The Partnership to Eliminate Child Abuse: Dr. Sandy Herr EMERGENCY DEPARTMENT Medical Director, Kosair Children’s Hospital Associate Professor of Pediatrics, University of Louisville

OBJECTIVES Review the scope of the child abuse epidemic Discuss the utility of a collaborative approach to addressing child abuse Describe the formation, goals, and initial efforts of the Partnership to Eliminate Child Abuse (PECA) Explore future directions for PECA and similar efforts

“The level of civilization attained by any society will be determined by the attention it has paid to the welfare of its children” Billy F. Andrews, MD Children’s Bill of Rights, 1968

A NATIONAL TRAGEDY More than 1,000,000 substantiated cases of child abuse and neglect/year in the U.S. Nearly 2000 documented deaths/year 80% < 4 years of age The leading cause of injury-related death < 1 year Rate is increasing 3.1/day in 1998, > 5/day in 2010

COSTS OF CHILD ABUSE Each child abuse case in a living victim costs approximately $200,000 Each child abuse death costs approximately $1.3 million Annual cost of child abuse and neglect in the U.S. estimated at $100 billion Likely an underestimate

A STATE OF EMERGENCY Kentucky Indiana More than 84,000 reported cases each year 30-40 known child abuse deaths/year Nearly 3 deaths/100,000 children Have ranked in the top 20 in child abuse fatalities for the past decade Ranked first in 2007 Indiana 29th worst for child abuse-related deaths 20-30 child abuse deaths/year

A CHILD’S SAFETY NET Family Community/church School/daycare Healthcare Social workers/child welfare Judicial system The following cases illustrate failure of one, several or all components of this safety net.

JJ: The infant with bruising 8 month old male with recurrent bruising since 3 months of age Multiple visits to his PMD Referred to hematology for a possible bleeding disorder Workup normal Referred to ENT for ear bruising Diagnosed with traumatic bruising, referred back to PMD Ultimately presents to ED with traumatic brain injury, multiple healing fractures

DS: The boyfriend factor 1 ½ year old boy admitted for genital bruising, abdominal trauma Diagnosed with non-accidental trauma, CPS report filed Letter from hospital child protection team stated that child would “be re-injured or killed if returned to that environment” Returned home after 2 months in foster care Presented to an outside ED 1 month later in full arrest, died from traumatic abdominal and brain injuries

TT: Little boy lost 3 year old boy with a femur fracture while in mom’s care No history CPS notified, child removed Due to prior domestic violence and paternal mental health issues, physicians and CPS recommended placement with grandparents At hearing, judge placed child with his father 1 month later, his father shot the child and himself to death

WHAT HAVE WE DONE ABOUT IT? Child abuse wasn’t even clearly recognized/described in the medical literature before the 1960s Animal protection laws pre- dated child protection Children viewed as property rather than people even through the first half of this century

HISTORY 1870s, 8yo Mary Ellen Wilson beaten daily by her foster family Lawyers for the ASPCA presented her case Foster mom received 1 year sentence NY Society for the Prevention of Cruelty to Children formed 1961: Dr. Kempe described the “Battered Child Syndrome” 1967: 44 states enact mandatory reporting for physicians

HISTORY 1974: Child Abuse Prevention and Treatment Act (CAPTA) passed Now all 50 states have mandatory reporting laws for all professionals involved in the care of children Criminal and civil liability for failure to report No liability for “good faith” reporting of suspicions Educational efforts largely focused on recognition and reporting of abuse

HISTORY Since the 1970’s, the dangers of shaking infants have been recognized “Never shake a baby” campaigns have lead to reductions in child abuse cases in some areas Education for new parents Dangers of shaking a baby Tips for dealing with crying infants Viewed by far more mothers than fathers Hospital-based in most cases

HISTORY Most pediatric centers and many communities have resources dedicated to addressing child abuse At KCH, we have had a Child Abuse Task Force since 2002, and a Pediatric Forensics Division since 2007 Law enforcement agencies specializing in child abuse investigation School and community-based social services Interaction between hospital and community-based resources are generally case-based and reactive

RESPONSE TO TRAGEDY: “REACTIVE” When a death or severe case of abuse occurs Family responses complex and often conflicted Denial Anger Grief Community shock and anger Media attention with shocking headlines and lead stories Within hours to days the case is forgotten by all but those directly involved

Child abuse often linked to unrelated, live-in lovers 2 charged in separate Jennings Co. child abuse cases Father tortures infant and leaves her with brain damage Child in Broomfield abuse case died of 'Oxycodone toxicity' Severely tortured toddlers mom and her boyfriend arrested Baby reportedly punched repeatedly in the stomach and face will likely die

A NEW APPROACH IS NEEDED: “PROACTIVE” Despite multiple efforts in all areas, abuse and abuse-related deaths have not decreased Improved detection, reporting are often too late High risk groups not identified/targeted for education Newborn education directed at new parents fails to address unrelated caregivers Abuse and neglect have not consistently been in the public consciousness Little collaboration/cooperation across groups

HOUSE BILL 285 KY Legislation mandating education on pediatric abusive head trauma New parents Child care providers EMTs and paramedics RNs ARNPs Law enforcement officers Foster parents Physician assistants Social workers

A NEW APPROACH Collaboration: “the act of working together in order to achieve shared goals” Can a collaborative effort link key players across all realms? Common goals Varied backgrounds, skill sets and resources Different levels of access to families and children at risk

WHAT DOES COLLABORATION LOOK LIKE? Who are the key players? How do we get the players to the table? What are the common goals on which to focus? How do we begin working toward those goals?

WHAT COLLABORATION DOESN’T LOOK LIKE

CHILD ABUSE COLLABORATIVES Successful efforts have occurred in other communities Most include healthcare providers, community leaders, social workers Few include judicial, law enforcement, and media representatives Most are limited to one hospital or system or a small geographical area

THE PARTNERSHIP “A group of people working together for a common purpose” Key players Physician leaders, hospital and community-based Child abuse/forensics, private practice, ED 4 Children’s Hospitals Riley, Peyton Manning, Kosair Children’s Hospital and Kentucky Children’s Hospitals 4 Medical Schools in Kentucky and Indiana Indiana, Pikeville, Kentucky, and Louisville

THE PARTNERSHIP Broad partners More than 200 groups, organizations, and individuals Social workers Child advocacy Media/PR representatives Community leaders School leaders Judicial and law enforcement organizations Legislators Judges Lawyers Business leaders

THE VISION Prevention, detection, and treatment have all fallen short of our goal Elimination should be the ultimate goal The name evolved from this lofty goal Vision statement: To completely eliminate child abuse in the areas served by our partnership’s member organizations

THE APPROACH Engage the media Public awareness campaign PSAs Op-ed columns Expert availability for interviews Public awareness campaign Videos Website: www.pecakyin.org Education for schools, community organizations, etc. Achieve a constant presence in the public consciousness

INITIAL EFFORTS Family champions Op-ed columns Families of victims sharing their stories Op-ed columns The child abuse problem in Kentucky and Indiana Warning signs of abuse Unrelated caregivers/boyfriends Crying New parents need extra support Expert media spokespersons identified

INITIAL EFFORTS Public Service Announcements Toolkit Allows others to borrow/use the PECA materials for their area/target audience Tips for eliminating child abuse Videos

THE FUTURE Educational campaigns Media saturation Social media School-based education Other high risk groups Expanded educational efforts for expecting/new parents Expanded mandatory education for physicians, others involved in the care of children Media saturation Keep abuse and neglect in the forefront Social media Perpetrator perspective?

CORNELL AND KARLIE

“All that is necessary for the triumph of evil is that good men do nothing” Irish philosopher Edmund Burke

SUMMARY The Partnership to Eliminate Child Abuse is a collaborative effort Linking diverse organizations and individuals across Indiana and Kentucky Common goal of completely eliminating child abuse Multifaceted approach using media, physician champions, families Educational and awareness campaigns Seeking to establish and maintain child abuse in the public consciousness