57534 • Child Abuse Identification and Reporting: An Update for New York

Table of Contents

57534 • Child Abuse Identification and Reporting: An Update for New York

How to Receive Credit

Course Overview

Audience

Accreditations & Approvals

Designations of Credit

Special Approvals

Course Objective

Learning Objectives

Faculty

Faculty Disclosure

Division Planner

Division Planner Disclosure

Director of Development and Academic Affairs

Director Disclosure Statement

About the Sponsor

Disclosure Statement

Implicit Bias in Health Care

1. HISTORICAL CONTEXT AND BACKGROUND

2. DEFINITIONS OF CHILD ABUSE AND NEGLECT

FORMS OF CHILD ABUSE AND NEGLECT

3. EPIDEMIOLOGY OF CHILD ABUSE AND NEGLECT

NATIONAL PREVALENCE

NEW YORK STATE PREVALENCE

4. INDICATORS OF CHILD MALTREATMENT AND ABUSE

THE VIRTUAL ENVIRONMENT

5. IMPACT OF CHILD ABUSE

TRAUMA AND ADVERSE CHILDHOOD EXPERIENCES

SPECIFIC CONSEQUENCES OF CHILD MALTREATMENT AND ABUSE

6. REPORTING SUSPECTED CHILD ABUSE

MANDATED REPORTERS

THE PROCESS OF REPORTING TO THE NEW YORK STATEWIDE CENTRAL REGISTER (SCR) OF CHILD ABUSE AND MALTREATMENT

BARRIERS TO REPORTING

7. ASSESSMENT GUIDELINES FOR PROFESSIONALS

TRAUMA-INFORMED PRACTICE

SCREENING FOR ABUSE IN CHILDREN WITH SPECIAL NEEDS OR DISABILITIES

SCREENING FOR ABUSE IN NON-ENGLISH-PROFICIENT FAMILIES

8. EXPLICIT AND IMPLICIT BIAS

IMPACT OF IMPLICIT BIAS IN CHILD WELFARE

STRATEGIES TO REDUCE IMPLICIT BIAS

9. INTERPROFESSIONAL COLLABORATIONS AND CHILD MALTREATMENT

10. CASE SCENARIOS

11. CONCLUSION

12. RESOURCES

NEW YORK STATE

NATIONAL

Works Cited

Evidence-Based Practice Recommendations Citations

57534 • Child Abuse Identification and Reporting: An Update for New York

Alice Yick Flanagan, PhD, MSW

www.netce.com

Copyright © 2023 NetCE, All rights reserved.

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.

57534 • Child Abuse Identification and Reporting: An Update for New York

Education Category. Ethics - Human Rights

Release Date. 10/01/2023

Expiration Date. 09/30/2026

How to Receive Credit

To complete this course for continuing education credit please go to http://www.netce.com/course/2692 in your browser.

For assistance with receiving continuing education credit, please contact us at help@netce.com.

Course Overview

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.

Audience

This course is designed for all New York dental professionals required to complete child abuse education.

Accreditations & Approvals

NetCE Nationally Approved PACE Program Provider for FAGD/MAGD credit. Approval does not imply acceptance by any regulatory authority or AGD endorsement. 10/1/2021 to 9/30/2027 Provider ID #217994. NetCE is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at www.ada.org/cerp. NetCE is approved as a provider of continuing education by the Florida Board of Dentistry, Provider #50-2405. NetCE is a Registered Provider with the Dental Board of California. Provider Number RP3841. Completion of this course does not constitute authorization for the attendee to perform any services that he or she is not legally authorized to perform based on his or her license or permit type.

Designations of Credit

NetCE designates this activity for 2 continuing education credits. AGD Subject Code 155. This course meets the Dental Board of California's requirements for 2 unit(s) of continuing education. Dental Board of California course #02-3841-24404.

Special Approvals

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.

Course Objective

The purpose of this course is to enable dental 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.

Learning Objectives

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

1. Evaluate indicators of maltreatment or abuse, including in a virtual setting.

2. Recognize the impact of trauma and adverse childhood experiences on children, families, and yourself.

3. Describe mitigating effects of the protective factors on trauma.

4. Analyze the impact of bias on your decision making.

5. Identify when you have a legal obligation to call the State Central Register (SCR).

6. Discuss how you may better connect individuals and families with services.

7. Outline how to prepare to make the call to the SCR.

8. Describe how to complete the LDSS 2221A form.

9. Review your rights as a mandated reporter.

Faculty

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.

Previously acting as a faculty member at Capella University and Northcentral University, Dr. Yick Flanagan is currently a contributing faculty member at Walden University, School of Social Work, and a dissertation chair at Grand Canyon University, College of Doctoral Studies, working with Industrial Organizational Psychology doctoral students. She also serves as a consultant/subject matter expert for the New York City Board of Education and publishing companies for online curriculum development, developing practice MCAT questions in the area of psychology and sociology. Her research focus is on the area of culture and mental health in ethnic minority communities.

Faculty Disclosure

Contributing faculty, Alice Yick Flanagan, PhD, MSW, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Division Planner

Mark J. Szarejko, DDS, FAGD

Division Planner Disclosure

The division planner has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Director of Development and Academic Affairs

Sarah Campbell

Director Disclosure Statement

The Director of Development and Academic Affairs has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

About the Sponsor

The purpose of NetCE 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.

Disclosure Statement

It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.

Implicit Bias in Health Care

The role of implicit biases on healthcare outcomes has become a concern, as there is some evidence that implicit biases contribute to health disparities, professionals' attitudes toward and interactions with patients, quality of care, diagnoses, and treatment decisions. This may produce differences in help-seeking, diagnoses, and ultimately treatments and interventions. Implicit biases may also unwittingly produce professional behaviors, attitudes, and interactions that reduce patients' trust and comfort with their provider, leading to earlier termination of visits and/or reduced adherence and follow-up. Disadvantaged groups are marginalized in the healthcare system and vulnerable on multiple levels; health professionals' implicit biases can further exacerbate these existing disadvantages.

Interventions or strategies designed to reduce implicit bias may be categorized as change-based or control-based. Change-based interventions focus on reducing or changing cognitive associations underlying implicit biases. These interventions might include challenging stereotypes. Conversely, control-based interventions involve reducing the effects of the implicit bias on the individual's behaviors. These strategies include increasing awareness of biased thoughts and responses. The two types of interventions are not mutually exclusive and may be used synergistically.

1. HISTORICAL CONTEXT AND BACKGROUND

Pre-Test

Before beginning this course, take time to pre-assess your understanding of child abuse identification and reporting in New York State.

1. When determining if a child shows indicators of maltreatment or abuse it is important to remember

A) indicators will always be of a physical nature and will be visible.

B) not to view indicators in isolation.

C) the explanation for the presenting concern is irrelevant.

D) your prior experience with this child should not be factored in.

2. Some mandated reporters connect with children virtually. Which of the following statements is TRUE?

A) Due to the virtual setting a mandated reporter cannot assess indicators of abuse/maltreatment.

B) Pay attention to non-verbal cues from the child. Does the child’s demeanor change when a particular adult enters the room?

C) Mandated reporters can only report what they see or hear in person.

D) Meeting virtually places children in more danger.

3. Which is not a form of maltreatment?

A) Excessive corporal punishment

B) Lack of supervision

C) Poverty

D) Inadequate guardianship

4. Adverse childhood experiences can have a lasting impact on

A) children.

B) persons legally responsible for children.

C) mandated reporters.

D) All of the above

5. The following are protective factors that can mitigate child abuse and maltreatment, EXCEPT:

A) Parents having concrete supports in time of need

B) Having a robust network of mandated reporters

C) The child’s social connections

D) Parental resilience

6. Research on bias throughout the child welfare system shows

A) an under-representation of families of color.

B) an over-representation of families in poverty and families of color.

C) a mandated reporter’s decision to make a report is hardly ever influenced by bias.

D) bias does not have long-lasting impact on families and communities.

7. As mandated reporters, you must use critical thinking when deciding whether to call in a report. Critical thinking includes

A) gathering adequate information about the current situation.

B) analyzing that information to separate facts from assumptions.

C) determining whether you are legally required to call the SCR, and if not, determine what alternative options are available.

D) All of the above

8. When are mandated reporters required to call the State Central Register (SCR) to report suspected child abuse or maltreatment?

A) Immediately

B) Within one week

C) Within 48 hours

D) Depends on the severity of the suspected injury

9. If you are a mandated reporter in a school and a child has been missing from school and the parents are not responding to the schools attempts to discuss the child’s lack of attendance, what should you do?

A) Make a report to the SCR for educational neglect.

B) Assess if other efforts can be made by the school to engage the family.

C) Discuss the matter with the child’s friends.

D) Call the police.

10. When a mandated reporter finds a family in crisis and the children are not in imminent danger of harm, it is best to

A) call the SCR and make a report, just in case.

B) assess the situation to see if the family could benefit from other community resources.

C) do nothing.

D) call law enforcement

11. What should a mandated reporter do before reporting any allegations of abuse/neglect?

A) Have clear and sufficient evidence of the abuse or neglect.

B) Discuss the concerns with the parent or guardian of the child.

C) Talk to the child about what to say to the child protective services worker.

D) Have reasonable cause to suspect the child has been abused or neglected.

12. When must an LDSS 2221A form be filed?

A) Depends on the severity of the injury

B) Within five business days of making the oral report

C) Within 48 hours of making an oral report

D) The 2221A is no longer required. Make a note of your answers.

We will return to these questions following the activity.

There is an established system in the United States 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 [1]. 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, 6,000 years ago in Mesopotamia, orphans had their own patron goddesses for help and protection [2].

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 [2,13].

It was not until 1861 that there was a public outcry in the United States 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 [2].

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 [2]. 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 [2].

The first public case of child abuse in the United States 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 [3]. 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 [2]. 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 [3]. 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 [3]. Because of this case, every state now has a child protective services (CPS) system in place.

As a result of Berge's advocacy for children's safety, other nongovernmental agencies were formed throughout the United States, and the establishment of the juvenile court was a direct result of the Prevention of Cruelty to Children [13]. In 1912, the U.S. Children's Bureau was established to monitor and report on children's social and physical welfare [45]. The Bureau was the first formal federal government vehicle to address the welfare of children [45]. During this time, many states and counties had also established child welfare boards or departments. By 1919, all but three states had juvenile courts. However, many of these nongovernmental agencies could not sustain themselves during the Depression [13].

The topic of child abuse and neglect received renewed interest in the 1960s, when a famous study titled "The Battered-Child Syndrome" was published by Henry Kempe [1,4]. In the study, researchers argued 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]. This seminal study was the impetus to the adoption of a formal reporting system, and by 1967, all 50 states required physicians to report child abuse [14,22]. In the early 1970s, Senator Walter Mondale noted that there was no official agency that spent its energies on preventing and treating child maltreatment [13]. Congress passed the Child Abuse Prevention and Treatment Act (CAPTA) of 1974, which targeted federal funds to improve states' interventions for the identification, reporting and training for child abuse [13,22].

Today, 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. In 2006, recognizing the role of physicians in the detection of child abuse, child abuse pediatrics became a board-certified subspecialty [46]. In 2010, additional prevention and treatment programs were funded through CAPTA, and in 2012, the Administration on Children, Youth, and Families began to focus on protective factors to child abuse and neglect [22].

Social Services Law requires the State Central Register (SCR) to be a single contact for reporting child abuse or maltreatment in New York. The law also requires a CPS department to be established in each local department of social services. In order to help prevent child abuse and maltreatment, CPS needs strong partnerships within the community. To this end, certain professionals are designated as "mandated reporters" under the law. Mandated reporters are legally obligated to call the SCR only in certain circumstances, as will be outlined in this course. Families in crisis may not meet the legal criteria required to call the SCR and may be better served by being connected to a variety of community services in their area.

2. DEFINITIONS OF CHILD ABUSE AND NEGLECT

The federal definition of child abuse is evident in 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 [5]. 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" [6]. The state of New York defines child abuse and maltreatment/neglect as follows [7]:

Generally, 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 an act of sex abuse against the child. A person who perpetrates any of these actions against a child in their care can be abusive, and so can a person who allows someone else to do these things to a child.

Maltreatment refers to the quality of care a child is receiving from those responsible for the child. Maltreatment occurs when a parent or other person legally responsible for the care of a child harms a child, or places a child in imminent danger of harm by failing to exercise the minimum degree of care in providing the child with any of the following: food, clothing, shelter, education, or medical care when financially able to do so. Maltreatment can also result from abandonment of a child or from not providing adequate supervision for the child. A child may be maltreated if a parent engages in excessive use of drugs or alcohol such that it interferes with their ability to adequately supervise the child.

In addition to parents, persons legally responsible for children include a child's custodian, guardian, and any person responsible for the child's care at the relevant time. The term "custodian" may include any person continually or at regular intervals found in the same household as the child when the conduct of such person causes or contributes to the abuse or maltreatment of the child.

Parents and legally responsible persons in New York State must provide their children with the minimum degree of care, including adequate food, clothing, shelter, education, supervision, and medical care (to include basic dental care, mental health services, and treatment for drug or alcohol misuse). Guardians' financial ability to provide these items is considered when determining minimum degree of care. Adequate education consists of children being actively enrolled in school; high grades, activity participation, and impeccable attendance are not required. In terms of supervision, there is no provision in New York State law or regulation that dictates how old a child must be to be left alone without adult supervision. A child left alone in a residence or in the community must be able to demonstrate that they have the knowledge and skills necessary to properly respond to a potential emergency and to care for themselves. Just because an individual child may be left safely alone does not mean that child has the necessary skills to supervise other children without an adult present. Determining whether a child can be safely left alone must be made on a case-by-case basis.

In addition to providing essential care, parents and legally responsible persons are required to avoid excessive corporal punishment. While New York State law permits parents to use corporal (physical) punishment to discipline their children, but it cannot be excessive. Excessive corporal punishment is present when:

- The child lacks the capacity to understand the corrective quality of the discipline.

- A less severe method is available and likely to be effective.

- The punishment is inflicted due to the parent's rage.

- The child receives injuries or bruises as a result.

- The length of punishment surpasses the child's endurance.

FORMS OF CHILD ABUSE AND NEGLECT

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

Physical abuse injuries can range from minor bruises and lacerations to severe neurologic 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 [8,61].

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 [8,61].

Sentinel injuries are those minor injuries (e.g., bruises, intraoral injuries, fractures) that are recognized by providers or parents prior to the formal recognition of child abuse [47,48]. It is crucial to monitor for these sentinel injuries.

Sexual Abuse

Sexual abuse is defined by CAPTA as [6]:

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.

Child sexual abuse can be committed by a stranger or an individual known to the child. Sexual abuse may be manifested in many different ways, including [9,10]:

- 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

- Commercial sexual exploitation and child sex trafficking: 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

This definition is wide in scope and includes behaviors beyond touching, contact, or physical force. Instead, it encompasses sexual intent against an individual's will. It also takes into consideration consent, as there may be some who cannot consent due to age, disability, fear of harm, and/or state of consciousness or intoxication [62].

Physical Maltreatment/Neglect

Undoubtedly, the definition of neglect is an area of controversy. Some argue that neglect is a form of abuse, because neglect involves a caregiver having lower priority and value of the welfare of the child [49]. Some differentiate between the two terms by the fact that emotional abuse involves a commission of an act, while emotional neglect involves an omission [50].

Due to the ambiguity of definitions of child abuse and neglect, CAPTA provides minimum standards that each state must incorporate in its definition. Examples of child neglect may include [6,11,12]:

- Failure to provide adequate food, clothing, shelter, hygiene, supervision, education, 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)

In New York state, neglect also involves parents/caregivers who fail to exercise a minimum of care of minor who "misuses drugs and alcohol to the extent he/she loses self-control of his/her actions" [63].

Emotional Abuse/Neglect

The following behaviors constitute emotional abuse and neglect [6,11,12]:

- 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

- 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

In New York, emotional abuse entails the above behaviors or behaviors that impair emotional health or mental or emotional condition [63].

Educational Neglect

All of the following elements must be present to warrant a report for educational neglect:

- Child must be of compulsory school age and currently living in New York State.

- Child must be excessively absent without a valid reason or excuse.

- The child's education must be impaired due to the excessive absenteeism (or the child has an IEP and has missed necessary services due to excessive absenteeism).

- The parent or responsible person has been made aware of the excessive absenteeism and impairment by means beyond simply sending a note home or leaving a voicemail message.

- School officials have made efforts to engage the child and parent/responsible person.

- No parent or responsible person has taken any action to rectify the situation.

It is important to note that poor school attendance, in and of itself, does not equate to a reasonable cause to suspect maltreatment. School personnel should first try working with the student, family, and community agencies to identify needs and resources available to meet those needs. A report of suspected educational neglect should be called in as a remedy for excessive absences only as a last resort.

Sex Trafficking

Enacted in 2015, the Justice for Victims of Trafficking Act includes an amendment to CAPTA, and several states now track data related to the numbers of victims of sex trafficking. In 2021, 35 states reported 1,086 child victims of sex trafficking [15].

Prenatal Substance Exposure

The Comprehensive Addiction and Recovery Act (CARA) of 2016 included an amendment to CAPTA to collect and report the number of infants with prenatal substance exposure. As of 2021, 47 states reported this data and referred prenatal substance exposure cases to CPS agencies. There were 40,799 reports in 2021 [15].

3. EPIDEMIOLOGY OF CHILD ABUSE AND NEGLECT

NATIONAL PREVALENCE

In 2021, there were 3.9 million referrals to CPS agencies in the United States [15]. More than 2 million were assessed to be appropriate for a response, and 28.7% of reports were made by health and mental or behavioral health professionals [15]. Girls tend to be victims at a slightly higher rate (8.7 per 1,000 girls) compared with boys (7.5 per 1,000 boys) [15]. More than a half (51.7%) of perpetrators are women, and the majority (83.2%) are between the ages of 18 and 44 years [15].

As of 2021, there were at least 3.5 million children referred to CPS agencies and who received an investigation and some form of response, and 8.1 of every 1,000 children in the United States were victims of abuse and/or neglect [15]. This is the unique rate, meaning each child is counted only once regardless the number of times a report may have been filed for abuse/neglect. The fatality rate for 2021 was 2.46 deaths per 100,000 children [15].

Research has shown that racial and ethnic minority children (particularly African American/Black, Native American/Alaska Native, and multi-racial children) tend to have higher rates of reported child maltreatment compared to their White counterparts (Table 1) [15]. However, the lowest reported rate is among Asian American children [15]. It is important to note the role of explicit and implicit bias in the higher rates of child abuse reports among minority populations.

Table 1: CHILD ABUSE VICTIMIZATION ACCORDING TO RACE/ETHNICITY, 2020

Race/Ethnicity

Child Abuse Rate Per 1,000 Children

Native American/Alaska Native

15.5

African American

13.2

Multi-race

10.3

Pacific Islander

9.0

White

7.4

Hispanic

7.8

Asian American

1.6

Source: [15]

NEW YORK STATE PREVALENCE

In 2021, the rate of child abuse and neglect in New York State was 13.8 per 1,000 children [15]. This translates to approximately 58,760 cases of child abuse and neglect in New York in 2021, a decrease of 20.3% compared with 2017 [15]. In terms of fatalities, 126 children in New York died in 2021 as a result of child abuse and neglect—a rate of 3.06 per 100,000 children [15]. This is greater than the national rate of 2.46 per 100,000 per children [15].

4. INDICATORS OF CHILD MALTREATMENT AND ABUSE

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 [8,10,12,15,16,64]:

- 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

- Unwanted pregnancy

- 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"

- Asks teacher to employ harsh disciplining for misbehaviors

Child risk indicators include [8,10,12,16,48,64]:

- Multiple school absences

- Learning or developmental disabilities or special needs

- History of multiple, unexplained illnesses, hospitalizations, or accidents

- Poor general appearance (e.g., fearful, poor hygiene, malnourished appearance, inappropriate clothing for weather conditions)

- Begs for money or food

- Stress-related symptoms, such as headaches or stomachaches

- Frozen watchfulness

- 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

- Symptoms of wasting (i.e., unintended and significant weight loss), protruding ribs or bones, abdominal distension, edema, and sparse hair indicating nutritional neglect

- Abuses/mistreats pets

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.

It is important to note that indicators of child abuse/maltreatment should be viewed in the context of the whole person and situation, not in isolation. Each indicator should be considered in relation to the child's current age and circumstances and in the context of their physical condition or behavior. Evaluate if there is an explanation for the presenting concern and whether the explanation is consistent with the observed physical and behavioral indicators. Any prior experiences with the child and deviation from usual observations should be a part of the assessment. Abuse or maltreatment should never be assumed. It is vital to make an objective assessment that is free from any implicit or explicit bias.

THE VIRTUAL ENVIRONMENT

Mandated reporters may have interactions with children that occur in a virtual environment. For example, children may attend school remotely, visit physicians and nurses using telemedicine, and participate in therapy sessions on virtual platforms. Those professionally interacting with children virtually have the same responsibilities as those interacting with children in person.

When assessing safety virtually, where possible:

- Be alert for indications that a child is trying to communicate something to you without someone else in the room noticing.

- Note if a child's demeanor or behavior is different when someone else enters the room.

- Listen for concerning statements a child makes to you, siblings, or their peers.

- Try to observe the child's body, even if you can only see the child's face, neck, shoulders, and chest, for anything suspicious

- Assess the child's mood and demeanor (e.g., does the child appear depressed or anxious?)

When interacting virtually, one may observe or hear an altercation between children or adults. Even if this does not rise to a level of making a report, it may create an opportunity for a conversation about safety or managing stress

Professionals utilizing technology to provide services should always use reliable technology, with adequate lighting and sound. At the start of each visit, it is good practice to verify the child's location, in the event you need to contact emergency services. Everyone present in the video or call should be introduced, even if they enter after the visit starts. The child should be present for at least part of the visit.

The child and/or parent should be asked if there is enough privacy to discuss sensitive matters. If necessary, nonparticipating household members may be asked to move to a different room or to leave the home, if possible.

Nonverbal cues should be monitored and noted. If a child's demeanor or behavior changes when someone else enters the room, this should prompt further exploration. Similarly, if a child turns off a webcam or is very hesitant to use one, this can be a sign that they are trying to avoid confrontation or assessment.

In addition, the child's environment should be monitored for noticeable unsafe conditions. It should be clear that there is appropriate supervision for the child. One may also see that young children are being held responsible for even younger siblings.

All professionals involved in virtual contact with children should provide clear channels to reach out via e-mail, phone, chat, text, or online tool.

5. IMPACT OF CHILD ABUSE

TRAUMA AND ADVERSE CHILDHOOD EXPERIENCES

Trauma is an intense event that threatens a person's life or safety in a way that is too much for the mind to handle and leaves the person powerless. Trauma can trigger physical reactions, including rapid heart rate, tense muscles, or shallow breathing. Common traumatic events could be going through or seeing:

- Family violence

- Sexual abuse

- Emotional abuse

- Violence in the community

For many parents, having a child removed from the home and dealing with the child welfare system are traumatic events. As such, trauma impacts much of the work mandated reporters do.

Adverse childhood experiences (ACEs) (including abuse and maltreatment) are defined as potentially traumatic experiences that affect an individual during childhood (before 18 years of age) and increase the risk for future health and mental health problems (including increased engagement in risky behaviors) as adults [76]. These experiences are broadly common, occurring in approximately 64% of the U.S. population [82]. ACEs and trauma alone may not rise to the level of child abuse or maltreatment; it is the impact on the child that should be assessed. ACEs have a lasting impact on children, persons legally responsible for children, and mandated reporters.

Toxic stress occurs when a person experiences severe, prolonged adversity without adequate support. Toxic stress means that the stress response stays continuously activated in the body. This prolonged exposure to adversity can impact children developmentally and behaviorally.

SPECIFIC CONSEQUENCES OF CHILD MALTREATMENT AND 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 [17]:

- 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 [18]. During infancy, physical abuse can cause neurologic impairments. Most cases of infant head trauma are the result of child abuse [19]. Neurologic 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 [20].

By middle to late childhood, the consequences are more notable. Studies have shown significant intellectual and linguistic deficits in physically abused children [18]. 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].

Surprisingly, there has been little research on the effects of childhood physical abuse on adolescents [18]. 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 [21]. 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 [21]. 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]. A 2019 meta-analysis found a robust association between five forms of child maltreatment (i.e., sexual abuse, physical abuse, emotional abuse, neglect, and exposure to intimate partner violence) and the development of mental disorders, including depressive disorders, anxiety disorders, and post-traumatic stress disorder [24]. Similar results were found in a longitudinal study that compared a child welfare cohort to a group with no child welfare involvement. The child welfare group was twice as likely to experience moderate-to-severe depression and generalized anxiety compared with the control group [25].

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 [23]. In the Wisconsin Longitudinal Study, men who disclosed a history of childhood sexual abuse were more likely to have or develop depression, somatic symptoms, and increased levels of hostility [51]. Other possible psychological outcomes include [10,52]:

- Affective symptoms: Numbing, post-traumatic stress disorder, anxiety, depression, obsessions and compulsions, somatization

- Various health problems, including general pain and gastrointestinal symptoms

- 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

Adult male survivors of child sexual abuse are three times as likely to perpetrate domestic violence as non-victims. In addition, female survivors of child sexual abuse are more vulnerable to bulimia, being a victim of domestic violence, and being dependent on alcohol [28].

In more recent years, research has focused on the impact of ACEs in general [76]. Abuse and neglect during childhood are clear ACEs, but other examples include witnessing family or community violence; experiencing a family member attempting or completing suicide; parental divorce; parental or guardian substance abuse; and parental incarceration [76]. Adults who experienced ACEs are at increased risk for chronic illness, impaired health, violence, arrest, and substance use disorder [77,78]. It has been found that other factors can intensify the effects of ACEs, including poverty, racism, generational trauma, and frequent unintended or indirect discrimination. The effects of ACEs can be reduced by supporting children and families and increasing protective factors.

The economic costs of non-fatal child maltreatment equate to $210,012 per child victim, excluding the costs associated with adverse physical and mental health consequences and those incurred by the criminal justice and special education systems [53]. A 2017 study found a cost of more than $400,000 per child abuse victim over the course of his or her lifetime [65].

6. REPORTING SUSPECTED CHILD ABUSE

MANDATED REPORTERS

In the state of New York, certain professionals are legally required or mandated to report immediately any suspected cases of child abuse, maltreatment, and/or neglect that they encounter in their professional roles (i.e., working or volunteering in a role that requires your specific licensure or certification) 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 [26]. Child abuse laws in New York, and in all states, do not require reporters to have absolute proof of abuse [27]. 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]. Good faith is defined as "the reporter, to the best of his or her knowledge, has reason to believe that the child in question is being subjected to abuse or neglect" [14]. Note that poverty, in and of itself, does not equate to maltreatment or abuse.

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 [26]. It is vital to remember that mandated reporters are not required to provide absolute evidence; this is the responsibility of CPS [29]. No employer or organization is permitted to require approval prior to calling the SCR. Mandated reporters' legal obligations are personal, and organizations may not impede calling the SCR. Further, all employers and organizations are prohibited from retaliating in any way for mandated reporters' fulfilling their duties. The law also does not require multiple reports on the same incident from the same organization.

The following individuals are classified as mandated reporters in the state of New York [26]:

- Physicians (including osteopaths)

- Registered physician's assistants

- Surgeons

- Medical examiners

- Coroners

- Dentists

- Dental hygienists

- Optometrists

- Chiropractors

- Podiatrists

- Medical residents

- Interns

- Psychologists

- Registered nurses

- Social workers

- Emergency medical technicians

- Licensed creative arts therapists

- Licensed marriage and family therapists

- Licensed mental health counselors

- Licensed psychoanalysts

- Hospital personnel engaged in the admission, examination, care, or treatment of persons

- Christian Science practitioners

- School officials

- 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

- Alcoholism counselors

- Peace officers

- Police officers

- District attorneys or assistant district attorneys

- Investigators employed in the Office of the District Attorney

- Any other law enforcement officials

Confidentiality

State law provides confidentiality for mandated reporters and all sources of child abuse and maltreatment reports. However, CPS or the SCR may be required to provide the identity of the source of the CPS report in very limited circumstances and only as described in the law.

The legal obligation to report suspected child abuse and maltreatment under New York State law supersedes client-patient confidentiality provisions. The Health Insurance Portability and Accountability Act (HIPAA) contains specific provisions allowing healthcare and other professionals to report information to the SCR, including personally protected health information that is otherwise confidential.

THE PROCESS OF REPORTING TO THE NEW YORK STATEWIDE CENTRAL REGISTER (SCR) OF CHILD ABUSE AND MALTREATMENT

When mandated reporters suspect a case of child abuse or maltreatment, they must report to the SCR at 1-800-635-1522. The general public can report suspected abuse by calling 1-800-342-3720 [38]. In an emergency situation, always call 911 first.

The SCR is open 24 hours per day, 7 days per week [26]. The mandated reporter is not obligated to contact the parents or the legal guardians of the child either before or after the call to SCR [26]. 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 [26]. (Additional child abuse hotline information may be found in the Resources section of this course.)

The worker who answers the phone will attempt to accumulate as much information from you as possible. According to the New York State Office of Children and Family Services, they will ask you the following types of questions [26,38]:

- What is the nature and extent of the child's injuries, or the risk of harm to the child?

- Have there been any prior suspicious injuries to this child or his/her siblings?

- What is the child's name, home address, age?

- What is the name and address of the parent or other person legally responsible who caused the injury, or created the risk of harm to the child?

- What are the names and addresses of the child's siblings and parents if different from the information provided above?

- Do you have any information regarding treatment of the child, or the child's current whereabouts?

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 [26]. The forms may be accessed on the New York State Office of Children and Family Services website at https://ocfs.ny.gov/forms/ldss/LDSS-2221/OCFS-LDSS-2221A.docx. Information required to complete the form includes:

- Full name of the parent or person legally responsible for the child

- Parents or other adults' dates of birth, when available

- Full name of the child or children you suspect are being abused or maltreated

- Child or children's dates of birth, when available

- Specific information that led to having a reasonable suspicion of abuse or maltreatment

- Addresses or locating information for the relevant adults and children (required in order for SCR to accept the report)

- Your full name

- The name of your agency or organization

- Your contact information, including phone number and email address

- The name of any other mandated reporter you believe personally observed or was provided with relevant information about the child

The SCR is bound by legal criteria that dictates whether they can accept a report:

- The child must be born and must be younger than 18 years of age

- The alleged perpetrator must be the child's parent or another person 18 years of age or older who is legally responsible for the child

- The conduct described must meet the legal definition of maltreatment or abuse

The SCR is not legally required to accept all reports from mandated reporters. The SCR staff will conduct their own interview to determine if the information you provide during the call rises to the legal level of suspected child abuse or maltreatment. If it does not rise to this level, based on the information provided, the SCR cannot accept the report. Mandated reporters have fulfilled their legal obligations even if the SCR declines to accept the report.

The CPS unit of the LDSS is required to begin an investigation of the reported abuse within 24 hours [26]. A CPS specialist will ask questions about the suspected abuse and the child and ill contact the child(ren) and alleged perpetrator. 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 substantiated or unsubstantiated. CPS is obligated to inform the child's parents or other subject of the report of their rights and offer potentially helpful services, according to the New York State Social Services Law, and must inform the SCR of the determination of the investigation [26]. The most common outcome of a CPS investigation is that the caseworker will work with the family to obtain necessary services or aid to alleviate problems and promote safety. However, CPS intervention is not required for parents, children, or families to obtain services.

BARRIERS TO REPORTING

Studies have shown that many professionals who are mandated to report child abuse and neglect are concerned and/or anxious about reporting. Identified barriers to reporting include [29,30,31,40,54,55]:

- 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.

- Practitioners may fear that reporting will negatively impact the therapeutic relationship.

- Loyalty to the family

- Fear of driving the family away from seeking health, social, and mental health services

- Some professionals have concerns that there might be negative repercussions against the child by the perpetrator.

- Some simply underestimate the seriousness and risk of the situation and may make excuses for the parents.

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 [32]:

- 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 [32]:

- 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

7. ASSESSMENT GUIDELINES FOR PROFESSIONALS

Evidence Based Practice Recommendation

The U.S. Preventive Services Task Force concludes that the current evidence is insufficient to assess the balance of benefits and harms of primary care interventions to prevent child maltreatment in children who do not have signs or symptoms of maltreatment. However, children with signs or symptoms suggestive of maltreatment should be assessed or reported according to the applicable state laws.

https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/child-maltreatment-primary-care-interventions

Last Accessed: September 21, 2023

Strength of Recommendation: I (Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be measured.)

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 [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 [16].

It is important for professionals to ask questions in a nonjudgmental manner [33]. 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 [34]. Be sensitive to the fact that children often wonder if the abuse actually happened, as the abuser may behave as if nothing occurred [56]. 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].

Supporting and facilitating the victim's emotions are also important. This helps to promote rapport between the interviewer and the child. One way of promoting the rapport is by expressing interest or care by saying: "I want to know more about how you are feeling" [65]. Certain feelings or events may be legitimized by confirming to the child that he/she is safe talking about bad things. Finally, the interviewer can reinforce these sentiments by thanking the child for expressing certain emotions [65].

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 [16,20]. An estimated 75% of victims of domestic violence live in a household with at least one child younger than 18 years of age, and between 3.3 million and 10 million children witness domestic violence annually [36,37]. 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 [39]. Because of the sensitive nature of child abuse, it can evoke extreme emotions on the part of the professional. However, it is important to manage emotions when talking to children [57].

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].

TRAUMA-INFORMED PRACTICE

All interactions with patients, regardless of whether or not they are potential victims of abuse, should be centered on the patient's experiences, needs, and preferences. Providing patient-centered care means that care will be respectful of and responsive to individual patient preferences, needs, and values and will reflect the patient's values. This should be considered at all stages of assessment, intervention, and continued care/follow-up.

It is important to use a trauma-informed approach when assessing and caring for potential victims, which requires that practitioners understand the impact of trauma on all areas of an individual's life. Physical, emotional, and psychological safety is at the heart of trauma-informed care. This approach allows for trust-building and continued communication, both vital to ensuring that patients receive the care and support they require.

Being trauma-informed is a strengths-based approach that is responsive to the impact of trauma on a person's life. It requires recognizing symptoms of trauma and designing all interactions with victims in such a way that minimizes the potential for re-traumatization. This involves creating a safe physical space in which to interact with survivors as well as assessing all levels of service and policy to create as many opportunities as possible for survivors to rebuild a sense of control. Most importantly, it promotes survivor empowerment and self-sufficiency. Children should have access to services that promote autonomy and are comprehensive, victim-centered, and culturally appropriate.

When assessing and providing care to children affected by trauma, it is important to consider protective factors that can lower the risk of negative health outcomes. Protective factors against child maltreatment and abuse include:

- Nurturing and attachment

- Knowledge of parenting and of child and youth development

- Parental resilience

- Social connections

- Concrete supports for parents

- Social and emotional competence of children

SCREENING FOR ABUSE IN CHILDREN WITH SPECIAL NEEDS OR DISABILITIES

The rates of child maltreatment for children with disabilities are reportedly 1.7 to 7 times higher compared with children without disabilities [42]. In one study, researchers found that among substantiated reports of maltreatment among children, 22% of victims had some form of disability, most commonly an emotional disability [58]. A systematic review found that there was a prevalence rate of 20.4% for physical abuse, 13.7% for sexual abuse, and 26.7% for both forms of abuse combined among children with intellectual disabilities [66]. Children with disabilities can be more vulnerable to maltreatment if the parents/caregivers view the disability and its associated behaviors as "difficult," if the parents have unrealistic expectations of the child's behavior or abilities, if the parents are facing additional caregiver stress, or if the parent perceives the child as unable to defend him/herself [43]. Furthermore, they may be less likely to disclose the abuse because they not only do not realize they have been harmed or they have impaired communication skills [59].

To effectively interview a child with a disability, the practitioner should first obtain some preliminary data, including [33]:

- 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 [41]. When questioning the child, it is important to ask open-ended questions, as this approach maximizes recall. Some assume that children with disabilities will not be able to handle open-ended questions, but this is not strictly true [67]. When working with those with intellectual disabilities, interviewers should try shorter open-ended questions before falling back to closed-ended questions [67]. Scaffolding questions, or breaking up the tasks and gradually building up the questions with specific instructions and comprehension checks along the way, can also be beneficial [68]. Comprehension check questions can be as simple as: "Can you repeat the question I just asked?" or "I just asked you <insert question>, what does that question mean to you?" [68].

SCREENING FOR ABUSE IN NON-ENGLISH-PROFICIENT FAMILIES

Communication with children and families regarding the signs and history of abuse is a necessary step in obtaining an accurate diagnosis. When interviewing children for whom English is not their first language, they may switch back to their first language during the interview, even if they express the wish to have the interview conducted in English [69].

There will also be many occasions when an interpreter is warranted. Without an interpreter, children may experience additional stress, struggling to find the right words in English, which can result in more feelings of fear, disempowerment, and voicelessness [44].

It may be tempting to locate a practitioner who has some language ability to speak to the child and/or family member; however, this should be avoided if at all possible [44]. When looking for an interpreter in the community, it is important to consider if the interpreter and the family are acquainted, as this can cause an uncomfortable situation [69]. The language for screening for child abuse requires precision as well as sensitivity, and professional interpreters are recommended.

In this multicultural landscape, interpreters are a valuable resource to help bridge the communication and cultural gap between patients and practitioners [33]. 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. They should be familiar with both the nuances of the language and the cultural norms and value systems of the target community [44]. When providing care for children and parents 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.

It is also vital to take into account interpreters' competence when working in the area of child abuse. Because of the sensitive nature of child abuse and the type of information being asked and recalled, interpreters should be well trained in communicating with victims and perpetrators [60].

8. EXPLICIT AND IMPLICIT BIAS

In a sociocultural context, biases are generally defined as negative evaluations of a particular social group relative to another group. Explicit biases are conscious, whereby an individual is fully aware of his/her attitudes and there may be intentional behaviors related to these attitudes [84]. There are also cases in which implicit cognitive processes are involved in biases and conscious availability, controllability, and mental resources are not [85]. The term "implicit bias" refers to the unconscious attitudes and evaluations held by individuals. These individuals do not necessarily endorse the bias, but the embedded beliefs/attitudes can negatively affect their behaviors [86,87,88,89]. Some have asserted that the cognitive processes that dictate implicit and explicit biases are separate and independent [89].

Because implicit biases occur on the subconscious or unconscious level, particular social attributes (e.g., skin color) can quietly and insidiously affect perceptions and behaviors [90]. According to Georgetown University's National Center on Cultural Competency, social characteristics that can trigger implicit biases include [91]:

- Age

- Disability

- Education

- English language proficiency and fluency

- Ethnicity

- Health status

- Disease/diagnosis (e.g., HIV/AIDS)

- Insurance

- Obesity

- Race

- Socioeconomic status

- Sexual orientation, gender identity, or gender expression

- Skin tone

- Substance use

Project Implicit is a research project sponsored by Harvard University and devoted to the study and monitoring of implicit biases. It houses the Implicit Association Test (IAT), which is one of the most widely utilized standardized instruments to measure implicit biases. A variety of IAT tests can be accessed at https://implicit.harvard.edu/implicit.

In an ideal situation, health professionals would be explicitly and implicitly objective and clinical decisions would be completely free of bias. However, healthcare providers have implicit (and explicit) biases at a rate comparable to that of the general population [85,92]. It is possible that these implicit biases shape healthcare professionals' behaviors, communications, and interactions, which may produce differences in help-seeking, diagnoses, and ultimately treatments and interventions [92]. They may also unwittingly produce professional behaviors, attitudes, and interactions that reduce patients' trust and comfort with their provider, leading to earlier termination of visits and/or reduced adherence and follow-up [87].

However, biases can be unlearned, and one of the benefits of being aware of the potential impact of one's own biases is that you can choose to take a proactive role in reducing how they impact your decision-making.

IMPACT OF IMPLICIT BIAS IN CHILD WELFARE

National research shows, and OCFS data confirm, that disparities exist throughout the child welfare system presently and historically [83]. The OCFS' Disproportionate Minority Representation data show historical over-representation of children and families of color in the child welfare system. Families of color have been more likely to be involved in a report to the SCR, and children of color have been more likely to be placed in foster care and generally experience slower achievement of permanency goals.

In addition, income status of families is a significant predictor of involvement with the child welfare system. Research shows that families investigated by CPS have several poverty-related risk factors, such as unemployment, single parenthood, food insecurity, housing instability, or lack of access to childcare [83]. Families living below the poverty line are three times more likely to be substantiated for child maltreatment than those with higher income.

A mandated reporter's decision whether to call the SCR can change the course of the life of a child and the members of a family. It is important to be aware of the propensity for implicit or explicit bias and to be intentional about making decisions based on the objective facts of a situation. Part of this process involves increase our own awareness regarding our own beliefs, including those that may be hidden or unconscious. Mandated reporters should only call the SCR when they have a legal obligation to do so.

All mandated reporters should approach their responsibility with empathy, compassion, care, and curiosity. When assessing information received about a child and their family, instead of making assumptions or jumping to conclusions that a child is being maltreated or abused, consider the right analytical and evaluative questions. Evaluate whether the needs of the child and family can be met through means outside of the CPS system.

STRATEGIES TO REDUCE IMPLICIT BIAS

The first step in unraveling implicit bias is understanding the lens through which one views the world. By their nature, implicit biases can be difficult to recognize in oneself. The IAT can be used as a metric to assess professionals' level of implicit bias on a variety of subjects [93]. When providers are aware that implicit biases exist, discussion and education can be implemented to help reduce them and/or their impact.

Another way of facilitating awareness of providers' implicit bias is to ask self-reflective questions about each interaction with patients. Some have suggested using SOAP (subjective, objective, assessment, and plan) notes to assist practitioners in identifying implicit biases in day-to-day interactions with patients [94]. Integrating the following questions into charts and notes can stimulate reflection about implicit bias globally and for each specific patient interaction:

- Did I think about any socioeconomic and/or environmental factors that may contribute to the health and access of this patient?

- How was my communication and interaction with this patient? Did it change from my customary pattern?

- How could my implicit biases influence care for this patient?

A proven strategy to reduce bias is to examine whether the facts of the situation would lead you to the same decision to call the SCR if the demographic information for the child or family were different. Consider if you would make the same decision if any of the following were different for the child or family:

- Race

- Ethnicity

- Gender/gender identity

- Sexual orientation or expression

- Religion

- Immigration status

- Primary spoken language

- Culture

- Age

- Neighborhood or place of residence

- Presence of a disability

- Occupation

- Socioeconomic status

The best tool to reduce bias is solid critical thinking. In the case of identifying possible abuse, this consists of identifying what specifically concerns you about the current situation, gathering adequate information about the current situation, analyzing that information to separate facts from assumptions, recognizing the possibility of bias, developing multiple hypotheses that could explain the situation, and determining whether you are legally required to call the SCR and, if not, whether an alternative option is better, such as connecting the individual or family to appropriate services in their community. In all cases, mandated reporters should approach the situation with humility and be open and willing to learn and consider information that might be different from first impressions and assumptions.

9. INTERPROFESSIONAL COLLABORATIONS AND CHILD MALTREATMENT

Interprofessional collaboration, defined as a partnership or network of providers who work in a concerted and coordinated effort on a common goal for clients/patients and their families to improve health, mental health, social, and/or family outcomes, is a vital component in child abuse identification and intervention [70]. Positive outcomes with this approach have been demonstrated on individual and organizational levels, including increased patient/client safety and satisfaction and improved health outcomes and quality of life [71,72,73].

However, promoting interprofessional collaboration can be challenging, as it challenges the Western paradigm that focuses on individualism and working in a silo [74]. For example, physicians and other health professionals often do not ask their patients and family members about child abuse/neglect or about contact with the child welfare system. Even if this issue is not acute, knowledge of this background information can help to better understand the patient or family as a whole unit. Similarly, child welfare workers rarely engage with physicians, instead focusing primarily on their investigation [75].

Practitioners should work with each other to learn and understand each other's roles and traditions [79,80]. In focus groups, physicians believed that child welfare workers were supposed to solve child abuse cases by providing social services and removing a child from the home but did not appreciate the underlying complexities of child abuse and neglect. Child welfare workers overestimated physicians' understanding of the child welfare system [75].

Social workers are often an integral part of the interprofessional practice for child abuse and neglect, acting as a liaison between the families, healthcare workers, and outside entities [81]. When a family has to deal with an issue of suspected child abuse, social workers are able to intervene and offer tools to manage the crisis.

10. CASE SCENARIOS

In the following case scenarios, consider if the case should be reported as possible child abuse in accordance with New York law.

A young girl, 2 years of age, is brought to the emergency department by her mother and stepfather for a scalp laceration. The girl is very quiet and appears listless and out of sorts. Her mother reports that she was injured when she fell onto a rock outside, but that the injury occurred when the girl was being watched by the stepfather. The girl undergoes assessment for traumatic brain injury, including assessment of function using the modified Glasgow Coma Score. The toddler is found to have mild impairment (a score of 13), and the follow-up test two hours later indicates normal functioning. The nurse notices that the toddler appears to be afraid of the stepfather, leaning away and crying when he is near her. The stepfather also appears to be easily frustrated with the child, saying that he does not know why she cries so much.

A boy, 13 years of age, is undergoing a routine physical exam with his family physician. The physician asks the boy if he is excited to start school in the next few weeks and how his baseball team is doing. The boy becomes quiet and states that he is nervous about an upcoming trip with his baseball team but does not give additional information. When asked directly, the boy says that he is uncomfortable with the new assistant coach, who watches pornography with them during out-of-town tournaments and supplies them with pornographic magazines. However, the boy states that he doesn't think it's a big deal and that "all of the other kids seem to really like it."

11. CONCLUSION

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.

12. RESOURCES

NEW YORK STATE

New York Statewide Central Register (SCR) of Child Abuse and Maltreatment

Mandated Reporters Hotline

1-800-635-1522

General Public

1-800-342-3720

Onondaga County

315-422-9701

New York State Office of Children and Family Services

Child Protective Services

518-473-7793

https://ocfs.ny.gov/programs/cps

OCFS Help, Empower, Advocate, Reassure and Support (HEARS)

1-888-554-3277 (Monday through Friday 8:30 a.m.-4:30 p.m.)

Child Welfare and Community Services: Adverse Childhood Experiences (ACEs)

https://ocfs.ny.gov/programs/cwcs/aces.php

Mandated Reporter Resource Center

http://nysmandatedreporter.org

Prevent Child Abuse New York

1-800-CHILDREN

https://www.preventchildabuseny.org

New York State Office for the Prevention of Domestic Violence

https://opdv.ny.gov/survivors-victims

New York State Trauma-Informed Network

https://www.traumainformedny.org

NATIONAL

American Academy of Pediatrics

https://www.aap.org

Childhelp

1-800-4-A-CHILD

https://www.childhelp.org

Child Welfare Information Gateway

1-800-394-3366

https://www.childwelfare.gov

Child Welfare League of America

202-688-4200

https://www.cwla.org

National Council on Child Abuse and Family Violence

202-429-6695

https://www.preventfamilyviolence.org

National Child Traumatic Stress Network

https://www.nctsn.org

National Center for PTSD

https://www.ptsd.va.gov

Parents Anonymous

https://parentsanonymous.org

Center for the Study of Social Policy

https://cssp.org

211 Helpline

https://www.211.org

Parents and caregivers may call 211, operated by the United Way, for health and human services information, referrals, assessments, and crisis support. 211 is multilingual and available 24 hours per day, 7 days per week.

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Evidence-Based Practice Recommendations Citations

1. U.S. Preventive Services Task Force. Interventions to prevent child maltreatment: U.S. Preventive Services Task Force recommendation statement. JAMA. 2018;320(20):2122-2128. Available at https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/child-maltreatment-primary-care-interventions. Last accessed September 21, 2023.