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Medical Residency Training Curriculum

On this page you'll find comprehensive information on Butler Center's one-month medical student/resident/fellow rotations.

Introduction

Learning Objectives
Medical Aspects
Psychosocial Aspects
Multidisciplinary Team Issues

Competencies
Physical Abuse and Suggested Reading
Sexual Abuse and Suggested Reading
Social Work/Legal Intervention and Suggested Reading

Introduction

The rotation is a rich experience; some of what you learn will be observational and some very much "hands on."

Before you begin, take time to think about what your personal goals are for this month. Your preceptor will ask you to fill out a learning contract at the beginning of the rotation.

You will also be asked to evaluate your experience at the Child Advocacy Center (CAC) upon completion of your time here.

The learning objectives will be accomplished through a number of different venues, including:

Observation of medical providers giving expert witness testimony in court
Suggested readings which have been placed in binders in the CAC
Review of several self-paced educational modules on child sexual abuse
Observation of the medical and social work providers as they evaluate (interview and examine) patients who are referred to the Child Advocacy Center or consultations in the ED and in-patient service
Didactic lectures/ slide review/ review of colposcopy images
Attendance at the Bronx Multidisciplinary Team meetings and other multidisciplinary forums
Observation of Joint (forensic) Interviews with the professionals of the agencies who are part of the Bronx Multidisciplinary Team

Learning Objectives

Overview of the Child Advocacy Centers and the Services of the Child Advocacy Center at The Children's Hospital at Montefiore

The learner will have an understanding of the following aspects of Child Protection:

History of child abuse response in the United States and the development of the Child Advocacy Center "movement"
Child Advocacy Center's Services
1. Medical
2. Social work
3. Mental Health
4. Advocacy
5. Follow up and tracking - The Harriet Feinman Child Protection Project
6. Participation on the Bronx Multidisciplinary Team
Extended Services
1. Individual therapy and therapeutic groups for abused children and their families
2. Disabilities Project

Medical Aspects
The learner will develop skills to evaluate the injured child including gathering detailed historical information and documenting injuries in a systematic and detailed fashion to allow for distinguishing unintentional from inflicted injuries.

The learner will develop an understanding of the approach to the evaluation of the sexually abused child or adolescent.
The learner will understand the role of the medical provider/social worker as an advocate for children at the local, regional, and national levels.

Psychosocial Aspects

The learner will develop skills in obtaining a complete psychosocial history.
The learner will develop an understanding of the behavioral characteristics of physically and sexually abused as well as neglected children.
The learner will develop an understanding of the child abuse reporting laws and the mechanics of making such a report.
The learner will learn to recognize the risk factors, which interact to create an abusive or neglectful milieu.

Multidisciplinary Team Issues

The learner will understand the importance of the multidisciplinary team evaluation of child abuse including the role and responsibilities of each team member.
The learner will develop a basic understanding of the structure of a forensic interview.

Competencies

Physical Abuse

Head injury

to understand the benign nature of the majority of "household" falls in children
to understand that head injury is the most common cause of child abuse deaths
to understand the clinical presentation of inflicted traumatic brain injury, previously referred to as Shaken Baby Syndrome
to understand that the majority of head trauma deaths in children less that 2 years of age are from non-accidental head injuries
to understand that retinal hemorrhages occur only in major severe accidental head trauma such as motor vehicle accidents and do not occur in minor trauma. They are one of the hallmarks of inflicted traumatic brain injury, but are not necessary for the diagnosis

Suggested Readings
Billmire ME, Myers PA. Serious head injury in infants: Accident or Abuse? Pediatrics 1985; 75: 340-342

Duhaime AC, Alario AJ, Lewander WJ, Schut L, Sutton LN, Seidle TS, Nudelman S, Budenz D, Hertle R, Tsiaris W, Loporchio S. Head injury in very young children: Mechanisms, injury types, and ophthalmologic findings in 100 hospitalized patients younger than 2 years of age. Pediatrics. 1992; 90: 179-185.

Hobbs CJ. Skull fractures and the diagnosis of abuse. Archives of Diseases in Childhood. 1984; 59: 246-252.

Odom A, et al. Prevalence of Retinal Hemorrhages in Pediatric Patients after in-hospital cardiopulmonary resuscitation: A prospective study. Pediatrics. 1997; Vol. 99. Issue 66.

Sato Y, Yuh WTC, Smith WL, Alexander RC, Kao S, Ellerbroek CJ. Head injury in child abuse: evaluation with MR imaging. Pediatric Radiology. 1989; 173: 653-657.

Buys Y, Levin A, Enzenauer R, Elder J, Letourneau M, Humphreys R, Mian M, Morin D. Retinal findings after head trauma in infants and young children. Ophthalmology. 1992; 99: 1718-1723.

Bruce D, Zimmerman R. Shaken Impact Syndrome. Pediatric Annals. 1989; 18: 482-494.

Duhaime A, et al. The Shaken Baby Syndrome. J Neurosurgery. 1987; 66: 409-515.

Davis HW, Zitelli B. Childhood injuries: Accidental or inflicted? Contemporary Pediatrics. Vol 12, No L, pp 94-112.

Burns

to understand that tap water scald burns are the most common type of inflicted burn injury (83%)
to understand the characteristics of immersion, spill and contact burns
to understand that the severity of burn injuries is dependent upon the type of burn, the temperature of the causative agent, the length of time exposed and the depth of the tissue burned
to understand the classification of burn injury

Suggested Readings
Purdue G, Hung J, Prescott P. Child Abuse by burning: An index of suspicion. J Trauma. 1988; 26: 221-224.

Hobbs CJ. Burns and Scalds: ABC of child abuse. British Medical Journal. 298: 1302.

Skeletal trauma

to understand that age is the single most important risk factor in abuse related skeletal injuries; 80% of non-accidental fractures are found in infants less that 18 months of age
to understand the frequency of inflicted skeletal injuries in children with abuse related head injury
to understand the appropriate use of the skeletal survey in an abuse evaluation
to understand the frequency of different types of fractures in both unintentional and abusive injury
to understand that rib fractures do not ordinarily occur as a consequence of CPR
to understand that metaphyseal long bone fractures, posterior rib fractures, scapula, sternum and vertebral spinous process fractures are highly suggestive of abuse in infants
to understand that multiple fractures and fractures of different ages are suggestive of child abuse and, as with all injuries in children, need to be evaluated carefully in light of the history
to understand the importance of assessing the mechanism of injury offered in the history and the developmental capability of the child
to understand that the majority of low height falls (<4 feet) do not result in fractures but in a small percentage of such falls, fractures can occur and are usually distal humerus, clavicle and linear skull fractures

Suggested Readings
Leventhal J. Thomas S. Rosenfield N, Markowitz R. Fractures in young children: Distinguishing child abuse from unintentional injuries. AJDC. 1993; 147: 87-92.

Merten DF, Carpenter BL. Radiologic imaging of inflicted injury in the child abuse syndrome. Pediatric Clinics of North America. 1990; 37: 815-837.

Anderson WA. The significance of femoral fractures in children. Annals of Emergency Medicine. 1982; 11: 174-177.

Mellick LB, Reesor K.Spiral tibial fractures of children: A commonly accidental long bone fracture. American Journal of Emergency Medicine. 1990; 8: 234-237.

Thomas SA, Rosenfield NS, Leventhal JM, Markowitz RI. Long bone fractures in young children: Distinguishing accidental from abuse. Pediatrics. 1991; 88: 471-476.

Worlock P, Stower M, Barbor P. Patterns of fractures in accidental and nonaccidental injury in children: A comparative study. British Medical Journal. 1986; 293: 100-102.

Soft tissue injuries (bruises and pattern injuries)

to understand that soft tissue injuries, while not associated with the greatest morbidity or mortality, are the most common type of inflicted child injury
to understand that bruises go through a predictable pattern of color change as they resolve which enables an estimation of injury age
to understand that multiple bruises of different ages and stages on a child are a strong indicator of abuse
to understand the typical locations of accidental bruises in children and that finding bruises in a pre-ambulatory child is unusual
to recognize the patterns of common inflicted soft tissue injuries in children (e.g. slap marks, bites, belts, and looped cords)
to understand that it is more common for unintentional bruises to occur over bony prominences than on other area of the body
to know how to describe, measure and document bruises accurately in the medical record
to know the location on the body where unintentional bruising is distinctly uncommon
to recognize some common mimics of bruises

Suggested Readings
Wilson EF. Estimation of age of cutaneous contusions in child abuse. Pediatrics. 1977; 60: 750-752.

Johnson CF. Inflicted injury versus accidental injury. Pediatric Clinics of North America. 1990; 37: 791-814.

Abdominal Injuries

to understand that inflicted abdominal injuries are the 2^nd leading cause of child abuse fatality
to understand that physical findings can be absent or subtle and there may not be visible signs of abdominal trauma on the exterior surface of the abdomen
to understand the need to assess for occult abdominal injury during the evaluation of a battered child and the appropriate use of blood and radiologic tests

Suggested Readings
Huyer Dirk. Abdominal injuries in Child Abuse. The APSAC Advisor. Volume 7, Issue 3; 1994: 5-8.

Sexual Abuse
General issues

to understand the definition of child sexual abuse
to understand the behavioral and physical indicators of child sexual abuse
to understand the spectrum of abnormal and normal sexual behaviors in children
to understand the use of a multi-disciplinary approach to child sexual abuse evaluations

Assessment

to become familiar with the age appropriate initial assessment of sexual abuse
to develop skills which can be applied to the initial screening of children who present in the clinic, office or emergency room setting
to develop skills in the initial approach to the family (or accompanying adults) and the other involved professionals

Physical examination

to become adept at the examination for sexual abuse including the explanation of the exam to the child and the family
to become skilled in the various techniques unique to the medical examination of child sexual abuse including positioning the child and engaging the accompanying adult's support to help facilitate the exam
to become familiar with the colposcope and the documentation of examination findings with photocolposcopy
to understand the indications and the correct techniques for testing patients for sexually transmitted infections and the significance of the various infectious diseases
to understand the capabilities and the limitations of the physical exam in "proving" that sexual abuse occurred
to recognized the critical importance of the history in the evaluation for sexual abuse and that the child's clear statement that he/she was abused is the most important support for the fact that abuse in fact occurred

Suggested Readings
Adams J. Significance of medical findings in suspected sexual abuse: Moving toward a consensus. Journal of Child Sexual Abuse. 1992; 1: 91-99.

Bays J, Chadwick D. Medical diagnosis of the sexually abused child. Child Abuse and Neglect. 1993; 17: 91-110.

Heger A, Emans SJ. Introital diameter as the criterion for sexual abuse. Pediatrics. 1990; 85: 222-223.

Berenson AB. Appearance of the hymen at birth and one year of age: A longitudinal study. Pediatrics. 1993; 91: 820-825.

McCann J, Wells R, Simon M, Voris J. Genital findings in prepubertal girls selected for nonabuse: A descriptive study. Pediatrics. 1990; 86: 428-439.

McCann J, Voris, Simon M, Wells R. Perianal findings in prespubertal children selected for nonabuse: A descriptive study. Child Abuse and Neglect. 1898; 13: 179-193.

Berson NL, Herman-Giddens ME, Frothingham TE. Children's perceptions of the genital examination during sexual abuse evaluations. Child Welfare. Vol. 72, No. 1 Jan/Feb 1993.

Social Work/Legal Intervention
Reporting Child Abuse

to understand the reporting laws and the consequences of failure to report a suspicion of child abuse
to understand the procedures for calling the State Central Register to file a report and the requisite paper work.
to understand the process of notification of the local field office of CPS by the State Central Register and how a child protective worker becomes involved in the evaluation
to understand the roles of the various professionals involved in a "Joint" response
to understand the obligation of the medical provider/social work team to insure a reasonable disposition plan, with careful evaluation of risks, and the value of hospital admission in selective cases
to understand the Instant Response Protocol (IRT) in New York City of Child Protective Services (called the Administration for Children's Services in NYC), law enforcement and Child Advocacy Centers
to understand the obligation of the medical provider and social worker to cooperate with the child abuse investigation including providing testimony in court
to understand how to notify the family of the need to make a report to the State Central Register in a non-accusatory, non-confrontational manner
to understand family dynamics/ cultural aspects and their impact on abuse/neglect situations
to understand behavioral disorders affecting an abused or neglected child, e.g. PTSD, depression, anxiety and substance use

The Interview

to become familiar with the techniques of the forensic interview for child sexual abuse evaluations (e.g. the Yuille Stepwise Interview) and to understand the difference between the forensic interview and the therapeutic interview
to become familiar with the detailed psychosocial history including the gathering of information and the documentation
to understand the issues of confidentiality and how the child abuse laws allow for sharing of some information with the investigatory agencies

Suggested Readings
Yuille John C. Et al. Interviewing Children in Sexual Abuse Cases

Yuille John C. The Step-Wise Interview: A Protocol for Interviewing Children

Court Testimony

to understand the varying roles of the medical provider in the courtroom (expert vs. fact witness)
to understand the basics of courtroom procedure (swearing in, review of credentials, certification, direct examination and cross examination)

Suggested Readings
Chadwick D. Irresponsible testimony by experts in cases involving the physical abuse and neglect of children. Child Maltreatment. Vol 2, No. 4; Nov 1997: 313-321.

Leake HC, Smith DJ. Preparing for and testifying in a child abuse hearing. Clinical Pediatrics. Nov 1977: 1057-1063.

Medical Record Documentation

to understand the importance of carefully documenting the history and physical in a way that will enable testimony on its contents at a future date by any professional in the same discipline
to understand the importance of avoiding nonstandard abbreviations
to understand the importance of avoiding the term "rule out" because to a non-medical professional it implies that the diagnosis has been ruled out
to understand the importance of including documentation in the record the developmental capability of the child
to understand the importance of including a statement about the consistency of the injury with the history
to understand the importance of documenting all telephone calls and names of police, ACS workers, etc.
to understand the importance of documenting the eventual disposition of the child
to learn the correct technique of photo-documentation

** Note: All of the suggested readings have been compiled and are available at Butler Center.

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