Child Abuse Identification and Reporting in New York State
Mandated Reporter Training

COURSE PRICE: $30.00

CONTACT HOURS: 3

This course will expire or be updated on or before May 31, 2015.

ABOUT THIS COURSE
You must score 70% or better on the test and complete the course evaluation to earn a certificate of completion for this CE activity.

ACCREDITATION / APPROVAL

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 an approved provider of continuing education by the American Occupational Therapy Association (AOTA), Provider #3313. Courses are accepted by the NBCOT Certificate Renewal program.

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.

LEARNING LEVEL: Introductory
TARGET AUDIENCE: Occupational Therapists, Occupational Therapist Assistants
CONTENT FOCUS
Domain of OT: Client Factors
Professional Issues: OT Education; Legal, Legislative & Regulatory Issues

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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. See our disclosures for more information.


Info NoteThis course is approved by the New York State Education Department and meets the requirement for mandated reporter training in identifying and reporting child abuse, maltreatment, and neglect in the state of New York.

Child Abuse Identification and Reporting in New York State
Mandated Reporter Training

By Sheree Goldman, RN, MSN

Sheree Goldman is a freelance writer with over three decades of clinical experience working with patients and families. For the past twelve years her focus has been in forensics, coordinating a community-based program that conducts medical-legal examinations for victims and suspects. Education has always been an important facet of her practice, and she has given numerous presentations to healthcare professionals, law enforcement, and the public.

Nancy Evans, BS

Nancy Evans is a health science writer and editor with more than three decades of experience in healthcare publishing. She served as senior editor at Mosby/Times Mirror, senior editor in the health sciences division of Addison-Wesley, and senior medical editor at Appleton & Lange. A breast cancer survivor since 1991, she has written and spoken extensively on breast cancer issues. Nancy co-produced the HBO documentary film Rachel's Daughters: Searching for the Causes of Breast Cancer. She is also the co-producer of Children and Asthma, a KQED documentary film, and the documentary, Good Food, Bad Food: Obesity in American Children.

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.

LEARNING OBJECTIVES

Upon completion of this course, you will be able to:

  • Define child maltreatment, neglect, and abuse according to New York State law.
  • Explain the risk factors contributing to child abuse.
  • Recognize physical and behavioral indicators of child abuse and maltreatment.
  • Differentiate situations in which mandated reporters must report suspected cases of abuse and maltreatment.
  • List procedures for placing a child into protective custody.
  • Discuss the legal protections afforded mandated reporters as well as the consequences for failing to report.

WHAT IS CHILD ABUSE?

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.

Maltreatment

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).

Neglect

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.

TYPES OF NEGLECT

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.

CASE

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

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

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

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:

  • Touching a child’s mouth, genitals, buttocks, breasts, or other intimate parts for the purpose of gratifying sexual desire
  • Forcing or encouraging the child to touch the parent, or other person legally responsible, in this way for the purpose of gratifying sexual desire
  • Engaging or attempting to engage the child in sexual intercourse or any deviate form of sexual intercourse
  • Forcing or encouraging a child to engage in sexual activity with other children or adults
  • Exposing a child to sexual activity or exhibitionism for the purpose of sexual stimulation or gratification of another
  • Permitting a child to engage in sexual activity which is not developmentally appropriate when such activity results in the child suffering emotional impairment
  • Using a child in a sexual performance such as a photograph, play, motion picture, or dance regardless of whether the material itself is obscene
  • Giving indecent material to a child

Sexual abuse and maltreatment include such criminal offenses as rape, sodomy, other non-consensual sexual conduct, and prostitution (NYS OCFS, 2010).

PSYCHOLOGICAL / EMOTIONAL ABUSE

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).

CASE

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.

ACE STUDY

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.

Special Definitions Relating to Children in Residential Care

(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).

ABUSED CHILD IN RESIDENTIAL CARE

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:

  • The New York State School for the Blind or the New York State School for the Deaf
  • A private residential school which has been approved by the Commissioner of Education for special education services or programs
  • A special act school district
  • State-supported institutions for the instruction of the deaf and blind that have a residential component
NEGLECTED CHILD IN RESIDENTIAL CARE

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.

MALTREATED CHILD IN RESIDENTIAL CARE

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).

CASE

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.

Boarder, Abandoned, and Discarded Infants

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:

  • Boarder babies are infants under the age of 12 months who remain in the hospital past the date of medical discharge. Boarder babies may eventually be claimed by their parents and/or be placed in alternative care.
  • Abandoned infants are newborn children who are not medically cleared for hospital discharge but who are unlikely to leave the hospital in the custody of their biological parents.
  • Discarded infants are newborns who have been abandoned in public places, other than hospitals, without care or supervision.

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:

  1. The abandoned infant can be no more than 30 days old.
  2. The person abandoning the infant must have intended the child be safe and well cared for. He or she cannot have intended the child any harm.
  3. The infant must be left in an appropriate or suitable location. Should the infant be left in a suitable location, an appropriate person must be notified immediately of the child’s location so the child can be taken into custody and cared for.

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.)

PREVALENCE AND RISK FACTORS

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:

  • Over 70% of these children were victims of neglect
  • 17% of maltreated children suffered physical abuse
  • 9% suffered sexual abuse
  • 8% suffered psychological maltreatment
  • 2% experienced medical neglect
  • 10% were victims of other forms of maltreatment such as abandonment, threats of harm or congenital drug addiction

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:

  • Children younger than 4 years of age
  • Special needs that may increase caregiver burden (e.g., disabilities, mental retardation, mental health issues, and chronic physical illnesses)
  • Parents’ lack of understanding of children’s needs, child development, and parenting skills
  • Parents’ history of child maltreatment in family of origin
  • Substance abuse and/or mental health issues, including depression in the family
  • Parental characteristics such as young age, low education, single parenthood, large number of dependent children, and low income
  • Non-biological, transient caregivers in the home (e.g., mother’s male partner)
  • Parental thoughts and emotions that tend to support or justify maltreatment behaviors
  • Social isolation
  • Family disorganization, dissolution, and violence, including intimate partner violence
  • Parenting stress, poor parent-child relationships, and negative interactions
  • Community violence
  • Concentrated neighborhood disadvantage (e.g., high poverty and residential instability, high unemployment rates, and high density of alcohol outlets)
  • Poor social connections

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.

RECOGNIZING PHYSICAL ABUSE

Physical Signs of Physical Abuse

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 AND WELTS

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.

Illustration

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:

  • On the face, lips, mouth, neck, wrists, or ankles
  • On the torso, back, buttocks, and thighs
  • On both eyes or cheeks (these lesions are always suspicious because an accident usually injures only one side of the face)
  • Clusters of lesions or those that form a regular pattern, reflecting the shape of the article used to inflict the injury (electric cord, belt buckle)
  • On several different surface areas
  • Injuries in various stages of healing
  • Injuries that regularly appear after absence from school or daycare (e.g., after a weekend or a vacation)

PhotographPhotograph

Left: This pattern signals the blow of a hand to the face of a child.
Right: Regular patterns reveal that a looped cord was used to inflict injury on this child.
(Source: New York Mandated Reporter, 2006.)

CASE

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.

LACERATIONS OR ABRASIONS

Typical indications of unexplained lacerations and abrasions include:

  • To mouth, lips, gums, eyes
  • To external genitalia
  • On backs of arms, legs, or torso
  • Human bite marks (these compress the flesh, in contrast to animal bites, which tear the flesh and leave narrower teeth imprints)
BURNS

Typical indications of unexplained burns include:

  • Cigar or cigarette burns, especially on soles, palms, back, or buttocks
  • Immersion burns by scalding water (sock-like, glove-like, doughnut-shaped on buttocks or genitalia; “dunking syndrome”)
  • Patterned like an electric burner, iron, curling iron, or other household appliance
  • Rope burns on arms, legs, neck, or torso

Photograph

A steam iron was used to inflict injury on this child. (Source: New York Mandated Reporter, 2006.)

FRACTURES

Typical indications of unexplained fractures include:

  • Fractures to the skull, nose, or facial structure
  • Skeletal trauma with other injuries, such as dislocations
  • Multiple or spiral fractures
  • Fractures in various stages of healing
  • Swollen or tender limbs
HEAD INJURIES

Typical indications of unexplained head injuries include:

  • Absence of hair and/or hemorrhaging beneath the scalp due to vigorous hair pulling
  • Subdural hematoma (a hemorrhage beneath the outer covering of the brain, due to severe hitting or shaking)
  • Retinal hemorrhage or detachment, due to shaking
  • Whiplash, or “shaken baby syndrome” (see “Abusive Head Trauma” below)
  • Eye injury
  • Jaw and nasal fractures
  • Tooth or frenulum (of the tongue or lips) injury

ABUSIVE HEAD TRAUMA

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:

  • Lethargy/decreased muscle tone
  • Extreme irritability
  • Decreased appetite, poor feeding, or vomiting for no apparent reason
  • Absence of smiling or vocalization
  • Poor sucking or swallowing
  • Rigidity or posturing
  • Difficulty breathing
  • Seizures
  • Head or forehead appears larger than usual
  • Fontanel (soft spot) bulging
  • Inability to lift head
  • Inability of eyes to focus or track movement; unequal size of pupils
  • Vomiting

Source: Fingarson & Pierce, 2012.

CASE

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.

Behavioral Indicators of Physical Abuse

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:

  • Shows fear of going home, fear of parents
  • Apprehensive when other children cry
  • Exhibits aggressive, destructive, or disruptive behavior
  • Exhibits passive, withdrawn, or emotionless behavior
  • Reports injury by parents
  • Displays habit disorders
    • Self-injurious behaviors (e.g., cutting)
    • Psychoneurotic reactions (e.g., obsessions, phobias, compulsiveness, hypochondria)
  • Wears long sleeves or other concealing clothing, even in hot weather, to hide physical injuries
  • Seeks affection from any adult

Presence of the following parent/guardian behaviors may also indicate an abusive relationship:

  • Seems unconcerned about the child
  • Takes an unusual amount of time to obtain medical care for the child
  • Offers inadequate or inappropriate explanation for the child’s injury
  • Offers conflicting explanations for the same injury
  • Misuses alcohol or other drugs
  • Disciplines the child too harshly considering the child’s age or what he or she did wrong
  • Sees the child as bad, evil, etc.
  • Has a history of abuse as a child
  • Attempts to conceal the child’s injury
  • Takes the child to a different doctor or hospital for each injury
  • Shows poor impulse control

MUNCHAUSEN SYNDROME BY PROXY (MSbP)

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).

RECOGNIZING PHYSICAL AND EMOTIONAL NEGLECT

Physical Neglect

Indicators of physical neglect include:

  • Consistent hunger
  • Poor hygiene (skin, teeth, ears, etc.)
  • Inappropriate dress for the season
  • Failure to thrive (physically or emotionally)
  • Positive indication of toxic exposure, especially in newborns, such as drug withdrawal symptoms, tremors, etc.
  • Delayed physical development
  • Speech disorders
  • Consistent lack of supervision, especially in dangerous activities or for long periods of time
  • Unattended physical problems or medical or dental needs
  • Chronic truancy
  • Abandonment

Emotional Neglect

A child may demonstrate behavioral indicators of neglect such as:

  • Begging or stealing food
  • Extended stays at school (early arrival or late departure)
  • Constant fatigue, listlessness, or falling asleep in class
  • Alcohol or other substance abuse
  • Delinquency, such as thefts
  • Reports there is no caretaker at home
  • Runaway behavior
  • Habit disorders (sucking, nail biting, rocking, etc.)
  • Conduct disorders (antisocial or destructive behaviors)
  • Neurotic traits (sleep disorders, inhibition of play)
  • Psychoneurotic reactions (hysteria, obsessive-compulsive behaviors, phobias, hypochondria)
  • Extreme behavior (compliant or passive, aggressive or demanding)
  • Overly adaptive behavior (inappropriately adult, inappropriately infantile)
  • Delays in mental and/or emotional development
  • Suicide attempt

A parent or guardian exhibiting the following behavioral indicators may be emotionally maltreating/neglecting the child:

  • Treats children in the family unequally
  • Seems not to care much about the child’s problems
  • Blames or belittles the child
  • Is cold and rejecting
  • Behaves inconsistently toward the child

RECOGNIZING SEXUAL ABUSE

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 Indicators of Sexual Abuse

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:

  • Symptoms of sexually transmitted diseases, including oral infections, especially in preteens
  • Difficulty in walking or sitting
  • Torn, stained, or bloody underwear
  • Pain, itching, bruising, or bleeding in the genital or anal area
  • Bruises to the hard or soft palate
  • Pregnancy, especially in early adolescence
  • Painful discharge of urine and/or repeated urinary infections
  • Foreign bodies in the vagina or rectum

Behavioral Indicators of Sexual Abuse

Children’s behavioral indicators of child sexual abuse include:

  • Unwillingness to change clothes for or participate in physical education activities
  • Withdrawal, fantasy, or regressive behavior, such as returning to bedwetting or thumb-sucking
  • Bizarre, suggestive, or promiscuous sexual behavior or knowledge
  • Reporting sexual assault by their caretaker
  • Prostitution
  • Forcing sexual acts on other children
  • Extreme fear of closeness or physical examination
  • Suicide attempts or other self-injurious behaviors

Sexually abusive parents/guardians may exhibit the following behaviors:

  • Very protective or jealous of child
  • Encourages child to engage in prostitution or sexual acts in presence of the caretaker
  • Misuses alcohol or other drugs
  • Is geographically isolated and/or lacking in social and emotional contacts outside the family
  • Has low self-esteem
    (Prevent Child Abuse New York, 2010)

RECOGNIZING AND RESPONDING TO VICTIMS’ DISCLOSURES

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:

  • Indirect hints. “My brother wouldn’t let me sleep last night.” “My babysitter keeps bothering me.” Appropriate responses would be invitations to say more, such as “Is it something you are happy about?” and open-ended questions such as “Can you tell me more?” or “What do you mean?” Gently encourage the child to be more specific. Let the child use his or her own language and don’t suggest other words to the child.
  • Disguised disclosure. “What would happen if a girl told someone her mother beat her?” “I know someone who is being touched in a bad way.” An appropriate response would be to encourage the child to state what he or she knows about the “other child.” It is probable that the child will eventually divulge who the abused child really is.
  • Disclosure with strings attached. “I have a problem, but if I tell you about it, you have to promise not to tell anyone else.” Most children know that negative consequences can result if they break the silence about abuse. Appropriate responses would include letting the child know you want to help him or her and telling the child, from the beginning, that there are times when you too may need to get some other special people involved.

TALKING WITH SUSPECTED VICTIMS OF CHILD ABUSE
DO DON’T
Source: Research Foundation of SUNY, 2006.
  • Find a private place
  • Remain calm
  • Be honest, open, and up-front with the child
  • Remain supportive
  • Listen to the child
  • Emphasize that the abuse is not the child’s fault
  • Report the situation immediately
  • Overreact
  • Make judgments
  • Make promises
  • Interrogate the child or try to investigate (this is especially important in sexual abuse cases)

CASE

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.

REPORTING CHILD MALTREATMENT / 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.

Who Must Report Abuse?

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.

MANDATED REPORTERS

Persons and officials required to report cases of suspected child abuse or maltreatment are as follows:

  • Physician
  • Registered physician's assistant
  • Surgeon
  • Medical examiner
  • Coroner
  • Dentist
  • Dental hygienist
  • Osteopath
  • Optometrist
  • Chiropractor
  • Podiatrist
  • Resident
  • Intern
  • Psychologist
  • Registered nurse
  • Social worker
  • Emergency medical technician
  • Licensed creative arts therapist
  • Licensed marriage and family therapist
  • Licensed mental health counselor
  • Licensed psychoanalyst
  • Hospital personnel engaged in the admission, examination, care, or treatment of persons
  • Christian Science practitioner
  • School official, which includes but is not limited to school teacher, school guidance counselor, school psychologist, school social worker, school nurse, school administrator, or other school personnel required to hold a teaching or administrative license or certificate
  • Social services worker
  • Director of a children’s overnight camp, summer day camp, or traveling summer day camp
  • Day care center worker
  • School-age child care worker
  • Provider of family or group family day care
  • Employee or volunteer in a residential care facility for children
  • Any other child care or foster care worker
  • Mental health professional
  • Substance abuse counselor
  • Alcoholism counselor
  • All persons credentialed by the Office of Alcoholism and Substance Abuse Services
  • Peace officer
  • Police officer
  • District attorney, assistant district attorney, or investigator employed in the office of a district attorney
  • Other law enforcement official

Source: NYS OCFS, 2011.

What Situations Require That a Report Be Made?

New York State law requires mandated reporters to report suspected child abuse or maltreatment in the following three situations:

  1. When a mandated reporter has reasonable cause to suspect that a child whom the reporter sees in his or her professional or official capacity is abused or maltreated
  2. When a mandated reporter has reasonable cause to suspect that a child is abused or maltreated where the parent or person legally responsible for such child comes before them in his or her professional or official capacity and states from personal knowledge facts, conditions, or circumstances which, if correct, would render the child abused or maltreated
  3.  Whenever a mandated reporter suspects child abuse or maltreatment while acting in his or her professional capacity as a staff member of a medical or other public or private institution, school, facility, or agency, he or she shall immediately notify the person in charge of that school, facility, institution or his or her designated agent, who will then (also) become responsible for reporting or causing a child abuse report to be made to the county Child Protective Services (CPS) agency

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.

CASE

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.

REASONABLE CAUSE

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).

When Must a Report Be Made?

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.

What Is Included in the Report?

At the time of an oral telephone report, the Child Protective Services (CPS) specialist will request the following information:

  • The effect on the child
  • Names and addresses of the child and parents or other person responsible for care
  • Location of the child at the time of the report
  • Child’s age, gender, and race
  • Nature and extent of the child’s injuries, abuse, or maltreatment, including any evidence of prior injuries, abuse, or maltreatment to the child or its siblings
  • Name of the person or persons suspected to be responsible for causing the injury, abuse, or maltreatment (“subject of the report”)
  • Family composition
  • Any special needs or medications
  • Whether an interpreter is needed
  • Source of the report
  • Person making the report and where reachable
  • Actions taken by the reporting source, including taking of photographs or x-rays, removal or keeping of the child, or notifying the medical examiner or coroner
  • Any personal issues for CPS workers (e.g., weapons, dogs)
  • Any additional information that may be helpful

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.

SUBJECT OF THE REPORT

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.

What Happens Once a Report Is Made?

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.

What Follow Up Can Be Made by the Reporter?

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.

What Are the Reporting Implications of HIPAA?

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.

GATHERING FORENSIC EVIDENCE

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.

Obtaining Consent

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).

Photographing Evidence

The goal for photographing evidence is to accurately document the findings that serve as a basis for one’s opinion.

  • Record the patient’s identification number, date of birth, and date the photos were taken. The first photo should include this identification number for the patient rather than using the patient’s name.
  • Use a rule of measure and a color scale.
  • At least four images of each finding should be photographed. These include an overview photograph from a distance, a midrange photo that contains anatomical landmarks, and at least two close-up shots.
  • The close-up shots must be done with and without a scale.
  • Always photograph the findings before altering the state in which they are found, unless it is medically necessary to do so. For example, photograph a wound before it is cleaned.
  • When using a digital camera, a blank memory card should be used for a single case.
    (Riviello, 2010)

PLACING A CHILD IN PROTECTIVE CUSTODY

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):

  1. If the child is in such circumstances or condition that continuing to stay in his or her residence or in the care and custody of the parent or other legally authorized caretaker presents an imminent danger to the child’s life or health, and
  2. If there is not enough time to apply to the family court for an order of temporary removal

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:

  • A peace officer (acting pursuant to his or her special duties)
  • A police officer
  • A law enforcement official
  • An agent of a duly incorporated society for the prevention of cruelty to children
  • A designated employee of a city or county Department of Social Services
  • A person in charge of a hospital or similar institution

When a child is placed in protective custody, the authorized person must take the following actions:

  • He or she must bring the child immediately to a place designated by the rules of the family court for this purpose, unless the person is a physician treating the child and the child is or soon will be admitted to a hospital.
  • He or she must make every reasonable effort to inform the parent or other person legally responsible for the child’s care about which facility the child is in.
  • He or she must provide the parent or other person legally responsible for the child’s care with written notice, coincident with removal of the child from their care (Family Court Act 1024(b)(iii)).
  • He or she must inform the court and make a report of suspected child abuse or maltreatment pursuant to Title 6 of the Social Services Law, as soon as possible (FCA, Section 1024(b)).
  • He or she must immediately notify the appropriate local Child Protective Service, which shall begin a child protective proceeding in the Family Court at the next regular weekday session of the appropriate Family Court or recommend that the child be returned to his or her parents or guardian. In neglect cases, pursuant to Section 1026 of the Family Court Act, the authorized person or entity (usually CPS) may return a child prior to a child protective proceeding if it concludes there is no imminent risk to the child’s health.

LEGAL ISSUES FOR REPORTERS

Consequences for Failing to Report

Any person, official, or institution required to report a case of suspected child abuse or maltreatment that willfully fails to do so:

  • Can be charged with a Class A misdemeanor and subject to criminal penalties
  • Can be sued in a civil court for monetary damages for any harm caused by such failure to report to the SCR

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).

Immunity from Legal Liability

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).

Confidentiality

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).

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RESOURCES

New York State

Healthy Families New York
518-474-3166

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 Council on Children and Families
http://www.ccf.state.ny.us

New York State Domestic Violence Hotline
800-942-6906 (English)
800-942-6908 (Spanish)

New York State Education Department
http://usny.nysed.gov/parents/genres.html

New York State Office of Children and Family Services
http://www.ocfs.state.ny.us

New York State Office for the Prevention of Domestic Violence
http://www.opdv.state.ny.us

Prevent Child Abuse New York
http://www.preventchildabuseny.org

National

Abandoned Infant Protection Act (AIPA) Information Hotline
866-505-SAFE (7233)

American Professional Society on the Abuse of Children
http://www.apsac.org

Child Care, Foster Care, and Adoption Information
800-345-KIDS (5437)

Child Welfare Information Gateway
http://www.childwelfare.gov

Child Welfare League of America
http://www.cwla.org

Children’s Defense Fund
http://www.childrensdefense.org

National Center for Missing and Exploited Children
http://www.missingkids.com
800-THE-LOST (800-843-5678)

National Clearinghouse on Child Abuse and Neglect Information
http://www.calib.com/nccanch

National Clearinghouse on Families and Youth
http://www.ncfy.com

National Runaway Switchboard
800-786-2929

Safe Horizon
http://www.safehorizon.org

Youth Crisis and Runaway Hotline
800-448-4663

REFERENCES

Botash AS. Photographic documentation. (2009). CHAMP practice recommendations.Retrieved June 2012 from https://www.champprogram.com/pdf/photographic-documentation-jan-2009.pdf.

Brannon G. (2011). Munchausen syndrome by proxy clinical presentation. Retrieved June 2012 from http://emedicine.medscape.com/article/295258-clinical#a0216.

California Attorney General’s Office, Crime and Violence Prevention Center. (2008). First impressions: exposure to violence and a child’s developing brain. Retrieved June 2012 from http://www.safefromthestart.org.

Carey C. (2011). Memorandum from NYCLU regarding minor consent to forensic evidence collection in the course of post-sexual assault care, October 19. Retrieved June 2012 from https://www.champprogram.com/pdf/Memo-on-Minor-Consent-to-Evidence-Collection-oct-19-2011.pdf.

Center for the Development of Human Services (CDHS). (2011). NYS laws regarding child abuse and maltreatment. Retrieved June 2012 from http://www.nysmandatedreporter.org/laws.html.

Centers for Disease Control and Prevention (CDC). (2012). Child maltreatment prevention. Retrieved July 2012 from http://www.cdc.gov/ViolencePrevention/childmaltreatment/.

Centers for Disease Control and Prevention (CDC). (2010a). Understanding child maltreatment fact sheet 2010. Retrieved June 2012 from http://www.cdc.gov/ViolencePrevention/pdf/CM-FactSheet-a.pdf.

Centers for Disease Control and Prevention (CDC). (2010b). Child maltreatment: facts at a glance. Retrieved July 2012 from http://www.cdc.gov/violenceprevention/pdf/CM-DataSheet-a.pdf

Centers for Disease Control and Prevention (CDC). (2009). Adverse Childhood Experience (ACE) Study. Retrieved June 2012 from http://www.cdc.gov/ace/.

Children’s Rights. (2012). Facts about foster care. Retrieved July 2012 from http://www.childrensrights.org/issues-resources/foster-care/facts-about-foster-care/.

Fingarson A & Pierce M. (2012). Identifying abusive head trauma. Contemporary Pediatrics, February 2012. Retrieved June 2012 from http://www.modernmedicine.com/modernmedicine/article/articleDetail.jsp?id=762577&sk=&.

Fingarson A, Flaherty E, & Sege R. (2011). Improving physician identification and reporting of child abuse case study and commentary. Journal of Clinical Outcomes Management, 18(4), 53–60. Retrieved June 2012 from http://jcom.imirus.com/Mpowered/book/vjcom11/i7/p55.

Flaherty E & Stirling J. (2010). Pediatrician’s role in child maltreatment prevention. Pediatrics, 136(4), 833–841. doi: 10.1542/peds.2010-2087.

Guttmacher Institute. (2012). State policies in brief: an overview of minors’ consent law. Retrieved June 2012 from http://www.guttmacher.org/statecenter/spibs/spib_OMCL.pdf.

Kleinman P. (2009). Diagnostic imaging of child abuse. Pediatrics, 123, 1430–1435. doi: 10.1542/peds.2009-0558.

Lazoritz S, Rossiter K, & Whiteaker D. (2010). What every nurse needs to know about the clinical aspects of child abuse. American Nurse Today, 5(7). Retrieved June 2012 fromhttp://www.americannursetoday.com/article.aspx?id=6902&fid=6846.

National Abandoned Infants Association Resource Center. (2005). Boarder babies, abandoned infants, and discarded infants. Retrieved June 2012 from http://aia.berkeley.edu/media/pdf/abandoned_infant_fact_sheet_2005.pdf.

National Coalition for Child Protection Reform. (2011). Foster care vs. family preservation: the track record on safety and well-being. Retrieved July 2012 from http://www.nccpr.org/reports/01SAFETY.pdf.

New York State Office of Children and Family Services (NYS OCFS). (2012). Child Protective Services. Retrieved June 2012 from http://www.ocfs.state.ny.us/main/cps/.

New York State Office of Children and Family Services (NYS OCFS). (2011). Publication 1159: Summary Guide for Mandated Reporters in New York State. Retrieved June 2012 from http://www.ocfs.state.ny.us/main/publications/pub1159text.asp.

New York State Office of Children and Family Services (NYS OCFS). (2010). Publication 1154: Protecting children against sexual abuse. Retrieved June 2012 from http://www.ocfs.state.ny.us/main/publications/pub1154text.asp.

New York State Office of Children and Family Services (NYS OCFS). (2006). New York State mandated reporter participant guide. Retrieved June 2012 from http://www.ocfs.state.ny.us/ohrd/handouts/539.pdf.

New York Society for the Prevention of Cruelty to Children (NYSPCC). (2006). Professional’s handbook: preventing and reporting child abuse and neglect. Retrieved June 2012 from http://www.nyspcc.org/nyspcc/exam/course_materials/nyspcc_handbook.pdf.

Oberman M. (2008). Comment: infant abandonment in Texas. Child Maltreatment, 13(1), 94–95. doi: 10.1177/1077559507310044.

Otto-Rosario J.(2011). Consequences and treatment of child sexual abuse. ESSAI, 9, article 31.Retrieved June 2012 from http://dc.cod.edu/essai/vol9/iss1/.

Perry B. (2009). Examining child maltreatment through a neurodevelopmental lens: clinical applications of the neurosequential model of therapeutics. Journal of Loss and Trauma, 14, 240–255. doi: 10.1080/15325020903004350.

Pierce M, Kaczor K, Aldridge S, O’Flynn J, & Lorenz D. (2010). Bruising characteristics discriminating physical child abuse from accidental trauma. Pediatrics, 125(1), 67–74. doi: 10.1542/peds.2008-3632.

Prevent Child Abuse New York. (2010). Factsheet: child sexual abuse. Retrieved June 2012 from http://www.preventchildabuseny.org/index.php/resources/about-child-abuse/facts-and-statistics/.

Research Foundation of SUNY/Center for Development of Human Services. (2006). Mandated reporter training: identifying and reporting child abuse and maltreatment/neglect. Buffalo, NY: author. Retrieved June 2012 from http://www.ocfs.state.ny.us/ohrd/materials/58451.pdf.

Riviello R. (2010). Manual of forensic emergency medicine: a guide for clinicians. Sudbury, MA: Jones and Bartlett, LLC.

Stirling J. (2007). Beyond Munchausen syndrome by proxy: identification and treatment of child abuse in a medical setting. Pediatrics, 119(5), 1026–1030. doi: 10.1542/peds.2007-0563.

U.S. Department of Health and Human Services (USDHHS), Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. (2011). Child maltreatment 2010. Retrieved June 2012 from http://www.acf.hhs.gov/programs/cb/pubs/cm10/.

Weiss S. (2008). Forensic photography for SANE and SART practitioners. Evidence Technology Magazine, 6(4). Retrieved June 2012 from http://www.evidencemagazine.com/index.php?option=com_content&task=view&id=69&Itemid.

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