Child Health Needs and the Child Abuse Pediatrics Workforce: 2020–2040

Each year, CPS completes about 1.8 million investigations for suspected child maltreatment in the United States involving ∼3.1 million children.²  After completing their investigations, CPS identifies, on average, 600 000 child victims of maltreatment annually, including ∼1800 fatalities (not including unreported cases or cases with insufficient evidence to indicate or substantiate maltreatment).²  The high incidence of fatal and nonfatal child maltreatment is estimated to result in an annual US economic burden of >$100 billion.³ 

The incidence of CPS-identified child maltreatment has ranged from 8.8 to 9.6 cases per 1000 children from 2007 to 2019.^2,4,5  Recently, the rate of CPS-identified child maltreatment decreased to 8.3 (2020) and 8.1 (2021) per 1000 children.²  This decrease is likely the result of a nationwide decrease in CPS reports during the coronavirus disease 2019 pandemic and is not believed to reflect a decrease in child maltreatment. Over the next 20 years, annual rates of child maltreatment are expected to return to about 9 cases per 1000 children, unless there are factors that significantly impact CPS reports, and subsequently, the number of children needing evaluations (eg, pandemics, wars, climate change, economic depression, changes to mandatory reporting laws, universal implementation of robust and effective national prevention programming).

Evaluations by CAP subspecialists increase the quality of care provided to suspected victims of child maltreatment and result in improved safety and diagnostic accuracy.⁶  Decisions about which children are referred to CAP subspecialists may depend upon provider availability, state laws, policies of investigative agencies, and hospital protocols. As a result, there is inconsistency across the country regarding which children are evaluated by CAP subspecialists versus other provider types.

To avoid missing cases, CAP subspecialists, or other specially trained experts if CAP subspecialists are not available, often evaluate children when abuse or neglect is confirmed or suspected by other professionals or investigative agencies (eg, CPS or law enforcement). Approximately 40% of evaluated children are not diagnosed with abuse or neglect.^7,8  Concerns most likely to receive the referrals include medical neglect, physical abuse, sexual abuse, and sex trafficking, with ∼170 000 confirmed cases per year.²  In addition, experts often provide medical evaluations for at-risk siblings or other children sharing the same care environment where maltreatment is suspected.⁹  Many cases of neglect may also require an expert’s medical attention because of injury, ingestion, or death. With fatalities, experts may provide expert consultation, testify in court, or review the case as part of child death reviews.

There are known racial and ethnic disparities in the children reported to CPS and identified by CPS as having been maltreated.^10,11  Per 2021 CPS data, children for whom CPS identified maltreatment in 2021 were predominantly female (52%) and white (42%).¹  CPS indicated maltreatment in 13.1 per 1000 Black or African American children; 15.2 per 1000 American Indian or Alaskan Native children; 1.4 per 1000 Asian American children; 7.7 per 1000 Hispanic-, Latino-, or Spanish-origin children; 10.3 per 1000 multiracial children; 8.5 per 1000 Native Hawaiian or Pacific Island children; and 7.1 per 1000 white children.²  Different rates of identified maltreatment across races and ethnicities and household income/material hardship raise concerns about inequity and bias in reporting and substantiating child maltreatment.^10,12  Using experts with specialized training in identifying child maltreatment and expertise in evidence-based decision-making may assist with decreasing inequity and bias in these evaluations.

Because of the complexity of evaluations for child maltreatment and the importance of an evidence-based, objective diagnosis, the American Board of Pediatrics (ABP) and the American Board of Medical Specialties established CAP as a recognized pediatric subspecialty in 2006. The ABP offered the first subspecialty certification examination in 2009. Currently, 33 United States-based CAP fellowships are accredited by the Accreditation Council for Graduate Medical Education.

On the basis of ABP data through June 2023, 425 physicians have been board-certified in CAP, of which 85.4% (363) were actively enrolled in Maintenance of Certification (MOC).¹³ 

Because the ABP does not know when an individual leaves the workforce, the CAP workforce numbers below are limited to those currently board-certified who are aged ≤70 years. As of June 2023, 342 CAP subspecialists met these criteria. This number does not accurately reflect the number of medical providers actively caring for children with suspected child abuse and neglect. Other clinicians working with this population include general pediatricians, emergency medicine physicians, family medicine physicians, physicians meeting ABP board certification eligibility criteria but not yet CAP-certified, physicians with expertise in child abuse and neglect without subspecialty certification, advanced practice providers (APPs), and sexual assault nurse examiners. No data exist on the number of nonboard-certified medical providers working clinically in child maltreatment.

Of the 342 CAP subspecialists in 2023, 83.0% identified as female and 17.0% as male (ABP has only offered other options since 2021).¹³  The median age was 52 years, with 21.1% aged 61 to 70 years, making CAP 1 of the pediatric subspecialties with the oldest workforce. About 88.3% were American medical graduates (AMGs) with a Doctor of Medicine (MD) degree, and 5.3% were AMGs with a Doctor of Osteopathy degree. Around 5.3% were international medical graduates (IMG) with an MD degree, and 1.2% were IMG with an international degree.

Race and ethnicity estimates from 2018 to 2022 suggest that ∼15.9% of CAP subspecialists self-identified as underrepresented in medicine (URiM),¹⁴  which include Black or African American; Hispanic, Latino, or Spanish origin; American Indian or Native Alaskan; or Native Hawaiian or Pacific Islander origin (Table 1). Although the CAP field is working to increase diversity among its providers, it still has a way to go before resembling the population of US children and those identified as victims of maltreatment.

The ABP's MOC enrollment surveys collect data on the work characteristics of currently certified CAP subspecialists.¹⁵  Surveys from 2018 to 2022 had a 59% response rate from CAP subspecialists, reflecting responses from 174 eligible individuals aged ≤70 years. Because of unanswered questions in the survey, percentages are reported below for individual questions.

Most CAP physicians reported being employed full time (81.5%); 48.9% reported working ≥50 hours per week on average over the last 6 months, exclusive of time on call but not working. Women (18.2%) were likelier to indicate part-time employment status than men (10.0%). Most child abuse pediatricians spend 50% to 75% of their time providing clinical care.¹⁶  This is likely because of some CAP subspecialists holding dual subspecialty certifications (eg, there were 21 dual pediatric emergency medicine/CAP subspecialist certificate holders aged ≤70 years in 2023),¹⁴  CAP subspecialists working in primary care or foster care clinics, and those pursuing other interests such as research, administration, or education. The largest proportion of respondents (31.8%) endorsed that their primary work setting was within a medical school or parent university, with most (85.3%) having a faculty appointment. The MOC survey also found that 163 general pediatricians (0.6% of the general pediatricians participating) were not board-certified in CAP and identified as allocating at least some of their time to child maltreatment.¹⁶ 

When the workforce is limited to the United States in 2023, there was an average of 6.5 CAP subspecialists per US state (range 0–34) and 0.5 CAP subspecialists per 100 000 children aged 0 to 17 years (range 0.0–3.2) across the United States. There was wide variability in the distribution of CAP subspecialists within states, most concentrated in urban settings (Fig 1). Analyses from 2019 showed the average driving distance to a board-certified CAP subspecialist was 35.0 miles; distances ranged from a low of 7.1 miles in Rhode Island to a high of 331.2 miles in Montana (excluding Alaska, Hawaii, Puerto Rico, and the District of Columbia).¹⁷ 

Over the last decade, the number of people entering CAP fellowships nationally has ranged from 7 (2016) to 26 (2022).¹⁸  Given that there has been an average of 15 to 16 new fellows registered with the ABP per year, the 26 fellows in 2022 appear to be an outlier, not a trend. This assessment is supported by the National Resident Matching Program data for the 2023 fall fellowship application cycle, when only 13 CAP fellowship positions were filled and 10 were not.¹⁹  Since 2014, between 19 and 27 fellowship positions were offered annually in the program, with about 8 unfilled positions each year.^18,19 

Of the 58 fellows in 2021 to 2022, 77.6% were female and 22.4% were male. Around 86.2% were AMGs, of which 65.5% had an MD degree, 19% a Doctor of Osteopathy degree, and 1.7% an unknown AMG degree. About 13.8% were IMGs (12.1% with an MD degree, 1.7% with an international degree). The percentage of CAP fellows from URiM backgrounds has fluctuated over the last 5 years (range 14.7%–26.5%).²⁰ 

Recent publications have highlighted differences in financial remuneration across pediatric subspecialties, and in comparison with adult subspecialties.^21–23  Although older reports suggest compensation may be less critical in choosing a pediatric subspecialty career,^21,22–25  increasingly high debt rates may impact decision-making. According to the ABP (personal communication, ABP, February 20, 2023), approximately 54.0% of current CAP fellows owe $200 000 or more compared with 39.5% for all pediatric subspecialty fellows, the highest of any pediatric subspecialty. A study quantifying the lifetime earning potential of pediatric subspecialists, while not explicitly looking at CAP physicians, demonstrated that pediatric subspecialties with similar income earning potential to CAP (eg, infectious diseases, nephrology) take a lifetime pay reduction of >$1 million compared with general pediatricians.²² 

This article reports on data from a pediatric subspecialty supply workforce model developed by the ABP Foundation, the Carolina Health Workforce Research Center at the University of North Carolina at Chapel Hill’s Sheps Center for Health Services Research, and the Strategic Modeling and Analysis Ltd. The model uses current and historical ABP workforce data on subspecialists aged ≤70 years to run a microsimulation, applying probabilities to individual-level behaviors related to retirement, geographic diffusion, out-of-country returners, and attrition.²⁶  The inflow of fellows is held constant at 2019 levels. The model includes baseline estimates at the national and subnational level per subspecialty and 10 alternative scenarios that alter specific factors like the inflow of fellows or retirement. The model also accounts for changes in the child population based on the US Census Bureau; differences by subspecialty for census regions are discussed in the summary article in this supplement.^27,28  An interactive Web-based visualization of the model is publicly available online.²⁹ 

Workforce projections presented in the model and below are reported in headcount (HC, absolute numbers) and clinical workforce equivalent (CWE, HC adjusted by the reported proportion of time spent in direct clinical or consultative care, including patient billing and charting with or without trainees), per 100 000 children aged 0 to 18 years. Figure 2 displays CAP subspecialists HC per 100 000 children and CWE per 100 000 children for the baseline model at the census region level; Tables 2–3 provide data for the scenarios at the census division level. Details of scenarios and 95% confidence intervals for all estimates are provided in Tables 2–3 and the interactive online tool. The numbers reported below may differ from those in the previous section because of differences in years (2020 vs 2023), sample selection criteria, and inclusion of self-reported clinical time.

Three scenarios particularly relevant to CAP discussed below are:

1. changes to the number of fellows;

2. midcareer child abuse pediatricians leaving the field earlier than anticipated; and

3. a decrease in clinical time.

These reflect the small size of the current workforce, the low baseline number of fellow applicants, and the known risk of burnout because of secondary trauma and harmful media exposure.

Among the 14 pediatric subspecialties included in the model, CAP is the smallest in overall size and projected growth. The baseline model showed an estimated total of 330 active CAP subspecialists (2020), with a 24% projected growth to 414 CAP subspecialists (2040) and an 8% growth from 0.23 CWE per 100 000 children (2020) to 0.24 CWE per 100 000 children (2040).

Across scenarios, growth by 2040 will range from −4% to +20%. The alternative scenario that increases incoming fellows by 12.5% by 2030 shifts the baseline projection of growth for CWE per 100 000 children from 8% to 12% by 2040. If clinical time increases by 7%, the 2040 supply projection for CWE per 100 000 children will increase from 8% to 16%. Finally, if those 2 changes occurred concurrently, supply projections will shift from 8% to 20% for CWE per 100 000 children. However, if fellows decrease by 12.5%, clinical time decreases by 7%, those factors combine with an early exit for all ages, or the 8% supply projection for CWE per 100 000 in 2040 changes to 4%, 0%, and −4%, respectively.

Model projections at the subnational level reveal that CAP supply projections vary regionally. Census regions (Northeast, Midwest, South, West) predictions for 2040 for HC per 100 000 children increase by 3%, 7%, 2%, and 17%, respectively (Fig 3). These growth estimates align with regional population growth estimates for children aged 0 to 18 years old of 4%, 2%, 29%, and 23%, respectively.²⁷  These projections suggest that misalignment between population growth and subspecialty growth may occur, especially in the South.

At the census division level (Tables 2–3), the South Atlantic division is likely driving the shortage of CAP subspecialists in the larger South region. The model projects that the South Atlantic division’s HC per 100 000 children will decrease by 35% by 2040, from 0.4 to 0.26. This projected decline is problematic because the division already has very few CAP subspecialists per 100 000 children. The Mountain division is also predicted to have a decrease of 23% CAP subspecialists per 100 000 children, indicating that the projected growth of subspecialists will likely not keep pace with the expanding child population in this area. The West South Central, East South Central, and Pacific regions are predicted to have increases of 48%, 41%, and 37%, respectively, in CAP subspecialists per 100 000 children, suggesting that these divisions may not see shortages like the South Atlantic or Mountain, but potentially further regional disparities.

Despite the high rates of child maltreatment (8 per 1000 children yearly),²  CAP remains the smallest pediatric subspecialty. There are simply not enough CAP subspecialists to evaluate every case of suspected child maltreatment, especially in less densely populated areas of the country or those without large academic children’s hospitals.³⁰  This results in many children with suspected maltreatment going without a medical evaluation by a CAP subspecialist; instead, evaluations are provided by other physicians and APPs with variable training in child abuse and neglect.

Even in the most favorable scenario predicted by this model, the increase in CAP subspecialists in the next 20 years is less than the growth in every other pediatric subspecialty and displays geographic variability across census divisions. This lack of growth does not reflect need or the limited availability of fellowship training programs. Instead, the biggest inhibitor to growth and potentially greater geographic dispersion is the number of pediatric residents and general pediatricians pursuing this rewarding yet challenging field. Although increasing the amount of time spent providing direct clinical care may increase the overall ability of CAP subspecialists to evaluate more children, it may also increase midcareer burnout, which already poses a risk to the CAP workforce. It might also limit educational and research activities, which remain critical for educating and informing the field. Therefore, asking CAP subspecialists to universally increase their clinical time evaluating children for maltreatment is an unsustainable solution.

Residents often decide to pursue fellowship early in pediatric residency training and determine which subspecialty by July of their second year, demonstrating the importance of early exposure to CAP for medical students and pediatric interns.³¹  Realizing this need, the Helfer Society, a society for physicians who evaluate suspected child maltreatment, has established the Next Generation program to encourage and support medical students and residents to learn about the CAP subspeciality.³²  Also, many CAP subspecialists have made it part of their mission to introduce the field to medical students and residents. Exposure to this subspecialty is especially important for persons from URiM backgrounds or underserved geographic areas. Despite these recruitment efforts, only 13 prospective fellows matched into CAP fellowship programs in 2022, a 12% decrease from the expected 16 new fellows per year predicted by the baseline model.

Support staff availability and the type and complexity of evaluations can significantly affect the number of cases a CAP subspecialist can safely evaluate each day, making it difficult to determine how many children can be safely evaluated per CAP subspecialist per year. When evaluating a case of sexual abuse in the outpatient setting, some clinics may have access to the child’s disclosure from a forensic interview and hire social workers to obtain additional history, assist with reporting, and connect families with resources, permitting child abuse pediatricians to focus on the medical evaluation. Other CAP subspecialists may be responsible for obtaining the medical history, completing the examination, and reporting and coordinating with CPS and law enforcement, limiting the number of patients. The time required to complete a hospital consultation also varies depending on case complexity but often requires more time than outpatient visits. After an evaluation, CAP physicians spend additional time writing detailed reports, doing case reviews with the multidisciplinary team, and testifying in court, not all of which are considered billable hours. Sharing different approaches nationally may help to create more standardization around CAP subspecialists’ work.

CAP became a board-certified pediatric subspecialty because of awareness of the required medical expertise and the ever-growing medical literature base in this field. With >1 million child maltreatment investigations annually, the current workforce is insufficient. There are other professionals (APPs, sexual assault nurse examiners, non-CAP physicians) with training in child maltreatment who are helping to fill the gap and provide care to this population. There are also partnerships and programs across the country that allow CAP subspecialists to review cases seen by non-CAP providers and provide guidance and expertise. Utilizing these other providers with oversight from a CAP subspecialist may allow the available workforce to provide expert review and consultation to more children, especially children in more geographically underserved areas. Incorporating a CAP consultant throughout the evaluation is recommended to improve outcomes for children, but might require policy changes to permit telemedicine across state lines. Cross-disciplinary training for pediatricians, emergency medicine physicians, family medicine physicians, and APPs would also better enable these teams to function in underserved practice settings.

Several factors may greatly affect the future of CAP:

1. financial compensation for CAP subspecialists;

2. funding for child abuse teams and CAP subspecialists;

3. state policies and legislation related to child maltreatment; and

4. representation of CAP in the media.

Like other pediatric subspecialties, CAP does not receive the same financial compensation as other fields of medicine. As a result, pediatricians may be hesitant to complete 3 additional years of training without a financial incentive, especially with CAP fellows having higher amounts of student debt than other subspecialty fellows. The most significant barrier to increasing salaries for CAP subspecialists is that they often do not bring in revenue to their institution. CAP subspecialists spend large amounts of time with patients and in the coordination of care, which is not reflected in billing. As a result, many programs may not have the resources to provide funding for support staff on child abuse teams, CAP fellowship positions, or more competitive salaries. Federal or state funding to increase the pay of these positions and provide loan forgiveness for those entering the field may increase the incoming number of fellows and assist with retention. Although increasing the salaries for CAP subspecialists may not drastically increase the number of fellow applicants, it may help motivate those considering the field. With only about 16 new fellows per year, any increase in fellows is beneficial.

State agencies, such as CPS or law enforcement, may also have specific policies or guidelines affecting the number of children referred to CAP physicians in a region. In Rhode Island, CPS refers every child with suspected sexual abuse for a medical examination by the child abuse team. In contrast, in other states, children may only be referred with known disclosure of penetration or when legal charges are being pursued. How state agencies use child abuse teams will ultimately affect the number of referrals to CAP subspecialists, regional demand, and potential state or local funding allocated to child abuse teams.

Changes to state laws defining child maltreatment may also affect the work of CAPS subspecialists, as would changing protections provided to mandatory reporters. State laws often define physical and sexual abuse and protect those reporting suspected child maltreatment. In Texas, for example, some groups are attempting to remove mandated reporting statutes and/or the protections for mandatory reporting. If this type of legislation moves forward, it will result in significantly fewer children coming to the attention of both CPS and CAP subspecialists. It would also likely increase the direct legal risk to all physicians for reporting child maltreatment concerns in good faith and dissuade people from wanting to pursue a CAP subspecialty.

CAP has also been affected by the media, both positively and negatively. Occasionally, after highly publicized legal cases, states and organizations put more resources toward reporting and evaluating child maltreatment, often because of a class action lawsuit. By contrast, some organizations provide negative media about child abuse pediatricians after speaking with families whose child(ren) has been diagnosed with maltreatment. Because of the Health Insurance Portability and Accountability Act, CAP subspecialists cannot explain their evaluations or diagnoses to noncustodial families or the media; therefore, inaccurate or incomplete information may be presented in the news and on social media. Even the awareness of this negative, likely threatening, exposure is a stressor for those in the field, because there is currently no organized way to respond.

Multiple questions still need to be answered about the CAP workforce in the United States. Future research should look specifically at child abuse teams to identify the teams’ components, the types of cases evaluated, and the number of children evaluated each year. It would also be beneficial to identify how many nonboard-certified pediatricians, other physicians, and APPs are working in this field and determine their level of training and available support from CAP subspecialists.

CAP subspecialists provide a level of expertise that is essential in the evaluation of suspected child maltreatment. However, there are currently not enough subspecialists in the United States to evaluate all children with suspected abuse or neglect, and many programs use non-CAP physicians or APPs to meet this need. These providers might benefit from CAP subspecialist oversight, support, and review. The model’s projected growth in the number of CAP subspecialists in the next 20 years is less than that of other pediatric subspecialties, displays geographic disparities, and is unlikely to meet child health needs. In addition to the threats to the CAP workforce identified by the model (ie, decline in entering fellows, reduced clinical time, early retirement because of midcareer burnout), there are other potential threats specific to CAP, such as legislative changes and harmful media exposure, which must be monitored while considering how to provide high-quality care to children experiencing child maltreatment in the future. Despite the workforce challenges, a dedicated, subspecialty-trained workforce remains providing critical care to this vulnerable population.

We thank Emily McCartha, Andrew Knapton, and Adriana R. Gaona for their review of the modeling data presented. We also thank Virginia A. Moyer and Patience Leino for their editorial support. Last, we thank the pediatricians who shared their information with the American Board of Pediatrics Foundation and made this Supplement possible.

ABP

American Board of Pediatrics

AMG

American medical graduate

APP

advanced practice provider

CAP

child abuse pediatrics

CPS

child protective services

CWE

clinical workforce equivalent

HC

headcount

IMG

international medical graduate

MD

Doctor of Medicine

MOC

Maintenance of Certification

URiM

underrepresented in medicine