Foreword

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Positive human relationships are built on a foundation of mutual trust and respect. For relationships between parents and their children, there is also the fundamental assumption that parents will do all that they can to support and promote their children's growth and development, and to act as advocates for their children's well-being. In their everyday work, pediatricians begin with these assumptions about parent-child relationships, since they form the foundation for sound data-gathering and for partnership with parents and their children in providing medical care. It is our baseline expectation that we are partners with parents in advocating for the best interests of their children.

Perhaps the most disarming and challenging scenarios in the professional life of the pediatrician take place when these underlying assumptions about parent-child relationships and about our partnership with parents are violated. It is difficult for us to accept that we may encounter situations in which the parent is not the best advocate for their child, or may even have done harm. For most of the history of the medical profession, the physical and sexual abuse of children by their caretakers was not recognized, and certainly was not discussed or understood. Indeed, it was not until 1946 that the phenomenon of intentional child injury inflicted by a caretaker was described by John Caffey, a pediatric radiologist,¹ and not until 1962 that the landmark article by C. Henry Kempe triggered more widespread recognition and the subsequent establishment of state-by-state child protection protocols.²

The relatively recent recognition of child abuse as a phenomenon by the American medical profession has its parallel in the history of American society as a whole, as the need to protect a child from a parent or caretaker was not formally or legally recognized until after the infamous “Mary Ellen” case in New York City in 1874. Etta Wheeler, a social worker visiting the home of this severely abused 9-year-old girl, appealed to the ASPCA to assist in protecting the girl. At that time there was an organization to protect animals from cruelty but none to protect children, and there were no specific child protection laws on the books. Shortly thereafter, the New York Society for the Prevention of Cruelty to Children was formed.³

In the half-century or so since the reports of Caffey and Kempe, we have come a very long way as a profession and as a society in understanding and responding to the challenges of child abuse and neglect. This month's article on child maltreatment is written by Drs. Legano, McHugh, and Palusci, the medical leaders of the Frances L. Loeb Child Protection and Development Center at Bellevue Hospital Center and nationally recognized experts in child protection. The authors present a broad and evidence-based review of child maltreatment, including the epidemiology, clinical approaches to diagnosis, a detailed discussion and illustration of normal and abnormal physical findings in physical and sexual abuse, and prevention and treatment strategies. The authors also provide very practical and detailed guidelines for data gathering and recording information when child maltreatment is suspected. Although confronting child maltreatment poses challenges to our fundamental assumptions about the pediatrician-parent relationship, this month's article provides helpful information and strategies to ensure that, despite these challenges, we will remain prepared to advocate effectively for children.

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References 

1. Caffey J. Multiple fractures in the long bones of infants suffering from chronic subdural hematoma. AJR. 1946;56:163–173
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2. Kempe CH, Silverman FN, Steele BF, Droegmueller W, Silver HK. The battered-child syndrome. JAMA. 1962;181:17–24
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   • MEDLINE
3. Jalongo MR. The Story of Mary Ellen Wilson: Tracing the Origins of Child Protection in America. Early Childhood Education Journal. 2006;34(1):1082
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