation frustrating, but it fails to provide the pediatrician with information that could be vital to the child’s follow-up care.  Privacy laws often prevent the sharing of information that a pediatrician could use to monitor a child’s physical, emotional, and mental health in the wake of a substantiated report.

While virtually all pediatricians report cases of child abuse and neglect over their careers, only about 200 pediatricians in our nation specialize in child maltreatment cases.  This small cadre of doctors not only perform exams, but they also serve as expert witnesses, see and treat patients, perform research, and teach residents and medical students.  These pediatricians often work in academic settings or with Child Advocacy Centers, and serve as a resource to their fellow health care providers, social workers, child protective services, law enforcement, the judiciary, and many others.  As one of these providers myself, I can attest personally that we are spread extremely thin, isolated from one another, and often find it difficult to communicate or collaborate on even basic issues like best practices.

It is important to note that pediatricians and other physicians are mandatory reporters in all 50 states.  If a pediatrician suspects that a child is suffering from abuse or neglect, he or she is legally required to report that to the authorities.    

The Health Child Abuse Research, Education and Services (CARES) Network

Over the past three years, the American Academy of Pediatrics has devoted substantial time, effort and resources to the development of an initiative to bring the medical profession into full partnership in the prevention, diagnosis, and treatment of child abuse and neglect.

We propose the establishment of a network of regional consortia dedicated to the medical aspects of child maltreatment.  The Health Child Abuse Research, Education and Services (CARES) Network would consist of “virtual” centers that would link all of the medical resources on child maltreatment in a given area.  Each consortium would be different depending on the resources that existed already in that region.  These consortia will link all medical providers in a given region who deal with child maltreatment – pediatricians, family practitioners, emergency medical services, dentists, orthopedists, nurses, allied health professions, and others.  The consortia themselves would form a nationwide network.

The network would serve a number of critical roles in improving the prevention, detection and treatment of victims of child abuse and neglect.  These include:

• Communication.  Currently, health care providers who deal with child maltreatment are scattered and isolated.  Many practitioners are unaware of the resources that exist in their community, state, or region.  As a result, they may not know where to turn when they need to consult or gather information.
• Collaboration.  Those of us who specialize in this field find it difficult to collaborate and compete effectively for the dollars that already exist.  There is no structure for finding colleagues who are interested in similar types of research.  One pediatrician may not see enough cases of a particular type to conduct scientifically valid research, but if three or four collaborated they could assemble a solid study.  This is not possible given the current lack of communications and infrastructure.
• Education and Workforce.  At present, there are not enough pediatricians entering the field of child abuse pediatrics to replace those who are approaching retirement.  However, child abuse medicine is expected to become a boarded subspecialty of pediatrics later this year.  There is already a desperate need for training programs, ranging from curriculum for medical schools to short training seminars for existing health care providers.  This network would facilitate the creation and sharing of educational materials and successful programs as well as expanding the field of trained professionals, both specialists and educated generalists. 

As I stated earlier, we specialists cannot handle this problem alone – we need to bring the rest of the medical profession into partnership.  The Academy envisions the Health CARES Network serving as a resource to social workers, the child protection system, law enforcement, the judiciary, and many other agencies and professionals.  We went to great lengths, however, not to duplicate any existing programs.  This proposal does not replicate the efforts of Child Advocacy Centers or the National Child Traumatic Stress Network.  It includes no dollars for services or research.  It purely establishes infrastructure to enable communication, collaboration, and the effective development of resources and materials.  The Academy urges Congress to provide $10 million to the Centers for Disease Control and Prevention’s National Center for Injury Prevention and Control to begin the Health CARES Network.

In some areas of the nation, communities and states are making commendable efforts to prevent child maltreatment and intervene as early as possible when it is detected.  New challenges sometimes arise, such as the current increase in foster care placements due to parents’ methamphetamine addiction.[7]  Recent research is teaching us that the effects of abuse and neglect can be pernicious and long-lasting, but that early intervention can be highly effective.  The American Academy of Pediatrics believes that the Health CARES Network could play a crucial role in establishing and advancing programs with proven success in preventing maltreatment and addressing its effects by integrating pediatricians and other health care providers closely into these efforts.  My colleagues and I who specialize in child abuse pediatrics are happy to take on this extraordinary challenge on behalf of our nation’s most vulnerable citizens.  We just ask for your help to make this enormous task a little more manageable.

Mr. Chairman and Members of the Subcommittee, I deeply appreciate this opportunity to offer testimony on behalf of the American Academy of Pediatrics.  I stand ready to answer any questions you may have, and I thank you for your commitment to the health of the children of our nation. 

[1] U.S. Department of Health and Human Services, Administration on Children, Youth and Families. Child Maltreatment 2004 (Washington, DC: U.S. Government Printing Office, 2006).

[2] Centers for Disease Control and Prevention.  Adverse Childhood Experiences (ACE) study.  http://www.cdc.gov/NCCDPHP/ACE/prevalence.htm.

[3] Committee on Early Childhood, Adoption and Dependent Care.  "Health Care of Young Children in Foster Care."  Pediatrics, Vol. 109, No. 3, March 2002.

[4] Centers for Disease Control and Prevention.  Adverse Childhood Experiences (ACE) study.  http://www.cdc.gov/od/oc/media/pressrel/r980514.htm.

[5] Centers for Disease Control and Prevention.  Adverse Childhood Experiences (ACE) study.   http://www.cdc.gov/NCCDPHP/ACE/findings.htm.

[6]Olson, Lynn M. et.al.  Overview of the Content of Health Supervision for Young Children: Reports From Parents and Pediatricians.  Pediatrics, Vol. 113 No. 6 June 2004.

[7] National Association of Counties.  The Meth Epidemic in America:  Two Surveys of U.S. Counties:  The Criminal Effect of Meth on Communities and the Impact of Meth on Children.  July 5, 2005.