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By Katherine Corley
Population Health Scholar
University of Texas System
Dual Degree Master's Student in Journalism and Global Policy
UT Austin Moody College of Communication & UT Austin LBJ School of Public Affairs
The Division of Child Protection Pediatrics doesn’t just exist to identify abuse and get law enforcement or CPS to intervene. We really exist to provide services to people who have suffered abuse and try to get them back on track. Help is available on all levels.
--Dr. Rebecca Girardet
When Dr. Rebecca Girardet began working in child abuse pediatrics, there wasn’t officially a field of child abuse pediatrics. Children’s Memorial Hermann Hospital, where she practices, didn’t have a dedicated consultation team for clinicians who suspected that a child they were seeing was the victim of abuse of neglect. This has all changed dramatically, thanks in no small part to physicians like Girardet and her colleagues at UTHealth in Houston, who have made it their mission to create the field, and then move it forward.
Girardet founded and directs the Forensic Assessment Center Network, a state-wide network of child abuse pediatricians who provide consultation and training for Child Protective Services (CPS), as well as for Adult Protective Services and Child Care Licensing. She is also Director of the Division of Child Protection at the McGovern Medical School at UTHealth in Houston, and heads their three-year fellowship program in Child Protection Pediatrics. Additionally, Dr. Girardet has started two clinical programs: the UT Physicians Child Abuse Resource & Education (CARE) Center, which provides inpatient consultations for suspected cases of child abuse and neglect and comprehensive outpatient services for child maltreatment victims as well as for families at risk; and UT PATH , a unique day treatment program for children and adolescents with medical issues complicated by emotional and behavioral challenges. We spoke to Dr. Girardet, also a pediatrics professor at McGovern Medical School, about her multi-faceted career in preventing child maltreatment and caring for child abuse and neglect victims.
Dr. Girardet received her B.A. in Human Biology from Stanford University, and her M.D. from the University of Arizona College of Medicine. She completed her pediatrics residency at Baylor College of Medicine, and she is board-certified in child abuse pediatrics.
Texas Health Journal: Tell me about the gap in services that you saw when you first began your work in child protection pediatrics.
Rebecca Girardet: When I started doing this years ago, there was no consult team at Children’s Memorial Hermann Hospital for suspected child maltreatment victims, and no group for doctors to turn to when they were concerned about abuse and neglect. Informally, there were providers who were more comfortable making those assessments and answering those types of questions than others, but ultimately you need more than just that. It takes extra time and expertise to talk to Child Protective Services investigators, to coordinate services and connections, to be available to other clinicians when they need you. Having it all formalized has made an enormous difference.
What has changed in the field of child protection since you started your career?
I think the biggest change was when child abuse pediatrics actually became an official field. That happened in 2009, and there's now actually a board examination and a three-year fellowship.
Texas has also done some really good things in terms of funding efforts to help families, providing more services to prevent child maltreatment, and intervening when it's occurred. For instance, the Texas Department of Family Protective Services (DFPS) has funded the H.O.P.E.S. (Healthy Outcomes through Prevention and Early Support) program, and DFPS and Texas Health and Human Services support child protection teams on the intervention side. In general, Texas has been good about recognizing the need for child protection and trying to fund interventions that will make things better. Unfortunately though, the level of state support that Texas child protection programs receive still falls short of helping all Texas children who need these services.
How are children and families referred to your clinic?
We use a non-confrontational screening tool at well child visits. It is called “Safe Environment for Every Kid,” and it assesses risk factors for child maltreatment, including depression, substance abuse, intimate partner violence (IPV), major parental stress, food insecurity, and use of harsh punishment. This is a national tool that has been studied a lot and is used in many UT clinics. We also get referrals from social workers at Children’s Memorial Hermann Hospital for families that they've assessed to have various risk factors, whether that's mental health needs in the parent, or intellectual disability in the parent, or substance abuse issues, or children who have really complicated chronic medical needs that are straining a family's social and physical resources.
What do you wish more doctors knew about child maltreatment?
I feel like many general practitioners are not aware of all the resources that are available to them, and they hesitate to call CPS because they don't feel sure enough that child abuse or neglect is happening with one of their patients. That's where a child protection team can be really useful. We live in such a big state that there are lots of areas where a dedicated child protection team is not available on site, but even in those areas there are resources that may just be a telephone call away. I've seen some cases where things were allowed to go on too long without someone intervening. I wish doctors would reach out to our team of Child Abuse Pediatricians more, as we have special expertise in identifying whether abuse or neglect has occurred.
What are some of the factors that contribute to child abuse and neglect?
As a society we're really tolerant of corporal punishment, and it would be great if that would change, because it doesn't improve a child's ability to learn how to be good. There are better ways to teach children, and when we use corporal punishment, we're inadvertently also teaching them that it's okay to hit someone when you're angry. Then sometimes corporal punishment escalates. There's actually a strong association—and of course association doesn't prove causation—in countries where regulations have been passed prohibiting corporal punishment or regulating it more than we do. There's less physical abuse, and there's likely a good reason for that. So that's something I think we could work on--helping families find other ways to discipline their children. And social stresses also contribute to abuse and neglect. As long as we have folks who are living in poverty or who struggle to get adequate medical care or adequate mental health services or who have food insecurity or transportation difficulties--all these things contribute to the stress in the home. When you add children on top of that, it's just a recipe for people getting upset and lashing out.
Tell me about the work you do at the UT PATH clinic with children who are risk for medical neglect or overmedicalization.
My whole motivation in starting this program was to come up with a more holistic manner of approaching cases of medical neglect or cases where there is a suspicion that a child may be receiving too little or too much medical care. It just seemed to me that waiting until things reach crisis mode wasn't the best way. So, we wanted to try to work with children and families at an earlier point in their story and try to help make them well.
The clinic is an intensive day treatment program that works with kids who have chronic medical problems and co-occurring emotional issues that prevent them from reaching their maximum potential health. These are often children whom providers have previously tried to manage in an outpatient setting. Many of them have been hospitalized multiple times, and they can't get better because there is no single facility that can address both the medical and the psychosocial issues together at the same time. For instance, some of the kids who come to us have things like diabetes or sickle cell disease that is poorly controlled because they don't want to take their medicine, or perhaps the family is not able to ensure that they get the medicine for whatever reason. We also have kids with pseudoseizures, chronic pain, or other somatoform disorders where the children truly feel medically unwell but the cause is more emotional than medical. The UT PATH clinic kids are there every day Monday through Friday, and they have school while they are there. A teacher connects to their home school so they don't have to unenroll from school while in the program. They also have group therapy twice a day, individual therapy twice a week, and family therapy once a week. The family really is the treatment unit.
What kind of support for children and families do you offer at the UT CARE (Child Abuse Resource & Education) Center?
Many of our kids and families have a lot of complicated needs, so we provide a lot of social and mental health support in addition to complete pediatric medical care. We have a dedicated social worker, a psychiatrist and therapists who work with children and adults, and pediatric providers. Having all of these services in the same location improves adherence and facilitates communication between the providers.. We follow a lot of the kids in our clinic for a long time—sometimes for years. Sometimes we'll become their primary care physician, because in a larger clinic they might get lost to follow up. We provide trauma counseling for parents when they need it, because some of our kids who suffer trauma are living in families where adults have been traumatized too. It's hard to make the kids better if we only focus on them--we have to focus on the whole family.
How do you manage the challenges of working with child abuse and neglect cases every day? Do you see happy endings?
I don’t really see child protection pediatrics as very different in that respect from other subspecialties. Any subspecialty has its sad cases and its happy cases. Child maltreatment is a disease like any other. It certainly has a big societal component, of course, but there are lots of physical considerations too. We have a lot of kids who get better and go on to lead happy, productive lives. For instance, one of the kids we've been following for several years got a scholarship to college this year, which is really exciting. We also follow a lot of families at risk, and it's nice to see them be able to stay away from CPS investigation and get better and stronger.