JOINING FORCES

Joining Families

Volume 18, Issue 4 • Spring 2020

R E A L W O R L D R E S E A R C H F O R F A M I LY A D V O C A C Y P R O G R A M S

F E AT U R E D I N T E R V I E W

The Armed Forces Center for Child Protection:
DoD’s Experts in Child Abuse Pediatrics
Interview with Barbara R. Craig, MD, FAAP, CAPT, MC, USN (Ret)Barbara R. Craig, MD

Dr. Craig has been a participant in Navyand DOD Family Advocacy Programs (FAP)
since she was a pediatric resident in 1979 at theNaval Regional Medical Center, Oakland, CA.
Her interest in the medical evaluation of child

In This Issue

The focus of this JFJF is expert medical consultation on child abuse
and neglect cases. We present an interview with Barbara R. Craig, M.D., achild abuse pediatrician who established the Armed Forces Center for Child
Protection (AFCCP), located at Walter Reed National Military Medical Center,
Bethesda, MD. The interview describes the range of services AFCCP staff
provide to health care providers (HPCs), criminal investigators, and attorneys
involved in the treatment, investigation, or prosecution of incidents of childmaltreatment DoD-wide. Additional related articles include a review of medical
conditions which health care providers may mistakenly label as child abuse,or conversely, fail to report despite having suspicions. Furthermore, we offera review of how the use of clinical prediction rules are helping HCPs identify
and more thoroughly evaluate cases of suspected child maltreatment, Finally,
we conclude with a review of individual and organizational factors which canhelp mitigate secondary traumatic stress (STS) related burnout among HPCs
and forensic interviewers with high exposure to child maltreatment. Websitesof Interest include the AFCCP website which provides contact information
and a brief overview of the services they offer, as well as National Children’s
Alliance (NCA) website with special emphasis on their efforts to establish
partnerships and collaboration between Children’s Advocacy Centers andmilitary installations.

Contents

The Armed Forces Center for Child Protection: DoD’s Experts in Child Abuse
Pediatrics.......................................................................................................1
Mimics, Missed Cases, and Flawed Theories of Child Maltreatment..............7
Predictors and Moderators of Burnout among Child Maltreatment
Professionals.................................................................................................9
Clinical Prediction Rules in Clinical Care......................................................10
Websites of Interest.....................................................................................12

maltreatment continued over many other Navy
assignments. Her evaluations have included allforms of child maltreatment. At the Naval Hospital Bremerton, she was introduced to the fieldof child abuse pediatrics and the forensic studyof child abuse including child forensic interviewing. Between 1990–1996, Dr. Craig offered thefirst clinical rotations for Navy pediatricians toobserve the clinical assessments of child abusecases and she developed training presentations
on the medical investigations of child maltreatment. While still at Bremerton, she created themilitary’s first child fatality review team. In 1996,
she founded the Armed Forces Center for Child
Protection at the [then] National Naval Medical
Center, Bethesda, MD, later to become the current
Walter Reed National Military Medical Center.


Dr. Whalen: What does the Armed Forces
Center for Child Protection do?
Dr. Craig: We provide objective childmaltreatment expertise when and where it isneeded throughout the DOD. We offer clinicalservices and consultations, training and education, medical-legal case reviews, and expert
testimony in military courts.
Dr. Whalen: What events led to its creation of
AFCCP in 1998?
Dr. Craig: Throughout my career as apediatrician, I have been interested in childabuse pediatrics. In 1996, I wanted to create a
consultative service for DOD on medical issues involving child maltreatment. I presented
Continued on page 2

An interview with Barbara
R. Craig, MD, from page 1

We provide a wide
variety of services
regarding childmaltreatment:
1. Clinical care — childforensic interviews andmedical examinations
2. Training andeducation
3. Medical legal casereviews
4. Expert consultationand testimony inmilitary courts.

my vision of the AFCCP to my commanding
officer at the National Naval Medical Center,
Bethesda. My proposal was approved by the
Board of Directors. We established our Centerat our current location, on the 10th floor of the
now Walter Reed National Military Medical
Center. Each wing of the floor is dedicated to adifferent aspect of our services. I invited LtCol
Kent Hymel, USAF, MC, another pediatrician
specializing in child maltreatment, to join me
at the newly created AFCCP. We borrowed atruck from the hospital, drove down to a General Service Administration (GSA) warehouse,
selected used government furniture, and handcarried it to our new spaces prior to our grandopening.
Dr. Whalen: Please describe the capabilitiesof your staff.
Dr. Craig: Child abuse pediatrics is abroad and difficult field that requires multidisciplinary expertise. Our staff includes
board certified child abuse pediatricians, apediatric nurse practitioner, a social worker
who conducts our forensic interviews, a clinic
administrative manager, and a medical support
assistant.
We provide a wide variety of services
regarding child maltreatment to multidisciplinary professionals within the DOD. These
include:JOINING FORCES
Joining Families
Joining Forces Joining
Families is a publication of
the Center for the Study ofTraumatic Stress (CSTS) andthe U.S. Army Installation
Management Command.
The CSTS is part of the
Department of Psychiatry,
Uniformed Services
University (USU), Bethesda,
MD 20814. The USU is the
US national federal military
medical school.

EditorRonald J. Whalen, PhD, LMSW
Research Assistant Professor
Department of Psychiatry, USU
e-mail to ronald.whalen.ctr@usuhs.edu(301) 319-8003
Editorial Consultants
Joshua C. Morganstein, MD
Captain, US Public Health Service
Assistant Director, CSTS
Associate Professor and Assistant Chair
Department of Psychiatry, USU
James E. McCarroll, PhD, MPH
Research Professor
Department of Psychiatry, USU
Assistants to the Editors
Alexandra Burris, BA
Britany Mullins-Husain, BA

2 • Joining Forces/Joining Families

1. Clinical care — child forensic interviews
and medical examinations
2. Training and education
3. Medical legal case reviews
4. Expert consultation and testimony in military courts
The AFCCP uses state of the art equipment
for recording the interviews. We have an observation room for health care and mental healthproviders in training, civilian child protective
service (CPS) personnel, military or civilian
law enforcement, and military family advocacy
program (FAP) personnel. Occasionally, JAGs
observe the child interviews. Our exam room isequipped with a video-photo-colposcope andvideo monitor for teaching and documentationof examination findings. We have the ability
to digitally record and photograph the exam
findings in both physical and sexual abusecases. Although we prefer to see the children
here at our facility, the AFCCP staff will travel
to see children at other military installations on
a case-by-case basis for special circumstances.
The AFCCP has performed many thousands of
medical-legal consultations in addition to seeing patients and providing guidance to military
physicians world-wide.
Dr. Whalen: What does a typical AFCCP
consultation involve?
Dr. Craig: The largest percentage of ourwork involves conducting medical-legal casereviews for criminal investigative agencies andmilitary attorneys and second opinions forhealth care providers and for FAP. If we accept
the case, they send us the written materials,
which can include thousands of pages of files,
recorded interviews, radiographs, scene photos,
and photographs of injuries. Once we havecompleted a thorough analysis of the records,
we return a report to the requesting agency.
We also offer assistance such as recommending
other medical, social, or criminal investigations and understanding the biomechanics of
injuries.
My staff and I assist physicians and other
health care providers with understanding theirrole in court proceedings. This includes discussing the questions they may be asked, how to respond in clear, concise and easy-to-understandlanguage, and the importance of attention tominor details. We also provide them with theContinued on p. 3

Spring 2020

An interview with Barbara
R. Craig, MD, from page 2

We consider
alternative
hypotheses in our
differential diagnoses
and explanations forinjuries that might
be accidental or
mimicked by medical
conditions.

latest literature applicable to the case in question.
For military JAGs, we provide consultation
to both the government (prosecution) and defense attorneys. Our medical opinions remain
the same for no matter which side we are consulting, as science is science. Because our social
worker is an expert child forensic interviewer,
she may even help attorneys edit questions thatare more developmentally appropriate for thechild or assist in pretrial preparation.
As child abuse pediatricians, we are conservative. We certainly are not zealots who thinkthat everyone abuses their children. The lastthing in the world that we want is for a childto be removed from their family. We take greatcare in performing thorough forensic reviews
and use peer reviewed research and literature
to assist in forming our opinions. We consider alternative hypotheses in our differential
diagnoses and explanations for injuries thatmight be accidental or mimicked by medical
conditions.
Dr. Whalen: What do child abuse pediatricians
bring to a medical-legal review that otherdoctors might not?
Dr. Craig: We have much more training andexperience than other pediatricians, family
medicine, and emergency medicine physiciansin dealing with all aspects of child maltreatment. We are able to review all the medical
records, including the labs and imaging studies
before forming an opinion. Our goal is to ruleout other possibilities while maintaining thesafety of the infant or child. In medical school
they taught me that when you hear hoof beats,
do not assume it is always a horse: look for thezebras too. For example, we find children withbrittle bone disease, or metabolic disorders,or cancer that can mimic the presentation of
abuse. We have had many cases over the yearsof children with leukemia, for example, who
presented with bruises or fractures that lookedatypical.
Dr. Whalen: What AFCCP referral trends haveyou noticed over the past several years?
Dr. Craig: Overall, in the U. S., there has
been a decrease in physical abuse and sexual
abuse cases reported and/or confirmed overthe past decade. Child neglect is not decreasing. We consult on more child neglect cases
than we did previously as well as on morecases involving emotional abuse and emotional
neglect. These are very difficult cases because

http://www.CSTSonline.org

they do not involve concrete evidence such as
findings on their physical exams, abnormal lab
studies, fractures on x-rays, or brain injuries
on CT or MRI scans. Many years ago, CPS andthe courts found it challenging to prove neglect
unless it was severe. The emotional neglect andemotional abuse situations were even morechallenging to prove. Now, with better tools toforensically interview children, more children
in therapy, and a better understanding of thelong-term sequelae of emotional trauma, suchcases are being handled more appropriately.
The biggest change affecting FAP since
May 1, 2019, is problematic sexual behavior
in children and youth (PSBCY). As soon as
DOD Instruction 6400.01 was published, the
AFCCP created an in-depth presentation on
problematic sexual behavior that offers definitions, recognition, and guidance regarding
problematic sexual behavior in youth and children. It has received much positive feedback.
FAP, medical professionals, and investigators
are eager to learn more about this new “hottopic.” My staff and I have evaluated many cases
involving children touching other children. We
have deployed on Family Advocacy Command
Assistance Teams (FACAT), mobilized to assist
with multiple victims, out-of-home abuse, andchild sexual abuse cases occurring on militarybases DOD wide. We are the only DOD clinicthat has the ability to conduct child forensic interviews and medical assessments in these casesin one location making it easier for the children
and their families. Our past experience has
shown that many problematic sexual behaviors
in children and youth cases often did not meetcriteria for FAP, or CPS, or law enforcement.
Even now, we see challenges with agencies
handling these cases in the most effective andexpeditious manner possible.
Dr. Whalen: What kinds of child neglect andemotional abuse and neglect cases do you see
and how do you evaluate them?
Dr. Craig: We consult on a wide variety ofcases. Neglect cases can include many forms:
supervisory, nutritional, medical, dental, educational, and emotional neglect are the mostcommon forms referred to the AFCCP. Each
one has special challenges in terms of medical assessments, as well as social evaluations,and possible criminal investigations. Children
may present as failing to thrive, having chronic
or acute illnesses which do not respond to apContinued on p.4
Joining Forces/Joining Families • 3

An interview with Barbara
R. Craig, MD, from page 3

Often, emotional
abuse and neglect
are discovered in
the course of the
AFCCP evaluating
an infant or childfor other injuries.

We want health careproviders in the
military to be better
prepared to recognize
potential abuse. We
emphasize the sentinel
injuries to look forwhen seeing infants
and children and what
to do if they are found.

propriate therapies, left alone without parental
supervision, dirty or dressed inappropriately
for the weather, chronic school tardiness or absences, delays in seeking medical care, serious
dental caries, or many other combinations ofsymptoms and signs. Many of these cases also
involve other forms of abuse. Often, emotional
abuse and neglect are discovered in the courseof the AFCCP evaluating an infant or child forother injuries. We work closely with the local
health care providers in their medical evaluations by offering recommendations for othertests or procedures that might be helpful inmaking the diagnosis. While it may seem thatsome of these issues can be handled at the local
level, the time required in the more complex
cases makes it challenging for the local healthcare providers (HCP) with busy clinics. We
have the ability to obtain and review all of thematerials from every agency and speak with all
those involved, coordinate conferences regarding the children, write detailed medical-legal
case reviews, and testify in court if the caserises to the level of a court-martial. It is notuncommon for one case review to take 20 ormore hours of time over several weeks. If thesituation occurs at non-local military installations and we are required to travel there forhearings or courts-martial, it may take up to afew days or a week while on TDY.
As mentioned above, not all forms of neglect rise to the level that involve the AFCCP.
Some may be due to a lack of parental knowledge about infant and child care. Examplesof where we would be unlikely to be involved
include an infant who is not gaining weightvery well. After an initial evaluation, we mightfind that the parents did not mix the formula
correctly, have breast feeding issues, but did
not seek help from their medical provider or alactation consultant. In other cases, they may
not feed the children appropriate food, or notgive medications according to the directions.
On the other extreme, we want to be consulted in serious cases such as when parents
deliberately starve their infants and children
and deprive them of other basic needs such as
medical and dental care, appropriate clothing, or a safe living or playing environment.
While some parents do not realize that a babyor young child cannot be left alone at homeor in a car unsupervised, at the other extreme,
they might deliberately leave their children
unattended while they are at work or go to abar instead of paying for child care. Obviously,in these types of cases, the first examples can

4 • Joining Forces/Joining Families

be treated by the local pediatrician or family
medicine physician with parental education andsupport. But, in the latter, it would require anything from social services and FAP intervention
to law enforcement involvement to removal of
the children from the home. In serious cases,
the AFCCP would consult and assist the local
agencies to assess their concerns and offer further guidance.
Our medical-legal case reviews assist otherprofessionals and provide a recommended
safety plan for the children. Nutritional neglect
might include medical child abuse cases (formerly Munchausen syndrome by proxy or factitious disorder). In such cases, parents deliberately withhold food or administer substancesthat cause vomiting or diarrhea to induce failure to thrive so that their children receive more
medical attention and the parent or guardiangarners significant attention and support fromthe hospital and clinic staff. Other situations
warranting a child abuse pediatric consultation
include serious infections left unchecked that
result in a medical emergency.
Likewise, emotional abuse and emotional
neglect are challenging cases. Without concrete
ways to measure the level of abuse and sequelae,
it is often difficult to protect children underthese circumstances. Emotional abuse and neglect can severely damage the mental health andphysical health of a child in addition to theirsocial and cognitive development. We use ourknowledge of the complex issues in emotional
trauma not only in dealing with our individual
cases, but we also provide training on the effects of child emotional neglect and emotional
abuse which can alter not only the developing
brain and neuroendocrine system, but even the
structure of the chromosomes with shortened
telomeres.
Dr. Whalen: What training needs have you
identified for medical providers who suspectchild abuse?
Dr. Craig: We want health care providers in
the military to be better prepared to recognize
potential abuse and how best to comply withmandatory reporting laws and regulations. We
emphasize the sentinel injuries to look for whenseeing infants and children and what to do ifthey are found. We provide concrete medical
guidance on the appropriate tests to be orderedwhen there are concerns for possible maltreatment: basic lab work, skeletal series, head CTs
or MRIs, checking for STIs, screening labwork
Continued on p. 5
Spring 2020

An interview with Barbara
R. Craig, MD, from page 4

Health care providers
must be careful withthe wording in theelectronic medical
record system.

We teach theresidents and medical
students about theimportance of writing
every inpatient andoutpatient medical
record as if it might
be seen again incourt.

to rule out bleeding disorders, leukemia, or
occult abdominal trauma. By omitting certain
laboratory or radiologic testing, or failing to
document some findings that seem minor at
the time, a local HCP might inadvertently jeopardize a case and open the window for a judge
to not issue a protection order, or for reasonable doubt to enter into the court-martial.
Health care providers must be careful withthe wording in the electronic medical record
system. We often find notes that are confusing
or do not fully document the findings in a waythat others can understand. We teach the residents and medical students about the importance of writing every inpatient and outpatient
medical record as if it might be seen again
in court. Advice is given regarding accuracy,
comprehensive details, and documenting theirfindings clearly.
Electronic records are invaluable tools in
medicine, but occasionally providers copy andpaste the birth and past medical history from
one note to another when the veracity of that
information provided by the parent or caregiver has not been questioned, or a new history
with more details has not been ascertained. The
notes need to convey the medical findings inlay terms and explain why a diagnosis is supported. There are well over a thousand articles
published each year in the English language
medical literature regarding child maltreatment, more than a general pediatrician, family
medicine physician, or emergency department
physician would have time to review. We strive
to incorporate the latest research findings in
the child abuse field into our reports and ourtraining.
For FAP and military criminal investigative agencies, our training is geared to provide
guidance to special agents, case managers, casereview or incident determination committee
members, and other FAP personnel with theunderstanding of what injuries are considered
to be the most concerning for non-accidental
trauma, the biomechanical forces needed tocause those injuries, and the limits of dating
certain injuries. Our goal is not to make them
medical experts, but rather to allow themto understand the significance of the medical findings and to be cautious of the medical guidance given in a case that may not be
consistent with the most up to date advances inchild abuse pediatrics.

Dr. Whalen: What types of training
opportunities do you provide?
Dr. Craig: The AFCCP staff provides presentations at conferences sponsored by FAP,
military medical treatment facilities, militaryjustice schools and criminal investigation
organizations, and other military commands.
In addition, the AFCCP offers multidisciplinary
courses world-wide throughout the DOD called“Advances in Child Maltreatment.” Our courses
are usually given over several days during
which my staff and I offer a wide variety of lecture presentations including both an advanced
medical track and an advanced non-medical
track running simultaneously. Although therequesting commands fund our travel expenses,
our conferences have no registration fees, andoffer free continuing education credits (CME,
CNE, CEUs, and certificates of attendance.)
The AFCCP staff personally coordinate thesecourses, provide all lecture and administrative
preparation with no honorarium. These courses
are funded by installations from Asia to Europe
and throughout the United States. The audiences are usually very multidisciplinary. In orderto foster better working relationships with theirlocal counterparts, we encourage them to invite
CPS, local law enforcement, members of thechild advocacy centers, attorneys, and local
health care providers to participate.
We are often asked to return to the same
installations every 2–3 years to provide training for their new staff members or to update
those who are still there about new topics andadvances in the field of child maltreatment.
Sometimes the trainings are requested becauseof a specific incident that occurred on the baseor at the hospital where the installation leadership feels that a stand-down for training is anappropriate course of action.
These trainings are extremely cost effective,
especially overseas and at more remote military
installations. The cost savings can be enormous.
We can train any size audience and have been
doing so for over 25 years — from 10 to 300
attendees. If we trained 100 local multidisciplinary professionals at the base, the expenses
for that many people going to a civilian course
would be $4,000 times 100 people, which equals$400,000 to receive the same type of training
we provide for about $6,000. We update ourlectures regularly and provide extensive bibliographies. If a particular command wants certain
specific topics, we will write new presentations
for them and tailor it to their needs.
Continued on p. 6

http://www.CSTSonline.org

Joining Forces/Joining Families • 5

An interview with Barbara
R. Craig, MD, from page 5

We also help families
that have beenreported to better
understand theprocess they might
have to go through. It
can be stressful whena child is referred
to various agencies
with abuse or neglect
concerns. Our goal isto help children andfamilies and ensurethat all military kids
are safe and thriving at
home.

Dr. Whalen: How do you and your staff prevent
professional burnout given all the secondary
trauma you are exposed to?
Dr. Craig: We really feel like we are contributing to protecting at-risk children, whether
it is in patient care providing training for thedifferent multidisciplinary professionals dealing with child maltreatment in the military,advising military lawyers with courts-martial,or assisting health care providers in understanding what tests and procedures should bedone in cases of suspected child abuse. It is avery rewarding career. We also help families
that have been reported to better understandthe process they might have to go throughunder such circumstances. It can be a stressful
time when a child is referred to various agencies with abuse or neglect concerns. Our goal
is to help children and families and ensure that
all military kids are safe and thriving at home.
The next thing that helps us with burnout
is that we share all the common experiences ofdealing with child abuse on a daily basis. Having a tough case and sharing our feelings witheach other can be very therapeutic. We all haveexperienced situations in which the findings
are so egregious that we still find it shocking. It
is nice to have a small group to sit down withand talk about how stressful the case was because it was so challenging and upsetting, butthat we did everything we could. Others not inthis situation may not understand the stressorsof our work and the enormous caseload andtravel obligations going to military bases from
Asia to Europe and everywhere in between.
When we travel, we might go out to dinner with the people we are working with, or
do some sight-seeing at the end of a long day.
This social connectedness can be a wonderful

way to relieve the tension of the courtroom or
the work we are doing. One of the best partsof a job that takes us all over the world is that
we run into professionals with whom we haveworked with over the years. We really enjoy
that. We have encountered doctors who did
rotations with us from a few years ago up to 20
or 30 years ago, or lawyers and special agents
we worked with previously in cases, or social
workers who have asked us to provide trainings
or consultations at three or four different duty
stations over the decades.
Finally, the military’s commitment to helping families helps fend off professional burnout.
Positive outcomes and helping families are
the best parts of our work. Medical conditions
which mimic child abuse come to mind. A recent case of a serious medical condition comesto mind, it was initially suspected to havebeen from abuse and the findings were indeed
suspicious for trauma. Once we were involved
and recommended more testing, the condition was diagnosed. What did the military do?
The mother’s command realized that her childneeded specialized medical care not available atthat remote overseas location. They were able tohave orders quickly written so that the motherand child could relocate to a base where she had
family for support, and could still continue inher job rating. What other employer would dothat? Family Advocacy, Community Services,
the local clinic physician, and the Exceptional
Family Member Program helped to make surethe command was actively engaged with thefamily. What better outcome could there be?
Dr. Whalen: Thank you for your work and yourtime and effort in giving us this information.
Dr. Craig: You are welcome.

We really feel like we are contributing to protecting at-risk children, whether it is in patient careproviding training for the different multidisciplinary professionals dealing with child maltreatmentin the military, advising military lawyers with courts-martial, or assisting health care providers inunderstanding what tests and procedures should be done in cases of suspected child abuse.

6 • Joining Forces/Joining Families

Spring 2020

Mimics, Missed Cases, and Flawed Theories of 		Child Maltreatment
By James E. McCarroll, PhD, Ronald J. Whalen, PhD, Joshua C. Morganstein, MD,
and Robert J. Ursano, MD

Medical conditions
can be mistaken
for maltreatment(mimics) which, if
missed by a physician
and reported as childmaltreatment, canresult in parents being
wrongly accused ofabuse, social and legal
battles, and failure
to treat the childmedically.

http://www.CSTSonline.org

The Armed Forces Center for Child Protection (AFCCP) tackles the difficult issuesof diagnosing child maltreatment. Medical
conditions can be mistaken for maltreatment(mimics) which, if missed by a physician andreported as child maltreatment, can resultin parents being wrongly accused of abuse,social and legal battles, and failure to treat thechild medically (Christian & States, 2017). The
examining physician is required to differentiate abuse from trauma to the head, bruising,abdominal trauma, skeletal injury, burns,
and many other medical conditions including mimics of sexual abuse (Pomeranz, 2018).
When there is the possibility of maltreatment,children should be evaluated by a child protection team including a child abuse pediatrician(Barnes, 2011).
The diagnosis of child abuse can be missed
based on many factors such as the inexperience of the provider, court phobia (Pomeranz,2018), and bias based on racial or socioeconomic status (Dakil, Cox, Lin, & Flores,2011). Missed cases can have tragic outcomes,
particularly in serious head injuries. Generally,
the most serious type of missed case is abusive
head trauma (AHT) or traumatic brain injury(TBI), formerly called shaken baby syndrome(SBS). Data from the Kids’ Inpatient Databases(KIDs) for 1997, 2000, and 2003 were used toestimate the incidence of inflicted TBI hospitalizations in infants less than one year old. Theseestimates were 27.5, 27.5, and 32.2/100,000,
respectively (Ellingson, Leventhal, & Weiss,2008). By comparison, falls and accidents aremuch less likely than AHT to result in serious injury. Falls and injuries in 11,466 infants
six months old or younger resulted in visible injuries in 14% of the infants, and 56%of those injuries were bruises (Warrington &Wright, 2001). Ninety-seven percent of injuries
involved the head, but less than 1% resulted inconcussion or fracture.
The physician in the ED or in primary careis usually the first contact for injured children.
A classic study of missed cases of AHT inchildren younger than three years that occurred 1990-1995 reported that 31.2% (n=54)
of 173 AHT cases were seen by physicians who

did not recognize the diagnosis (Jenny, Hymel,
Ritzen, Reinert, & Hay, 1999). Cases involving young, white children from intact families
were more unlikely to be missed. Nine of the 54
children with unrecognized AHT died, 15 werereinjured, and 22 experienced medical complications related to the diagnosis. This study
was repeated using data from 232 children
who had been diagnosed with AHT between
2009-2011 (Letson et al., 2016). The medianchild age was 5.4 months, 69% were white and60% were males. The overall mortality rate was
10%. Twenty-five percent of 232 children with
an AHT diagnosis had 98 prior opportunities
for diagnosis that were missed in a medical setting and 22 were missed by CPS. Five of the 59
children died (Pfeiffer et al., 2018).
Unfortunately, there are controversies surrounding the AHT diagnosis. AHT is a medical
diagnosis made by a multidisciplinary team of
medical professionals and social workers whoare informed by findings from child protection
and police investigations to exclude medical
mimics (Hymel, 2019). Unfortunately, scientifically unsupported theories have been presented
to the public and courts about the diagnosis ofphysical child abuse, particularly AHT. However, there is no controversy about the diagnosis of AHT in clinical medicine (Leventhal &Edwards, 2017). AHT is a medical conclusion,
not a legal determination of the intent of theperpetrator or a “diagnosis” of murder. Thereis broad consensus among medical professions that current evidence-based diagnostic
methods render an accurate diagnosis of AHT.
An accurate AHT diagnosis gives the physician the tools necessary to distinguish between
legitimate medical opinions based on clinicalfindings, medical evidence, and evidence-based
literature and the legal arguments or etiological
speculations that are unwarranted (Choudhary
et al., 2018).
There are clinical prediction rules that can
assist clinicians in assessing AHT. Several havebeen developed to assist with decisions at various stages of the diagnostic process. These rules
are aids that can be used to prompt clinicians toseek further clinical, social, or forensic informaContinued on page 8
Joining Forces/Joining Families • 7

Mimics, Missed Cases,from page 7Child protection isa difficult and anemotionally charged
endeavor that requires
the diligence andknowledge of childabuse professionals,
medical, legal, andsocial service providers,
to recognize, diagnose,
refer, treat, and preventthe maltreatment ofchildren.

tion (Pfeiffer et al., 2018). Prediction rules forthe pediatric intensive care unit physician weredeveloped by the Pediatric Brain Injury Research Network. These rules provide evidencebased estimates of the probability of AHT for
acutely injured children less than three years
old. Such estimates can inform the physician’s
decisions to evaluate, confirm, exclude, and/or report suspected child abuse (Hymel et al.,2019).
Child protection is a difficult and anemotionally charged endeavor that requires
the diligence and knowledge of child abuseprofessionals, medical, legal, and social service
providers, to recognize, diagnose, refer, treat,and prevent the maltreatment of children.

References

Barnes, P. D. (2011). Imaging of nonaccidental
injury and the mimics: issues and controversies in the era of evidence-based medicine.
Radiological Clinics of North America, 49(1),205-209.
Choudhary, A. K., Servaes, S., Slovis, T. L.,
Palusci, V. J., Hedlund, G. L., Narang, S. K.,…
Offiah, A. C. (2018). Consensus statement
on abusive head trauma in infants and young
children. Pediatric Radiology, 48(8), 10481065. doi:10.1007/s00247-018-4149-1
Christian, C. W., & States, L. J. (2017). Medical
mimics of child abuse. American Journal of
Roentgenology, 208(5), 982-990.
Dakil, S. R., Cox, M., Lin, H., & Flores, G. (2011).
Racial and ethnic disparities in physicalabuse reporting and child protective services
interventions in the United States. Journal of
the National Medical Association, 103(9-10),
926-931.

Hymel, K. P. (2019). Denying the abusive headtrauma denialists their day in court, one step at
a time. Pediatric Radiology, 49(13), 1710-1711.
Hymel, K. P., Wang, M., Chinchilli, V. M., Karst,
W. A., Willson, D. F., Dias, M. S., . . . (PediBIRN). (2019). Estimating the probability ofabusive head trauma after abuse evaluation.
Child Abuse & Neglect, 88, 266-274.
Jenny, C., Hymel, K. P., Ritzen, A., Reinert, S. E.,& Hay, T. C. (1999). Analysis of missed casesof abusive head trauma. Journal of the American Medical Association, 281(7), 621-626.
Letson, M. M., Cooper, J. N., Deans, K. J.,
Scribano, P. V., Makoroff, K. L., Feldman, K.
W., & Berger, R. P. (2016). Prior opportunities
to identify abuse in children with abusive headtrauma. Child Abuse & Neglect, 60, 36-45.
Leventhal, J. M., & Edwards, G. A. (2017). Flawed
theories to explain child physical Aabuse:
What are the medical-legal consequences?
JAMA, 318(14), 1317-1318.
Pfeiffer, H., Crowe, L., Kemp, A. M., Cowley, L. E.,
Smith, A. S., Babl, F. E., & Paediatric Researchin Emergency Departments International, C.
P. (2018). Clinical prediction rules for abusive
head trauma: a systematic review. Archives of
Disease in Childhood, 103(8), 776-783.
Pomeranz, E. S. (2018). Child abuse and conditions that mimic it. Pediatric Clinics of North
America, 65(6), 1135-1150.
Warrington, S. A., & Wright, C. M. (2001). Accidents and resuilting injuries in premobile
infants: data from the ALSPAC study. Archives
of Disease in Childhood, 85, 104-107.

Ellingson, K. D., Leventhal, J. M., & Weiss, H. B.
(2008). Using hospital discharge data to track
inflicted traumatic brain injury. American
Journal of Preventive Medicine, 34(4 Suppl),
S157-162.

Prediction rules for the pediatric intensive care unit physician were developed by the
Pediatric Brain Injury Research Network. These rules provide evidence-based estimates ofthe probability of AHT for acutely injured children less than three years old.

8 • Joining Forces/Joining Families

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Predictors and Moderators of Burnout among Child
Maltreatment Professionals
By Ronald J. Whalen, PhD, James E. McCarroll, PhD, Joshua C. Morganstein, MD, 		
and Robert J. Ursano, MD

The tasks of CAPs—
identification,
diagnosis, and researchof the physical andmental marks of childabuse and neglect,parental and societal
education, advocacy forprevention, and expert
testimony—make themvaluable components
in stopping current
child maltreatment andpreventing future cases.

http://www.CSTSonline.org

Occupations with high levels of exposure to traumatized children, like child abuse
pediatricians (CAPs) and forensic interviewers(FIs), are at increased risk of burnout (i.e., along-term psychological response characterized by emotional exhaustion and cynicism as
a consequence of prolonged stress and anxiety
at work). Secondary exposure to the traumatic
experiences of others (e.g., via physical examinations and interviews with children who
describe their abuse) is associated with secondary traumatic stress (STS) symptoms (i.e., reexperiencing, avoidance, arousal) that parallel
post-traumatic stress disorder (Park, Meyer, &Gold, 2020). And yet, some professionals findcoping strategies to that help mitigate the risksof burnout despite ongoing exposure to STS.
Two recent studies examined the relationship between STS and burnout among CAPs
(Passmore, Hemming, McIntosh, & Hellman,2019) and FIs (Fansher, Zedaker, & Brady,2020). Not surprisingly, both studies found apositive association between STS and burnout—as CAP and FI exposure to traumatizedchildren increased, STS and burnout scoresalso increased. The challenge for this line ofresearch is to identify individual and/or organizational factors that help mitigate STS relatedburnout.
Passmore et al. (2019) found that amongchild abuse pediatricians (n=151), hope andmeaning-in-work scores (individual-level attributes) were negatively associated with STS andburnout and that both hope and meaning-inwork mitigated the relationship between burnout and STS. The Dispositional Hope Scale
was used to measure the extent to which CAPs
feel motivated to attain goals (agency) and see
viable ways to achieve these goals (pathways)(Snyder, Harris, Anderson, Holleran, Irving,
Sigmon, ... Harney, 1991). Item examples
include: “I energetically pursue my goals” and“I can think of many ways to get out of a jam.”
The Work as Meaning Inventory was used toassess CAP’s sense that their work has value intheir life (Wrzesniewski, 2012). Item examples
include: “The work that I do is important” and“What I do at work makes a difference in theworld.”In addition to individual-level attributes
like compassion satisfaction (i.e., the pleasure
respondents derive from being able to performtheir work well), a construct very similar to
the meaning-in-work used by Passmore, et al.
(2019), Fansher et al. (2020) examined workrelated characteristics among FIs (n=250) andtheir association with burnout and STS scores.
Compassion satisfaction was negatively associated with burnout among FIs, just as meaningin-work was negatively associated with burnout
among CAPs. Furthermore, FI perceptions oforganizational support were negatively associated with burnout. Three open-ended questions
on their survey allowed respondents to add
qualitative details to quantitative finds:
1. What is the hardest thing about your work?
2. What helps you the most in coping withyour work?
3. What is the most beneficial thing the agency
you work for could do to help you cope with
the negative aspects of your job?
The importance of social support fromco-workers and supervisors was a common
theme across all three open-ended questions,with increasing emphasis on concrete measuresorganizations can take to help mitigate burnout (e.g., instrumental support like physicalresources that help FIs improve their job skills).
CAPs and FIs provide an essential expertisein a national strategy to accurately identify andultimately prevent incidents of child abuse andneglect. Findings from these study suggest thatorganizational efforts to promote hope andmeaning-in-work among CAPs and FIs mayhelp prevent burnout. Promoting healthy coping (e.g., mentoring), assessing CAP and FI behavioral health at regular intervals, and offering
professional development opportunities may
prevent burnout in these critical occupations.

References

Fansher, A. K., Zedaker, S. B., & Brady, P. Q.
(2020). Burnout Among Forensic Interviewers,
How They Cope, and What Agencies Can Do
to Help. Child Maltreatment, 25(1), 117-128.

Continued on p. 11
Joining Forces/Joining Families • 9

BUILDING BRIDGES TO RESEARCH

Clinical Prediction Rules in Clinical Care
By James E. McCarroll, PhD, Joshua C. Morganstein, MD, Ronald J. Whalen, PhD
and Robert J. Ursano, MD

A clinical prediction
rule (CPR) is used
to forecast an event
such as a diagnosis
or a need for further
evaluation for that
person.

Clinical prediction rules (CPR) are tools
developed from biomedical research that help
physicians quantify a patient’s history, resultsof clinical examinations, and diagnostic tests
to predict (or estimate the probability of) a
diagnosis. They are most useful when they canbe applied quickly, such as in an emergency
department, to diagnose or determine if there
is a need for further evaluation of a suspectedcondition.
Before a CPR can be developed, it should
go through three steps: (1) derivation (predictor variables are identified and the rule isdeveloped); (2) validation (the rule is tested ina new population); and (3) impact analysis interms of patient outcomes, costs, and physician
behavior (Keogh et al., 2014). The only variables that can be used for the model must be
available at the time the prediction is made.
When developed, a CPR requires three criteria: (1) known variables are used to estimate
the event being predicted; (2) the predictors
must be known prior to the outcome being
predicted; and (3) the model must be accurate when applied to new observations (i.e.,
it must be generalizable). Other factors to beconsidered are the cost, invasiveness, and how
frequently the condition to be predicted is
encountered in clinical practice (Leisman et al.,2020).
There are many statistical and practicalmethods and limitations in developing a CPR.
Statistical methods used to develop CPRs
include univariate and multivariate analysis
including multiple regression and many highlysophisticated techniques. Statistical considerations include whether the variables tested in
the model are based on prior theory and evidence or selected statistically by their strengthof association (e.g., including a predictor basedon its probability value in multiple selection
procedures). In some cases, too many variables
will be found to be statistically significant to
be included and cannot be supported by thedataset used as the basis of prediction. Models
based on the former approach (prior knowledge
based on evidence) is the preferred approach toprobability modeling (Leisman et al., 2020).

One of the practical considerations iswhether the model is really necessary. For example, it may fulfill an unmet clinical need suchas identifying high-risk patients who may not
be ordinarily recognized or it improves discrimination compared to the current practice(Leisman et al., 2020). There are hundreds of
CPRs, but many will not be used in practice or
their impact will not be analyzed through rigorous research. A search for CPRs in literature
published from 1965-2009 found 434 uniquerules that had been derived; 54.8% had beenvalidated and 2.8% had undergone analysis of
their impact on the process or outcome of clinical care. The most common were for cardiovascular disease, respiratory, or musculoskeletal
conditions (Keogh et al., 2014).
An example of a CPR is the 4-variable clinical prediction rule (CPR) screening instrument
for abusive head trauma (AHT) developed by
the Pediatric Brain Injury Research Network(Hymel et al., 2014). This instrument predicts
whether a child under three years of age withpossible AHT should undergo a full medical
workup. The rule was found to predict AHT
with a high degree of sensitivity of head-injured
children admitted to a pediatric ICU thus helping to insure that cases will not be missed due
to failure to conduct a full evaluation.
Another example of a CPR is the preliminary study of a tool predicting the need for hospitalization for alcohol withdrawal. This study
was conducted in a retrospectively in 2,038
patients presenting to an emergency department (Mahabir et al., 2020). Alcohol withdrawal symptoms are mostly mild, but some could
progress to seizures of delirium tremens, which
can be fatal. In order to develop a tool to predict the need for hospital admission, Mahabir
et al. developed and validated a tool, the alcohol
withdrawal triage tool (AWTT), to predict
severe alcohol withdrawal syndrome (SAWS).
They identified eight independent predictors,
available to the ED at the time of evaluation.
Scoring each symptom as “1” if present, theyfound that a score of three or above predictedhigh risk with a sensitivity of 90% and suggested the need for hospitalization. The authors
Continued on p. 11

10 • Joining Forces/Joining Families

Spring 2020

Clinical Prediction Rules inClinical Care, from page 10

revolutionize clinicalsuggested that this tool could be useful as partof a standardized admission protocol by identifying patients at low risk for SAWS that could
be safely discharged from the ED.
Increasingly sophisticated statisticaltechniques in healthcare that involve machine
intelligence have the potential to revolutionize clinical research that allows physicians
to make better decisions and achieve better
patient outcomes. However, many issues need
to be addressed including data quality, the useof electronic medical records, the transparencyof the system in the context of clinical workflow, and the impact of bias on system outputs(Cutillo et al., 2020). It is also critical to examine barriers in implementing CPRs such as
clinician’s beliefs, local contextual factors, andhow to integrate CPRs into the clinical workflow (Wallace & Johansen, 2018).

research that allows

References

Increasingly
sophisticatedstatistical techniquesin healthcare thatinvolve machine
intelligence havethe potential tophysicians to makebetter decisions andachieve better patient
outcomes.

Cutillo, C. M., Sharma, K. R., Foschini, L.,
Kundu, S., Mackintosh, M., & Mandl, K. D.
(2020). Machine intelligence in healthcare—
perspectives on trustworthiness, explainability, usability, and transparency. npj Digital
Medicine, 3(1).
Hymel, K. P., Armijo-Garcia, V., Foster, R.,
Frazier, T. N., Stoiko, M., Christie, L. M.,…
Pediatric Brain Injury Research Network, I.
(2014). Validation of a clinical prediction rule
for pediatric abusive head trauma. Pediatrics,
134(6), e1537-1544.

Predictors and Moderators,
from page 9Park, E., Meyer, R. M. L., & Gold, J. I. (2020). The
role of medical specialization on posttraumatic symptoms in pediatric nurses. Journalof Pediatric Nursing, 53, 22-28.
Passmore, S., Hemming, E., McIntosh, H. C.,& Hellman, C. M. (2019). The relationshipbetween hope, meaning in work, secondary
traumatic stress, and burnout among childabuse pediatric clinicians. The Permanente
Journal, 24.

Hymel, K. P., Wang, M., Chinchilli, V. M., Karst,
W. A., Willson, D. F., Dias, M. S., . . . (PediBIRN). (2019). Estimating the probability ofabusive head trauma after abuse evaluation.
Child Abuse & Neglect, 88, 266-274.
Keogh, C., Wallace, E., O’Brien, K. K., Galvin, R.,
Smith, S. M., Lewis, C., . . . Fahey, T. (2014).
Developing an international register of clinicalprediction rules for use in primary care: a descriptive analysis. Annals of Family Medicine,
12(4), 359-366.
Leisman, D. E., Harhay, M. O., Lederer, D. J.,
Abramson, M., Adjei, A. A., Bakker, J., . . .
Maslove, D. M. (2020). Development andreporting of prediction models: Guidance forauthors from editors of respiratory, sleep, andcritical care journals. Critical Care Medicine.
doi:10.1097/ccm.0000000000004246.
Mahabir, C. A., Anderson, M., Cimino, J., Lyden,
E., Siahpush, M., & Shiffermiller, J. (2020).
Derivation and validation of a multivariable
model, the alcohol withdrawal triage tool
(AWTT), for predicting severe alcohol withdrawal syndrome. Drug and Alcohol Dependence, 209, 107943.
Wallace, E., & Johansen, M. E. (2018). Clinical prediction rules: challenges, barriers, andpromise. The Annals of Family Medicine, 16(5),390-392.

Snyder, C. R., Harris, C., Anderson, J. R., Holleran, S. A., Irving, L. M., Sigmon, S. T., …
Harney, P. (1991). The will and the ways:
Development and validation of an individualdifferences measure of hope. Journal of Personality and Social Psychology, 60(4), 570-585.
Wrzesniewski, A. (2012). Finding meaning inwork. In K. S. Cameron, J. E. Dutton, & R. E.
Quinn. (Eds.). Positive Organizational Scholarship. (pp. 296-308). San Francisco, CA:
Berrett-Koehler Publishers, 296-308.

It is particularly important for agency leaders to look for ways to alleviate potential
organizational risk factors of burnout, as these play a significant role in the process.

http://www.CSTSonline.org

Joining Forces/Joining Families • 11

Websites of Interest
The Armed Forces Center for Child Protection(AFCCP) provides objective medical expertise to
military and civilian professionals who address childmaltreatment in military communities. The AFCCP
website describes the range of services (e.g.,
medical evaluations, forensic interviews, medicallegal reviews, child abuse education) offered by amultidisciplinary team and contact information.
https://tricare.mil/mtf/WalterReed/Health-Services/
M_S/Pediatrics/Armed-Forces-Center-for-ChildProtection

National Children’s Alliance (NCA) is thenational association and accrediting body forChildren’s Advocacy Centers (CACs). Formed in
1988, NCA has been providing support, technicalassistance, and quality assurance for CACs, whileserving as a voice for abused children for morethan 25 years. A Children’s Advocacy Center is achild-friendly facility in which law enforcement,child protection, prosecution, mental health,
medical and victim advocacy professionals work
together to investigate abuse, help children heal
from abuse, and hold offenders accountable. NCA
is committed to supporting the establishment ofpartnerships and collaboration between Children’s
Advocacy Centers (CAC) and military installations.
They have worked closely with Congress to identify
and allocate funding specifically aimed at enhancing
these critical relationships. CACs now have accessto a dedicated NCA staffer, the Coordinator for
Services to Military Families, to support and advise
members on military-related matters. Accredited
members will also have access to funding to help
promote and support military communities witha coordinated investigation and comprehensive
response to child victims of abuse, similar to theircivilian counterparts.
https://www.nationalchildrensalliance.org/supportfor-military-families/

12 • Joining Forces/Joining Families

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