at many—though still not all—hospitals. Recently, Jenny worked with the National Association of Children's Hospitals to write standards for child protection programs. And, she adds, the organization is recommending that every hospital have one. Over the years, Jenny has trained and supervised 22 fellows in forensic pediatrics, many of whom are now running child protection programs themselves. In fact, one of them is Dr. Kent Hymel, the medical director of the Child Advocacy and Protection Program at Dartmouth-Hitchcock Medical Center.

"It's just amazing," Jenny says of the advances in her field. For example, she explains, "we've devised ways to diagnose physical abuse," by showing how its effects are different from those of accidental injuries. One way is a skeletal survey of children under one year old. Instead of depending on visible, evident injuries, such a survey will reveal skeletal injuries that a child that young cannot describe or even indicate. "That was very powerful," she says.

"We've learned so much about infant trauma, head trauma, the presentation of head trauma," Jenny continues. She herself has worked with a Japanese company, Aprica Childcare Institute, to develop biomechanical research models that led to a better understanding of shaken baby syndrome and other pediatric head injuries.

Shaking a baby generates very unusual patterns of retinal hemorrhage. And shaking also leaves injuries in the brain that look very different from those received in car accidents, for example. Victims of car accidents will show injury in one part of their brain, while "babies who have abusive injuries come in with these horrible injuries—what we call 'big black brain,' " Jenny explains.

"If they survive," Jenny says of babies who have been subjected to such abuse, "they are seriously handicapped. There's probably a very different regulation of cerebral circulation in infants, and it's probably very vulnerable to periods of prolonged hypotension in the brain after an episode of rotation force being applied."

The term "big black brain," Jenny adds, was first used by Dr. Ann-Christine Duhaime, director of pediatric neurosurgery at DHMC.

In her many court appearances—several every month, many of them in other countries—Jenny has heard all the reasons for shaking and injuring young children. Abusers will often say they just couldn't stand a child's crying. Abuse also correlates with mental illness or anger at a spouse. Risk factors for child abuse include poverty, drug and alcohol abuse, and domestic stress. "With sexual abuse, we find much higher rates with children who live with people who are not their biological or adoptive parents," Jenny says.

Research into child abuse is critically important, she explains, because mistaken diagnoses—either way—can be disastrous. "If you send a child home who has been abused, the chance is they're going to come back with other injuries or even death," she says. On the other hand, "if you make the wrong call and say it's abuse and it turns out not to be, you've destroyed a family."

How has a pediatrician who is a mother herself dealt for so many years with the horrific cases that she sees every day? Jenny says the hardest time was when her own children were young—the same

age as many victims. She learned then how to cope. "I have my work-life and my life-life," she says. "Now, in my life-life, I have my English garden and my grandchild, and my nice family and husband. I read English novels where the most exciting thing is that the spinster in the congregation falls in love with the vicar. I don't read novels where people are raped or killed or blown up. I never go to violent movies."

She also enjoys the travel that comes with her work-life. Frequently invited to lecture all around the world, she is often joined on trips by her husband—
especially if the destination offers a chance of sighting an exotic bird. "My husband is an avid birder. I enjoy seeing a nice, colorful bird, but I don't obsess about it," says Jenny. But she does love the lecturing and the traveling. "The rest of the world is starting to realize child abuse hurts kids, and if they want to see their country progress and life be better for the next generation, they're going to have to pay attention to it."

Jenny has addressed pediatric professionals all over the U.S. and in 18 countries—including Cambodia, Japan, Germany, England, Ireland, Bolivia, Poland, Mexico, and Canada. She has also lectured extensively for the U.S. military (for whom she also testifies in court-martial cases), the FBI, and Interpol, as well as local police forces.

In fact, the variety of her work is one of the things she likes best about it. "One day," she says, "I'll be tracking down the epidemiology of some STD [sexually transmitted disease] and how some five-year-old came up with [it]. The next day I'll be going to a forensic autopsy. The next day I'll be diagnosing a major head injury of a seven-month-old. The next day I'll be going down to the statehouse to lobby for changes in the law to protect kids. Right before Christmas, I was at a Congressional briefing on the Hill about the long-term ramifications of abuse on the population."

All that variety means child abuse pediatrics is a great field for someone with a short attention span, she jokes.

But it's clear that for Carole Jenny, the attraction of the field is the opportunity to do everything humanly possible—"in a big way"—for mistreated children. And that's not a job she'll ever quit.