Fred Silverman, MD, (center) and Corning Benton, MD (left) check a patient's X-ray.
Cincinnati Children's Led the Way in Recognizing Child Abuse
Fred Silverman, MD, the first director of Radiology at Cincinnati Children's, was a pioneer in the use of diagnostic radiology to identify child abuse.
In the early 1980s, Children’s Hospital’s fledgling Child Abuse Team was facing an unexpected “pandemic.” The numbers of child sexual abuse cases had been increasing dramatically over the past 5 years, from a few dozen cases to now several hundred cases annually. The team’s limited resources and expertise were being stretched beyond capacity.
Fred Silverman’s landmark paper, “The Battered Child Syndrome,” co-authored with C. Henry Kempe, had appeared in the Journal of the American Medical Association (JAMA) in 1962, but it had taken nearly 20 years for physicians to openly acknowledge the reality of child abuse, and even longer for many hospitals to develop protocols and to hire physicians, nurses, and social workers who were willing to deal with this emerging problem.
Cincinnati Children’s was one of the first in the country to establish a child abuse team, and this was due largely to the vision and advocacy of Pat Myers, director of Social Services. In 1976, drawing upon her contacts from her previous employment at the Hamilton County Children’s Services Department, she put together a multidisciplinary team of hospital physicians and social workers, case workers from 241-KIDS (the county’s emergency abuse hotline), protective, foster care and adoption services, and the Youth Aid Police, a special unit dealing with child abuse and juvenile delinquency. Ambulatory Services director Mark McGovern, MD, and his fellows were early physician members of the team.
Ironically, the team was formed the same year that Silverman, who had served for over 30 years as the pioneering director of Radiology at Children’s, departed for an academic position at Stanford. Fortunately, he left behind a team of colleagues with exceptional expertise in the radiological pathology of child abuse, including Corning Benton, MD, and Alan Oestriech, MD.
Finding Our Way
The new Child Abuse Team met weekly to review all new and ongoing child abuse cases and to develop protocols for management. Increasing awareness led to increasing identification. Victims of physical child abuse usually presented to the ED. But at this time, there were no Emergency Medicine specialists. The ED was run by house staff and moonlighting fellows. A few Ambulatory staff physicians were available for consultation during peak hours. As a result, child abuse cases were usually managed by residents, most of whom were inexperienced and uncomfortable dealing with these highly charged situations and fearful of the consequences, such as being called to testify in court.
At the time, the only guideline the ED had available was “Rape Protocol A,” which had been copied from the one used at University Hospital for adult victims. It was basically a forensic exam: the victim’s body was swabbed and brushed for “evidence,” which was then placed into a sealed paper bag for the police to pick up the next day.
It quickly became apparent to the team that this protocol was inappropriate for handling young victims of alleged sexual abuse. Unlike adults, most children presented weeks to months after the abuse, making a forensic exam unnecessary. More to the point, young children were not particularly good historians: they were often vague about dates, times and places. They typically lacked the vocabulary to accurately describe what had happened. In fact, their stories often emerged in stages, requiring several interviews by trusted, experienced staff. Often, the nature of the sexual contact itself left no obvious physical findings.
Pat Myers, director of Social Services, was the driving force behind the SAM Clinic.
"Going to court was nerve-wracking. Sometimes I had to remind myself that I was not the one on trial."
Ann Saluke, MD
Bob Shapiro, MD, who now directs the Child Abuse Team in the Mayerson Center for Safe and Healthy Children, was an early advocate for protecting kids via the SAM Clinic.
A New Approach
Myers was convinced that there had to be a better way to manage this problem. She brainstormed with her colleague Jeri Shamroy, who was becoming the team’s sexual abuse interviewing expert, and with Elaine Billmire, MD, then physician-director of the team. They decided that they needed to find a more comfortable environment than the ED, where these children and their families could come to be examined and interviewed by experienced professionals. And thus, the Social and Medical (SAM) Clinic was born in 1982. It was operated by staff physicians and social workers and met weekly; children presenting acutely to the ED could be referred there; private physicians, as well as caseworkers from 241-KIDS could also refer patients directly.
Demand for appointments in the SAM Clinic soon outstripped availability. Many of the victims preferred a female physician. And so, Myers solicited the aid of community pediatricians. Drs. Nancy DeBlasis, Jan Borcherding, Evie Joseph, and Ann Saluke all volunteered time out of their private practices to make SAM Clinic a viable, preferred alternative to ED evaluation.
“I started in 1984,” recalled DeBlasis, “Pat recruited us and helped train us. We had regular meetings together to discuss issues/cases and try to keep up to date. I worked on my day off. It was a stressful but also very rewarding experience.”
SAM clinic physicians were the first to learn how to use the colposcope, which had just been introduced as a tool to assist in the identification of the often subtle physical findings.
“In clinic we completed a history and exam and determined if there was physical evidence of abuse,” recalled Saluke, who worked at SAM at Burnet Campus, and later at its satellite in Eastgate, from 1986 through 2003, “Cultures were sometimes sent. In the majority of cases, there was not physical evidence. Then a determination was made about referral to police and prosecutor if they were not already involved.”
Both she and DeBlasis acknowledged the stress of having to testify.
"Going to court was nerve-wracking,” Saluke admitted, “Sometimes I had to remind myself that I was not the one on trial. I felt my role as physician—completing the exam and testifying if need be—was a small piece compared to the work of the social workers and the long term effects on the patient and family.”
The SAM Clinic continued to provide these services for nearly 20 years, eventually operating with a core of seasoned staff members in addition to these community physician volunteers: Drs. Bob Shapiro and Chuck Schubert, social worker Ann Brandner, and nurse Robin Lambert, along with many other nurses and social workers, all collaborated to continuously improve the outcome for sexual abuse victims.
The SAM Clinic was eventually subsumed into the Mayerson Center for Safe and Healthy Children, which opened in January 2001, with Frank Putnam, MD, as division director, Myers as clinical director and Shapiro as medical director of its Advocacy Center. The center operates under a Memo of Understanding in Hamilton County, with law enforcement and, at times, Children’s Protective Services co-located within the center.
“It is so much better than the kids having to tell their story to strangers multiple times,” acknowledged Saluke. The center provides not only direct clinical services to abused children and their families, but also professional education and training, research, advocacy and outreach.
The SAM Clinic was the early prototype of supportive services for victims of child sexual abuse, which are now provided efficiently and comprehensively at the Mayerson Center for Safe and Healthy Children.
Elaine Billmire, MD, served as the physician-director of the Child Abuse Team.