The University of Texas Health Science Center at San Antonio (UTHSCSA) fellowship in Child Abuse Pediatrics was established in 2006 and is a fully accredited ACGME 3- year fellowship. The Division currently consists of four faculty members, 3 full-time child abuse pediatricians (Drs. Kellogg, Lukefahr, and Kissoon) and a pediatric nurse practitioner Ms. Kathleen Buckley, a certified Sexual Assault Nurse Examiner (Ms. Annette Santos), a Division Administrator (Ms. Sandra Quiroz), and a Project Coordinator (Joan Zhao) for the Forensic Assessment Center Network (a state-funded initiative). This fellowship is a well-balanced experience in physical abuse, sexual abuse and neglect in both outpatient and inpatient settings.

Program Description
Established in 2006, this fellowship was one of the first to become accredited by ACGME. The program provides an extensive and diverse clinical experience in outpatient and inpatient settings. Patients are referred through unique multi- and interdisciplinary collaborations:

  1. Center for Miracles (CFM): outpatient facility and office space for faculty, fellows, staff and social workers. A collaboration between UTHSCSA and Children’s Hospital of San Antonio (CHofSA).
  2. Inpatient consultations provided at two hospitals, University Hospital and CHofSA; ongoing collaborative work with two additional hospitals that provide care for children and two facilities that house detained juveniles and human trafficking victims.
  3. Forensic nurse examiner program at CHofSA: fellows rotate with extensively trained forensic nurses who assess suspected victims of abuse and severe neglect in the emergency department. CFM provides follow up care and consultations for these patients.
  4. Case consultations/record review: as a center of excellence receiving state funding, CFM provides medical expertise for CPS workers in more than 50 counties through a unique web-based referral system.
  5. Serious injury staffings are held twice per week at the CPS regional office to assess safety plans and ensure adequate medical assessment and follow up care.

Recognizing that fellow interests are variable and educational experiences should evolve, our program strives to provide the flexibility and freedom for fellows to explore their interests, allowing them to participate in community, multidisciplinary and advocacy activities.

All fellow graduates passed the CAP board exam the first time and all obtained employment in their position of choice following fellowship.

Program Aims
Aim 1: to build and improve intra- and interdisciplinary collaborations to optimize detection, investigation, assessment, management and prevention of child maltreatment, and to provide a variety of team-building experiences and strategies that will enable fellows to be effective in their post-fellowship careers. These collaborations will also preserve the patient referral base which is a strength of the fellowship program.

Aim 2: to optimize opportunities to educate medical and non-medical professionals in clinical settings, classrooms, communities, and courtrooms, which may further strengthen intra- and interdisciplinary collaboration.

Aim 3: to identify gaps in fellow clinical experiences and explore ways to provide access to experiences and patient populations not currently accessible to ensure a more comprehensive fellowship experience.

Aim 4: to explore strategies for enhancing fellow applicant pool

There are several practice sites and opportunities for a comprehensive and varied learning experience in this new field:

  1. Center for Miracles: Located in an outpatient facility adjacent to the Children’s Hospital of San Antonio, Center for Miracles opened in May 2006. This referral-only clinic evaluates children referred by Child Protective Services, law enforcement, forensic interviewers, and physicians, and is a collaborative program staffed by UTHSCSA faculty and fellows working with CSR social workers and medical assistants. Children with non-emergent injuries and conditions suspicious for physical abuse, sexual abuse and/or neglect are evaluated in this clinic, as well as siblings of child abuse victims. In addition, follow-up skeletal surveys and examinations are provided for children with severe injuries. Volume: 1000-1200/year
  2. Child Protective Services, Regional Building: Multi-disciplinary staffings are conducted two half-days a week at CPS offices. This service is funded by the Forensic Assessment Center Network described below. Volume: 500-600/year.
  3. Forensic Nurse Examiner program: Located at CSR Children’s Hospital, the child abuse fellow rotates with extensively trained nurses who provide assessments of children and adolescents who are suspected victims of acute sexual assault, physical abuse or severe neglect. The child abuse fellow and the FNE provide photo-documentation and assault examination of children presenting to the emergency department.

Several activities and experiences comprise the Child Abuse fellowship:

  1. Out-patient clinical assessments: conducted at Center for Miracles.
  2. In-patient clinical assessments: provided at CSR and University Hospital. Estimated volume: 80-100/year.
  3. Case reviews/consultations: CPS caseworkers, law enforcement, and attorneys contact the Child Abuse Pediatricians in a variety of ways: face-to-face meetings, email, and telephone. Through the Forensic Assessment Center Network program, almost 1000 case consultations are provided to CPS each year, in addition to the above-mentioned clinical assessments. This state-funded program was initiated in 2006.
  4. Multidisciplinary case staffings: face to face reviews of major child abuse investigations are held at CPS Regional offices (twice weekly) and at the San Antonio Police headquarters (twice monthly) and are two opportunities to interact with regional law enforcement, CPS supervisors, mental health professionals, and district attorneys. Fellows also attend regional child fatality review meetings.
  5. Court testimony: physicians testify an average of 4 times per month.
  6. Research: Staff physicians and fellows have published several articles. See attachment for sample listing.
  7. Weekly radiology rounds: through the FACN funding, a pediatric radiologist reviews radiographs with all faculty and fellows each week at Center for Miracles.
  8. Scholarly activity: Fellows are placed on Scholarly Oversight subcommittees which provide a mentoring experience with UTHSCSA Pediatric faculty from other departments.

Selected References
Kellogg ND, Menard SW, Santos A. Genital anatomy in pregnant adolescents: 'normal' does not mean 'nothing happened'. Pediatrics 2004 Jan;113(1 Pt):67-69.

Kellogg ND. Oral and dental aspects of child abuse and neglect. Pediatrics 2005 Dec;116(6):1565-1568.

Kellogg ND, Lukefahr JL. Criminally prosecuted cases of child starvation. Pediatrics 2005 Dec;116(6):1309-1316.

Kellogg ND. Evaluation of Suspected Child Physical Abuse Pediatrics 2007 Jun;119(6):1232-1241

Kellogg N, Anderst J. Evidence-based or evidence-biased? (letter to the editor) Journal of Forensic and Legal Medicine. 2008; 15(7) 471-472.

Anderst J. Assessment of factors resulting in abuse evaluations in young children with minor head trauma. Child Abuse and Neglect 2008;32(3) 405-413.

Anderst J. Chylothorax and child abuse. Pediatric Critical Care Medicine 2007 Jun;8(4):1-3.