Commentary

As read today, the 1962 landmark article by Kempe et al¹ seems almost naive. The authors included case reports of 2 children with head injuries and unexplained fractures. They surveyed colleagues and noted that other institutions had treated children with similar injuries. In addition, they described the perpetrators of the abuse as possible "psychopathic or sociopathic characters" and gave speculative psychological explanations about why parents would severely beat their children. Finally, Kempe et al¹ provided radiographic clues to whether trauma was accidental or nonaccidental. So why is this article considered one of the best pediatric research articles in the last 150 years? Because with this article, Kempe et al¹ established that physicians have a special responsibility to children—a responsibility to help keep them safe, sometimes even from their own parents.

It is difficult for many physicians today to appreciate the culture of the United States in 1962. Physicians did not diagnose child abuse, even when treating children with serious unexplained injuries. Child abuse was not a medical problem, it was a social problem that was often ignored. In their article, Kempe et al¹ commented, "Many physicians find it hard to believe that such an attack could have occurred and they attempt to obliterate such suspicions from their minds, even in the face of obvious circumstantial evidence."¹ The response to the article was mixed. Kempe's daughter described the reaction in her lovely biography of her father, A Good Knight for Children²: ". . . .he got diametrically opposed opinions, on one extreme or another: either, ‘thank you so much for confirming what I’ve suspected, and for educating us;’ or, ‘I don't know where you get your information. I’ve been in practice for years and have never seen any evidence of child abuse.’"^2(p164)

Kempe did not stop his child welfare advocacy with the publication of his articles. He led the effort to establish laws mandating the reporting of cases of suspected child abuse and neglect to child protection agencies.³ Between 1963 and 1967, every state in the United States passed mandatory child abuse reporting legislation.

Even prior to publishing "The Battered-Child Syndrome," Kempe established a multidisciplinary child protection team at Colorado General Hospital in Denver in 1958. He encouraged the development of child protection teams in other hospitals to identify and treat abused and neglected children. A recent study by the National Association of Children's Hospitals and Related Institutions found that 89% of US children's hospitals support multidisciplinary child protection teams (K. Seaver-Hill, oral communication, September 2008). These teams meet regularly to discuss child maltreatment cases with individuals from the hospital and the community and to coordinate care for maltreated children.

In addition to the 1962 article, Kempe brought another serious childhood issue to the fore. In 1977, he presented the Anderson Aldrich lecture at the annual meeting of the American Academy of Pediatrics. His speech and the subsequently published article⁴ was entitled "Sexual Abuse, Another Hidden Pediatric Problem." Prior to this article, sexual abuse and incest were considered to be extremely rare. Again, Kempe widened the awareness of health care problems (in this case, sexual abuse of children) that physicians needed to address.

Since the publication of Kempe's original work, understanding of the ways children can be maltreated has expanded greatly. Over the years there has been acknowledgement that overwhelming numbers of children are abused physically and sexually. The National Child Abuse and Neglect Data System reported that in 2006, 905 000 children in the United States were found by social service agencies to be survivors of child abuse or neglect (12.1/100 000 children).⁵ A meta-analysis of surveys of adults reported that 30% to 40% of women and 13% of men experienced sexual abuse during childhood.⁶ Although there is no evidence that the actual prevalence has increased, these numbers would have been unbelievable in the 1960s.

Physicians and other health care professionals have learned about the lifelong effects of child abuse and neglect on the physical and mental health of survivors. For example, Anda et al⁷ have studied the long-term consequences of childhood trauma in the adult population and have documented a wide variety of adverse outcomes. These include increased occurence of many physical conditions such as heart and liver disease, mental health problems (depression, anxiety, alcohol and drug abuse), and social problems such as unemployment and unwanted pregnancy. Their work over the years has shown that the long-term consequences of childhood trauma are not only persistent but they are additive.

We have become more sophisticated in the diagnosis of child abuse, using methods such as colposcopy,⁸ biomechanics,⁹ proteomics,¹⁰ biochemistry,¹¹ and genetics.¹² The National Child Traumatic Stress Network, developed by the US Center for Mental Health Services, has contributed to the dissemination of resources and information for professionals treating this population of children.¹³

Success has been more limited for prevention of child mistreatment. Effective prevention of sexual abuse of children has been an elusive goal. Conversely, home visitation and family development programs using nurse home visitors have shown promising results for prevention of physical abuse and neglect.¹⁴

Overall, an online search of the MEDLINE database yields important data about the development of child maltreatment awareness by health care professionals since the article by Kempe et al¹ was published in 1962. His battered-child article was assigned the following keywords by the National Library of Medicine: wounds and injuries, child, child welfare, and infant. In 1963, the keyword child abuse was added to the MEDLINE system. That same year, 12 articles were categorized under this keyword and in 2006, almost 600 articles were listed in MEDLINE under the keyword child abuse (Figure).

View larger version (16K): [in this window] [in a new window] [as a PowerPoint slide]   Figure. Increase in Number of MEDLINE Articles With Child Abuse as a Keyword, 1962 to 2006

The marked increase in knowledge about child maltreatment has led to the development of a new pediatric subspecialty, child abuse pediatrics.¹⁵ In 2009, the American Board of Pediatrics will administer the first examination for board certification in this subspecialty. One result of Kempe's battered-child syndrome article has been the evolution of a cadre of pediatricians who are dedicated to diagnosing, treating, and preventing child abuse and neglect. The subspecialty of child abuse pediatrics is his legacy.

AUTHOR INFORMATION
Corresponding Author: Carole Jenny, MD, MBA, Department of Pediatrics, Albert Medical School of Brown University, 593 Eddy St, Potter-005, Providence, RI 02903 (cjenny{at}lifespan.org).

Financial Disclosure: None reported.