COURSE PRICE: $30.00
CONTACT HOURS: 3
This course is approved by the New York State Education Department (provider ID #80607) and meets the requirement for mandated reporter training in identifying and reporting child abuse, maltreatment, and neglect in the state of New York.
Wild Iris Medical Education is approved as a provider by the New York State Department of Education Professional Education Program. Registered course completions are automatically reported to the NY State Department of Education.
Course Availability: Expires May 31, 2015. You must score 70% or better on the test and complete the course evaluation to earn a certificate of completion for this CE activity. Wild Iris Medical Education, Inc. provides educational activities that are free from bias. The information provided in this course is to be used for educational purposes only. It is not intended as a substitute for professional health care. Medical Disclaimer Legal Disclaimer Disclosures
NOTE: This course is not approved for Pennsylvania.
Copyright © 2012 Wild Iris Medical Education, Inc. All Rights Reserved.
COURSE OBJECTIVE: The purpose of this course is to prepare mandated reporters in New York State with the information and tools needed to identify and report child abuse and maltreatment/neglect.
Upon completion of this course, you will be able to:
The government has a responsibility to protect children when parents fail to provide proper care and to intervene in cases of child maltreatment. Likewise, healthcare professionals have a responsibility to recognize and report suspected child abuse and maltreatment.
The federal Child Abuse Prevention and Treatment Act (CAPTA) (42 U.S.C.A. § 5106g) is one of the key pieces of legislation that guides child protection. This piece of legislation has been in place since 1974 and has been amended on a regular basis since that time.
The amended CAPTA Reauthorization Act of 2010 defines child abuse and neglect as, at minimum:
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 an act or failure to act which presents an imminent risk of serious harm.
The federal legislation provides guidance to the states in defining child maltreatment and abuse. New York State provides its own definitions of child maltreatment (which includes neglect) and abuse within civil and criminal statutes. Legal definitions are found in Section 1012 of the Family Court Act and Section 412 of the Social Services Law.
New York State’s Social Services Law, Section 412, defines a maltreated child as a child less than 18 years of age who is defined as a neglected child by the Family Court Act or who has had serious physical injury inflicted upon him or her by other than accidental means.
Maltreatment means that a child’s physical, mental, or emotional condition has been impaired, or placed in imminent danger of impairment, by the failure of the child’s parent or other person legally responsible to exercise a minimum degree of care by failing to provide sufficient food, clothing, shelter, education; or failing to provide proper supervision, guardianship, or medical care (including dental, optometric, or surgical care); or inflicting excessive corporal punishment, abandoning the child, or misusing alcohol or other drugs to the extent that the child was placed in imminent danger. Poverty or other financial inability to provide the above is not maltreatment (NYS OCFS, 2012).
Section 1012(f) of New York State’s Family Court Act defines a neglected child as:
[A] child less than 18 years of age whose physical, mental, or emotional condition has been impaired or is in imminent danger of becoming impaired, or his or her parent or other person legally responsible for his or her care failed to exercise a minimum degree of care in supplying adequate food, clothing, shelter, education, medical or dental care, though financially able to do so, or the parent failed to provide proper supervision or guardianship, inflicted excessive corporal punishment, or misused drugs or alcohol, and there is a causal connection between the child’s condition and the subject’s failure to exercise a minimum degree of care, or the parent has abandoned the child by demonstrating an intent to forgo his or her parental rights.
Child maltreatment is a crime that inflicts permanent damage on victims and families of every culture and socioeconomic level. According to the Child Abuse Prevention and Treatment Act of 2010, more children suffer neglect than any other form of maltreatment.
Neglect can be physical or emotional in nature. Physical neglect is the failure to provide a child with adequate food, shelter, clothing, education, hygiene, medical care, and/or supervision needed for normal growth and development. Emotional neglect includes parent or other caretaker behaviors that cause or have the potential to cause serious cognitive, affective, or other behavioral health problems. These behaviors may include chronic use of verbally abusive language, harsh criticism, denigration, confinement, or torture. The resulting emotional impairment must be clearly attributable to the unwillingness or inability of the parent or other person legally responsible for the child to exercise a minimum degree of care toward the child.
Leaving a young child or children without supervision by a responsible person is a type of neglect. Infants and toddlers should never be left alone, even briefly. Each child develops and matures at his or her own rate, so parents need to make careful decisions about who can be safely left at home alone. Some older preteens are responsible and independent enough to be left alone, while some older teenagers are too irresponsible or have special needs that limit their ability to be safe if left alone. Over one third of all fatalities in fiscal year 2008 were attributed to neglect alone.
Robert attends fifth grade at a public school with his childhood friend Kevin. Robert’s mother provides him with lunch money or prepares a lunch for him to bring to school. Recently, Robert began to come home from school hungry every day and told his mother that he had given his lunch or his money to Kevin. He also let Kevin borrow a jacket, and it was never returned. His mother queried him as to why he was doing this, and Robert denied any bullying behavior on Kevin’s part; he said Kevin was just really poor and hungry and cold every day. Robert’s mother contacted the school about Kevin.
The school nurse called Kevin into the office, and a sensitive discussion revealed that Kevin’s parents were separated and that he was living with his father in a hotel room. His father was unemployed and drinking and using drugs daily, leaving little money left for food or clothing to care for Kevin’s needs. The nurse contacted Child Protective Services (CPS), and Kevin was found to be the victim of neglect. He was placed in the care of his mother, whose income was also below the poverty level, and social services assisted her in obtaining assistance in order to care for Kevin.
Abuse encompasses the most serious injuries and/or risk of serious injuries to children by their caregivers. An abused child is one whose parent or other person legally responsible for his or her care inflicts serious physical injury upon the child, creates a substantial risk of serious physical injury, or commits a sex offense against the child. Abuse also includes situations where a parent or other person legally responsible knowingly allows someone else to inflict such harm on a child (NYS OCFS, 2012).
Approximately 70% of the cases investigated by Children’s Services in New York City involve some form of substance abuse. Evidence has shown that there is a correlation between children who grow up in homes involving the abuse of alcohol and/or drugs and child maltreatment. Parents or caregivers who are substance-dependent are often more focused on using and obtaining the substance than considering the emotional and physical needs of the child. Giving birth to a drug-addicted infant and manufacturing and using drugs in the presence of children are considered forms of child abuse.
Physical abuse is the most obvious form of child abuse. Physical abuse of a child includes any non-accidental physical injury of a child that is inflicted by a parent or caretaker. Physical abuse injuries can range from superficial bruises and marks to fractures, burns, and serious internal injuries. In severe cases, the physical abuse may lead to death. The legal definition of physical abuse includes actions that pose a substantial risk of physical injury to the child, even if no injury is sustained.
In addition to the observable physical injuries, such as frequent and unexplained bruises, burns, and cuts, the child may be overly afraid of the parent’s reaction to misbehavior.
Sexual abuse includes situations in which the parent, or other person legally responsible for a child under 18 years of age, commits or allows any one of the following activities:
Sexual abuse and maltreatment include such criminal offenses as rape, sodomy, other non-consensual sexual conduct, and prostitution (NYS OCFS, 2010).
The Centers for Disease Control and Prevention (2010a) defines emotional abuse as behaviors that harm a child’s self-worth or emotional well-being. Examples include name calling, shaming, rejection, withholding love, and threatening. Emotional or psychological abuse is sometimes called “invisible” abuse, because it does not leave any physical marks. The unseen scars of emotional abuse can leave devastating effects.
The CDC viewpoint is that education of parents can prevent many types of abuse, including emotional abuse. Programs may be offered to parents in different forums, such as in schools, health clinics, homes, and other community settings. These programs also offer social support to parents.
Exposure to an environment of domestic violence is another form of emotional abuse and can significantly contribute to behavioral health problems. Children who are subjected to domestic violence are more likely to develop problems such as attachment disorder, depression, anxiety, and oppositional defiance disorder than are those who are the victims of direct abuse. This is because the developing brain of a child is highly sensitive, and the chronic state of fear and stress that these children experience prevents the brain from developing normally. Instead, the brain is influenced adversely by abnormal patterns of neurological activities and brain chemicals. A violent environment will have the greatest adverse effects on the brains of the youngest children (Perry, 2009).
Beginning at age 8, Riley, the youngest of four children, has spent every other week at his father’s apartment without his siblings so that he and his father can have “one-on-one time.” When Riley’s parents divorced, and although the judge was aware that Riley’s father was possibly abusive, it was the philosophy of the court that children suffer more damage when they have no contact at all with their parents.
At age 9, Riley was developing obvious signs of anxiety, such as running away from Little League baseball games because he did not enjoy playing while people watched. His father ridiculed him and physically picked him up and put him back on the field in anger in the middle of the game. The coach tried to intervene, but the father prevailed, and Riley stood motionless in the field.
By age 10, Riley was resisting visitation with his father, and a neighbor called 911 after observing Riley’s father yelling at him and forcing him into the car, followed by Riley trying to jump out of the moving vehicle. Riley’s teacher also reported to the authorities that he had been dropped off to school late by his father 10 days in a row following a visitation. After school, Riley requested to go home to his mother on nearly a daily basis because he had a “stomach ache.”
An investigation revealed that Riley was having severe separation anxiety from his mother and siblings and that the apartment where he stayed with his father was filled with storage items, leaving little room for the child. There was no bed at the residence for Riley, who slept on a mat on the floor, nor was there food in the refrigerator. Riley’s father said that the child was “fat” and that he did not want to keep any food around for that reason.
A multidisciplinary team helped Riley and his family. Riley began seeing the school counselor, and at the recommendation of Child Protective Services, his visitation schedule was amended to exclude overnights with his father. In addition, his father was ordered by the court to attend parenting classes. The school nurse recognized that the symptoms that frequently brought Riley into her office were due to panic attacks, and she contacted the child’s mother, who was amenable to treatment and took him to his family doctor for evaluation.
Riley’s symptoms improved within a few months after counseling, treatment with anti-anxiety medication, and the revised visitation schedule.
Many children suffer multiple types of abuse, which increases their risk of serious health consequences as adults. The Childhood Adverse Experience (ACE) Study, published in 2009, investigated the association between childhood maltreatment and later-life health and well-being (CDC, 2009).
The ACE Study findings suggest that child maltreatment experiences are major risk factors for the leading causes of illness and death as well as poor quality of life in the United States. The more adverse childhood experiences that were experienced by an individual, the greater the risk of developing alcoholism, chronic obstructive pulmonary disease (COPD), depression, illicit drug use, intimate partner violence, sexually transmitted infections, criminality, and smoking.
(Material in this section is taken from New York State’s Social Services law, Section 412-A, Special Definitions Relating to Children in Residential Care, revised February 2012.)
New York is one of nine states in the United States that together house over half of all American foster children. The average amount of time that children in the U.S. child welfare system spend in foster care is 26.7 months, although 11% of children in foster care stay for 5 or more years. The majority of children in foster care live in family settings, but a substantial 16% live in either institutions or group homes (Children’s Rights, 2012).
Sadly, residential care may not always be a safe haven for abused children. Studies suggest that the occurrence of both physical and sexual abuse for children in foster care is in all likelihood significantly higher than for those who live in their homes (National Coalition for Child Protection Reform, 2011).
The definition of an abused child in residential care settings is comparable to the definition of abuse occurring in a family setting, but the age limit may be extended up to 21 years old if the child is in one of the following residential settings:
Section 412.9 of the Social Services Law provides a separate definition of a neglected child in residential care:
A neglected child in residential care means a child whose custodian impairs, or places in imminent danger of becoming impaired, the child’s physical, mental, or emotional condition by intentionally administering to the child any prescription drug other than in accordance with a physician’s or physician assistant’s prescription, by failing to adhere to standards and regulations for the care, services or supervision of children in such a way that inflicts or allows to be inflicted physical or serious emotional injury, or a substantial risk thereof.
This definition pertains to children residing in group residential facilities under the jurisdiction of the State Department of Social Services, Division for Youth, Office of Mental Health, Office of Mental Retardation and Developmental Disabilities, or State Education Department. Section 412.6 defines a custodian as a director, operator, employee, or volunteer of a residential care facility of program.
Section 412.2(c) also specifies that a maltreated child can include a child with a disability who may be up to 21 years of age when he or she is defined as a neglected child in residential care (as defined earlier).
Christine, age 17, suffering from severe depression, had attempted suicide twice in the past 6 months. She was experiencing panic attacks, agoraphobia, and self-cutting. She had been treated as an outpatient during that time and had not been able to attend school. In desperation, her parents agreed to residential treatment in a state-subsidized group home for a 3-month evaluation.
Christine’s symptoms seemed to be getting worse, and she was seldom allowed to have visits or even phone calls from her parents. When her parents called, they were told that all of the children had lost their privileges for phone calls and visitors several weekends in a row. One Sunday, her parents decided to visit the home unannounced. They found Christine quarantined in a small sitting room with eleven other children. All of the children had been kept awake all night as a “punishment” because two children had attempted to run away. One staff member was banging pots and pans in the faces of the exhausted children, who were falling asleep sitting up, as they were not allowed to lie down.
Christine’s parents took her home immediately, signing her out “AMA” (against medical advice), and contacted the Department of Social Services. An investigation followed, and the group home was closed.
The terms boarder babies, abandoned infants, and discarded infants are frequently confused or used interchangeably. The National Abandoned Infants Assistance Resource Center (2005) provides the following definitions:
All 50 states have enacted some version of a “safe-haven” law that allows parents to relinquish an infant to the state by leaving the newborn in a safe location such as a hospital, fire department, or police station. The purpose of these statutes is to decriminalize leaving unharmed infants anonymously in a safe location in order to save the lives of these unwanted infants.
In 2000, New York State became one of the first states to enact an Abandoned Infant Protection Act (AIPA), commonly called the Safe Haven Act, to prevent individuals from abandoning an infant up to 30 days old. The law designates specific locations as safe places for parents to relinquish their unharmed newborns safely, legally, and anonymously. This law protects parents who feel that they have no choice other than abandonment and want to protect their child from harm.
Statistics on the number of babies who are discarded or relinquished annually are not tracked, and awareness of babies who are abandoned, relinquished, or discarded often results only from media reports. Research thus far suggests that safe haven laws may not be as effective in protecting the lives of newborns as legislators had anticipated. The profile of a parent who discards a newborn is one who is a minor, single, and frequently chemically dependent woman. Most discarded infants are not born in hospital settings and are born to mothers who had no prenatal care. The mothers generally have no social support and have concealed the pregnancy from family and friends (Oberman, 2008).
Abandonment (discarding) of newborn infants in unsafe places is an example of extreme neglect. Under New York State law it is considered a Class E felony and a Class A misdemeanor and must be reported as such by mandated reporters. The Abandoned Infant Protection Act (AIPA), amended in 2010, offers an affirmative defense (i.e., that the parent or their agent is shielded from prosecution) to these criminal charges if the following criteria are met:
Although the law does not define “suitable location” or “appropriate person,” district attorneys have stated that hospitals, police stations, and fire stations could be suitable if they are open and staff is present.
Any mandated reporter who learns of abandonment is obligated to fulfill mandated reporter responsibilities (see “Reporting Child Maltreatment/Abuse” below). Even if the reporter is unsure of the name of the person abandoning the child, he or she must make a report, simply listing the unknown person as “Unknown.” (For more information, see AIPA in the “Resources” section at the end of this course.)
In 2010, 18 out of every 1,000 children in New York State were abused or neglected. The 79,668 victims were identified from 170,224 reports of suspected child abuse or neglect. Approximately 30% of suspected reports were substantiated, and many of the reports involved multiple children. In New York State, 114 children died as a result of abuse or neglect, bringing the fatality rate to 2.58 per 100,000 children (USDHHS, 2011).
Nationally, an estimated 3.3 million reports of suspected child maltreatment were made to state child protective services agencies in 2009. A total of only 60% of the cases were investigated, bringing the nationally estimated number of victims to 695,000 during that year. Investigations have determined that:
The youngest children suffered the highest rates of victimization; almost half of all fatalities occurred in children less than one year of age, and more than three quarters in children under four. Children with disabilities or children who were of African American, American Indian, Alaska Native, or multiple racial descent had disproportionately high rates of abuse (CDC, 2010b).
Health professionals need to be alert for individual, relational, community, and societal factors that increase the risk of child maltreatment. The CDC (2012) cites the following risk factors as contributing to child abuse:
Presence of these factors signals the need for the professional to examine the situation more closely, carefully, and methodically. These factors seldom appear in isolation but rather in clusters.
Healthcare professionals need to be alert for physical injuries that are unexplained or inconsistent with the parent or other caretaker’s explanation and/or the developmental state of the child.
Bruising is one of the most common and most readily visible injuries resulting from physical child abuse, but it may be overlooked because it is usually clinically insignificant. In cases of abuse, however, it may be the only visible sign of injury or signal of internal injuries. Bruising can be an indicator of occult trauma and should prompt further evaluation (Pierce et al., 2010).
Bruising should always generate suspicion in infants who are not yet mobile. The normal activities of daily life in an infant should not generate bruises, and if bruises are observed, the parent should be able to provide a reasonable explanation for their presence. Bruises on the soft tissue of the body, ears, neck, and trunk of an infant should particularly elicit suspicion of child abuse. In children who are under four years of age, bruising on the torso, ears, or neck is highly suspicious of abuse. If suspicious bruising is observed, the child should undergo a complete exam to check for other injuries.
The assessment of an infant with a bruise should also include skeletal imaging and coagulation studies. In addition, the workup may include a computed tomography (CT) scan and a retinal examination—screening tools that may reveal more evidence of abuse. For example, bruising on the abdomen may necessitate a CT scan to explore for an intra-abdominal injury, and a retinal exam may reveal evidence of non-accidental head trauma (formerly referred to as “Shaken Baby Syndrome”) (Lazoritz et al., 2010).
Normal accidental bruising in children is generally seen over bony prominences. A careful history should be taken when bruising is observed in suspicious areas such as the back, posterior thighs and calves, or buttocks.
It is important to know both normal and suspicious bruising patterns when assessing children’s injuries. (Source: Research Foundation of SUNY, 2006.)
Typical indications of unexplained bruises and welts include:
This pattern signals the blow of a hand to the face of a child. (Source: New York Mandated Reporter, 2006.)
Regular patterns reveal that a looped cord was used to inflict injury on this child. (Source: New York Mandated Reporter, 2006.)
Susan, the school nurse, was doing routine height and weight measurements for the fifth grade. She valued the opportunity to spend a little time alone with each child. Tommy, small for his age and withdrawn, was in Susan’s office for evaluation. He was new this year to the school district, and his records indicated he was already frequently absent. Susan observed that Tommy was dressed in jeans and a long-sleeved, hooded jacket even though it was 80 degrees out. He also had a black eye as well as a bruise on his opposite cheek. She asked him if he would remove his jacket before stepping on the scale, and when he did so, she noticed four round bruises on the outside of his upper right arm and one round bruise on the inside of his upper right arm. Susan asked Tommy how he had hurt himself, and he said he ran into a door.
Susan believed that the injuries were more consistent with physical abuse and reported her suspicions to CPS. Tommy was interviewed by a social worker, and it was determined that Tommy had been battered by his stepfather. The injury to his eye was the result of being punched. The injury to the right side of his face was sustained when his stepfather struck him as he tried to flee. He incurred the bruises to his right arm when the stepfather grabbed him from behind, causing a patterned injury of four fingers and a thumb.
Tommy’s stepfather was arrested and incarcerated. He pleaded no contest to the charges. Tommy and his mother were referred to counseling funded by the Violence Against Women Act.
Typical indications of unexplained lacerations and abrasions include:
Typical indications of unexplained burns include:
A steam iron was used to inflict injury on this child. (Source: New York Mandated Reporter, 2006.)
Typical indications of unexplained fractures include:
Typical indications of unexplained head injuries include:
In 2009, the American Academy of Pediatrics (AAP) recommended using the term abusive head trauma in place of shaken baby syndrome. Although the policy statement continued to recognize shaking as a potential cause of serious neurologic injury, AAP recommends the use of abusive head trauma in order to include all mechanisms of inflicted head injury, such as battering and other forms of trauma.
In addition to the change of the name, the possibility of wrongful criminal conviction resulting from failure to diagnose a condition that mimics abusive head trauma has been addressed. The list of differential diagnoses for abusive head injury is extensive, and it is important that healthcare providers explore all of the possibilities in an objective manner.
Signs and symptoms of abusive head trauma may include:
Source: Fingarson & Pierce, 2012.
Nurse Elizabeth met her first client of the day at the WIC (Women, Infant, Children) clinic, a disheveled 17-year-old single mother cradling a 6-month-old boy. The mother said she was worried about the baby because he had been vomiting and was very sleepy.
The baby was arousable but appeared lethargic on exam. He did not seem interested in feeding when the mother offered him a bottle. Elizabeth weighed the baby and checked the vital signs. The baby had gained weight appropriately since the last visit, and his vital signs were normal.
Recent history per the mother revealed that the baby had been “colicky” the night before and was crying a lot, but she had not noticed any signs of illness. The mother said she had left the baby with her boyfriend for 20 minutes while she went to the store to buy diapers, and when she returned, the baby was quiet and slept through the night, which was unusual. The mother said she could not get him to wake up enough to take a bottle and that he had been vomiting all morning.
Elizabeth was concerned and sent the mother and child to the emergency department for an examination. The baby was diagnosed with abusive head trauma and admitted. An investigation revealed that the boyfriend had shaken the baby because he was crying and then put him in the crib.
The boyfriend was charged with abuse. The mother voluntarily relinquished custody of the child to her parents until the investigation was completed. The mother was not charged because she was unaware of the boyfriend’s abuse and therefore did not knowingly allow it.
Careful assessment of a child’s behavior may also indicate physical abuse, even in the absence of obvious physical injury. Behavioral indicators of physical abuse include the following:
Presence of the following parent/guardian behaviors may also indicate an abusive relationship:
A rare form of child abuse known as Munchausen Syndrome by Proxy (sometimes referred to as factitious disorder by proxy) occurs in a medical setting and is characterized by unexplainable, persistent, or recurrent illnesses and discrepancies among the history, clinical findings, and child’s general health. This type of abuse is a combination of physical abuse, medical neglect, and emotional abuse. It is the child’s parent (almost always the biological mother) who creates a fictitious illness in the child by giving the child medications, inducing bruising or fever, and often causing the child to become hospitalized. Munchausen Syndrome by Proxy should be suspected in cases where children have unusual illnesses and/or do not respond to treatment.
The characteristics of the parents in this syndrome are predictable. The child’s mother frequently has past experience in healthcare and is often a nurse. She gets along well with the hospital staff and appears to be a devoted mother and never leaves the child’s side. She may demonstrate a lack of emotion or an inappropriate affect when discussing the child’s illness. The mother often reports a history of past abuse and may report falsehoods about her life, such as having earned a law degree. In addition, the mother has both poor relationship and coping skills. If there is a father, he may not ever visit the hospital, and he presents as dependent with a high level of denial and a very supportive attitude towards the mother.
Some of the warning signs of the syndrome are that the signs and symptoms of the child’s illness only occur in the mother’s presence, the mother never leaves the child alone in the hospital, and the child is intolerant of the prescribed treatment. The mother may interact more with the medical staff than she does with the child. This syndrome may occur in families in which an unexplained infant death occurs (Brannon, 2011).
Diagnosis of Munchausen Syndrome by Proxy may require a multidisciplinary team approach in the hospital setting. Video surveillance may be necessary to discover parental behaviors that are causing illness in the child (Stirling, 2007).
Indicators of physical neglect include:
A child may demonstrate behavioral indicators of neglect such as:
A parent or guardian exhibiting the following behavioral indicators may be emotionally maltreating/neglecting the child:
Child sexual abuse involves the coercion of a dependent, developmentally immature person to commit a sexual act with someone older. For example, an adult may sexually abuse a child or adolescent, or an older child or adolescent may abuse a younger child.
Detecting child sexual abuse can be very difficult. Physical evidence is not apparent in most cases, and victims fear the consequences of reporting their “secret.” Most perpetrators of child sexual abuse are people who are known to the victim. In more than half of cases of repeated abuse, the perpetrator is a member of the family. Anyone, even a mother, can be a perpetrator, but most are male.
The fact that such abuse is carried out by a family member or friend further increases the child’s reluctance to disclose the abuse, as does shame and guilt plus the fear of not being believed. The child may fear being hurt or even killed for telling the truth and may keep the secret rather than risk the consequences of disclosure. Very young children may not have sufficient language skills or vocabulary to describe what happened.
Child sexual abuse is found in every race, culture, and class throughout society. Girls are sexually abused more often than boys; however, this may be due to boys’—and later, men’s—tendency not to report their victimization. There is no particular profile of a child molester or of the typical victim. Even someone highly respected in the community—the parish priest, a teacher, or coach—may be guilty of child sexual abuse. The majority of perpetrators of child sexual abuse were once victims themselves, but not all victims will become perpetrators.
Negative effects of sexual abuse vary from person to person and range from mild to severe in both the short and long term. Victims may exhibit anxiety, difficulty concentrating, and depression. They may develop eating disorders, self-injury behaviors, substance abuse, or suicide. The effects of childhood sexual abuse often persist into adulthood.
Physical evidence of sexual abuse may be not be present or may be overlooked. Victims of child sexual abuse are seldom injured due to the nature of the acts. Most perpetrators of child sexual abuse go to great lengths to “groom” the children by rewarding them with gifts and attention and try to avoid causing them pain in order to insure that the relationship will continue. If physical indicators occur, they may include:
Children’s behavioral indicators of child sexual abuse include:
Sexually abusive parents/guardians may exhibit the following behaviors:
Victims of child abuse often feel helpless and hopeless and think that no one can do anything to help them. They may also attempt to protect an abusive parent or be reluctant to report any abuse for fear of the consequences. Therefore, abuse may continue for months and even years, particularly if the abuser is someone close to the child.
Victimized children may cry out in a variety of nonverbal or indirect ways, for example, a drawing left behind for the teacher, the counselor, or a trusted relative to see. Some children report vague somatic symptoms to the school nurse, hoping the nurse will guess what happened. To the child, this indirect approach is not betrayal of the abuser and therefore not grounds for punishment.
Some children may come to a trusted teacher or other professional and talk directly and specifically about their situation if that person has established a safe, nurturing environment and a sense of trust. More commonly, however, abused children use other, less direct approaches, such as:
|Source: Research Foundation of SUNY, 2006.|
Nurse Katy was working in the triage area of the emergency department. A mother brought in her 12-year-old daughter, Haley. She said that her daughter had been complaining about painful urination and wanted to check if she might have a bladder infection. Katy asked the mother, who appeared to be in the last trimester of pregnancy, to fill out some paperwork while she took the girl to the bathroom for a urine specimen.
Katy noticed that the daughter looked terrified and sat in silence while her mother did all of the talking. When they were behind closed doors, the nurse asked Haley if there was anything that she wanted to talk about privately. Haley shook her head no, but Katy sensed that she was holding something back.
Haley was able to produce a clear, pale yellow urine specimen and then followed Katy to the exam room. Katy asked Haley if she was still having pain when she urinated, and Haley said yes. Katy asked her if she had begun menstruating, and Haley again said no.
Katy brought the mother into the exam room to wait with Haley. After obtaining a brief history from the mother, the doctor ordered a urinalysis. The urinalysis was negative. The doctor did an external genital exam that revealed numerous vesicular lesions on her labia. The child denied any sexual activity. The doctor cultured the lesions for herpes and asked the mother to step into his office to discuss his findings.
Once Katy and Haley were alone in the room, Haley burst into tears and told the nurse that her mother’s boyfriend had been rubbing his “private” on her and said that if she told anyone, her mother would probably die in childbirth.
Katy did not ask for more details, but she called CPS, and Haley was interviewed by a social worker with specialized training in forensic interview skills. Katy knew that if a victim of child sexual abuse is asked too many questions, she or he may not disclose the information to the child forensic interviewer, or she or he might change the responses.
On the following day, Haley underwent a sexual abuse forensic exam in a child-friendly advocacy center. She and her mother, who was also a victim of child sexual abuse, received counseling for over a year. The mother’s boyfriend was convicted of sexual abuse.
Anyone may report suspected child abuse at any time and is encouraged to do so. All reports are confidential and may be made anonymously by members of the public.
Physicians, nurses, and other healthcare professionals are legally required to report suspected cases of child abuse, maltreatment, and neglect. New York State Law specifies these and other professionals and persons who are classified as mandated reporters.
Persons and officials required to report cases of suspected child abuse or maltreatment are as follows:
Source: NYS OCFS, 2011.
New York State law requires mandated reporters to report suspected child abuse or maltreatment in the following three situations:
Mandated reporters can be held liable by both the civil and criminal legal systems for intentionally failing to make a report of suspected abuse that was encountered while acting in their professional capacity.
Barbara, a public health nurse, stops by her friend Janie’s house on the way to work to drop off some flowers. While she is there, Janie’s 5-year-old son Bobby runs into the kitchen and for no apparent reason shoves his 2-year-old sister, who falls and hits her head on the floor. The sister is not injured, but Janie rages at Bobby, picks him up, and throws him across the kitchen, where he slides into a cabinet, hitting the back of his head very hard. Bobby has been diagnosed as autistic, and it is obvious that Janie is not coping well with his behavior.
Barbara takes off her coat and examines Bobby to be sure he is okay. While she is not mandated to report a suspicion of child abuse since she is not currently acting in her professional capacity, Barbara recognizes the importance of taking action for the safety of her friend’s young son. Barbara sits down with Bobby on her lap to talk to Janie. She empathizes with her friend and expresses her concern for the family. She acknowledges how frightening and stressful it must be for Janie to have a child with a serious condition, and asks Janie if she could refer Bobby to a program for autistic children that is provided by the school district. Janie tearfully agrees, and Barbara makes a few calls before leaving to obtain phone numbers that she can provide to Janie.
Barbara makes a point to call Janie the next day and frequently thereafter, and one month later, Janie tells Barbara that she has learned appropriate ways of dealing with Bobby’s acting-out behaviors and that Bobby is doing well in his program.
There can be “reasonable cause” to suspect that a child is abused or maltreated if, considering the physical evidence observed or told about, and based on the reporter’s own training and experience, it is possible that the injury or condition was caused by neglect or by non-accidental means.
Certainty is not required. The reporter need not be certain that the injury or condition was caused by neglect or by non-accidental means. The reporter should only be able to entertain the possibility that it could have been neglect or non-accidental in order to possess the necessary “reasonable cause.” It is enough for the mandated reporter to distrust or doubt what is personally observed or told about the injury or condition.
In child abuse cases, many factors can and should be considered in the formation of that doubt or distrust. Physical and behavioral indicators may also help form a reasonable basis of suspicion. Although these indicators are not diagnostic criteria of child abuse, neglect, or maltreatment, they illustrate important patterns that may be recorded in the written report when relevant (New York State OCFS, 2012).
The law requires that mandated reporters must “personally make a report to the Statewide Central Register of Child Abuse and Maltreatment (SCR)” and “immediately notify the person in charge of the institution, school, facility, or agency where they work or the designated agent of the person in charge that a report has been made.” Mandated reporters are required to report suspected child abuse, maltreatment, or neglect immediately, by telephone, at any time of day, seven days a week. In addition, a written report must be filed within 48 hours of the oral report.
Oral telephone reports should be made to the New York State Central Register of Child Abuse and Maltreatment (SCR) by calling the statewide, toll-free telephone hotline at 800-635-1522.
A written report on Form LDSS-221A, signed by the reporter, must be filed within 48 hours of the oral report with the local Department of Social Services (LDSS) assigned the investigation. Mandated reporters can request the mailing address of the local agency when making the oral report to the hotline. (A written report involving a child cared for away from the home [e.g., foster care, residential care] should be submitted to the New York State Child Abuse and Maltreatment Register, P.O. Box 4480, Albany, NY 12204-0480.) Written reports are admissible as evidence in any judicial proceedings; accurate completion is vital.
It should be noted that Section 413.1 of the Social Services Law does not require more than one report from the institution, school, facility, or agency on any one incident of suspected abuse or maltreatment. However, the mandated reporter’s obligation is not discharged unless the report is made.
A situation could occur in which the staff member is mistaken about the standard of abuse or maltreatment, or about whom the subject of a report may be; the person in charge, or his or her designated agent, could determine that a report need not be made in this situation. Nevertheless, the person in charge—or his or her designated agent—may not prevent the staff member from making a report.
Reporters may wish to maintain careful notes for their own personal records, noting dates, times, places, names of individuals involved in any reporting incident, and any other pertinent comments.
At the time of an oral telephone report, the Child Protective Services (CPS) specialist will request the following information:
Note: A reporter is not required to know all of the above information in making a report; therefore, lack of complete information does not prohibit a person from reporting. However, information necessary to locate a child is crucial.
For purposes of reporting suspected cases of child abuse and maltreatment to the Statewide Central Register of Child Abuse and Maltreatment (SCR) and Child Protective Services, it is important to understand the definition of who can be the “subject of the report” as defined by Section 412.4 of the Social Services Law.
“Subject of the report” means any parent, guardian, custodian, or other person 18 years of age or older who is legally responsible for a child and who is allegedly responsible for causing—or allowing the infliction of—injury, abuse, or maltreatment to such child.
“Subject of the report” also means an operator of, or employee or volunteer in a home operated or supervised by an authorized agency, the Division for Youth, or an office of the Department of Mental Hygiene, or a family daycare home, daycare center, group family daycare home, or a day-services program who is allegedly responsible for causing—or allowing the infliction of—injury, abuse, or maltreatment to a child.
Individuals other than a parent or person legally responsible for the child’s care may also commit abuse and maltreatment. Examples of other individuals are teachers, coaches, neighbors or strangers. Such individuals might not fit the legal definition of the “subject of the report.” If a report is made about such an individual to the SCR, and the SCR believes that the alleged acts or circumstances described by the caller may constitute a crime or an immediate threat to the child’s health or safety, the SCR is required by Section 422.2(c) to transmit the information to the appropriate law enforcement agency, district attorney, or other public official empowered to provide necessary aid or assistance.
Sections 411.2(a) and 422.11 of the Social Services Law establish the procedures to be followed by the Department of Social Services after the phone report is received. If the Department of Social Services is notified of any allegations that could reasonably constitute an instance of child abuse or maltreatment, the Department of Social Services must immediately transmit the information to the appropriate agency or local CPS for investigation.
The CPS unit of the local Department of Social Services is required to begin an investigation of each report within 24 hours. The investigation includes an evaluation of the safety of the child named in the report and any other children in the home and a determination of risk to the children if they continue to remain in the home.
If the Department records indicate a previous report concerning a “subject of the report,” other persons named in the report, or other pertinent information, the appropriate agency or local CPS must be immediately notified of this fact.
Section 422.4 of the Social Services Law provides that a mandated reporter can receive, upon request, the findings of an investigation made pursuant to his or her report. This request can be made to the SCR at the time of making the report or to the appropriate local CPS at any time thereafter. However, no information can be released unless the reporter’s identity is confirmed.
If the request for information is made prior to the completion of an investigation of a report, the released information shall be limited to whether the report is “indicated” (i.e., substantiated), “unfounded,” or “under investigation,” whichever the case may be.
If the request for information is made after the completion of an investigation of a report, the released information shall be limited to whether a report is “indicated” or, if the report has been expunged, that there is “no record of such report,” whichever the case may be.
Note: Reports are expunged for lack of credible evidence of alleged abuse or maltreatment after an investigation, or 10 years after the eighteenth birthday of the youngest child named in the report.
The Health Insurance Portability and Accountability Act of 1996 (HIPPA) contains privacy provisions that have caused confusion regarding the obligation of a mandated reporter to provide copies of written records that underlie the report. However, these HIPAA provisions do not affect the responsibilities of mandated reporters as they are defined in New York Social Services Law.
As part of the Governor’s Permanency Bill of 2005, SSL 415 was amended to clarify that the obligation of a mandated reporter who makes a report that initiates an investigation of suspected child abuse or maltreatment also extends to providing CPS with the written records essential for a full investigation of the report.
The amendment specifies that this includes “all records relating to diagnosis, prognosis, or treatment, and clinical records, of any patient or client that are essential for a full investigation of allegations of child abuse or maltreatment, provided that disclosure of substance abuse treatment records shall be made pursuant to the standards and procedures for disclosure of such records delineated in federal law.”
If the mandated reporter is employed by an institution, that institution is required to provide all of the records of the institution that pertain to the report, regardless of who actually made the report. In addition, the records that CPS requests should be limited only to information that directly pertains to the report itself.
The mandated reporter makes the initial determination of what information is essential for a full investigation. However, if CPS believes that the mandated reporter has additional essential information pertaining to the report, CPS will request additional records and attempt to come to agreement regarding any additional records. If CPS and the mandated reporter cannot reach agreement, CPS may seek a court order directing the mandated reporter to produce the essential information.
Whenever there are allegations of suspected child abuse or neglect, the mandated reporter should keep in mind that any records of physical findings may be used as evidence at a trial. Photos, diagrams, and accurate reporting of medical examination findings are invaluable. The mandated reporter should use language that is not open to misinterpretation when documenting findings (NYSPCC, 2006).
Social Service Law, Section 416, states:
Any person or official required to report cases of suspected child abuse and maltreatment may take or cause to be taken, at public expense, photographs of the areas of trauma visible on a child who is subject to report, and if medically indicated, cause to be performed a radiological examination on the child. Any photographs or X-rays taken shall be sent to the Child Protective Service at the time the report is sent, or as soon thereafter as possible. Whenever such person is required to report under this title in his capacity as a member of the staff of a medical or other public or private institution, school, facility, or agency or his designated agent, who shall then take or cause to be taken, at public expense, color photographs of visible trauma and shall, if medically indicated, cause to be performed a radiological examination of the child.
Photographs and x-rays provide objective visual evidence to substantiate a report of suspected child abuse and are, along with other imaging studies, legally admissible evidence in court proceedings. Photographs are subject to the same guidelines as other medical records.
In New York State, permission from a parent or guardian is required prior to taking photographs of suspected child abuse victims but is not necessary once suspected child abuse has been reported to the State Central Register. Documentation of the consent or refusal should be indicated in the medical record. Force should never be used if a child or adolescent refuses to be photographed (Botash, 2009).
Parents and adolescents who are mature minors can provide consent. A mature minor is defined as person under the age of 18 who is emotionally and intellectually mature enough to give informed consent and who lives under the supervision of a parent or guardian. A person may be declared a mature minor at the discretion of a healthcare provider (Weiss, 2008).
The goal for photographing evidence is to accurately document the findings that serve as a basis for one’s opinion.
Mandated reporters may place an alleged abused or neglected child in protective custody under certain circumstances. A child may be taken into protective custody (without court order or parental consent):
However, protective custody should not be confused with the status of the child admitted voluntarily to the hospital by parent(s).
Other persons legally authorized to place the child into physical protective custody include:
When a child is placed in protective custody, the authorized person must take the following actions:
Any person, official, or institution required to report a case of suspected child abuse or maltreatment that willfully fails to do so:
Failure to report also leads to broader repercussions. CPS cannot act until child abuse is identified and reported—that is, services cannot be offered to the family nor can the child be protected from further suffering (Research Foundation, 2006).
To encourage prompt and complete reporting of suspected child abuse and maltreatment, Social Services Law Section 419 affords the reporter certain legal protections from liability. Any persons, officials, or institutions that in good faith make a report, take photographs, and/or take protective custody of a child or children have immunity from any liability, civil or criminal, that might result from such actions.
All persons, officials, or institutions who are required to report suspected child abuse or maltreatment are presumed to have done so in good faith as long as they were active in the discharge of their official duties and within the scope of their employment and so long as their actions did not result from willful misconduct or gross negligence (CDHS, 2011).
The Commissioner of Social Services and the local Department of Social Services are not permitted to release to the subject of a report any data which identify the person who made the report unless that person has given written permission for the SCR to do so. The person who made the report may also grant the local CPS permission to release his or her identity to the subject of the report. If a reporter needs reassurance, he or she should feel free to emphasize the need for confidentiality if the situation warrants (Research Foundation of SUNY, 2006).
New York State
Healthy Families New York
New York State Child Abuse Hotline
800-635-1522 (Mandated Reporters)
800-342-3720 (General Public)
315-422-9701 (for Onondaga County)
585-461-5690 (for Monroe County)
New York State Domestic Violence Hotline
Abandoned Infant Protection Act (AIPA) Information Hotline
Child Care, Foster Care, and Adoption Information
National Center for Missing and Exploited Children
National Runaway Switchboard
Youth Crisis and Runaway Hotline
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