EndCAN Part 2: Our Zoom Interview With Dr. Richard Krugman

"Childhood abuse is the one area of child wellbeing that I noticed after 50 years in paediatrics, we were stuck. We want to remind people that it is okay to talk about it and we just need to bring this out so that we can address it from the beginning."

Dr. Richard Krugman is one of the preeminent experts and scholars in the field of child abuse and neglect and a protégé of Dr. Kempe himself. Dr. Krugman, Dick as many know him, is a paediatrician and Distinguished University Professor at The Kempe Center. He is the former Director of The Kempe Center and served as both Dean and Vice Chancellor for Health Affairs at the University of Colorado School of Medicine. In the 1970’s, he also served an appointment with the Public Health Service at the National Institute of Health and the Food and Drug Administration and was a Robert Wood Johnson Health Policy Fellow in Washington D.C. Most notably, Dr. Krugman headed the U.S. Advisory Board on Child Abuse and Neglect from 1988-1991. Throughout his career, he has authored over 100 original papers, chapters, editorials, and six books. Dr. Krugman co-founded EndCAN, a long time dream of his with Lori Poland after retiring as Dean so to help move child abuse from being seen solely as a social and legal issue, to also a health, public and mental health issue.

SWY: Can you tell us a little bit about yourself and how you came into this field of work.

DK: I got interested in the field of child abuse when I was a medical student and that was 54 years ago. In March of 1967, there was a professor of paediatrics, at the University of Colorado School of Medicine, whose name was Henry Kemp. Kemp had come to New York, and gave a lecture, called the battered child syndrome. I was on pediatrics at the time I heard his talk. Henry actually happened to be a friend of my father also. My father was a pediatrician and they did work on vaccines. Henry was working on the smallpox vaccine my father was working on the measles vaccine. But Henry's other interest was battered children, and he was the one who wrote the paper that was published in the journal of the American Medical Association in 1962, called the battered child syndrome. Now, abuse has been around for centuries but pretty much ignored. It was Henry's paper that really brought attention to the problem, not only in the US but in Canada and around the world. He was such an amazing person. My wife at the time said, I thought you were going to be a cardiologist in Connecticut, and I said well I think I've changed my mind. Anyway, long story short, I came to Colorado for my internship and residency in 1968, worked with Henry, and had such a good experience here. Actually, My wife and I both did that after spending two years in the service. I came back to Colorado in 1973. I had a number of cases where children had been abused, and Henry, and another man named Ray Helfer sort of taught me how to be very calm and caring and dispassionate about talking with parents of abused children. First of all, it isn't always the parents who abused the children and they may have no idea. So we really can't accuse anybody or do things so I learned a lot, and I was comfortable with it.

Medicine is an interesting field as are all fields. You find things that depress you and you find things that you're comfortable dealing with. In the 1960s, I was very depressed about cancer because all of the three and four-year-old children who came to my Pediatric ward with leukemia died. So, I wondered how anybody could do that work. But of course, there were people who were interested in immunology, and therapeutics, and were interested in the challenge of trying to keep children alive, and eventually prevent cancer. They did that, 50 years later, and now three-year-olds with leukemia, 95% of them live forever. I was always interested in human behaviour. Whenever I saw a child who had been abused, I was always interested in what was it that led to that. What was it that led to that problem? That's when I got interested in it, and then I came back to the faculty from 1973 to 1980. In 1980, I was doing general pediatrics and teaching physician assistants and nurse practitioners and medical students and residents. I did Rural Health for a while. I spent time all over Colorado from 77 to 80.

In 1980, I got something called a health policy fellowship. That health policy fellowship took me to Washington to work in Congress for the year. However, before I left Colorado, Henry, who had started the National Center for the Prevention and Treatment of Child Abuse and Neglect in Denver was going to retire and move to Hawaii. He said to me before I left for Washington, I know you, and if you don't have something different to do than rural health you are going stay in Congress for the rest of your career. I need you to direct my child abuse center. I have never been able to say no to Henry. So I said, yes and by the way, he was right. If I hadn't made the commitment to him to come back to Denver in 1981, I'd probably still be in Washington. So, I came back to Denver in 1981, and all of a sudden, I was a national and international expert on child abuse, because I was directing the National Center. So I figured I better learn something about it. That's really how I got involved in it.

SWY: What inspired you to become the Co-founder of EndCAN?

DK: It's been an interesting time because I've now been in pediatrics for over 50 years. All of the areas, such as leukemia, and diabetes, and meningitis, and all of the illnesses that I took care of were very serious and either seriously harmed or killed children back in the 60s and 70s, and 80s. They're all better, and progress has been made in every one of those areas, except in child abuse. 50 years later they're still five children a day, we think, in the US, who die every day of abuse. It's the one area of child wellbeing that I noticed after 50 years in pediatrics, we were stuck. That's actually why I decided with Lori, that we were going to start the National Foundation to End Child Abuse and Neglect.

SWY: You explain that a goal of yours is to help move child abuse from being seen solely as a social and legal issue to also a health, public, and mental health issue. What do you believe is the importance of this?

DK: Well, as again as I look at what is it that's made a difference in the health and well being of not just children but adults over the last half-century. It's been because there has been research, training, and prevention. But most importantly, advocacy by the parents or the children or adults who've had the condition, to try to make it better. So, when I was in the fifth grade, my seatmate in our little twin desks to the left, was a guy named Bruce. One day Bruce wasn't there and he didn't come back and three weeks later, we visited him in Bellevue Hospital in New York and he was in an iron lung as he got polio. At that time in the early 50s, the mothers of America who were very worried about their children, and started what they call the Mothers March of Dimes. I watched over the last 50 years, the March of Dimes raise money and advocate for the eradication of first polio, which happened, and we don't see polio anymore. Everywhere you look, there are, there is literally a not for profit organization that raises money for every adult and Pediatric disease for every organ of the body. We have the American Heart Association, the Lung Association, the liver association, the kidney association. There are hundreds and hundreds, and they've all made progress. But when you look around, there's nothing on child abuse because we deal with abuse as primarily a social and legal issue. This actually because in the 1960s and 70s, physicians and other health people weren't interested in the area. They thought it was a social problem when Henry presented his paper to 1000 pediatricians in 1961. There were no questions and they all walked out of the room silently and said not in my practice that wouldn't happen here, that's just poor people or other people. Well, it's not.

One of the reasons I know it's not is because in the 1970s we rediscovered sexual abuse as an issue, and sexual abuse is clearly an issue that crosses all lines. Even in the 80s, this is what Lori experienced. What Lori and I realized was that if the person who kidnapped and abused her had gotten the help when he was a three-year old that she got when she was a three-year-old, maybe this wouldn’t have happened to her in the first place. So, because we viewed it in such a legalistic way for so long. The instinct is to punish and punish the abuser instead of sitting down and finding out how. The truth is back in the 1960s if the caregiver never abused the child again, the child was back with a family within a year if the child had to be placed with someone else for a while. The problem was our child protection system, and now in the United States and I think to a certain extent in Canada, there's no treatment. There's just identifying cases. Labeling people. There's no real treatment for the child or the family and there's no long term follow up to see what it is we did as a system from when we reported them to when they were taken on by child welfare. There's no follow up to know whether that actually helps the family. So that's another thing we hope with our Foundation is that we can begin to help the field that's working with abused children and their families learn how to be public and honest about our mistakes. I asked people how the experience was working with us. Did we actually make things better or did we make it worse and how can we make it better? I think that point of intervention is so important and the follow up afterward would really make a difference in someone's life.

SWY: What do you think we need to do as a society to change the perspective we have of childhood abuse as mentioned above?

DK: From a pediatric perspective because I spent a lot of time walking around newborn nurseries, and taking care of newborn babies who are unbelievably cute and innocent. But as you walk around that nursery you say to yourself what's this little boy or little girls trajectory going to be? Are they heading toward what we saw in the inauguration of our new president on Monday with a 20-year-old young woman who was our young poet who was an amazingly creative individual? Or are they going to be someone like the individuals who rushed our capital and are angry and violent? When you look and you realize that some of it is probably some genetic predisposition, but it also depends a whole lot on how they're cared for and how they learn to care for others. But, we realized that there was no such thing as abuse because everyone thinks it's someone else's problem. The other thing is that there's been so much shame and so much stigma that those who have been abused, the vast majority of them will survive it and will do well, or even transcend the way Lori has but never talked about it.

When I was growing up in the 1950s, I had an aunt with breast cancer. Nobody ever talked about it. It was the secret because there was shame. Similarly, there was an individual in my extended family who sexually abused the girls, and nobody ever talked about it. It wasn't until the 1980s when I was doing this work that I realized that I had a grandparent, who was an abuser and nobody talked about it. Not the young women in the family who were abused by him, not my aunts and uncles who knew about it but never talked about it. So the burden of all of that falls on the child who's victimized, and that's just not right. How they survive it is with a lot of help and support and talking about it. That's why we've decided that the advocacy group we’ve created here at EndCAN are the millions of adults who've experienced abuse and neglect as children and have never talked about it and are doing well now but who clearly have periods of pain or flashbacks or other things. We want to remind people that it is okay to talk about it and we just need to bring this out so that we can address it from the beginning.

SWY: Research has suggested that most abusers were once abused him/herself. What do you think we need to know and do to change this for the better?

DK: Well, first, while it's true that all of the abusers we've ever seen have experienced abuse in their childhood. The public believes also and I think it contributes to the silence. There's a belief that if you were abused, you will be an abuser, and that's absolutely not true. The majority of abused children will not grow up to be an abuser, They will do, okay. The reason for that is in part because they're usually other adults in their environment, grandparents, aunts, uncles, teachers, ministers, friends, neighbors who recognize what's going on, and basically give them the message what's happening to you is not your fault. What's happening to you shouldn't be happening. If you need me to help and protect you I will do that, but you don't need to grow up like that. The abused child who believes that they are a bad child, a bad kid, and that the beatings that their parent or stepparent gave them were needed to make them a good kid. These are the ones who are likely to repeat the cycle. If you believe that this is the way to love children and care for children, you'll tend to repeat the cycle.

"If you believe that this is the way to love children and care for children, you'll tend to repeat the cycle."

The psychiatrist who worked with Henry Kemp and who I worked with also for many years was a man named Bradt Steele. He described abuse as like a cancer of the soul. It's treatable, like most cancers. But for some people it's not and it's malignant. Brandt also said if you don't understand somebody's behavior, then you don't have enough history. So when someone is acting out, and you don't understand why they're behaving the way they are, instead of hitting them or screaming at them telling them to stop it, sit down and have a conversation and find out what's going on. It was good advice.

For me, the most important group to focus on because they've been ignored is the boys. The boys between the ages of three or four or five, and 10, who something happens to either within their family or more often with boys I think outside the family, and they're abused, physically, sexually, emotionally. The women's movement in the 1970s had a large impact on bringing sexual abuse into the open, primarily for women. But even now we see with the experiences of men in their 40s, 50s, and 60s, who are abused in the scouts or in churches, or on teams or in other settings. They've never talked about it. They may have some alcoholism, they may have periods of depression. But something happens to boys early on that nobody notices and they don't talk about. I think this is our opportunity for intervention to really make a difference and improve the outcomes for boys and the other boys and women that they will later abuse.

SWY: Why do you think funding for research to help us understand the long term impacts of maltreatment and current interventions for childhood abuse are so limited? What do you think needs to be done to change this?

DK: Well you know we believe and follow the model that has been in place for 50 years I actually don't know the exact name but there is a Research Council. Intuitively, looking at what happens to, and the struggle that our child welfare colleagues have in trying to meet the mandate that we give them of investigating and helping every family that we report to them, it's not working. So we have to have approaches where there has been research done. We now know much more about recognizing abuse than we did before. There is research going on but it's mostly self-funded. There's some wonderful research that's been done on prevention. We know that if we provide someone like a public health nurse home visitor to a pregnant woman with a new baby, and she stays with her for the first two years of the baby's life that over the course of that mother and babies career, both will do much better and there won't be any abuse in 87% of the cases. So there are interventions that work, but because we have this social mindset, instead of the health mindset we create a prevention program that's a non for profit NGO type organization that you have to raise money to sustain. If we know that, providing home visitation support to families is enormously helpful. Why isn't that part of our health system? Just like it is part of the health system that you can go get your knee replaced should also be that you need a home visit because you're four months pregnant. It's not so easy to go through pregnancy and have a baby, and particularly if you yourself have experienced trauma in your childhood. Having help is critical. I know as a pediatrician there are new mothers and fathers who can use a lot of good help. For most families, that's their own parents.

But for a lot of families, their parents are part of the problem, not part of the solution. They're the ones that we need as a health system, and as neighbors to gather around and provide support. So, we've got to have more research to understand the impact we have to understand how best to effectively treat people and help them. Bring it out in the open.

SWY: Why do you think it is important to get more funding for pediatric subspecialists to focus on childhood abuse? What do you think these pediatric subspecialists can do to help break the cycle?

DK: Well that's interesting because I should tell you that 15 years ago when the proposal to have pediatric subspecialists in child abuse was put up before the American Board of Pediatrics, I opposed it. I thought it was a bad idea. I thought it was a bad idea because there was no NIH research or training money to support the subspecialty, but it passed anyway. We have hundreds of child abuse pediatricians, many of whom are my colleagues, But what I've noticed is most of their work, maybe 80, 90% is done for prosecutors and the courts, and for child welfare to have expert testimony. That's not my vision of what a subspecialty in child abuse should look like. Testifying is something the subspecialty should include.

When I did child abuse work in the 80s, I testified in court in the first criminal prosecution of child abuse death here in Colorado in 1981. But it's got to be more than that, it has to include, how do we engage our behavioral health colleagues to psychologists and psychiatrists and social workers, how do we engage community workers and family support centers and others in creating an environment that can not only treat the abused children and their families so that the children can go back with their families. We can focus on prevention. There's practically no prevention work coming out of this subspecialty, and there's very little treatment coming out of the subspecialty. So it's right now, all forensic. I'm hopeful that if we can first get the five to 10 million people to sign up with us the way they sign up with the Society for the Prevention of Cruelty to Animals, and the abuse community and those who have experienced it can come together, and if we can build the advocacy group, the research will follow. Then the sub-specialty will really grow and flourish. But I can't grow and flourish if its only source of revenue is expert testimony.

We want to thank Dr. Krugman for sharing his expertise and insight into childhood abuse and neglect. Make sure to check out the EndCAN website for more information about their Foundation and the resources that they offer.