|Use these tools to enrich your learning experience!|
|View the Evidence-Based Practice Recommendations to determine the validity or relevance of the information.|
Assess your retention of the subject matter with these
See your score at the end. This self-assessment is optional.
|Use this objective-based question and answer exercise to enhance your course knowledge.|
|Download this course as a PDF to avoid shipping charges and mail time. Print or save at any time!|
|Download this course for your eReader to access the content immediately, anywhere!|
According to the U.S. Department of Health and Human Services, the rate of child abuse and neglect was 9.3 per 1000 children in 2009. In 2009, the rate of child abuse and neglect in New York State was 17.5 per 1000 children, higher than the national rate. Healthcare professionals, regardless of their discipline or field, are in a unique position to assist in the identification, education, and prevention of child abuse and neglect. This course describes how victims of abuse can be accurately identified and provides the community resources available in the state of New York for child abuse victims. Mandated reporter laws will also be outlined.
Education Category Ethics - Human Rights
Release Date 10/01/2011
Expiration Date 09/30/2014
This course is designed for all New York physicians, physician assistants, nurses, social workers, and counselors required to complete child abuse education.
CME Resource is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. CME Resource is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. CME Resource is an NBCC-Approved Continuing Education Provider (ACEP™) and may offer NBCC-approved clock hours for programs that meet NBCC requirements. Programs for which NBCC-approved clock hours will be awarded are identified on the course material and website. CME Resource is solely responsible for all aspects of the program. Provider number 6361. CME Resource, #1092, is approved as a provider for social work continuing education by the Association of Social Work Boards (ASWB) www.aswb.org through the Approved Continuing Education (ACE) Program. CME Resource maintains responsibility for the program. ASWB Approval Period: 03/13/2013 to 03/13/2016. Social workers should contact their regulatory board to determine course approval for continuing education credits. This program is approved by the National Association of Social Workers (Approval #886531582-1526) for Mandated Reporting continuing education contact hours. CME Resource has been accredited as an Authorized Provider by the International Association for Continuing Education and Training (IACET), 1760 Old Meadow Road, Suite 500, McLean, VA 22102. In obtaining this approval, CME Resource has demonstrated that it complies with the ANSI/IACET Standard which is widely recognized as the Standard of good practice internationally. As a result of their Authorized Provider accreditation status, CME Resource is authorized to offer IACET CEUs for its programs that qualify under the ANSI/IACET 1-2013 Standard. CME Resource is approved as a provider of online continuing education for certified nursing assistants through the California Department of Public Health Licensing and Certification Division. Nurse Aide Certification (NAC) Provider #7005.
CME Resource designates this enduring material for a maximum of 2 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. CME Resource designates this continuing education activity for 2 ANCC contact hour(s). CME Resource designates this continuing education activity for 2.4 hours for Alabama nurses. CME Resource designates this continuing education activity for 1 NBCC clock hour(s). Social workers participating in this intermediate to advanced course will receive 2 Clinical continuing education clock hours, in accordance with the Association of Social Work Boards. This program is approved by the National Association of Social Workers for 2 Mandated Reporting continuing education contact hours. AACN Synergy CERP Category B. CME Resource is authorized by IACET to offer 0.2 CEU(s) for this program.
In addition to states that accept ANCC, CME Resource is approved as a provider of continuing education in nursing by: Alabama, Provider #ABNP0353, (valid through December 12, 2017); California, BRN Provider #CEP9784; California, LVN Provider #V10662; California, PT Provider #V10671; Florida, Provider #50-2405; Iowa, Provider #295; Kentucky, Provider #7-0054 through 12/31/2017.
In addition to states that accept ASWB, CME Resource is approved as a provider of continuing education by the following state boards: Alabama State Board of Social Work Examiners, Provider #0515; California Board of Behavioral Sciences, Provider #PCE 1632; Florida Board of Clinical Social Work, Marriage and Family Therapy and Mental Health Counseling, CE Broker Provider #50-2405; Illinois Division of Professional Regulation for Social Workers, License #159.001094; Illinois Division of Professional Regulation for Licensed Professional and Clinical Counselors, License #197.000185; Illinois Division of Professional Regulation for Marriage and Family Therapists, License #168.000190; Texas State Board of Social Worker Examiners, Approval #3011; Texas State Board of Examiners of Professional Counselors, Approval #1121; Texas State Board of Examiners of Marriage and Family Therapists, Approval #425.
This course is approved by the New York State Education Department to fulfill the requirement for 2 hours of training in the Identification and Reporting of Child Abuse and Maltreatment. Provider #80673. This activity is designed to comply with the requirements of California Assembly Bill 1195, Cultural and Linguistic Competency.
The purpose of this course is to enable healthcare professionals in all practice settings to define child abuse and identify the children who are affected by violence. This course describes how a victim can be accurately diagnosed and identifies the community resources available in the state of New York for child abuse victims.
Upon completion of this course, you should be able to:
Alice Yick Flanagan, PhD, MSW, received her Master’s in Social Work from Columbia University, School of Social Work. She has clinical experience in mental health in correctional settings, psychiatric hospitals, and community health centers. In 1997, she received her PhD from UCLA, School of Public Policy and Social Research. Dr. Yick Flanagan completed a year-long post-doctoral fellowship at Hunter College, School of Social Work in 1999. In that year she taught the course Research Methods and Violence Against Women to Masters degree students, as well as conducting qualitative research studies on death and dying in Chinese American families.
Currently, Dr. Yick Flanagan is a faculty member at Capella University, School of Human Services and Canyon College, Department of Social Work. Her research focus is on the area of racism and mental health consequences in ethnic minority communities. She and her fellow colleagues are currently administering a survey on Asian Americans, Hispanics, and African Americans’ experiences with racism and discrimination.
Contributing faculty, Alice Yick Flanagan, PhD, MSW, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.
The division planners have disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.
The purpose of CME Resource is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.
Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.
It is the policy of CME Resource not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.
Table of Contents
Supported browsers for Windows include Microsoft Internet Explorer 7.0 and up, Mozilla Firefox 3.0 and up, Opera 9.0 and up, and Google Chrome. Supported browsers for Macintosh include Safari, Mozilla Firefox 3.0 and up, Opera 9.0 and up, and Google Chrome. Other operating systems and browsers that include complete implementations of ECMAScript edition 3 and CSS 2.0 may work, but are not supported.
There is an established system in the U.S. to respond to reports of child abuse and neglect; however, this has not always been the case. This is not because child abuse, neglect, and maltreatment are new social phenomena. Rather, the terms "child abuse," "child neglect," and "child maltreatment" are relatively new, despite the fact that this social problem has existed for thousands of years . Cruelty to children by adults has been documented throughout history and across cultures. In China, infant girls were often neglected during times of famine or sold during times of extreme poverty. There is also historical evidence that cultures have taken steps to stop child abuse and cruelty. For example, 6000 years ago in Mesopotamia, orphans had their own patron goddesses for help and protection .
In many cases, the physical abuse of children has been linked to physical punishment. Throughout history, physical child abuse was justified because it was believed that severe physical punishment was necessary either to discipline, rid the child of evil, or educate . It was not until 1861 that there was a public outcry in the U.S. against extreme corporal punishment. This reform was instigated by Samuel Halliday, who reported the occurrence of many child beatings by parents in New York City .
Sexual abuse of children, particularly incest (defined as sex between family members), is very much a taboo. The first concerted efforts to protect children from sexual abuse occurred in England during the 16th century. During this period, boys were protected from forced sodomy and girls younger than 10 years of age from forcible rape . However, in the 1920s, sexual abuse of children was described solely as an assault committed by "strangers," and the victim of such abuse was perceived as a "temptress" rather than as an innocent child .
The first public case of child abuse in the U.S. that garnered widespread interest took place in 1866 in New York City. Mary Ellen Wilson was an illegitimate child, 10 years of age, who lived with her foster parents . Neighbors were concerned that she was being mistreated; however, her foster parents refused to change their behaviors and said that they could treat the child as they wished . Because there were no agencies established to protect children specifically, Henry Berge, founder of the Society for the Prevention of Cruelty to Animals, intervened on Mary's behalf . He argued that she was a member of the animal kingdom and deserved protection. The case received much publicity, and as a result, in 1874 the New York Society for the Prevention of Cruelty to Children was formed . Because of this case, every state now has a child protective services (CPS) system in place.
The topic of child abuse and neglect received renewed interest in the 1960s, when a famous study titled "The Battered-Child Syndrome" was published [1,4]. In the study, it was stated that the battered-child syndrome consisted of traumatic injuries to the head and long bones, most commonly to children younger than 3 years of age, by parents [1,4]. The study was viewed as the seminal work on child abuse, alerting both the general public and the academic community to the problems of child abuse [1,2].
Child abuse and neglect are considered significant social problems with deleterious consequences. As noted, a system has been implemented in all 50 states to ensure the safety of children, with laws defining what constitutes abuse and neglect and who is mandated to report.
The federal definition of child abuse is evident in the Child Abuse Prevention and Treatment Act (CAPTA), published as a product of federal legislation. CAPTA defines a child to be any individual younger than 18 years of age, except in cases of sexual abuse. In cases of sexual abuse, the age specified by the child protection laws varies depending on the state in which the child resides . CAPTA defines child abuse as, "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 state of New York defines child abuse and neglect as follows :
"The term abuse encompasses the most serious harms committed against children. An 'abused child' is a child whose parent or other person legally responsible for his/her care inflicts upon the child serious physical injury, creates a substantial risk of serious physical injury, or commits a sex offense against the child. Not only can a person be abusive to a child if they perpetrate any of these actions against a child in their case, they can be guilty of abusing a child if they allow someone else to do these things to that child."
There are several acts that may be considered abusive, and knowledge of what constitutes abuse is vital for healthcare providers and other mandated reporters. In this section, specific behaviors that fall under the category of abuse and neglect will be reviewed.
Physical abuse injuries can range from minor bruises and lacerations to severe neurological trauma and death. Physical abuse is one of the most easily identifiable forms of abuse and the type most commonly seen by healthcare professionals. Physical injuries that may be indicative of abuse include bruises/welts, burns, fractures, abdominal injuries, lacerations/abrasions, and central nervous system trauma .
Bruises and welts are of concern, particularly those that appear on:
The face, lips, mouth, ears, eyes, neck, or head
The trunk, back, buttocks, thighs, or extremities
Multiple body surfaces
Patterns such as the shape of the article (e.g., a cord, belt buckle, teeth, hand) used to inflict the bruise or welt should be noted. Cigar or cigarette burns are common, and they will often appear on the child's soles, palms, back, or buttocks. Patterned burns that resemble shapes of appliances, such as irons, burners, or grills, are of particular concern.
Fractures that result from abuse might be found on the child's skull, ribs, nose, or any facial structure. These may be multiple or spiral fractures at various stages of healing. When examining patients, note bruises on the abdominal wall, any intestinal perforation, ruptured liver or spleen, and blood vessel, kidney, bladder, or pancreatic injury, especially if accounts for the cause do not make sense. Look for signs of abrasions on the child's wrists, ankles, neck, or torso. Lacerations might also appear on the child's lips, ears, eyes, mouth, or genitalia. If violent shaking or trauma occurred, the child might experience a subdural hematoma .
Sexual abuse is defined by CAPTA as :
"the employment, use, persuasion, inducement, enticement, or coercion of any child to engage in, or assist any other person to engage in, any sexually explicit conduct or simulation of such conduct for the purpose of producing a visual depiction of such conduct; or the rape, and in cases of caretaker or interfamilial relationships, statutory rape, molestation, prostitution, or other form of sexual exploitation of children, or incest with children."
Verbal: Obscene phone calls or talking about sexual acts for the purpose of sexually arousing the adult perpetrator
Voyeurism: Watching a child get dressed or encouraging the child to masturbate while the perpetrator watches
Child prostitution: Involving the child in sexual acts for monetary profit
Child pornography: Taking photos of a child in sexually explicit poses or acts
Exhibitionism: Exposing his/her genitals to the child or forcing the child to observe the adult or other children in sexual acts
Molestation: Touching, fondling, or kissing the child in a provocative manner; for example, fondling the child's genital area or long, lingering kisses
Sexual penetration: The penetration of part of the perpetrator's body (e.g., finger, penis, tongue) into the child's body (e.g., mouth, vagina, anus)
Rape: Usually involves sexual intercourse without the victim's consent and usually involves violence or the threat of violence
Failure to provide adequate food, clothing, shelter, hygiene, supervision, and protection
Refusal and/or delay in medical attention and care (e.g., failure to provide needed medical attention as recommended by a healthcare professional or failure to seek timely and appropriate medical care for a health problem)
Abandonment, characterized by desertion of a child without arranging adequate care and supervision. Children who are not claimed within two days or who are left alone with no supervision and without any information about their parents'/caretakers' whereabouts are examples of abandonment.
Expulsion or blatant refusals of custody on the part of parent/caretaker, such as ordering a child to leave the home without adequate arrangement of care by others
Inadequate supervision (i.e., child is left unsupervised or inadequately supervised for extended periods of time)
Verbal abuse: Belittling or making pejorative statements in front of the child, which results in a loss or negative impact on the child's self-esteem or self-worth
Inadequate nurturance/affection: Inattention to the child's needs for affection and emotional support
Witnessing domestic violence: Chronic spousal abuse in homes where the child witnesses the violence
Substance and/or alcohol abuse: The parent/caretaker is aware of the child's substance misuse problem but chooses not to intervene or allows the behavior to continue
Refusal or delay of psychological care: Failure or delay in obtaining services for the child's emotional, mental, or behavioral impairments
Permitted chronic truancy: The child averages at least 5 days a month of school absence and the parent/guardian does not intervene
Failure to enroll: Failure to enroll or register a child of mandatory school age or causing the child to remain at home for nonlegitimate reasons
Failure to access special education services: Refusal or failure to obtain recommended services or treatment for remedial or special education for a child's diagnosed learning disorder
According to the U.S. Department of Health and Human Services, the rate of child abuse and neglect was 9.3 per 1000 children in 2009. Neglect represented the most frequent type of abuse, occurring in 78.3% of victims; physical abuse occurred in 17.8% of victims .
Children of color are over-represented in the CPS system . Approximately 28.8% of victims are African American and 24.6% are Hispanic. African American, American Indian, and Alaska Native children have the highest rates of victimization at 15.1, 11.6, and 12.4 victims respectively per 1000 children. Studies have found that children of color are more likely than white children to be reported victims of child abuse and neglect . In addition, child mistreatment reports involving children of color are more likely to be substantiated than those cases involving white children .
Child abuse is found to occur at generally equal rates among girls and boys. It is reported that 48.2% of child abuse and neglect victims are male, and 51.1% are female . The majority (37.7%) of abuse and neglect cases are perpetrated solely by the mother, whereas 18.6% are perpetrated by the father alone. In 18% of the cases both parents are perpetrators . In approximately 19.3% of cases a person other than a parent is the perpetrator of child abuse .
In 2009, the rate of child abuse and neglect in New York State was 17.5 per 1000 children, which is higher than the national rate . This translates to approximately 77,620 cases of child abuse and 83,017 cases of child neglect in New York annually. The majority of the cases included instances of neglect; 11.4% included cases of physical abuse . In 2009, 109 children in New York died as a result of child abuse and neglect .
It is crucial that practitioners become familiar with the indications of child abuse and neglect. These factors do not necessarily conclusively indicate the presence of abuse or neglect; rather, they are clues that require further interpretation and clinical investigation . Some parental risk indicators include [8,10,12,15,16]:
Recounting of events that do not conform either with the physical findings or the child's physical and/or developmental capabilities
Inappropriate delay in bringing the child to a health facility
Unwillingness to provide information or the information provided is vague
History of family violence in the home
Parental misuse of substances and/or alcohol
Minimal knowledge or concern about the child's development and care
Environmental stressors, such as poverty, single parenthood, unemployment, or chronic illness in the family
Early adolescent parent
Expression that the parent(s) wanted a baby in order to feel loved
Unrealistic expectations of the child
Use of excessive physical punishment
Healthcare service "shopping"
History of parent "losing control" or "hitting too hard"
Multiple school absences
Learning or developmental disabilities
History of multiple, unexplained illnesses, hospitalizations, or accidents
Poor general appearance (e.g., fearful, poor hygiene, malnourished appearance, inappropriate clothing for weather conditions)
Stress-related symptoms, such as headaches or stomachaches
Mental illness or symptoms, such as psychosis, depression, anxiety, eating disorders, or panic attacks
Regression to wetting and soiling
Sexually explicit play
Excessive or out-of-the-ordinary clinging behavior
Difficulties with concentration
Disruptions in sleep patterns and/or nightmares
Some of the types of behaviors and symptoms discussed in the definitions of physical, sexual, and emotional abuse/neglect are also warning signs. For example, any of the injuries that may result from physical abuse, such as a child presenting with bruises in the shape of electric cords or belt buckles, should be considered risk factors for abuse.
The consequences of child abuse and neglect vary from child to child; these differences continue as victims grow older. Several factors will mediate the outcomes. These factors include :
Severity, intensity, frequency, duration, and nature of the abuse and/or neglect
Age or developmental stage of the child when the abuse occurred
Relationship between the victim and the perpetrator
Support from family members and friends
Level of acknowledgment of the abuse by the perpetrator
Quality of family functioning
In examining some of the effects of physical abuse, it is helpful to frame the consequences along a lifespan perspective . During infancy, physical abuse can cause neurological impairments. Most cases of infant head trauma are the result of child abuse . Neurological damage may also affect future cognitive, behavioral, and developmental outcomes. Some studies have noted that, in early childhood, physically abused children show less secure attachments to their caretakers compared to their nonabused counterparts .
By middle to late childhood, the consequences are more notable. Studies have shown significant intellectual and linguistic deficits in physically abused children . Other environmental conditions, such as poverty, may also compound this effect. In addition, a number of affective and behavioral problems have been reported among child abuse victims, including anxiety, depression, low self-esteem, excessive aggressive behaviors, conduct disorders, delinquency, hyperactivity, and social detachment [8,10,12,18,20].
Surprisingly, there has been little research on the effects of childhood physical abuse on adolescents . However, differences have been noted in parents who abuse their children during adolescence rather than preadolescence. It appears that lower socioeconomic status plays a lesser role in adolescent abuse as compared to abuse during preadolescence . In addition, parents who abuse their children during adolescence are less likely to have been abused as children themselves compared to those parents who abused their children during preadolescence . It is believed that the psychosocial effects of physical abuse manifest similarly in late childhood and adolescence.
Research findings regarding the effects of childhood physical abuse on adult survivors have been less consistent. Some adult survivors function well socially and in terms of mental and physical health, while others exhibit depression, anxiety, post-traumatic stress, substance abuse, criminal behavior, violent behavior, and poor interpersonal relationships [17,18].
Although not all adult survivors of sexual abuse experience long-term psychological consequences, it is estimated that 20% to 50% of all adult survivors have identifiable adverse mental health outcomes [22,23]. Possible psychological outcomes include [10,24,25]:
Affective symptoms: Numbing, post-traumatic stress disorder, anxiety, depression, obsessions and compulsions, somatization
Interpersonal problems: Difficulties trusting others, social isolation, feelings of inadequacy, sexual difficulties (e.g., difficulties experiencing arousal and orgasm), avoidance of sex
Distorted self-perceptions: Poor self-esteem, self-loathing, self-criticism, guilt, shame
Behavioral problems: Risk of suicide, substance abuse, self-mutilation, violence
Increased risk-taking behaviors: Abuse of substances, cigarette smoking, sexual risk-taking
In the state of New York, certain professionals are legally required or mandated to report any suspected cases of child abuse, maltreatment, and/or neglect that they encounter in their professional roles to the New York Statewide Central Register (SCR) of Child Abuse and Maltreatment. Reasonable cause for suspicion is based upon behaviors that have been observed or reported that cause the professional to believe that a specific circumstance might involve child abuse or neglect . Child abuse laws in New York, and in all states, do not require reporters to have absolute proof of abuse . Reporting suspected cases should be done in good faith, and mandatory reporting laws give the reporter immunity from criminal and civil liability regardless of the substantiation of abuse [16,28]. However, if mandated reporters fail to report an incident of suspected child abuse or maltreatment, they may be charged with a Class A misdemeanor, subject to criminal penalties, and can be sued for monetary damages for any harm in a civil court .
The following individuals are classified as mandated reporters in the state of New York :
Registered physician's assistants
Emergency medical technicians
Licensed creative arts therapists
Licensed marriage and family therapists
Licensed mental health counselors
Hospital personnel engaged in the admission, examination, care, or treatment of persons
Christian Science practitioners
Social services workers
Day care center workers
Providers of family or group family day care
Any employees or volunteers in a residential care facility for children
Any other childcare or foster care workers
Mental health professionals
Substance abuse counselors
District attorneys or assistant district attorneys
Investigators employed in the Office of the District Attorney
Any other law enforcement officials
When mandated reporters suspect a case of child abuse or maltreatment, they must report to the SCR at 1-800-635-1522. The SCR is open 24 hours a day, 7 days a week . The mandated reporter is not obliged to contact the parents or the legal guardians of the child either before or after the call to SCR . Good practice dictates that the reporter either seek consent or notify the parent(s) that essential information is being (and is required to be) shared, unless doing so would put the child's health or safety at risk. However, even if the parent does not consent, the mandated reporter is still obligated to contact the SCR . (Additional child abuse hotline information may be found in theResourcessection of this course.)
Within 48 hours of reporting the suspected abuse to SCR, the reporter must also complete and sign a written report (LDSS-2221A) and submit the report to the local department of social services (LDSS) that has been assigned to the investigation .
The CPS unit of the LDSS is required to begin an investigation of the reported abuse within 24 hours . A CPS specialist will ask questions about the suspected abuse and the child. For example, the specialist will ask for the child's name, age, and home address, the name of the suspected person who inflicted the abuse, his or her address, and the nature of the abuse. The specialist should also evaluate the safety of the child named in the report as well as that of any other children in the home. If the child's safety is at risk, the specialist may take the child and other children in the home into protective custody to prevent further abuse or maltreatment. CPS has 60 days after receiving the report to determine whether it is "indicated" or "unfounded." CPS is obligated to inform the child's parents or other subject of the report of their rights, according to the New York State Social Services Law, and must inform the SCR of the determination of the investigation .
Professionals may not feel skilled in their knowledge base about child abuse and neglect. In addition, they lack the confidence to identify sexual and emotional abuse.
Professionals may be frustrated with how little they can do about poverty, unemployment, drug use, and the intergenerational nature of abuse.
Although professionals understand their legal obligation, they may still feel that they are violating patient confidentiality.
Many professionals are skeptical about the effectiveness of reporting child abuse cases given the bureaucracy of CPS and the large caseloads.
Practitioners may be concerned that they do not have adequate or sufficient evidence of child abuse.
Practitioners may have a belief that government entities do not have the right to get involved in matters within the family arena.
There may be some confusion and emotional distress in the reporting process.
The failure to identify and report child abuse may result in continued abuse of the child and potentially severe consequences. Improved and ongoing education about child abuse and maltreatment has been shown to improve identification and reporting rates among physicians and other professionals. The education should include :
Management and outcomes
The role of the CPS investigator
The role of the physician/other reporting professional
The benefits of CPS involvement
The benefits of mandated education on identification/reporting
The benefits of professional debriefing for the reporter
The benefits of collaboration (e.g., with local emergency departments, pediatric specialists)
Other suggestions for improving reporting include :
Improving the relationship between CPS and medical providers
Allowing certain registered professionals with demonstrated expertise in identifying/treating child abuse "flexible reporting options" (e.g., defer reporting when no immediate threat exists or make the report confidentially and defer an investigation until deemed necessary)
Improving interaction with the legal system
Assessment for child abuse and neglect involves the systematic collection of data. Information should be obtained regarding the primary reason for the visit, family health history, the child's health history, history of illnesses, the parents' attitudes toward discipline, and the child's pattern of nutrition, sleep, and diet [15,16]. If abuse is a concern after the preliminary evaluation, consultation with a child abuse specialist, pediatric specialist, or pediatrician experienced in this area, if available, may be helpful in determining the best way to proceed with assessment .
It is important for professionals to ask questions in a nonjudgmental manner . An environment where support and concern facilitate an open, trusting relationship between the parent and the practitioner should be created. By providing such an environment, the parent has the opportunity to voice concerns and ask for help . Questions that convey concern and may provide valuable information to the professional include, "Who helps you care for your children?" or "How do you discipline your children?" . It may be necessary to interview the child and parent separately; however, by spending some time with the child and parent together, practitioners can observe interactions and communication.
Accuracy in record taking is also important. Be sure to record the date and time of the visit, the sources of any information, and the date, time, and place of the alleged abuse or assault [16,34]. When talking to the child, the practitioner should use developmentally appropriate language that will be easily understood. Leading questions should be avoided . Asking the following questions may be helpful when interacting with children [34,35]:
"Do you know why you are here today?"
"Can you tell me what happened?"
"How did it begin?"
"What happened next?"
"Where did this happen?"
"Have you been hurt lately?"
It is important to note the child's demeanor during questioning. Some children may be protective of their abuser, openly fearful of their abuser, or may fear retribution for "telling." Strong nonverbal cues of anxiety and reluctance to answer questions about potential abuse are important considerations when a safety plan for the child is necessary [16,33].
Because studies have demonstrated a correlation between child abuse and domestic violence, there is a need for dual screening for both types of family violence [16,36]. It is estimated that in 45% to 50% of cases in which there is domestic violence, child abuse is also present . Consequently, when a woman presents with a child whom the professional suspects to be at risk for child abuse, the professional should ask the woman if she has ever been hurt or injured by her spouse/intimate partner. Professionals should minimize the discomfort associated with the questioning by first discussing the prevalence of domestic violence in intimate relationships and by stating that such questioning is commonly done [38,39].
In cases of child sexual abuse, the child should be interviewed alone. The professional should try to keep a neutral tone of voice and manner. Open-ended, nonleading questions should be used. For example, the practitioner may ask: "Has anyone ever touched you in a way that you did not like or that made you feel uncomfortable?" . Because the interview may be admissible in court, careful documentation of the questions and responses is important; the exchange should be documented verbatim [16,40].
The child's primary disability
Accompanying disabilities, if any
How the disability affects the child's current functioning
Whether the child is highly distractible
What the appropriate method of communication will be (e.g., sign language, language board, facilitative communication) if communication is an issue
What, if any, behavioral challenges (e.g., compulsive, withdrawal) the child has
Overall, when conducting an interview of a child with a disability or special need, the practitioner should work with someone to validate impressions or feelings about the child, develop and use a multidisciplinary resource team, be aware of the child's vulnerabilities (e.g., behavioral challenges, accompanying disabilities), and remember that he/she may be the first person able to stop the child from being further victimized .
Communication with patients and families regarding the signs and history of abuse is a necessary step in obtaining an accurate diagnosis. When there is an obvious disconnect in the communication process between the practitioner and patient due to the patient's lack of proficiency in the English language, an interpreter is required. Frequently, this may be easier said than done, as there may be institutional and/or patient barriers.
In this multicultural landscape, interpreters are a valuable resource to help bridge the communication and cultural gap between patients and practitioners . Interpreters are more than passive agents who translate and transmit information back and forth from party to party. When they are enlisted and treated as part of the interdisciplinary clinical team, they serve as cultural brokers, who ultimately enhance the clinical encounter. When providing care for patients for whom English is a second language, the consideration of the use of an interpreter and/or patient education materials in their native language may improve patient understanding and outcomes.
Child abuse and neglect are considered significant social problems with deleterious consequences. As noted, a system has been implemented in all 50 states to ensure the safety of children, with laws defining what constitutes abuse and neglect and who is mandated to report. Healthcare professionals, regardless of their discipline or field, are in a unique position to assist in the identification, education, and prevention of child abuse and neglect.
|American Academy of Pediatrics|
|141 Northwest Point Blvd|
|Elk Grove Village, IL 60007|
|Child Abuse Hotlines|
|New York Statewide Central Register (SCR) of Child Abuse and Maltreatment|
|General Public: 1-800-342-3720|
|15757 N 78th St, Suite B|
|Scottsdale, AZ 85260|
|Child Welfare Information Gateway|
|1250 Maryland Ave SW, Eighth Floor|
|Washington, DC 20024|
|Child Welfare League of America|
|1726 M St NW, Suite 500|
|Washington, DC 20036|
|National Council on Child Abuse and Family Violence|
|1025 Connecticut Ave NW, Suite 1000|
|Washington, DC 20036|
|New York State Office of Children and Family Services Child Protective Services|
|Capital View Office Park|
|52 Washington Street|
|Rensselaer, New York 12144|
|Prevent Child Abuse New York|
|33 Elk Street, Second Floor|
|Albany, NY 12207|
1. Johnson JM. Horror stories and the construction of child abuse. In: Best J (ed). Images of Issues: Typifying Contemporary Social Problems. New York, NY: Aldine De Gruyter; 1989: 5-19.
3. Gelles RJ. Family violence. In: Hampton RL (ed). Family Violence: Prevention and Treatment. 2nd ed. Thousand Oaks, CA: Sage Publications; 1999: 1-32.
4. Kempe HC, Silverman FN, Steele BF, Droegemueller W, Silver HK. The battered-child syndrome. JAMA. 1962;181(1):17-24.
5. U.S. Department of Health and Human Services. The Child Abuse Prevention and Treatment Act: Including Adoption Opportunities and the Abandoned Infants Assistance Act. Available at http://www.acf.hhs.gov/programs/cb/laws_policies/cblaws/capta/capta2010.pdf. Last accessed July 18, 2011.
6. U.S. Department of Health and Human Services. Definitions of Child Abuse and Neglect: Summary of State Laws. Available at http://www.childwelfare.gov/systemwide/laws_policies/statutes/define.cfm. Last accessed July 18, 2011.
7. New York State Office of Children and Family Services. Definitions of Child Abuse and Maltreatment. Available at http://www.ocfs.state.ny.us/main/prevention/critical.asp. Last accessed July 18, 2011.
8. MedlinePlus. Child Abuse—Physical. Available at http://www.nlm.nih.gov/medlineplus/ency/article/001552.htm. Last accessed July 18, 2011.
9. Winton MA, Mara BA. Child Abuse and Neglect: Multidisciplinary Approaches. Boston, MA: Allyn and Bacon; 2000.
10. MedlinePlus. Child Abuse—Sexual. Available at http://www.nlm.nih.gov/medlineplus/ency/article/007224.htm. Last accessed July 18, 2011.
12. MedlinePlus. Child Neglect and Psychological Abuse. Available at http://www.nlm.nih.gov/medlineplus/ency/article/007225.htm. Last accessed July 18, 2011.
13. U.S. Department of Health and Human Services, Administration for Children and Families. Child Maltreatment 2009. Available at http://www.acf.hhs.gov/programs/cb/pubs/cm09/cm09.pdf. Last accessed July 18, 2011.
14. Courtney ME, Barth RP, Berrick JD, Brooks D, Needell B, Park L. Race and child welfare services: past research and future directions. Child Welfare. 1996;75(2):99-137.
15. Humphreys J, Ramsey AM. Nursing care of abused children. In: Campbell J, Humphreys J (eds). Nursing Care of Survivors of Family Violence. 2nd ed. St Louis, MO: Mosby; 1993: 211-247.
16. Kellogg ND, American Academy of Pediatrics Committee on Child Abuse and Neglect. Evaluation of suspected child physical abuse. Pediatrics. 2007;119(6):1232-1241.
17. U.S. Department of Health and Human Services, Administration for Children and Families. Long-Term Consequences of Child Abuse and Neglect. Available at http://www.childwelfare.gov/pubs/factsheets/long_term_consequences.cfm. Last accessed July 18, 2011.
18. Milner JS, Crouch JL. Child physical abuse: theory and research. In: Hampton RL (ed). Family Violence: Prevention and Treatment. 2nd ed. Thousand Oaks, CA: Sage Publications; 1999: 33-65.
19. Rivara FP, Kamitsuka MD, Quan L. Injuries to children younger than 1 year of age. Pediatrics. 1988;81(1):93-97.
20. Egeland B, Sroufe A. Developmental sequelae of maltreatment in infancy. N Dir Child Adolesc Dev. 1981;11:77-92.
21. Garbarino J. Troubled youth, troubled families: the dynamics of adolescent maltreatment. In: Cicchetti D, Carlson V (eds).Child Maltreatment: Theory and Research on the Causes and Consequences of Child Abuse and Neglect. New York, NY: Cambridge University Press; 1989: 685-706.
22. Finkelhor D. The trauma of childhood sexual abuse. In: Wyatt GE, Powell GJ (eds). Lasting Effects of Child Sexual Abuse. Thousand Oaks, CA: Sage Publications; 1988.
23. Springer KW, Sheridan J, Kuo D, Carnes M. The long-term health outcomes of childhood abuse: an overview and a call to action.J Gen Intern Med. 2003:18(10):864-870.
24. Neumann DA. Long-term correlates of childhood sexual abuse in adult survivors. N Dir Ment Health Serv. 1994;(64):29-38.
25. Riggs S, Alario AJ, McHorney C. Health risk behaviors and attempted suicide in adolescents who report prior maltreatment. J Pediatr. 1990;116(5):815-821.
26. New York State Office of Children and Family Services. Summary Guide for Mandated Reports in New York State. Available at http://www.ocfs.state.ny.us/main/prevention/faqs_mandatedreporter.asp. Last accessed July 18, 2011.
27. Bryant J, Milsom A. Child abuse reporting by school counselors. Prof Sch Counseling. 2005;9(1):63-71.
28. Hinson J, Fossey R. Child abuse: what teachers in the '90s know, think, and do. J Educ Students Placed Risk. 2000;5(3):251-266.
30. Carleton RA. Does the mandate make a difference? Reporting decisions in emotional abuse. Child Abuse Rev. 2006;15(1):19-37.
31. Kenny MC. Child abuse reporting: teachers' perceived deterrents. Child Abuse Negl. 2001;25(1):81-92.
32. Flaherty EG, Sege R. Barriers to physician identification and reporting of child abuse. Pediatr Ann. 2005;34(5):349-356.
33. U.S. Department of Health and Human Services, Administration for Children and Families, Washington State Criminal Justice Training Commission, Harborview Center for Sexual Assault and Traumatic Stress. Child Interview Guide. Available at http://www.childwelfare.gov/responding/iia/investigation/interviewing.cfm. Last accessed July 18, 2011.
34. Leder MR, Knight JR, Emans J. Sexual abuse: when to suspect it, how to assess for it. Contemp Pediatr. 2001;18:59-74.
35. National Institute of Child Health and Human Development. NIH News Alert: NICHD Researchers Improve Techniques for Interviewing Child Abuse Victims. Available at http://www.nichd.nih.gov/news/releases/interviewing.cfm. Last accessed July 18, 2011.
36. Bullock K. Child abuse: the physician's role in alleviating a growing problem. Am Fam Physician. 2000;61(10):2977-2980.
37. Bullock KA, Schornstein SL. Improving medical care for victims of domestic violence. Hospital Pract. 1998;34:42-58.
38. Campbell J, McKenna LS, Torres S, Sheridan D, Landenburger K. Nursing care of abused women. In: Campbell J, Humphreys J (eds). Nursing Care of Survivors of Family Violence. 2nd ed. St Louis, MO: Mosby; 1993: 248-289.
39. Erickson MJ, Hill TD, Siegel RM. Barriers to domestic violence screening in the pediatric setting. Pediatrics. 2001;108(1):98-102.
40. Lahoti SL, McClain N, Girardet R, McNeese M, Cheung K. Evaluating the child for sexual abuse. Am Fam Physician. 2001;63(5):883-892.
41. U.S. Department of Health and Human Services, Administration for Children and Families. Interviewing Strategies. Available at http://www.childwelfare.gov/responding/iia/investigation/interviewing.cfm. Last accessed July 18, 2011.
1. Kellogg ND, American Academy of Pediatrics Committee on Child Abuse and Neglect. Evaluation of suspected child physical abuse. Pediatrics. 2007;119(6):1232-1241. Summary retrieved from National Guideline Clearinghouse at http://www.guidelines.gov/content.aspx?id=11057. Last accessed August 29, 2011.
2. Hibbard RA, Desch LW, American Academy of Pediatrics Committee on Child Abuse and Neglect, American Academy of Pediatrics Council on Children With Disabilities. Maltreatment of children with disabilities. Pediatrics. 2007;119(5):1018-1025. Summary retrieved from National Guideline Clearinghouse at http://www.guidelines.gov/content.aspx?id=11059. Last accessed August 29, 2011.