Located in New York's borough of the Bronx, Montefiore Medical Center's social workers in its Butler Child Advocacy Center could be expected to deal with the worst possible cases of child abuse. But they were shocked when a journalist from Israel told them about the accusations against two mothers - one in Jerusalem and the other in Ramat Beit Shemesh. Among their alleged crimes were systematic beatings with hammers, knives and other instruments until a three-year-boy old suffered irreversible brain damage; shaking, burning hands with a lighter and a heater, giving them freezing showers; pouring salt on one child's burns, stuffing his mouth with a skullcap and sealing it with masking tape and giving the children alcoholic drinks until they vomited; beating a young girl in the face with a rolling pin and slamming her face into a marble kitchen countertop; forcing children to sleep outside in a locked shed when they had come home "late"; throwing water on children to wake them up; and forcing them to eat feces. "We haven't seen such abuse for a long time!" Dr. Linda Cahill medical director of the Child Advocacy Center at Montefiore's Children's Hospital and associate professor of clinical pediatrics at Yeshiva University's Albert Einstein College of Medicine, told The Jerusalem Post. The Children's Hospital was this year ranked by a leading journal as one of America's best. Cahill recalls with irony: "I remember years ago that a young medical resident was sent to our emergency room tio get training in identifying abused children, but he said it was unnecessary because he was planning to move to Israel and, he insisted, 'Israel has no child abuse.' " MONTEFIORE WAS founded in 1884 by leaders of New York's Jewish community who recognized the need for a facility to handle patients with tuberculosis and other chronic illnesses. The hospital, named in honor of the famed philanthropist Sir Moses Montefiore, has grown to become one of the largest in the US, with four separate hospitals. There are 140 pediatric beds and some 1,200 beds at its main campus in the Bronx, which has about 1,366,000 residents, including 400,000 children, and also serves growing and wealthy Westchester County and others to the north. Just a few weeks ago, Montefiore acquired Our Lady of Mercy Medical Center, also in the Bronx, with its 369 inpatients beds and 2,500 employees, for a total of more than 16,000 staffers, including 2,600 physicians. It was apparently the growing number and greater severity of reported child abuse cases that prompted the Health Ministry in Jerusalem to send a pediatrician from every Israeli general hospital to Montefiore for six to eight weeks to see how it deals with such cases. The project was initiated and is being funded by the Haruv Institute of Israel's Schusterman Foundation. Dr. Yoram Ben-Yehuda of Jerusalem's Hadassah University Medical Center organized the course. Dr. Hadas Knaani-Levinz, a pediatrician at Haifa's Rambam Medical Center, was the first to participate (due to her advanced pregnancy) in the program and returned a few days after our interview. "I don't know for sure why Israel decided to send pediatricians to train at Montefiore, but I think it may be because we have been doing it longer," explains Cahill. "We have trained professionals from other American hospitals and from other countries, including France, Japan, Poland and Jordan. We have a different approach and try to identify child abuse much earlier than others," adds Cahill, who studied medicine in Pennsylvania, was a resident in pediatrics at Manhattan's Beth Israel Hospital, and has been at Montefiore for 26 years - 20 of them in the child advocacy unit. "SUCH PROGRAMS were rare at the beginning of my medical career. In my general pediatric practice, I saw neglected kids. They would be brought to the medical center with medical complaints, but we couldn't find out what was wrong with them. We would be told they had been wheezing all night, but we never heard the wheezing. Most came from needy families with domestic violence. They were stressed families, on the edge. Even if they were working, they lived below the poverty line. They lacked food, social services or medical care, and because there was then - and there is today - no national health insurance, they went to a hospital emergency room even when they had a cold. This situation hasn't changed very much." Today, Cahill and her team of social workers see many families who are not intact - single mothers who are trying to go to school and leaving their children in day care that is too expensive for them. "We deal with many families on edge. Many get public assistance [welfare payments] and we are trying to get them back into the work force. They want to have a better life and be educated for a job. She recalls the case of a girl who had to be attached to a feeding tube because of an illness, and "because her mother couldn't afford day care, she took the child with her to the welfare office and remained there with her for hours." Many of the fathers are not involved in the home, except when they are violent against the women. She estimates that about 70 percent of the children seen at Montefiore's child advocacy unit have witnessed violence against their mothers. "It's a hidden phenomenon, and we don't have good data about it. These women are financially dependent on violent people, so they may be violent toward their children. There is emotional abuse, which is much harder to detect, as well as physical abuse. We do a lot of domestic violence counselling." CHILD ABUSE, she says, is much more common among immigrants, especially illegal ones who fear being identified by the authorities, so their abuse is less likely to be detected and their children are at higher risk. Many illegals don't even want health insurance because they are reluctant to fill out detailed information about themselves." Referrals to Cahill's center for sexual abuse of children is very common - with higher rates than those reflected in US national statistics. Cahill adds that "I don't mean to paint a totally bleak picture. Many poor families are doing well and improving themselves. As for abuse among wealthy families, "it certainly exists. No sector is immune, though we don't see many such cases because the wealthy have many ways to hide it." As Montefiore is the owner of four hospitals and one of the largest health providers in New York City, it coordinates information on abuse cases. Parents who abuse children will often bring them to a different hospital each time so the pattern of their actions is not identified. But some go to hospitals in other US states, and this makes the situation more complicated. Knaani-Levinz, who spent some of her time in New York at Manhattan's (public) Bellevue Hospital, said she was glad to be chosen for training at Montefiori. She works in the emergency department at Rambam's Meyer Children's Hospital, and will be in charge of abuse detection and treatment, as well as teaching colleagues. "We had a course in child abuse, diagnosis and treatment in Israel once a week for nine months, but I have learned even more here," she reports. At the Bronx medical center, she observed how children suspected of having been abused are interviewed and how to deal with their parents, but didn't interview them herself, even though her English is good. "I was presented with many new ideas and techniques, including physical examination after sexual abuse. I certainly learned from the vast experience of the Montefiore staff." "We were able to teach Hadas what normal is and how hard it is to identify abnormal findings," adds Cahill. "There is a large population who come through with no findings and no signs of abuse. It isn't easy to make sure that a child who has been abused is treated properly. You have to be hyper-vigilant - on the lookout - all the time. The symptoms resulting from child abuse can be very confusing. In a small baby, even a stomach virus can look like physical trauma, with signs on the head or abdomen. Physical disease can cause lethargy, weight loss and excessive vomiting - but these can also be the result of abuse," Cahill explains. "And you don't want to falsely accuse people of being abusers. Some children show no physical symptoms, but they may have not been given enough or nutritious food, or the adult is guilty of inappropriate behavior. Babies and toddlers can't tell us what they have gone through. We are often told by a parent that their child's fall was an accident. But when children are intentionally pushed or thrown, there will be different signs. A baby who is too young to walk is too young to break a bone by himself; there is only a small possibility that it was accidental. Sometimes we'll get partial confessions from parents when they see we know the difference." CHILDREN MAY be brought to the emergency room for treatment, or childcare professionals, teachers and neighbors report their suspicions. "Our emergency room staff are always attuned to the possibility of abuse and highly trained. We miss fewer cases today," notes Cahill. Asked why she thinks the Israeli authorities chose Montefiore to train Israeli pediatricians, Cahill replies: "We have decades of experience, and are trained to detect abuse at an early stage. The Child Advocacy Service is expensive to run, as it works round the clock with skilled social workers and pediatricians and trains about 15 medical residents a year. Only a small part of the costs comes from the hospital budget. "Most of our funding comes from private donations, foundations, gifts and grants. The federal government allocates funding to the individual states, and this goes to educational projects but not to hospitals." The social workers try to prevent abuse by educating families. It is not illegal here to slap a child with an open hand over clothing, but it is illegal to hit a child with an object and leave a mark. Some parents really don't know it can be dangerous to shake a baby. It can cause irreversible brain damage. There is a New York law that now requires the education of new mothers about this. As a result, we have seen a decrease in shaken-baby syndrome," Cahill reports. "We used to see 10 cases a year, but not even one in 2008. We have to attribute this to education. If parents lose control with colicky babies or older ones who seem to cry endlessly, we offer suggestions on what to do - including leaving the room so the children can calm down or putting them in a stroller and walking them around. We tell them that this is a normal phenomenon. Doing what we suggest is certainly better than shaking them." Education, including the use of public service announcements, is the best way to reduce child abuse, says Cahill, "and across the US, there is an overall decline - albeit not dramatic - in reported cases. There are theories that overall crime has declined in the US, and this may have had an effect." But, she suggests, as the economic situation in the US worsens, the number of cases can easily increase. "We feel we have an important mission, as child abuse can develop into an intergenerational pattern. People who were abused as children will often abuse their own. We try to break this link."