Medicine: Detecting Child Abuse
During his first six months at the pediatric emergency unit of a busy Tel Aviv-area hospital, Dr. Yoram Ben Yehuda saw not one instance of child abuse. “I had just got back from a two-year fellowship at the Children’s Hospital of The King’s Daughters in Norfolk, Virginia,” he says. “There, I had seen at least one such case every shift.”
He checked with neighboring hospitals and found they, too, seldom saw child abuse. “Are we Israelis really so exemplary?” he recalls musing. “I wanted to believe it, but it made no sense. With one third of Israel’s population under 18, and abuse and neglect of children occurring at all social, economic and educational levels, and especially in stressed populations, it seemed more likely it was there, but undiagnosed.”
Today, Dr. Ben Yehuda is head of the pediatric emergency unit at the Hadassah–Hebrew University Medical Center in Jerusalem, responsible for youngsters under 18 at its newly created Bat Ami Center for Treating Sexual Abuse and proactive in child protection nationwide. However, it was in Virginia that Dr. Ben Yehuda’s eyes were forcibly opened to failure to diagnose.
“A pretty young blond woman brought in a toddler covered in livid bruises,” he says. “Suspecting a blood-clotting disorder, the ER team ran blood counts and coagulation function tests. The child was sent to his primary-care physician for further testing. Abuse was not considered. All results were negative. ‘Had the hospital team thought of abuse?’ asked the primary-care physician. The physician was a woman, working in a community practice and had a foreign accent,” says Dr. Ben Yehuda. (She was, in fact, Israeli.) “Her suggestion was discarded.”
Two weeks later, the child was in pediatric intensive care. Scans showed multiple fractures and hemorrhages, old and new—irrefutable evidence of shaking and battering. “Three weeks later, this little boy died,” says Dr. Ben Yehuda. “His tragedy indelibly taught me that damage deliberately inflicted on children by adults must always be considered in the differential diagnosis.”
Dr. Ben Yehuda returned to Israel in late 1999 on a mission far broader than his new job of founding and directing a pediatric emergency unit at the Wolfson Medical Center in Holon. As the months passed without any abuse cases reported, he began teaching colleagues—physicians, nurses and social workers—what to look for. “Your starting point,” he would always begin, “is a very high index of suspicion.”
It was only 12 years since Israel had officially accepted that child abuse existed in the country, and few in the medical establishment knew much about diagnosing it. A rare exception was Dr. Yigal Shvil, a pediatrician at Hadassah. In 1970, he had saved a 9-month-old baby from her violent father and took the offender to court in the first child abuse case ever heard in the Israeli judicial system (the father was ultimately prosecuted under a different charge). Dr. Shvil would prove a valued colleague and mentor. In 2006, Dr. Ben Yehuda moved to Hadassah to revamp and direct its pediatric emergency service and was in place to succeed Dr. Shvil as head of the medical center’s Child Protection Center when he retired shortly afterward.
The efforts of these two physicians made hadassah Israel’s referral center for diagnosing and treating child abuse. When the medical center opened Jerusalem’s first center for sex abuse victims in October 2009, Dr. Ben Yehuda was appointed director of its pediatric section. Bat Ami, funded primarily by Hadassah and the Israeli government, was created to provide a streamlined, sensitive service and encourage victims to report the crimes against them. It has seen a continual increase in numbers, according to Bat Ami director Dr. Sagit Arbel-Alon, who treats adult victims who have been sexually attacked or raped.
“Our patients are not only hurt physically, but are also sometimes deeply ashamed of what has happened,” she says. “We provide emergency medical treatment from specially trained physicians, nurses and social workers, along with access to the police and legal authorities.”
Diagnosing children who are victims of sexual abuse differs radically from diagnosing adults. “When you see a 5- or 6-year-old with syphilis or gonorrhea, it’s a 100-percent indication of abuse,” says Dr. Ben Yehuda. “But diagnosis can sometimes be far more difficult than this, because there are no outward signs. Sexual abuse is not always deep penetration. Even when it is, the genitalia and anus heal very fast in children, often without scarring, so you need to look beyond the visible indications.”
Dr. Ben Yehuda’s role at Bat Ami is a natural progression in his mission of combating child abuse. From informally teaching colleagues at Wolfson after returning from Virginia, he went on to teach at other hospitals in Israel. When Israel’s Ministry of Health decided that health workers must be trained to identify sexual abuse in children, he joined the steering committee.
“The ministry thought we should train gynecologists, but I favored pediatricians,” Dr. Ben Yehuda says. “I steered the steering committee in my direction!”
In 2008, Dr. Ben Yehuda set up a 12-month diploma program for 18 pediatricians from 16 Israeli hospitals, through Israel’s Haruv Institute, funded by the Schusterman Foundation. All its graduates are active in examining child abuse victims, on the child protection committees of their hospitals and in consulting and teaching.
Two training programs will shortly be launched for community pediatricians. After that, he expects there will be programs for gynecologists, surgeons, nurses and social workers. Dr. Ben Yehuda’s national role in child protection is not only fully supported by Hadassah, which readily agreed to his continued involvement when he moved to the medical center four years ago, but also by a changed international climate.
“The system has finally grasped that domestic violence and sexual abuse are not only social and moral outrages, but also major public health issues,” he says. “The World Health Organization believes it is at epidemic proportions. This means it is now dealt with as a medical disorder. Our role is not judging the abusers, but protecting the victims.”
Bat Ami reflects this perspective. It is, hope Drs. Ben Yehuda and Arbel-Alon, the forerunner of dedicated one-stop violence intervention facilities that will treat injuries inflicted by brutality, neglect and sexual abuse; bring medical, social, legal and police services to victims; and serve as a hub of teaching and research.
In the meantime, health workers must remain constantly alert, says Dr. Ben Yehuda. While high-profile child abuse cases receive public attention—last July, for example, Hadassah doctors saved a dying 3-year-old whose mother had Munchausen syndrome by proxy and was systematically starving him—the spotlight on horrific episodes like these can obscure the ongoing caseload.
“Neglect is far more common than actual abuse,” says Dr. Ben Yehuda. He recalls a 4-year-old left alone at home for a half-hour while his mother bought cigarettes. The child climbed onto the bed to look for her from the 4th-floor window, fell out and died.
Sometimes, he says, attentive parents turn neglectful. He remembers a disabled child, lovingly cared for until a healthy sibling was born five years later. “After that,” he says, “the parents overlooked him to the point of forgetting to feed him.”
Sometimes another baby can be one too many. “An ER nurse alerted me to a 6-year-old brought in with chicken pox,” he says. “The child was dirty, malnourished and wore thin summer clothes, midwinter. A colleague said: ‘I know the family. You need not worry. They have 11 kids. They are great parents.’ But I did need to worry. The family’s emotional resources had run out, and this 11th child was severely neglected.”
The ER nurse recognized the problem partly because it was so blatant, but also because of the medical system’s new emphasis on child abuse to account for irregular or otherwise unexplained symptoms. Israeli emergency rooms are now picking up at least one suspected case a week—a rate similar to that in Europe and North America. But Dr. Ben Yehuda is far from satisfied.
“Not only must physicians, hospital staff, social workers and teachers know how to recognize abuse, they should be able to help prevent it,” he says. “We need national programs, like a pilot we ran in the western Negev, that teach, for example, how to deal with a crying baby—and that shaking is not among the options.”
Child abuse has probably been around as long as humankind, and Dr. Ben Yehuda is under no illusions that it can be eliminated entirely. That, however, does not deter him. “The outrage never diminishes,” he says. “But the reward for every child saved is overwhelming.” H