Rachel Berger and Will Bachman talk about Rachel’s journey since graduating from Harvard. Rachel graduated with a degree in biochemistry and moved to New York City to attend Columbia medical school. She moved to Pittsburgh for her residency and ended up staying for 27 years. After completing her residency, she did a fellowship in general academic paediatrics in Braddock, Pennsylvania.
Rachel took a job at the Children’s Hospital of Pittsburgh in a new division for child advocacy as a child abuse pediatrician. She eventually became board certified in the field when it became a subspecialty. Rachel then advanced in her career to become a tenured professor in 2016. After nine years as the leader of the division of child advocacy, Rachel stepped down in September of 2022 and is now focusing on clinical research and advocacy for children.
Establishing the Child Advocacy Centre
Child abuse work in the United States has been around since the mid-1970s, when laws were passed which mandated reporting of child abuse but it wasn’t a subspecialty until 2009. Establishing this subspecialty and law to report was in response to the number of children who were abused and sent back into a situation that was often fatal. The Child Advocacy Center was set up at the hospital and employed physicians, nurses, social workers and forensic interviewers to ensure that this would not happen again. The subspecialty combines expertise in pediatric and orthopaedic medicine, as well as knowledge in communicating with criminal courts and family courts to help keep children safe. Unfortunately, it is the most underfunded and understaffed of any pediatric subspecialty in the country. However, there are fellowships and other resources available for medical students and residents interested in this field.
Recognising and Reporting Child Abuse
Rachel explains that there are several different paths a child may take to get to see a child abuse pediatrician. These may include being referred by a hospital, Child Protective Services (CPS) if the child turns up at the Emergency room. Schools are a major source of reports, as teachers often have a close relationship with the children they are supervising, and can be more likely to spot possible abuse. Sometimes a family member may reach out. If abuse is suspected, the school or other responsible body can call the child abuse pediatrician to access their expertise.
Rachel talks about how the specialists determine if abuse is taking or has taken place but they put support and services in place that, hopefully, help the children and family. To help recognise whether a child is the victim of abuse, Rachel suggests checking the TEN-4 FACES P mnemonic to identify any signs of abuse that may be serious.
The Prevalence of Child Abuse
While it is difficult to determine the number of abuse cases since most children don’t or won’t talk about it until they are adults, the official data states that around one in seven girls say they have been victim of sexual abuse before they reached the age of 18. She also states that there is a myth that you can “tell” the perpetrators of abuse, and that parents who abuse their children don’t love them. Sometimes, it’s anger control issues, or even discipline gone awry.
Rachel also reflects on the importance of communication between medical experts and child protective services, social workers, attorneys, and police. This can be difficult because they don’t understand the medical information.
She talks about how the subspecialty of child abuse pediatrics had developed to advocate for children in court. It was seen as a combination of different elements, such as the increasing evidence base and the need for experts to advocate for children. However, there was a concern that other pediatrician reporters may become less involved if the subspecialty was created.
There is concern that this could lead to a dangerous precedent where the responsibility for reporting child abuse cases is removed from other pediatricians because they don’t think it’s their job to do so.
The advantages of having a child abuse pediatrics subspecialty is that there has been a growth in high quality research, and that the NIH has now funded a child abuse pediatric research network. However, Rachel is concerned that there are not enough people going into this field and that this could lead to a lack of access to people with expertise in this field. She suggests that the high bar of board certification might be discouraging people from people covering a small area of child abuse. Overall, they believe that the subspecialty has been a benefit to children and research, but that there is still a need for more people in this field.
Rachel has focused her research on how to better identify physical abuse in its early and mildest forms to prevent catastrophic injury. She mentions the Child Abuse Pediatric Research Network (CAP-NET) as a resource for research and noted that it has numerous projects looking into better ways to identify risk, concerning injury, and intervene in cases of physical abuse. Rachel explains how electronic records and machine learning can help track and identify cases of abuse across different hospitals, locations, systems, and services.
Socio Economic Factors in Child Abuse
Rachel discusses policy surrounding child protection and laws established to do so. Research has proven that fatalities from child abuse are far higher than expected and this has led to the need for protective laws to be passed. She goes on to talk about the difficulty of creating laws that protect both the child and the family from maltreatment or misjudgement, and what she offers suggestions on how the systems could be improved.
She cites decreasing childhood poverty as the major factor in reducing abuse. She explains that 30% of kids in the United States are supported by Medicaid, but 70-80% of children involved in child welfare rely on it. While abuse does occur in wealthier families, it is much more common in lower socioeconomic classes, and neglect is the most common form of child maltreatment. To decrease child abuse, Rachel suggests using the earned income tax credit and housing vouchers as two ways to reduce the impacts of childhood poverty.
Rachel shares examples of neglect, such as supervisory neglect, malnourishment, educational neglect, and medical neglect. She discusses physical abuse and sexual abuse, explaining that physical abuse often results in the child being admitted to the hospital for treatment, whereas sexual abuse is seen more often in an outpatient setting. Rachel also noted that sexual abuse often involves someone the child knows and trusts. Overall, the conversation highlighted the prevalence of different forms of child abuse and the need for society to address the issue.
Working on The Obama Commission to Eliminate Child Abuse and Neglect Fatalities
Rachel talks about her position as a research lead on the Obama Commission to Eliminate Child Abuse and Neglect Fatalities and why she was selected for the commission. The commission traveled to 17 places in the United States, including at least one Indian Reservation, and talked to different child welfare agencies, hospitals, police, and child advocacy centers. The commission’s report focused on different types of child abuse and how communities respond to these situations. She was shocked to discover that communities were not seeking out information from other communities on how they were dealing with situations of abuse despite reports sent out from newspapers around the country about children who had died or nearly died of abuse. The commission put together a public report at the end, but it wasn’t implemented due to the change in presidential administrations. Some of the recommendations from the commission have been implemented by the Casey Family Programs.
Rachel reflects on how powerful the experience was, how it shaped the next step of her career, and how she learned a lot about politics and how it is involved in an area that should be beyond political machinations of the day.
Courses and Professors of Influence
Professors mentioned by Rachel include Doug Melton.
07:42 Child Abuse Referrals and Prevalence
15:15 Myths Surrounding Child Abuse and Navigating External Systems
15:39 The Challenges of Communicating Medical Information to Non-Medical Professionals
17:51 The Evolution of Subspecialty in Child Abuse Pediatrics
24:41 Research in the Field of Child Abuse Pediatrics
28:46 Potential for Machine Learning to Identify High Risk Kids in Medical Records
31:07 Exploring the Benefits of Electronic Health Records in Clinical Practice
34:28 Policy Changes to Better Protect Children from Abuse
39:19 Socioeconomic Distribution of Child Abuse
45:15 Child Maltreatment and Presidential Commissions
Rachel Berger, Will Bachman
Will Bachman 00:02
Hello, and welcome to the 92 report conversations with members of the Harvard and Radcliffe class of 1992. I’m your host, will Bachman and I’m here today with Rachel Berger, who many of you may have known when we were at Harvard as Rachel Pardus. Rachel, welcome to the show.
Rachel Berger 00:20
Hey, thanks. Well, thanks for having me. And for all the work you’ve done on this, what a great way to hear about our classmates and what they’re doing now.
Will Bachman 00:26
Well, thank you very much. And let’s see, let’s hear about you. So tell me about your journey since Harvard.
Rachel Berger 00:32
Well, I said I graduated in 92, like everyone else with a degree in biochemistry, and I moved to New York City to go to Columbia medical school, lived in Washington Heights for my four years or three of my four years at Columbia, then moved downtown a little bit for the last year. And then I picked up and moved to Pittsburgh, which at the time was not what Pittsburgh is today. And it was a very big change from New York City. And I started my T hattrick residency at Children’s Hospital of Pittsburgh. When my husband was starting his PhD at CMU, and this was our big adventure, which is supposed to be three years and 27 years later, I’m still sitting in Pittsburgh in my office so that clearly, that was not a quick stint. After I finished my residency, I did a fellowship in general academic pediatrics, and worked in a place called Braddock, Pennsylvania, which nobody had heard of until John Fetterman showed up. And then everyone’s now heard of Braddock. So that’s where I did my fellowship in general, peds general pediatrics. And then I took a job at Children’s Hospital of Pittsburgh in a new division called the division of child advocacy as a child abuse pediatrician. And I kind of think back then I was kind of flying by the seat of my pants, child abuse was not a board certified subspecialty of Pediatrics yet. And if you’re willing to do it, they were happy to take you. And that’s what I started doing. And I’ve been here ever since I became a board certified child abuse pediatrician, when it became a subspecialty, I kind of worked my way through academia, from an assistant professor to a tenured associate professor, and then to a full professor with tenure, I think, in 2016. And for nine years, I led the division of child advocacy and just stepped down actually, in September of 2022, I decided nine years at the helm was enough time in administration. And I wanted to kind of go back to what I love doing more, which is clinical research and advocacy for four children. And so that’s what I’m doing right now.
Will Bachman 02:46
Tell us a bit about what that subspecialty is about. One could make some guesses based on the name of it. But tell us a little bit about how this specialty evolved. And what what it is it you know, when when a child has been there’s been suspect that there’s been child abuse that person gets diverted to that. Just tell us about the evolution of your specialty?
Rachel Berger 03:10
Yeah, so I mean, I think there have been people that did child abuse work for many, many years in the United States. I mean, there’s been, some people know, the United States, the first child abuse laws were in the mid 1970s. And that’s when we started having mandated reporting for child abuse. So people have been doing child abuse work for many years. But it was not a subspecialty as until 2009. And I think the reason our hospital set up a child advocacy center kind of encompasses what the problem was. So at our hospital, there had been a couple of children who were seen in our hospital for injuries, which were due to child abuse. And for various reasons physicians didn’t show up in court physicians didn’t really provide the testimony that was needed to protect the kids. Those kids went back to violent homes and they died. And as a response, our hospital set up a child advocacy center, with physicians, nurses, social workers, what we call forensic interviewers, people who specialize in interviewing children, to really make sure that that wouldn’t happen again. And that’s kind of what happened in this country that over time, people recognize that, just like we needed a subspecialty for pediatric oncology and pediatric gastroenterology. We needed a subspecialty of people whose expertise was really a combination of expertise in pediatrics and injury in orthopedics in emergency room and radiology. And then it also in the systems with communicating to criminal courts, family courts, all these other people outside of the medical system that really have the responsibility of keeping children safe, but require the expertise of physicians and others to make those decisions. So I think over time As you know, it became clear that there was the knowledge base had gotten bigger and bigger, and that this expertise was needed. So in 2009, it became a board certified subspecialty. It is the American Board of Pediatrics, it says actually the most understaffed of any subspecialty. in pediatrics, it’s an ongoing problem. Maybe it’s not that surprising that not a lot of people want to do this work. But there it is a subspecialty. There are fellowships around the country. And we hope that over time more, we can encourage more and more medical students and residents to come into the subspecialty.
Will Bachman 05:35
Well, I imagined it’s a very, very needed specialty. And my wife was on the social worker side, she, for a number years before she went to law school was doing Child, child social worker. And so, you know, kind of heard many stories about kind of the terrible things that that she witnessed. So tell us a little bit about how children would kind of get to see a child abuse pediatrician specialist, would that be like they go to the hospital, and you know, when someone suspects that they may be subject to child abuse, because they probably don’t normally just walk in and say, hey, you know, my parents are abusing me. Often it might be, you know, like, they’re not talking about it and someone diverts them, or maybe a teacher raises a flag or someone else raises a flag, like how does it what’s the path for a child to get to see someone like you,
Rachel Berger 06:24
there’s lots of different paths. But you’re right, you can’t really go out on your own and put out a shingle child abuse pediatrician. So pretty much everybody’s in an academic type center. And so we didn’t involve for lots of reasons, if somebody comes to an emergency room, and somebody’s concerned about abuse, they will call us. If a child protective services agency concerned about a child that they’ve gotten a call on, you know, from some anonymous reporting source from a school from other people, they may call us and ask for our expertise. Certainly schools, they’re actually advising for children over five who are in school, they’re a major source of reports, because they see children every day. They know children and children become comfortable with those adults, so they’re likely more likely to say something to them. So certainly schools can send children, police can send children, we really get us at primary care providers can send children, we really get referrals from many, many different people and sometimes family self refer, they are concerned that somebody else in the family may be hurting the child, so they may self refer. So yeah, we get there’s a lot of different ways we may see children, and we see them from a really birth up to age 18. So a wide range of children from a wide range of different referral sources.
Will Bachman 07:42
Is there a spectrum of cases where some it’s like, really obvious that someone’s been abused? And some it’s, it seems like, almost certainly they haven’t been but then there’s maybe like, a gray area in the middle, where you as a professional, it’s hard to tell if it was just legitimately an accident, or if they’ve been abused? And like, what do you do in those cases?
Rachel Berger 08:05
Yeah, I mean, I think you’re exactly right. I think there are cases that we say there’s always the black and white, or anybody you wouldn’t even need to be a doctor knows, okay, this child is the victim of abuse, right. And then there are some where other physicians may be concerned about abuse, about half of the time that we get called, we actually don’t think it’s abuse. It’s either a medical disease that could look like abuse, or the physician person who was making the referral didn’t have enough knowledge, they were concerned. But actually, there are other reasons why that child wasn’t abused. So I say about half the time that we get called, we actually don’t end up thinking it’s child abuse. And then of course, there is that gray area. And I think that’s the area of the most discomfort because of course, you know, if we have a child who can’t talk, or won’t talk, and we have injuries, or situations that just are not black and whites, we have to be comfortable with not knowing and that’s a really uncomfortable part of our job, because if we’re wrong, and they’re being abused, and we miss it, they may come back re injured or dead, right. But we also don’t want to call something abuse. That’s not because potentially that could cause a child to be removed from a home that’s not dangerous to be in. So those gray cases certainly do happen. And I think that’s one of the most difficult parts of our job is knowing that if we’re wrong, either way, the implications for a child and family are can be pretty catastrophic. And sometimes we have to just be comfort, we have to just be comfortable with the fact that we don’t know and hope that we have set up enough resources for a family and set up as we often say, a safety net for that child. And if a child becomes old enough to talk or comfortable to talk, we hope they will go to a mandated reporter. And we hope that sometimes when we were able to put services in a home that fixes the problem, right, even if we don’t ever know for sure whether a child was hurt
Will Bachman 09:56
as a bit of a public service announcement right here, could you share us what are some Some signs of abuse that we should all be aware of. I mean, I suppose some are obvious, but some might not be so obvious.
Rachel Berger 10:07
So I think actually, it’s interesting you say that. So there’s a mnemonic that we called and four faces. And actually in Chicago, they hang signs that say, 10. For faces in the bathrooms, much like we often see those signs for, you know, if you’re worried about someone who’s a victim of intimate partner violence, you know, you should do X, Y, and Z. So 10 for faces stands for areas of the body, where children should not bruise and 10 is torso, which is area under a girl’s bathing suit, IE is yours, and his neck. And four stands for the age. So children, four months of age and younger, should never have any bruises. And any bruise and a child four months of age or younger, is concerning for abuse. And young children, we also, of course, worry if they could have underlying disease that could cause that. And then under for a child should not bruise in those 10 areas. And so I think that’s the, I think the easiest way for us to, you know, let the public be aware that there are types of bruises that you should be worried about, when you see children, you know, in a public place, the faces are other parts of the face that are worrisome, you know, about the frenulum, the angle of the jaw, the conjunctivitis, which is the white area of your eyes, and said, these are different areas that we should get concerned about. So as the I think the 10 Four is probably the best thing that I can tell people to look for. And I think some of the worst cases of abuse that we have seen, have been recognized by somebody in a public place. I said, I will never forget one where it was a server in a McDonald’s, who recognize that one of the families children looked really thin, and had a really big bruise on their face. And they call Child Protective Services. And clearly that worker in McDonald’s was not a giant tree and child abuse pediatrician. But recognize that there was something not right. So I do think that the public really does have a role to play. And just that simple, recognizing of that 10. Four is something that I think everybody can kind of put in their back pocket if they should see a child with those areas of bruising.
Will Bachman 12:24
Can you talk a little bit about the prevalence of child abuse and any myths around it that that you encounter?
Rachel Berger 12:32
Well, it’s a really good question. I mean, I think in terms of prevalence, I think we don’t know really what the prevalence is, because many people don’t talk about it when they’re children. They only talk about it as adults. I mean, the official data would say that about 1% of children under the age of one, or even a little more than that are victims, we know that about 34% of children in the United States undergo some kind of Child Protective Services investigation during their 18 years, which is was pretty striking. But the rate, if you look, for example, in adults who talk about it for sexual abuse, it’s as high as about one in seven or eight girls will say they have been a victim of sexual abuse by the time they get to 18, which is pretty striking. So it’s far more common. And I think people would like to believe and I think part of it is people are sometimes ashamed. And they don’t talk about it. I mean, just think about the Catholic Church. And all these episodes of abuse that went on as I’m in Pennsylvania, we had Jerry Sandusky for many, many years abusing children. And, you know, people didn’t talk about it even after people didn’t want to talk about it. Right that they had been a victim. So, you know, I think we don’t really know the prevalence, but we know it’s it’s quite common both for sexual abuse and physical abuse. I think in terms of myths, I think I think one of the myths is that you can tell a parent who’s abused their child just by looking at them. And I’ll never forget, there was a commercial ones in which somebody got into an elevator with a child and on the person shirt, it said, I am a sexual predator. And and then the elevator opens. And it was basically they said, if it was only this easy, right? So I think that kind of stuck with me, because I think people somehow think that they can tell. And I also think people think that parents who abuse their children don’t love them. Right? And I always say this is I don’t think in my whole career, or very, very rarely in my career, is there a parent intent who is intentionally abusing their child, right? It’s often out of frustration or anger that gets out of control. But parents can love their children and abuse their children at the same time. And you can’t tell by looking or talking to a parent whether they have perpetrated abuse on their child. So I think I spent a lot of time my career. You know, talking to people about how loving your child abusing your child are not mutually exclusive, and that parents often don’t intend to hurt their children. But often it’s discipline gone awry. And so I think that’s an important, I think it’s really important that I always tell people about abuse and about abusers.
Will Bachman 15:15
One thing that caught my attention was your point about the an area of expertise is also interacting with the external systems, that in addition to being kind of the medical expert, that you also have to, to help the child you have to advocate effectively, you have to be able to effectively navigate all those tell us a bit about that part of the of the role.
Rachel Berger 15:39
Yes, that’s a really interesting, I think it’s a really interesting, but also very frustrating part of my job. So right, I always say you can spend, you know, a million dollars on saving a child. But if we don’t protect them from another incident of abuse, all the medical care we gave is for naught. And so being able to communicate, for example, with Child Protective Services, who is whose responsibility is to keep the child safe. But who is stuck with, you know, social workers who have no medical knowledge can be a real challenge. So a lot of what myself and my colleagues do is explained to Child Protective Services, you know, what injuries a child has, why those injuries are concerning why these are not accidental injuries, or sometimes why they are accidental injuries. And so trying to explain sometimes very complicated medical information to people with no medical training. And similarly, we do that with attorneys. We do that with police. And unfortunately, with a part of our job is we also do that in court. And I think that’s one of the most difficult, and I think least liked part of the jobs of a child abuse pediatrician, is to be in a court testifying, just because I think courts are, by their very nature. I’d say antagonistic, that would be a minimalist statement, but very antagonistic, and not the way physicians like to practice medicine. And they force you to have, you know, to make very strong statements in ways that physicians don’t tend to do that. And to think about things in ways that physicians often don’t, we don’t use the term medical certainty or beyond a reasonable doubt, those aren’t medical terms, but they’re terms that are used in the court systems. So I’d say at least half of my job, and my colleagues job is about answering subpoenas, explaining things to family, civil courts, family courts, and criminal courts. But if we didn’t do that part of our job, as it really we wouldn’t be able to protect children, because we don’t protect them. It’s all these other systems that are responsible for doing that.
Will Bachman 17:51
Tell me a bit about the evolution of your subspecialty from being something that was a bit informally, you’re focusing on to when it became board certified, and just how it evolved. And just, it’s a relatively unusual thing to kind of see something go from being this, you know, sort of practice area that people were doing, but didn’t really have necessarily an official designation. What was it like to I mean, imagine conferences appeared or more, you know, official training programs came out or just tell us a bit about that evolution, what that was like?
Rachel Berger 18:28
Yeah, so it’s kind of interesting, because I will acknowledge that I was one of the people that did not really think this should be a subspecialty. And I had a lot of concerns about it. So it kind of evolved in so far, as you know, the evidence base became bigger. There were more people doing research in the field, it was clear that there needed to be people that were experts in these areas of injury and in how to testify. I think that’s a big one is that the reality is you get better at testifying, the more you do it. And sometimes I look back, you know, because all poor, there’s always a stenographer there, right. And you can always look at your testimony. I said, I look back at some of the testimony I gave you 20 years ago. And I thought that was it was an accurate, it’s just I wasn’t really very good at articulating my opinions in a way that non medical people could understand in a way that I think, most appropriately protected children, I look back and I say, oh, my gosh, like I really wasn’t very good at it. And I hope that 20 years later, after testifying hundreds and hundreds of times, I’ve gotten better at it. So I think part of the subspecialty was recognizing that if you don’t people don’t know how to testify, children get hurt. And that having people that do this, as a lot of their job was was helping children. I think it was a combination of a lot of different things. That realizing that this evidence base was getting bigger, you couldn’t be a specialist in everything. We needed experts to advocate For children, as if we didn’t have people that had expertise in these other kinds of non medical parts of our job. My concern about making it a subspecialty had been that other people who are mandated reporters would suddenly think that they didn’t have any role in child abuse cases. And we could kind of see that with all sub specialties. For example, I used to take care of kids with asthma when I was a general Peters and all the time, right, I would, I didn’t really refer to a pulmonologist until it was something I couldn’t handle anymore. But then when more and more pulmonologist came around, all of a sudden, all families wanted to go to a pulmonologist or the expectation was that I would send a family even with a child with mild asthma, to a pulmonologist. So kind of left my practice. And they get the same thing happened with allergies, the same thing happened with child development, your children with autism, or ADHD, where it used to be part of the purview of a general pediatrician. And as more and more people became sub specialist, it moved out of that purview and into the sub specialist purview. And I think my concern with making child abuse pediatrics, a subspecialty, was that other pediatricians would say, Well, this is not my job. This is the job of the child abuse pediatrician. Right? And that’s kind of a dangerous precedent. One because we can’t possibly have enough child abuse pediatricians for all the, you know, 3 million or millions of reports of child abuse made to Child Protective Services every year, right, you just couldn’t possibly have enough people. And that the whole point of mandated reporting, right was that all people in jobs where they interact with children are mandated reporters, right. And if people kind of felt like this was no longer their responsibility, my fear was that children would become less safe. So you know, now we are more than 10 years into the sub specialty. And I think there have been advantages, real advantages of having a sub specialty, I think one of the most important ones is that we have so much more research, really, really high quality research being done in this field. When I came out of a fellowship, and I was interested in getting what’s called a K award, which is a, basically a five year grant from the NIH to develop independent researchers, there was literally not one person that I could get as a mentor who did child abuse, because nobody had child abuse grants from the NIH. Right. And so I had as a mentor for my CAE Award, a pediatric critical care physician who was willing to mentor and then I also had a pediatric neurosurgeon, who obviously had done some child abuse in the operating room. And then I had a child abuse pediatrician without any research experience, but who was able to provide some expertise in the field, right. And it was really difficult. In fact, the NIH didn’t really know what to do, they’re like, well, who’s going to fund this, right, because we don’t really have any place for this in the NIH. Whereas now, we have, you know, probably 20 fellows a year that are coming through. And we have many more researchers. In fact, we have our first NIH funded child abuse pediatric Research Network, which is now in its third year. And I’m very happy to say that actually, three of my former fellows who worked with me on the research are the PIs for that national research network. So I see that part of the advantage of having a subspecialty is that it has brought about a lot more really high quality research, which I think has really moved our field forward. I still am concerned that we don’t have nearly enough people in this field. And that’s a problem for children, because we have whole counties, even just in Pennsylvania rural counties that have no access to people with an expertise in pediatrics. And because we have this high bar, you know, anything board certified, it discourages people from doing just a little bit of child abuse, which is what a lot of people used to do. A lot of people used to do a little bit of child abuse, and now we have fewer people doing a lot of child abuse. And I don’t think we’re in the same place. Because we’ve just there’s just not enough people. So I think I think overall the sub specialty has been a benefit to children certainly has been a benefit to research. But I still do worry that there’s just not enough people going into this field. It’s a really tough field. There’s a lot of turnover, a lot of secondary trauma. And the fewer people we have, the harder it is for the people that are here.
Will Bachman 24:41
It’s such an interesting point about how making it this official subspecialty puts in place kind of bureaucratic type structures that allow the funding and so forth. Could you talk a little bit about some of the areas of research that you think are really important that are happening now in this area?
Rachel Berger 25:01
So I said my area of expertise in physical abuse. So there is a lot of really good research in other areas. But the area that I know best is physical abuse. And so I think my area of interest since I started has been in how do we do a better job of identifying physical abuse in the mildest forms, so we can prevent the most catastrophic injuries. So the most common reason that children die of child abuse from physical abuse is abusive head trauma, which most people know is shaken baby syndrome. And we know that many kids who ultimately are either permanently brain injured or die from abusive head trauma have been injured before, and actually have been seen by medical providers who didn’t recognize maybe those 10, four faces if they were a three month old with a bruise didn’t recognize that this might be child abuse. So I’ve really focused my research in the last 20 years on how do we do a better job recognizing children when they first present with maybe just a bruise or a fracture before they have the catastrophic and irreversible injury to their brain. And I think a lot of the research which is happening now, particularly because of our National Research Network, which is called cap net, which is child abuse pediatric Research Network. We have 1000s and 1000s of cases of physical abuse from 11 hospitals from around the country, where everybody is now entering the same data on every case into this national database. And I think that our knowledge about these injuries, we call them Sentinel injuries that happened before the catastrophic injuries, our understanding is greatly improved. And we’re being able to develop more and more objective ways to identify risks to identify which injuries are most concerning. And I think that’s really how we can improve. You know, this field, how do I know which bruise I should be worried about? How do I know which fracture I should be worried about? How do I know which children which tap us for rare diseases we could have? Right, which we make sure that we’re not thinking it’s not the National Research Networks are really going to move forward, our field. The other thing that is going to is Michigan. And some of other I would say like things we are able to do with the electronic health record, as a lot of what the work that I’ve been working on is how do we harness what the electronic health record can do to again, help us protect children, because the electronic medical record, for example, can very quickly check whether the same child has been anywhere else in our hospital network, which with injuries that are concerning, right, and parents who abuse their children sometimes do intentionally go to different hospitals, right, because they don’t want anyone to notice that they’ve been to multiple different hospitals. And so, you know, the ability to talk between medical records, I said, use machine learning to quickly quickly scan, you know, huge amounts of information to identify kids who might otherwise be missed. I think there’s a lot of potential there. And so I think I’m really I am really excited about, you know, into the future, about the communication between medical records, I’ve said about how we can use machine learning to help us identify high risk kids, and then combine that with all the information we’re getting from this huge national data set.
Will Bachman 28:46
So is the idea there something around, you would track people over time track kids over time to see, you know, to be able to look back and say, what were the injuries, you know, earlier on that, you know, could have predicted the more serious injuries so that you can, because I imagine there’s a lot of false positive, potentially, where a kid might have a bruise, and they just, you know, whatever, fell off the bed or something or, you know, you know, whereas totally not abuse, but just an accident. So you’re trying to figure out how to sort those out from the actual positives?
Rachel Berger 29:24
Absolutely. And we have some of that ability now. So if I, for example, we’re really focused on very young children, because the reality is, is that older children, they get a lot of injuries because they’re being normal, older children, you know, it’s really the infants that we worry most about because infants aren’t out riding their bikes or, you know, jumping on pogo sticks or anything like that. And so we can now if I have a child who comes in, for example, with a fracture a young child, the electronic medical record can go back and say, Look, this child has actually been in the emergency room three other times with three other injuries and they’re only safe seven months old, right? Provider can then say wait a second, I’m not looking at a single injury, I’m actually looking at four consecutive injuries and a seven month old now burned. Right. So while a single visit might not be concerning the ability to look back and say, Look, this same baby has been to three different emergency rooms with different injuries, right, in the past, you know, three months, that may raise their concern clinically, just the ability to have that information at their fingertips is something it was really hard to do before, right? I mean, we had paper records, I guess you could start flipping through paper records. But nobody could really do that in an emergency room, right? Because you’re hurrying up and trying to move through, no one’s going to look at 1000 pieces of paper, while someone’s in an emergency room. But now the electronic health record can pretty quickly go back and say, Look, you know, we’ve had all these ICD 10 codes, for example, look, this child had two prior fractures, that’s a lot of fractures for a seven month old. Right. So I think that’s the way that we’ll be able to help use prior information to make decisions about what’s the child that’s sitting in front of us right now.
Will Bachman 31:07
It’s never easy sharing all that information in the healthcare system. So I’ve been told, tell us a little bit about what it took to actually put that system in place where you have all these different states and hospitals systems, reporting their data and sharing it with one another, tell us a bit about behind the scenes, what it takes to make that happen.
Rachel Berger 31:31
So I should say, so the the cap net, which is the research network, those are not communicating in real time. But some of the work, for example, with the clinical information changes, so that there is much more communication between health systems in most health systems are in clinical exchanges. So our hospital system, for example, UPMC, is in a health exchange with many other hospital systems. So those kinds of happen, no matter what, if I’m taking care of any patient, I can go in and see all the other stuff from other exchanges that are in our hospital system, some of the way that we were able that we’ve been working to look at other visits through, you know, for specific use of looking at child abuse, for example, is we can code for example, like give up the system. You know, here’s a list of really high risk, ICD 10 codes, right, and this ICD 10 code in this age, and this ICD 10 code in this age, these are concerning. So the system can then say, okay, look, we’ve seen this same child in a different hospital in this system, right with this ICD 10 code on this date. Right. So the actual exchanges have already been set up right through, because that’s what people are using now in clinical practice. And people have looked at certain ICD 10 codes that are concerning for abuse. And then the issue is, how do you, you know, harness that ability to do that. And some of it is very simple. So for example, we have a system in our hospital that has different triggers for child abuse. So if I’m a provider, and I order a x ray, in a four month old child, and then I subsequently order an orthopedic consult, right? The assumption is that I wouldn’t be ordering the orthopedic consult if I did have a fracture. So the provider will get an alert saying, Look, you this is a high risk situation, we had an infant that you got an x ray on and look, now you’re calling the orthopedist, or you have a child who got an x ray on and now look, you’re sedating them. So presumably, you’re sedating them, because they have a fracture, and we need to cast that fracture. So there’s things that we can pick up in the medical record, to then say to the provider, you may have already thought about abuse, but if not, look, what we see something that makes us concerned, right, or certain discharge diagnoses, and those we can do now. And we have those systems in place. And they’re in place in many hospitals around the country. It’s called child abuse, clinical decision support. And it helps clinicians make good decisions with the data that’s being entered into the medical record as part of clinical care. And the system picks up those things that are concerning, and alerts the physician to just want to let you know, you know, you might want to be worried about abuse, you know, can we help you make some decisions, and then leads the physician hopefully in the right direction?
Will Bachman 34:28
What’s your point of view on any kind of policy changes that you would like to see? So if you think that the current kind of policies are about right to protect kids from abuse, or are there changes that you would, you know, that you would suggest that either schools make or that, you know, other institutions make to better protect kids?
Rachel Berger 34:57
So that’s a question that’s near and dear to my heart. heard and I said, I’ve spent a lot of time on policy related issues. I started when after Sandusky was arrested in Pennsylvania, I served on that task force for child protection, and then Pennsylvania. And that was the first time that I was really sitting down and helping to change laws, right? We changed a lot of laws in Pennsylvania, to try to do a better job protecting children really so that a Sandusky never happened again, you know, and after that I served in the Obama administration, as the research lead for their commission to eliminate child abuse and neglect fatalities. And this was a commission that lasted for two years, and was trying to decrease how you know how as a country, can we decrease fatalities and near fatalities from abuse. And really, there was a protect our Children’s Act back in 2012, which led to this commission, which was actually based on a report from the accountability office really pointing out, you know, how many we have almost 2000 deaths a year from child abuse, we really, if you added up all our deaths from COVID, and flu and all these other diseases, it’s not even close, maybe it’s actually more than the deaths from cancer every year. I mean, it’s it is a real public health issue. And so through all these, you know, through these Commission’s I’ve really had a lot of time to think about, you know, how do we make better laws? Right? How do we protect children, of course, recognizing that, you know, we want to protect children, but we also need to protect parents ability to raise their children. And that’s really, I think, where it’s so difficult to know what the right thing to do is, right. So the, the bounce is always a parental rights versus a child’s rights, a child’s rights to be raised in a loving environment without violence, and a parent’s right to raise their child in the way that they see fit. And the how you make that bounce is really how you try to strike a balance in the laws on child protection. Right. And so I think there’s, there’s a lot of different ways that as a country, we could change the balance. And different states also make different decisions. Just it’s a state. That’s a, although we have laws in the country about child abuse, each state has its own laws as well. So I have thought a lot about, you know, what could we do, and clearly, if this was something simple, somebody would have thought of how to do this before. But I think the most important thing is one of the most important things is that we have a child protective services system that is staffed by the best people that we can get kind of like we want the best teachers, we can, as teachers, you know, really important role in our children’s lives, we want a system that is well financed, that has the best qualified people that is able to take advice from the most qualified physicians, psychologists, psychiatrists, you know, they’re just the best people around, and that they use the best data to make the best decisions for children. And that sounds like a very basic thing. But if that happened, then I think our children would be better for it. And we have a very under financed understaffed child welfare system, just like we don’t have enough child abuse, pediatricians and our most vulnerable kids, which I would argue are children who are victims of abuse or neglect, really, sometimes get the short end of the stick, because we don’t put our money where our mouth is, we want to help our children, but we’re not putting that money there. I always see the most important thing we can do in child welfare, to improve children’s lives is to decrease poverty. And if we could do one thing in this country to decrease child abuse, it would be to decrease childhood poverty. There is no question that decreasing poverty decreases abuse. And so you know, we can there are a lot of things I’d like to see done in the child welfare field in terms of how do we change policies and procedures. But if there was one thing I would say we need to do as a society is to decrease or get rid of childhood poverty.
Will Bachman 39:19
Could you say a bit more about that in terms of the kind of the socio economic distribution of child abuse at least as far as it’s it’s known? Is it? Is it more concentrated among, you know, parents at the lower end of the income spectrum?
Rachel Berger 39:35
Yes, it is. In fact, I gave a talk on on this past week at a conference about actually racial disproportionality and child welfare. And if you, we have a lot, a lot of studies and it’s actually not, if you look at race and socio economic status, it’s actually the socio economic status and poverty, which is driving a lot of the racial disproportionality. Not to say that structural racism and implicit bias and all these issues aren’t affecting it. But the most important is poverty. And about 30% of kids in the United States get Medicaid, but about 70 to 80% of children involved in child welfare are on Medicaid. So certainly there is abuse in wealthier families. That’s, it’s there is certainly it occurs in all socioeconomic classes, but it is much more concentrated in lowers people of lower socioeconomic status. And part of that is because neglect is actually the most common form of child maltreatment. And that’s so connected to poverty. But there’s, I think the reality is there’s so much data about how to decrease child abuse by decreasing poverty, everything from the earned income tax credit to housing vouchers. I mean, we know how to do this. But again, it’s a societal choice. That we haven’t done it. So overwhelmingly, I’ll say it is 70 to 80% of kids who are victims of abuse, are getting Medicaid, which is showing that they are a lower socio economic group. But we can decrease that if we decrease poverty.
Will Bachman 41:17
Could you talk a bit about just the distribution of abuse in terms of you said the most common is neglect. You spoke earlier about kind of the child abuse of infants under one year old, like the Shaken Baby Syndrome, and so forth, can you just kind of characterize child abuse? Like, to the extent that you can in terms of by injury type or by age of the kid or, like, you know, when you say neglect, like, what does that what does that mean? Like not feeding a kid or not watching them or just give us a sense of just how you think about the characterizing, characterizing it, that.
Rachel Berger 41:58
So I think about I think there’s a lot of different kinds of abuse and neglect is the most common, and there’s a lot of neglect. So there could be, for example, Supervisory neglect. So I’m not watching my child, and they drowned in the pool, or I’m watching a child and they get into my medication, a lot of illegal drug ingestions, I have a child who has cocaine in their system, or fentanyl in their system, those would be considered generally types of neglect. And, yes, children, for example, some children that are malnourished, not gaining weight, even if there’s a medical cause that’s not child abuse, but when parents aren’t feeding their child, and that’s why they’re not growing, that will be considered under neglect. There’s also educational neglect, children who are missing a lot of school, the truancy not like teen, not the older teenagers, but you know, eight year olds who have missed 75 days of school, that’s educational neglect. So if I think about neglect is all the things that children should have access to. And their acts of omission. It’s something that parents are not doing that they should be doing, they should be watching their child in an age appropriate way. And or they shouldn’t be sending them to school. So those things or they should be taking care of their medical needs. So medical neglect is often under their child has a complicated medical issue, which the parents are not either willing or able to care for. And because of that, the child has an outcome that they shouldn’t have had they die for their asthma, right, or they end up with a kidney transplant from their diabetes, things that shouldn’t happen, but are happening because of a failure to get medical care. So those kind of all going through the umbrella of neglect. And then so we talked a little about physical abuse. And I think about that as an act of comission. Right, somebody is doing something they shouldn’t have done, right? They break their child’s bones or they shake their baby. And so that’s, that’s physical abuse. And that’s also pretty common, not as common as neglect. But a lot of what we see in a hospital setting a lot of neglect. We will see in a hospital setting physical abuse, we see a lot of in a hospital setting, because many times those injuries are severe enough that they have to get admitted to a hospital to get treated. And then there’s sexual abuse, which we don’t see very much in an inpatient setting, but we see a lot in a clinical setting like an outpatient clinic. And since sexual abuse I think a lot of people know about because they hear about the Catholic Church. And most frequently, that’s somebody that the child knows and is feel safe with, which is why this happens. Because the child thinks somebody that they should trust. And so we see a lot of sexual abuse in our outpatient setting, but very little in our inpatient setting. So I think there’s no there’s other kinds of abuse, which I think are less common, but people have heard of like medical child abuse, which is often called Munchausen syndrome by proxy when parents are either fabricating a disease giving actually making a child have symptoms. We see some of that. So those are all we see a lot of different types of abuse. But that kind of is an umbrella of all the things that somebody would put under the umbrella of child maltreatment.
Will Bachman 45:15
And wonder what return to one thing that you talked about, which is that you’re on to the Obama commission? That’s not something that I talk to every day of someone who’s been on a presidential commission. Could you tell us a bit about, you know, how you were selected for that? And also, what it’s like, do you kind of get together once a month in person? Or is it sending memos to each other or what goes on if you are on a presidential commission?
Rachel Berger 45:42
So that commission was in 2014, to 16. Over. But it’s an interesting how actually got on that commission, I think it’s one of those things where you never know, who you will meet, that will turn out to be a really important person. So I had about I said, probably three or four years before the this commission, I had done a small grant, or study related to childhood fatalities. And I presented at a meeting, I remember down in New Orleans, and there was a person there named David Sanders, who was headed at the time of the Casey Family Programs, which is a nonprofit, based in Seattle, which tries to approve the child welfare system. And, and I met him at this meeting, and I talked to him. And then lo and behold, he was appointed as the head of this commission to eliminate child abuse and neglect fatalities. And he called me and said, Would you be willing to be, you know, the research lead for this commission? And I said, No. Okay. What does that mean? He said, Well, I want you to be the research expert to make sure that the Commission makes their decisions based on the most up to date research in the field. And so I obviously accepted, the Commission traveled to 17 places in the United States, including at least one Indian Reservation, over the 12 to 16 months of the actual commission itself. And we really traveled all over the United States, listening to different child welfare agencies, hospitals, police. We call child advocacy centers, where they interview children with concerns for generally sexual abuse, talk about child fatalities, and near fatalities, what they had done in their community, what they perceived to be the barriers. And we, as a commission, put together a report. And I said, as the research lead us, and my job was to ensure or try to ensure that the members of the commission were making their decisions based on evidence. And so this was a really intensive 17 months, I said, I think I got Starbucks mugs from everywhere around the country and all the cities that we had been to. And I said I learned a tremendous amount, not surprisingly, but I think most whose was frustrating was that it seemed like every city community, we went to, had to learn for themselves, what that how terrible fatalities and your fatality was and how to solve them. It was almost as if no community could look to another computer and say, Wait a second, they have this, let’s do something before we have one ourselves. Right. And it was, while the commission was going on, there was a person who was the I was the research lead, there was a child welfare lead. And through the commission every day, he’d send out emails from newspapers around the country of all the children in the public press who had died or nearly died of child abuse. And it was an overwhelming thing, like we were going to all these communities and all over the country, there were newspaper articles every day about children dying in nearly dying. And there was something so profound about that, that like, you know, we were going all these communities, and everybody was learning on their own. And yet, all these articles were all over the press, like literally on a daily basis. So the conditions had met very intensely. And then we put together a report, which is a public report. And then after the Obama administration, it pretty much finished at the very end. And I think the commission assumed that Hillary Clinton would be president and that everything that was recommended would happen. And that didn’t happen. And there is some work from Casey Family Programs to try to bring about some of those recommendations from the Commission. There has been some success. And I think it was, it was an experience I’ll never forget, I think partly because of how brilliant the people on the commission were and the other people in the staff and how much I learned, you know, as a faculty member about and as a child abuse pediatrician, but I think it also showed a lot about politics and How timing is everything. And you know, in a way, I feel bad. That was a, I think it was a $4 million grant for this kind of thing and to $4 million for the commission to exist. And it’s kind of upsetting how little in the end I think was changed. I do think there were some changes, I still think there are changes being made. But overall, I thought it was it was a little bit eye opening about the how how politics mixes in with something that you think shouldn’t be political.
Will Bachman 50:32
What an incredible experience to travel around the country and be talking to so many different stakeholders about your area of expertise.
Rachel Berger 50:41
It was definitely it was definitely a my something I will never forget. And actually interesting. It led to a sabbatical I took with Casey Family Programs soon after, to try to improve the child welfare system. So it really, I think, directed the next couple of years of my career.
Will Bachman 50:59
So Rachel, one question that we always ask is, switching gears a little bit, turning back to Harvard. Were there any courses or professors that you had at Harvard that continue to resonate with you in some way?
Rachel Berger 51:16
You know, it’s funny, I knew you’re going to ask this question. And I was thinking a lot about this last evening. And so I, I think one thing was that I, Mark attache was the person I worked in for my senior thesis. And Mark was I did phage, lambda and Saccharomyces a different, very basic science. And Mark was, he only taught one course that I took, but he resonated with me because he was able to bounce his just passion for science with his passion for music. And I think because I’m a musician, also, I always thought it was amazing that he continued to take violin lessons and play his violin, even as he was spending hours and hours in this lab. And I think that that was one of my always my takeaway of this person who was so successful, who was able to bounce. I think what’s funny also, though, is that we shared a lab at Harvard with Douglas melt, Doug Melton, who I didn’t know who he was, at the time, he was the guy with the next lab and I went to medical school. And like, every everything we learned about like diabetes, it kept coming back to Doug Melton, I just thought it was the funniest thing that he was in a lab next to us. And I didn’t know that he was any of this. He was famous because I wasn’t really interested in medicine back then. So I just picked that was a interesting memory, just the people all around you at Harvard, many of them have done incredible things. But the only other thing that I really professors that I think that I remember is I remember that Harvard just had so many large classes. And I really wanted to get into a small class. And it’s interesting, because both my two of my sons are ones at Harvard, one graduated, and they both took these freshman seminars, which I think was what I should have done. I don’t think many of us took it back then I think it existed, but we didn’t really have the small classes. And I decided that Chinese history was the way to get into a small class. I don’t know why, because I that’s to get out of, but I took an introductory Chinese history class. And then I took a series of these Chinese history classes, because the classes were only like 10 people. And I don’t even remember exactly who each of the professors were. But I just remember that. That was one of the things I enjoyed most getting into these small classes. And I don’t know why I didn’t know about freshman seminars, or maybe none of us did them back then. But I that was one thing I really remember is the small classes, where I was learning that it didn’t even matter what I was learning about. Interesting. But I got to have the attention of a professor in this very small, you know, this very small group. So it’s funny when you think back what things you remember about about Harvard?
And it’s, it’s pretty funny. I’ll take any class as long as it’s small.
Rachel Berger 53:56
All the call. Exactly. Intro big class in Chinese. That was okay, because I got to take the small class.
Oh, that’s pretty good. Rachel, before we
Will Bachman 54:06
finish up here, are there any places if people wanted to follow your research, or find out what you’re working on? Where would you point them online?
Rachel Berger 54:15
Um, I actually don’t have a very good online presence. I think I think intentionally because of the work I do in court, I tried to get off social media very intentionally. But I would say you go to the Children’s Hospital of Pittsburgh website, I am on there. And there’s an email address on there. So it’s UPMC Children’s Hospital of Pittsburgh. ww.ch p.edu. And you’ll see, you can go to look up my name or look under child abuse, and you’ll see me that’s probably the best way or you can always email me, and I think people have my gmail address. It’s Rachel P. email@example.com. And I’m always interested to hear from people in my class.
Will Bachman 54:55
Well, Rachel, thank you for the work that you do, protecting kids, and thanks for being with us. Oh today
Rachel Berger 55:01
hey thank you so much well have a good day