Physicians do not learn much about child protective services and the legal system during their training, yet in pediatric practice there is an increasing need for understanding of these two areas, especially in the area of child maltreatment. Medical professionals often have questions regarding the process of mandated reporting of child abuse to state agencies, as well as the civil and criminal court actions that may result from those reports, which may require physicians to provide factual and expert testimony.

The Federal Child Abuse Prevention and Treatment Act (CAPTA) (Public Law 93-247), and subsequent amendments, provides definitions to inform national, state, and community efforts to prevent, identify, and treat child abuse and neglect and provides federal assistance to states to support these efforts.¹ Federal legislation defines child abuse and neglect as, at a minimum:²

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  “Any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation”; or

  
  
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  “An act or failure to act which presents an imminent risk of serious harm.”

Each state provides its own definitions of maltreatment within civil and criminal statutes.² It is important for inpatient pediatricians to be familiar with their state laws and definitions of the various types of maltreatment.

All 50 states allow anyone—but have statues that require certain professionals—to report incidents of suspected child abuse and neglect to the state child protective services (CPS) agency. Common mandated reporters are physicians, nurses, teachers, psychologists, social workers, and law enforcement personnel. Only a reasonable suspicion or belief of abuse is required to make a report to state authorities; a person does not need evidence that abuse or neglect exists to make a report.

All states have immunity provisions for mandated reporters, so that the reporter is protected from any civil or criminal liability if a report is later deemed erroneous or unsubstantiated.³ In contrast, failure of a mandated reporter to report suspected child abuse may result in a fine, malpractice suit, or criminal sanctions. Therefore a report should be filed any time there is “reasonable cause” to believe that abuse or neglect exits.

As an inpatient pediatrician, it is essential to confirm that a report has been made in all cases in which doing so is necessary. If another person or institution has filed a report about the same episode of abuse, no other professionals are required to duplicate that report.³ However, if a new indicator of abuse is observed, a new report must be filed. For example, a report is filed for a nonambulatory child with an unexplained femur fracture. He is subsequently transferred to another hospital for further treatment, where he is found to have suspicious rib fractures as well. The accepting physician must make a supplementary report about the rib fractures. As practices may vary from state to state, pediatric providers should become knowledgeable about the reporting requirements within their institution.

CPS is a state-administered governmental agency responsible for investigating reports of child maltreatment, determining whether child abuse or neglect has occurred, and intervening to ensure a safe environment for the child. In most cases, CPS agencies assist families in finding appropriate support services to protect and improve the well-being of their children. When it is deemed necessary, these agencies also secure alternative placements for children or pursue the termination of parental rights. Although CPS agencies vary by state and county, professional standards of practice have been widely accepted and implemented.

REPORTING MALTREATMENT

When a report is made to CPS, it is important to provide as much information as possible regarding the child and the incident or circumstances that led to the suspicion of maltreatment. State laws protect the identity of reporters if they choose to remain anonymous. However, especially in the inpatient setting, it is recommended that parents or guardians be notified when a medical professional is going to make a report to preserve (to the extent possible) an open, honest relationship with the child’s caretakers. The most effective means of notifying parents or guardians is to express concern that someone may be harming their child, rather than directly accuse them of maltreatment. When providing this information, the physician can ask whether the parents know of anyone who might be hurting their child. Although the physician–parent relationship may become strained, parents generally respond better to honesty and directness than to secretiveness. This should facilitate a more comfortable working relationship while the child remains in the hospital, and may encourage appropriate follow-up care.

Once a report is made, the CPS staff determines whether the report meets criteria to be accepted as an investigation or assessment and is thus “screened in.” Reports that do not meet the criteria may be “screened out” and referred to other services.⁴ Rules vary by state regarding whether the CPS agency must thoroughly investigate every report.¹ This remains a controversial issue as states attempt to balance their mandates for child protection with limited financial resources.

THE INVESTIGATION

The CPS investigation begins by gathering all the relevant information about the case. Many state laws and regulations outline the investigative procedure in great detail. Most require contact with the child and family within 24 hours of the most serious reports of abuse and within 2 to 5 days for other reports.^1,4 Interviews are conducted with the child, the parents, other family members, and other individuals who might have knowledge about the specific allegations or about the family’s treatment of the child in general.

Many jurisdictions have children’s advocacy centers in place to assist and guide the child interview process. Children’s advocacy centers provide a multidisciplinary team approach to investigations of child abuse, including forensic interviews, therapeutic interventions, victim support and advocacy, and case management. Such facilities provide a safe, child-friendly environment to conduct forensic interviews of a neutral, fact-finding nature. Often these agencies work in collaboration with law enforcement and CPS to minimize the number of times the child victim is interviewed.

If the alleged maltreatment constitutes criminal behavior, law enforcement personnel should be brought into the investigation to ensure that the criminal aspect of suspected maltreatment is thoroughly investigated and that the evidence necessary for criminal prosecution is adequately safeguarded.¹ The reporter may contact the police directly, or this may be done through an established mechanism within CPS. Many jurisdictions have guidelines to ensure cooperation between law enforcement and CPS.

EMERGENCY REMOVAL

One of the most important aspects of the child protection system is the ability to take a child into protective custody on an emergency basis if he or she is in imminent danger. State laws vary whether CPS or law enforcement maintain the authority for this emergency intervention. Once this is done, the CPS agency must obtain a retroactive court order granting it temporary legal custody of the child within 24 to 72 hours from the time the child was placed in protective custody.⁵

Emergency removal orders are usually entered ex parte (with the court only hearing from CPS and without notice to the parent or guardian). Immediately after the 24- to 72-hour period, the matter must be brought before the court at the initial hearing, where the parents are present and have an opportunity to be heard. The main purpose of this initial hearing is to determine whether there is enough evidence to conclude the child is at risk of harm and should remain in substitute care or be returned to the parents pending further proceedings. In addition, the court may issue other types of protective orders against individuals alleged to be responsible for the child’s maltreatment, such as orders for those individuals to vacate the home and have no contact with the child or other family members.⁵

DISPOSITION AFTER THE INVESTIGATION

State laws and regulations require that the CPS agency conclude the investigative process by arriving at a disposition or a formal finding of whether child abuse or neglect has occurred within a given time frame.¹ A number of terms, including indicated, supported, confirmed, or substantiated, are used when CPS believes that the child was a victim of maltreatment; words such as unfounded or unsubstantiated indicate that there was insufficient evidence to conclude that child maltreatment occurred. It is important to keep in mind that these CPS conclusions are not the result of a hearing.