The process whereby a clinician decides that child abuse is a diagnostic possibility is often marked with doubt and fear. Abusive parents can present convincing lies, and children with suspicious injuries can have unusual accidents. Personal thresholds for reporting suspected abuse vary considerably. Clinicians may mistrust or misunderstand the roles and responsibilities of the investigators and legal professionals involved. This article aims to improve understanding of the community responses to a report of child abuse, and enable the clinician to work effectively with child protective services, law enforcement agencies, and legal professionals to ensure child safety and family integrity when appropriate.
Key points
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Lack of recent education in child abuse and a lack of knowledge about reporting laws and practices impede reporting tendencies among physicians.
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Primary practice characteristics, such as limited time to adequately evaluate a child for abuse, lack of quick accessibility to a child abuse specialist, desire to preserve a professional relationship with the family, and negative prior experiences with reporting affect the clinician’s ability to diagnose and report child abuse.
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Reporting child abuse entails both an emotional and cognitive response in the reporter.
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Improved communication with child protective and law enforcement investigators, child abuse specialists, and other resources enhances the clinician’s confidence in reporting suspected abuse.
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Suggested approaches to improving the clinician’s ability to detect, report, manage, and collaborate with investigators include seeking opportunities to update knowledge, implementing a screening tool, establishing contact with child abuse resources in the community, and communicating effectively and promptly with child abuse investigators.
Introduction
The process whereby a clinician decides that child abuse is a diagnostic possibility is often marked with doubt and fear. Abusive parents can present convincing lies, and children with suspicious injuries can have unusual accidents. Personal thresholds for reporting suspected child abuse vary considerably with bias, training, subspecialty, and situational factors. In addition, clinicians may mistrust or misunderstand the roles and responsibilities of the investigators and legal professionals involved after a report is made. The goals of this article are to improve understanding of the community responses to a report of child abuse, and to enhance the ability of the clinician to work effectively with Child Protective Services (CPS), law enforcement, and legal professionals to ensure child safety and family integrity, when appropriate.
Introduction
The process whereby a clinician decides that child abuse is a diagnostic possibility is often marked with doubt and fear. Abusive parents can present convincing lies, and children with suspicious injuries can have unusual accidents. Personal thresholds for reporting suspected child abuse vary considerably with bias, training, subspecialty, and situational factors. In addition, clinicians may mistrust or misunderstand the roles and responsibilities of the investigators and legal professionals involved after a report is made. The goals of this article are to improve understanding of the community responses to a report of child abuse, and to enhance the ability of the clinician to work effectively with Child Protective Services (CPS), law enforcement, and legal professionals to ensure child safety and family integrity, when appropriate.
What happens when you report child abuse
Reporting Laws
In all states of the United States, health care providers are mandated by law to report suspected child abuse or neglect to designated child protection and/or local law enforcement agencies. Although terminology varies, laws generally require a report when the clinician suspects abuse or has reason to believe that a child has been abused or neglected. Proof that abuse has occurred is generally not required to make a report of child abuse. However, in some states the standard for reporting does require the professional to believe that the child’s mental or physical health has been adversely affected by maltreatment. In this latter circumstance, the physician is required to assess harm for those injuries resulting from abuse or neglect.
When Does Sexual Contact Equate to Sexual Abuse?
In general, any sexual contact involving children younger than 17 years and adults should be reported to CPS and/or law enforcement. Sexual contact involving children and family members or individuals residing in the child’s home are usually investigated by CPS in addition to law enforcement. Sexual contact between minors and nonrelated adults, and nonconsensual sexual contact involving minors are reported to law enforcement. Clinicians should also report parents who are aware that abuse is occurring but fail to protect the child.
State laws vary with regard to mandatory or discretionary reporting of sexual activity between 2 consenting minor children. Some states mandate reporting for any child below a designated “age of consent,” whereas other states mandate reporting when the sexual activity is deemed physically or emotionally abusive or harmful. Penal code definitions for “sexual assault of a minor” typically use age-based criteria that differ from reporting mandates.
State laws protect the confidentiality of reporters; child protection and law enforcement professionals may not release the name of the reporter to the family or individuals involved in the investigation. However, physician reporters are often asked to provide records, affidavits, and testimony during or following the investigation, so the reporter is often known or revealed to the family. Many clinicians prefer to inform the family that they are reporting to child protection or law enforcement “so we can make sure everything is being done to keep your child safe.”
Clinicians are protected from liability as long as they make a report of suspected abuse “in good faith” ; in some states, there is a presumption of good faith unless it is disproved. Many state statutes specifically deny immunity for any reporter who knowingly makes a false or malicious report, and may impose either civil or criminal penalties for false reporting. Similarly, there are penalties for failing to report suspected abuse or neglect; punishments range from fines to imprisonment.
Child Protective Services Responses
CPS is responsible for determining whether the child is safe, and for implementing measures or “safety plans” to ensure the child remains safe during the investigation. When an individual makes a report to a child protection agency, the report may be either closed without investigation or assigned to investigation. Reports to investigation are assigned a priority ranking that determines the time within which the child protection worker must initiate the investigation. In general, reports involving younger children or serious injuries are prioritized. The results of the investigation are provided to the reporter in most states. Physicians may be contacted by a child protection worker for additional information whether or not the physician is the reporter. The Health Insurance Portability and Accountability Act (HIPAA) permits disclosure of information without authorization of a legal guardian for situations relating to the investigation of abuse or neglect. Although the physician should inform the parent or legal guardian when such disclosures are made, HIPAA also permits the physician to withhold the child’s information from the parent if there is a possibility that the parent is the abuser or is protective of a suspected abuser. The physician should confer with the child protection investigator if there is uncertainty about whether release of information to the parent could jeopardize the child’s safety.
A timely report to CPS not only protects children, but can also initiate services to strengthen families. In some states, the court can mandate that family members participate in services while the child is kept safe with another relative. In general, CPS is required to make reasonable efforts to prevent removal of the child from the family if the child’s safety can be assured while services are being offered. Services for families are expected to be strength-based, family-centered, trauma-informed, and respectful of culture, customs, beliefs, and needs.
When children cannot remain safely with their families, CPS provides out-of-home placements and, in some cases, adoption services. Foster children often have emotional or behavioral problems, chronic disabilities, developmental delays, and poor academic performance. However, foster care also offers the opportunity to address unmet medical, dental, and mental health needs, and to provide a medical home. After initial health screening, children in foster care should receive comprehensive medical, dental, developmental, and mental health evaluations, with ongoing primary care monitoring of their health status.
Law Enforcement Responses
Most states permit the physician to report to either child protection or law enforcement agencies when abuse is suspected. Referrals made to one agency often result in a joint investigation with the other agency. In general, child protection agencies investigate allegations of abuse or neglect involving a family member or occurring in a registered day care, whereas law enforcement investigates possible crimes involving both family member and non–family member suspects. A physician should call law enforcement if immediate safety measures are needed ( Box 1 ).
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Parent is belligerent or violent
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Parent is threatening to leave when child needs further medical assessment or treatment
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Concern that parent will not comply with recommendations to take child to hospital immediately for further testing or admission
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To request a visit to the home to check on the child’s welfare after the child has been dismissed from clinic (and child protective services is not yet involved)
Legal Responses
After a report of child abuse is made the physician may be required to testify, most commonly in either a child protection hearing or criminal trial, or both. After receiving a subpoena, the physician should place himself on standby (a phone number or contact person should be listed on the subpoena) and speak to the attorney issuing the subpoena. Physicians may request to be called to testify just prior to when testimony is needed (taking account of travel time). Although courts do not have to honor this request, it is reasonable to ask for consideration of patients who will have to be rescheduled because of physician testimony. The attorney requesting testimony should confer with the physician before testimony to review the medical findings and anticipated questions ( Box 2 ). Sometimes telephone or videoconference testimony is allowed for certain legal proceedings.
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Name, educational background
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How clinician became involved with caring for the child
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What were the clinical findings: history, examination, ancillary testing
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What was the diagnosis
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What were the differential diagnoses, and how were they excluded
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What was done after the diagnosis was made (report, admit to the hospital, ordered a skeletal survey, and so forth)
Problems physicians face when child abuse is suspected
Physicians confront several questions in considering the decision to report suspected abuse and neglect:
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Is this really abuse?
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Are these parents capable of abusing their child?
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Would physician intervention with the parents be more effective than the child protection responses?
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Would referring the child and family to a social worker be better than making a report to a child protection agency?
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Will CPS really do anything?
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Will CPS take unnecessary drastic measures, jeopardizing the family rather than helping them?
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Will reporting affect the clinician’s relationship with the family? If the family is lost from the clinician’s practice, is the ability to monitor and protect the child in the future also lost?
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How much time will it take to make a report?
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How much time will be needed to prepare and provide testimony relating to the medical assessment of this child’s injury or condition?
The importance of each question varies considerably among health care providers, depending on practice characteristics, education and knowledge in child abuse, past experiences with CPS, and personal experiences and opinions.
What Is the Threshold for Reporting?
State laws for reporting rely primarily on the individual’s judgment that the child may have suffered abuse or neglect. A physician does not have to make a definitive diagnosis of child abuse to report.
In making a decision to report, physicians may consider where an injury falls on the continuum between abuse and accident or medical condition ( Fig. 1 ). Similarly, physicians may consider a continuum between neglect and accidental or medical causes when evaluating the need to report a child with failure to thrive. Sometimes it may not be clear where an injury falls on the continuum between abuse and neglect, but generally all injuries along this continuum are reported; for example, a 15-month-old with scald burns from a large pot with hot water that was placed on the kitchen floor and left unattended may have sustained the burns through inflicted or accidental causes, but both raise significant concerns for child safety.
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