Identifying and Reporting Child Abuse, Neglect, and Trafficking

LEARNING OUTCOME AND OBJECTIVES:  Upon completion of this course, you will have gained the knowledge to identify and report child abuse, child neglect, and trafficking. Specific learning objectives to address potential knowledge gaps include:

• Define terminology related to child abuse.
• Explain the risk and protective factors contributing to child abuse and neglect.
• Recognize physical and behavioral indicators of abuse, neglect, and trafficking.
• Summarize strategies for responding to victims’ disclosures.
• Describe situations in which mandated reporters must report suspected cases of child maltreatment.
• Discuss the consequences for failing to report suspected child abuse.

WHAT IS CHILD ABUSE?

The abuse or maltreatment of children is against the law. The government has a responsibility to protect children when parents or other persons legally responsible for a child’s care fail to provide proper care and to intervene in cases of child abuse or maltreatment. Likewise, healthcare professionals have a responsibility to recognize and report suspected child abuse and maltreatment.

State statutes are divided into criminal and civil categories within each state’s statutory codes. Civil statutes provide guidance for mandated reporters and intervention by child protection agencies. Criminal statutes define which acts are criminal and can lead to arrest and prosecution of an offender.

Child abuse and neglect are significant public health problems that can lead to long-term adverse consequences for a child’s health and well-being. Therefore, healthcare professionals have both a legal and professional responsibility to recognize and report suspected child abuse and maltreatment.

Definitions

The Centers for Disease Control and Prevention (CDC) views child maltreatment as a serious public health problem and has developed uniform definitions pertaining to child maltreatment. The CDC states that child abuse and neglect include all types of abuse and neglect of a child under the age of 18 by a parent, caregiver, or another person in a custodial role (e.g., a religious leader, a coach, or a teacher) that results in harm, the potential for harm, or the threat of harm to a child. CDC definitions include:

• Child Maltreatment: Any act or series of acts of commission or omission by a parent or other caregiver that results in harm, potential for harm, or threat of harm to a child
• Child Abuse (Acts of Commission): Words or overt actions that cause harm, potential harm, or threat of harm to a child. Acts of commission are deliberate and intentional and include:
  • Physical abuse
  • Sexual abuse
  • Emotional abuse
• Child Neglect (Acts of Omission): The failure to provide for a child’s basic physical, emotional, or educational needs or to protect a child from harm or potential harm, including failure to provide:
  • Housing
  • Food
  • Clothing
  • Education
  • Access to medical care
  • Validation and responding appropriately to a child’s feelings
  (CDC, 2024a)

(See also “Types of Abuse” below for more details.)

Different states and government entities vary in their legal definitions of these terms. Therefore, it is important for healthcare professionals to know the definitions for child abuse and other related terms in the state(s) in which they live or practice.

Types of Abuse

Four commonly recognized categories of abuse are physical abuse, sexual abuse, emotional abuse, and human trafficking.

PHYSICAL ABUSE

Physical abuse of a child includes any intentional use of physical force that can result in physical injury of a child that is inflicted by a parent, caretaker, or another person in a custodial role. Type of acts include biting, kicking, hitting, shaking, burning, or other types of physical force. The legal definition of physical abuse also includes actions that pose a substantial risk of physical injury to the child even if no injury is sustained (CDC, 2024b).

SEXUAL ABUSE

Child sexual abuse generally includes any attempted or completed sexual activity or contact with a child by a caregiver. Examples include touching, fondling, penetration, or exposing a child to other sexual activities. In 36 states, the definition of sexual abuse includes human trafficking, including sex trafficking or trafficking of children for sexual purposes (CDC, 2024b; CWIG, 2022).

Child sexual abuse does not need to include physical contact between a perpetrator and a child. Some forms of child sexual abuse include:

• Exhibitionism (exposing oneself to a minor)
• Fondling
• Intercourse
• Masturbation in the presence of a minor or forcing a minor to masturbate
• Obscene phone calls, text messages, emails, or digital interaction
• Producing, owning, or sharing pornographic images or movies of children
• Sex of any kind with a minor, including vaginal, oral, or anal sex
• Sex trafficking (see below)
• Any other sexual conduct that is harmful to a child’s mental, emotional, or physical welfare
  (RAINN, 2024)

EMOTIONAL ABUSE

Emotional abuse involves actions that harm the self-esteem or emotional health of a child. Behaviors may involve shaming, rejecting, name-calling, and suppressing love or affection. Emotional abuse may lead to impaired psychological growth and development and involves words, actions, and indifference. This form of abuse may be hard to recognize because there are no visible injuries. Children who are sexually or physically abused may also be emotionally abused.

Emotional abuse may include:

• Verbal abuse
• Constant criticism
• Shaming
• Name-calling
• Excessive demands on a child’s performance (e.g., expectations of high grades in school or becoming “champion” school athletes)
• Not allowing a child to attend school
• Threats
• Rejecting
• Withholding affection
• Isolation
• Negligence
  (Kids Matter, 2022; CDC, 2024b)

HUMAN TRAFFICKING

There are different types of human trafficking, also known as trafficking in persons.

The crime of sex trafficking of children is a type of child abuse increasingly encountered in the healthcare setting. It is defined in the Trafficking Victims Protection Act (18 USC §1591) as “to recruit, entice, harbor, transport, provide, obtain, or maintain by any means a person, or to benefit financially from such action, knowing or in reckless disregard that the person has not attained the age of 18 years and will be caused to engage in a commercial sex act.”

In 2023, an estimated 1 in 6 of the 28,800 U.S. children who were reported to the National Center for Missing and Exploited Children (NCMEC) as missing were likely trafficked. It is likely that an estimated 19% of the children who ran away from foster care also became involved in sex trafficking in the same year. And NCMEC received 18,400 reports of child sex trafficking in 2023 (NCMEC, 2024).

According to U.S. federal law (22 USC § 7102), labor trafficking is the recruitment, harboring, transportation, provision, or obtaining of a person for labor or services through the use of force, fraud, or coercion for the purposes of subjection to involuntary servitude, peonage, debt bondage, or slavery. As with sex trafficking, force, fraud, or coercion do not need to exist if the labor trafficking victim is under the age of 18.

Child labor trafficking may include agricultural, domestic service, or factory work where workers provide involuntary labor. Labor trafficking can also occur in beauty services, restaurants, small businesses, or informal settings. Some common situations include peddling and traveling sales crews where young people are moved from town to town selling cheap products such as jewelry or magazines for little or no pay. Other situations include drug dealing in which children are forced to sell drugs.

Sometimes labor trafficking may occur when a child is staying with a custodial family member or nonfamily member and is forced to work. Children are controlled through fear and abuse by their traffickers. It is possible that a child is a victim of labor and sex trafficking simultaneously (NCSSLE, 2021).

Types of Neglect

Neglect is defined as the failure of a parent or other person with responsibility for the child to provide a child with basic physical and emotional needs such as food, clothing, shelter, education, and healthcare to the degree that the child’s health, safety, and well-being are threatened with harm (CDC, 2024a).

PHYSICAL NEGLECT

Physical neglect is the failure to provide a child with adequate food, shelter, clothing, education, hygiene, medical care, or supervision needed for normal growth and development. Leaving a young child or children without supervision by a responsible person is a type of neglect (Childhelp, 2021). Infants and toddlers should never be left alone, even briefly. While older preteens may be responsible and independent enough to be left alone, some older teenagers are too irresponsible or have special needs that limit their ability to be safe if left alone.

EMOTIONAL NEGLECT

Emotional neglect includes parent or other caretaker behaviors that cause or have the potential to cause serious cognitive, affective, or other behavioral health problems. The resulting emotional impairment must be clearly attributable to the unwillingness or inability of the parent or other person legally responsible for the child to exercise a minimum degree of care toward the child.

MEDICAL NEGLECT

Medical neglect is the failure to provide a child with necessary medical or mental health treatment. Some states make provisions for parents who choose not to seek certain forms of medical care for a child due to religious beliefs.

EDUCATIONAL NEGLECT

Educational neglect is the failure to educate a child (e.g., failure to enroll a child in school or preventing a child from attending school) or attend to special education needs (e.g., failure to obtain remedial education services). About half the states, the District of Columbia, American Samoa, Puerto Rico, and the Virgin Islands include failure to educate a child as required by law in their definition of neglect (CWIG, 2022).

ABANDONMENT

Abandonment is a form of neglect in many states. A child is generally considered to be abandoned when a parent’s whereabouts are unknown, the child has been left alone and suffers serious adverse consequences, or the parent fails to maintain contact with or provide reasonable support for a specified period of time.

COMPARING ABUSE AND NEGLECT

Abuse	Neglect
Parent or other persons legally responsible: Inflict or allow to be inflicted serious injury or substantial risk of physical injury Inflict or allow to be inflicted emotional harm Commit or allow to be committed a sex offense, including sex trafficking or other forms of commercial sex	Parent or other persons legally responsible impair a child’s physical, mental, or emotional condition by: Failing to provide basic needs of food, clothing, shelter, education, medical care, or education when financially able Failing to provide adequate supervision Engaging in excessive use of drugs or alcohol that interferes in the ability to provide adequate supervision

RISK AND PROTECTIVE FACTORS

Health professionals must remain alert for risk factors that may increase the likelihood of child abuse and maltreatment. Risk factors may be either characteristics of a caregiver or of a child and may go undetected. Similarly, certain factors have been shown to safeguard children from experiencing adverse effects such as abuse and neglect.

Risk Factors for Perpetrating Child Abuse

A caregiver may have certain characteristics that increase the likelihood that they may become a perpetrator of child abuse or neglect. When health professionals observe indicators of possible abuse, they should consider whether the presence of risk factors in a caregiver may signal a need to examine the situation more carefully.

Individual risk factors include:

• Caregivers with drug or alcohol issues
• Caregivers with mental health issues, including depression
• Caregivers who don't understand children's needs or development
• Caregivers who were abused or neglected as children
• Caregivers who are young or single parents or parents with many children
• Caregivers with low education or income
• Caregivers experiencing high levels of parenting stress or economic stress
• Caregivers who use spanking and other forms of corporal punishment for discipline
• Caregivers in the home who are not a biological parent
• Caregivers with attitudes accepting of or justifying violence or aggression

Relationship/family risk factors include:

• Families that have household members in jail or prison
• Families that are isolated from and not connected to other people (extended family, friends, neighbors)
• Families experiencing other types of violence, including relationship violence
• Families with high conflict and negative communication styles

Community risk factors include:

• Communities with high rates of violence and crime
• Communities with high rates of poverty and limited educational and economic opportunities
• Communities with high unemployment rates
• Communities with easy access to drugs and alcohol
• Communities where neighbors don't know or look out for each other
• Communities where there is low community involvement among residents
• Communities with few community activities for young people
• Communities with unstable housing and where residents move frequently
• Communities where families frequently experience food insecurity
  (CDC, 2024c)

Nationally, the most common risk factors reported with child maltreatment are substance abuse and domestic violence (U.S. DHHS, 2024).

Child Risk Factors

While children are not responsible for being abused, certain factors increase their risk for abuse or neglect:

• Children younger than 4 years of age
• Children with special needs that may increase caregiver burden (disabilities, mental health issues, and chronic physical illnesses)
  (CDC, 2024c)

Youth at greater risk for human trafficking include those who have experienced:

• A history of abuse and neglect
• Social disconnection
• Social stigma and exclusion
  (NHTTTAC, n.d.)

(See also “Recognizing Trafficking” later in this course.)

Protective Factors Against Adverse Childhood Experiences

Individual, family, and community protective factors safeguard children from experiencing adverse effects such as abuse and neglect. There is scientific evidence to indicate that a supportive family environment and social networks have a protective effect against adverse childhood experiences.

Individual and family protective factors include:

• Nurturing relationships in the family
• Stable family relationships where children are safe, cared for, and supported
• Children having positive peer relationships
• Children being successful in school and education being valued by the family
• Children having relationships with caring adults outside the family
• Families being able to provide shelter, food, clothing, and healthcare for children
• Caregivers having college degrees or higher education
• Caregivers being consistently employed
• Families having a good social support network
• Caregivers monitoring children and enforcing rules
• Adults resolving conflict in a nonviolent manner
• Families participating in fun activities together

Community protective factors include:

• Access to financial assistance in the community
• Access to medical and mental health services
• Access to housing that is safe and stable
• Access to good-quality childcare
• Access to good-quality preschool
• Access to good-quality afterschool programming
• Access to work opportunities with policies that are supportive to families
• Strong partnerships in the community between businesses, healthcare, government, and other institutions
• Residents feeling connected and involved with one another
• Violence not being tolerated
  (CDC, 2024c)

Resilience and Protective Factors

The ability to bounce back from challenges and hardship is called resilience. This quality has been shown to reduce the negative impacts of ACEs in both parents and children. Certain protective factors can boost resilience in both parents and children. These include:

• Supportive and caring relationships and social connections
• Programs that understand a person’s background and culture
• A healthy lifestyle (e.g., regular exercise, mindfulness, sufficient sleep, a healthy and nutritious diet)
• Economic support/stability for families
• Quality childcare and education early in life
  (NYS OCFS, n.d.-c)

Professionals can help reduce the effects of ACEs by supporting children and families to increase these protective factors.

RECOGNIZING PHYSICAL ABUSE

There are many possible indicators of child maltreatment or abuse, and these indicators should be viewed together, not in isolation. Similarly, each indicator must be considered in relation to the child’s current age and circumstances and in the context of their physical condition or behavior. These indicators are not all-inclusive, and some children may not demonstrate signs or symptoms of abuse or neglect.

Another important aspect to assessing for possible abuse is obtaining an explanation for the presenting concern and whether that explanation is consistent with the observed physical and behavioral indicators. Abuse or maltreatment should never be assumed.

The mandated reporter is encouraged to consider any prior experiences with the child and possible differences between past and present observations.

Any assessment must be objective and free from implicit or explicit bias.

Physical Indicators of Physical Abuse

Healthcare professionals must be alert for physical injuries that are unexplained or inconsistent with the parent or other caretaker’s explanation or the developmental state of the child. However, it is important to remember that indicators of maltreatment or abuse may not always be of a physical nature or visible to view.

BRUISING

Bruising is the most common indicator of physical child abuse, and attention to bruises can be an important factor in identifying children who are at risk of physical abuse. It is important to know both normal and suspicious bruising patterns when assessing children’s injuries. Normal bruising usually occurs in the front of the body over bony areas such as the forehead, knees, shins, and elbows.

The TEN-4-FACESp validated clinical screening tool, developed by Dr. Mary Clyde Pierce, can be used to evaluate bruises in children under 4 years of age. The tool guides the clinician to assess bruising associated with three components (regions, infants, patterns) if there is no reasonable explanation for a bruise (Pierce et al., 2021). Children who are under 4 years should not have any bruises in the areas indicated in the chart below, and infants under 4 months should have no bruises anywhere. The size of the bruise is not as important as the location.

LACERATIONS OR ABRASIONS

Typical indications of unexplained lacerations and abrasions that are suspicious include:

• On the face, lips, or mouth
• To external genitalia

BURNS

Unexplained burns include:

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

FRACTURES

Unexplained fractures may include:

• Fractures to the skull, nose, or facial structure
• Multiple or spiral fractures
• Fractures in various stages of healing
  (SD DSS, 2020)

HEAD INJURIES

Typical indications of unexplained head injuries include:

• Absence of hair and/or hemorrhaging beneath the scalp due to vigorous hair pulling
• Subdural hematoma (a hemorrhage beneath the outer covering of the brain, due to severe hitting or shaking)
• Retinal hemorrhage or detachment, due to shaking
• Whiplash or pediatric abusive head trauma (see box below)
• Eye injury
• Jaw and nasal fractures
• Tooth or frenulum (of the tongue or lips) injury

Behavioral Indicators of Physical Abuse

Careful assessment of a child’s behavior may also indicate physical abuse, even in the absence of obvious physical injury. Behavioral indicators of physical abuse include the following:

• Withdrawal
• Problems with school or work
• Illegal or violent behavior
• Abuse of others
• Suicide attempts
• Self-harm
• Poor social skills
  (Mayo Clinic, 2024)

RECOGNIZING NEGLECT

Child neglect is the most common type of child maltreatment and occurs when parents and caregivers do not provide basic needs to children such as food, shelter, education, emotional validation, and medical care. Although all families experience stress from time to time, neglect is more likely to occur in families that are dealing with multiple stressors. It is important to remember that when parents and caregivers fail to provide basic needs to children because of poverty, this is not the same as neglect.

Physical indicators of neglect include:

• Consistent hunger
• Poor hygiene (skin, teeth, ears, etc.)
• Inappropriate attire for the season
• Failure to thrive (physically or emotionally)
• Positive indication of toxic exposure, especially in newborns, such as drug withdrawal symptoms, tremors, etc.
• Delayed physical development
• Speech disorders
• Consistent lack of supervision, especially in dangerous activities or for long periods of time
• Unattended physical problems or medical or dental needs
• Chronic truancy
• Abandonment
  (Clermont County CPS, 2021)

A child may also demonstrate behavioral indicators of neglect such as:

• Begging or stealing food
• Extended stays at school (early arrival or late departure)
• Constant fatigue, listlessness, or falling asleep in class
• Alcohol or other substance abuse
• Delinquency, such as shoplifting
• Reports there is no caretaker at home
• Runaway behavior
• Habit disorders (sucking, nail biting, rocking, etc.)
• Conduct disorders (antisocial or destructive behaviors)
• Neurotic traits (sleep disorders, inhibition of play)
• Psychoneurotic reactions (hysteria, obsessive-compulsive behaviors, phobias, hypochondria)
• Extreme behavior (compliant or passive, aggressive or demanding)
• Overly adaptive behavior (inappropriately adult, inappropriately infantile)
• Delays in mental and/or emotional development
• Suicide attempt
  (Clermont County CPS, 2021; NYS OCFS, n.d.-b)

RECOGNIZING SEXUAL ABUSE

Child sexual abuse involves the coercion of a dependent, developmentally immature person to commit a sexual act with someone older. For example, an adult may sexually abuse a child or adolescent, or an older child or adolescent may abuse a younger child. A perpetrator does not have to be an adult in order to sexually abuse a child (RAINN, 2024).

The fact that sexual abuse may be carried out by a family member or friend further increases the child’s reluctance to disclose the abuse, as does shame and guilt plus the fear of not being believed. The child may fear being hurt or even killed for telling the truth and may keep the abuse secret rather than risk the consequences of disclosure. Very young children may not have sufficient language skills or vocabulary to describe what happened (Clermont County CPS, 2021; RAINN, 2024).

Child sexual abuse is found in every race, culture, and class throughout society. Girls are sexually abused more often than boys; however, this may be due to boys’—and later, men’s—tendency not to report their victimization.

Most perpetrators of child sexual abuse are people who are known to the victim. As many as 93% of children who are sexually abused under the age of 18 know the abuser. There is no particular profile of a child molester or of the typical victim. Even someone highly respected in the community—the parish priest, a teacher, or coach—may be guilty of child sexual abuse. Anyone, including parents, can be a perpetrator, and most are male.

Negative effects of sexual abuse vary from person to person and range from mild to severe in both the short and long term. Victims may exhibit anxiety, difficulty concentrating, and depression. They may develop eating disorders, self-injury behaviors, substance abuse, or suicide. The effects of childhood sexual abuse often persist into adulthood (Clermont County CPS, 2021; RAINN, 2024).

Indicators of Sexual Abuse

Physical evidence of sexual abuse may not be present or may be overlooked. Victims of child sexual abuse are seldom injured due to the nature of the acts. Most perpetrators of child sexual abuse go to great lengths to “groom” the children by rewarding them with gifts and attention and try to avoid causing them pain in order to ensure that the relationship will continue.

If physical indicators occur, they may include:

• Symptoms of sexually transmitted diseases, including oral infections, especially in preteens
• Difficulty in walking or sitting
• Torn, stained, or bloody underwear
• Pain, itching, bruising, or bleeding in the genital or anal area
• Bruises to the hard or soft palate
• Pregnancy, especially in early adolescence
• Painful discharge of urine or repeated urinary infections
• Foreign bodies in the vagina or rectum
• Painful bowel movements
  (Clermont County CPS, 2021; RAINN, 2024; NYS OCFS, n.d.-b)

Children’s behavioral indicators of child sexual abuse include:

• Unwillingness to change clothes for or participate in physical education activities
• Withdrawal, fantasy, or regressive behavior, such as returning to bedwetting or thumb-sucking
• Inappropriate, bizarre, suggestive, or promiscuous sexual behavior
• Inappropriate sexual knowledge for age
• Verbal disclosure of sexual assault
• Involvement in commercial sexual exploitation
• Forcing sexual acts on other children
• Extreme fear of closeness or physical examination
• Suicide attempts or other self-injurious behaviors
• Layered or inappropriate clothing
• Hiding clothing
• Lack of interest or involvement in activities
  (Clermont County CPS, 2021; RAINN, 2024; NYS OCFS, n.d.-b)

RECOGNIZING TRAFFICKING

The media often portrays trafficking victims as women who are in chains or have a sign written on their hands that says, “Help Me.” However, this is not what most trafficking victims look like. When victims of human trafficking present in healthcare settings, it is uncommon for them to self-disclose that they are victims. They have significant trust issues, and even when asked directly, they are not likely to disclose that they are victims. The exploiter may also accompany victims, and as with victims of domestic violence, that presence will discourage victims from making any disclosures to a clinician.

It is important for healthcare providers to ask about exploitation because up to 88% of adolescent victims of trafficking reported an encounter with a healthcare provider during the time that they were being exploited (Polaris, 2024).

Physical Signs

• Signs or a history of deprivation of food, water, sleep, or medical care
• Physical injuries typical of abuse, such as bruises, burns, cuts, scars, prolonged lack of health or dental care, or other signs of physical abuse
• Brands, scars, clothing, jewelry, or tattoos indicating someone else’s “ownership”
• Presence of sexually transmitted infections
• Pregnancy
• Possession of cell phones, jewelry, large amounts of cash, or other expensive items that appear inconsistent with the patient’s stated situation
• Substance abuse or dependence signs and symptoms
• Clothing that is inappropriate for the weather or emblematic of commercial sex
  (Polaris, 2024)

Psychological/Emotional Signs

• Fear, anxiety, depression, nervousness, hostility, flashbacks, or avoidance of eye contact
• Restricted or controlled communication or use of a third party to translate with no indicator of inability to understand English
• Inconsistencies in the history of the illness or injury
• Denial of victimization
• Attempted suicide, submissiveness, fearfulness, self-harm, or other signs of psychological abuse
• Appearing to be controlled by a third party (e.g., looking for permission to speak, not being left alone)
• Isolation from family or former friends
• Fear of employer
• Described or implied threats to self or family/friends
• History of running away
  (Polaris, 2024)

Environmental/Situational Signs

• Working and living in the same place
• Lacking the freedom to leave their working or living conditions
• Being escorted or kept under surveillance when they are taken somewhere
• Not being in control of their own money
• Having no, or few, personal possessions
• Frequently lacking identifying documents, such as a driver’s license or passport
• Indicators of being a minor in a relationship with a significantly older adult
• Not knowing their own address
• Being in possession of hotel keys
  (Polaris, 2024)

Signs in the Healthcare Setting

• Delaying seeking care for an illness
• Malnourishment
• Physical injuries consistent with long-term abuse, such as bruises in various stages of healing or signs of physical or sexual abuse
• Substance use
• Poor hygiene
• Health conditions of vulnerability such as disabilities and mental health issues
• Giving scripted answers/stories
• Minimizing abuse or injuries
• Being anxious
• Not being aware of location, date, or time of day
• Hesitating when answering questions about an injury or illness
• Symptoms related to depression or PTSD
• Presence of a third party who monitors the child’s responses, answers for them, behaves in an aggressive or verbally abusive manner, insists on filling out paperwork, or demands to remain in the room with the child
• Leaving against medical advice or seeming pressured to leave quickly
• Reporting not having a fixed address
  (Polaris, 2024)

RECOGNIZING AND RESPONDING TO VICTIMS’ DISCLOSURES

It is difficult for young children to describe abuse. They may only disclose part of what happened, or they may make an indirect disclosure such as, “My stepdad keeps me up at night.” It is important not to rush the child and to listen to their concerns so that the child feels safe and supported. If a child discloses abuse, the following actions by the healthcare professional will help the child:

• Avoid denying what the child discloses.
• Provide safety and reassurance.
• Listen without making assumptions.
• Do not interrogate.
• Limit questioning to only four queries:
  1. What happened?
  2. When did it happen?
  3. Where did it happen?
  4. Who did it? (How do you know them?)
• Do not make promises.
• Document the child’s statements using exact quotes.
• Remain nonjudgmental and supportive.
• Understand the dynamics of abuse and neglect.
• Report suspicions to the authorities.
  (Childhelp, 2021)

Interviewing for Sexual Assault

If a child or adolescent discloses sexual abuse to a trusted adult or there is cause for the adult to suspect sexual abuse, the adult should not question the child further. They should instead contact Child Protective Services or, if the child is in imminent danger, the police. These professionals have protocols in place to interview the child by a child interview specialist while police, prosecutors, and caseworkers observe.

Such forensic interviewers are trained to communicate in an age- and developmentally appropriate manner. Coordination of services with a child forensic interviewer is essential to minimize trauma and to ensure the use of evidence-based practices to listen more effectively to the child. Forensic interviewers rely on critical thinking, ethical standards, and professional judgment. They must participate in ongoing training and peer review. The American Professional Society on the Abuse of Children published updated practice guidelines for forensic interviewing in 2023 (APSAC Taskforce, 2023).

Management

A physically abused child is screened for emergent needs. Once stability has been established, the child undergoes a history and physical. ChildLine should be informed when there is a suspicion of abuse and the child may need to be seen in an in-patient facility so that lab work and imaging can be done.

A child who has been sexually abused is also evaluated for physical, mental, and psychosocial needs. Baseline testing is performed for sexually transmitted infections (STIs) for children of all ages. Pregnancy testing and empiric treatment for STIs may also be given to adolescent victims. STI prophylaxis and emergency contraception may be offered if the patient presents within 120 hours. Medication may include a regimen of non-occupational post-exposure prophylaxis (nPEP) if the patient presents within 72 hours. Evaluation at the earliest opportunity can be helpful to examine for anogenital injury and collect forensic evidence (CDC, 2021).

Photographing Evidence

Whenever there are allegations of suspected child abuse or neglect, any records of physical findings may be used as evidence at a trial. Therefore, photos, diagrams, and accurate reporting of medical examination findings are invaluable. Such documentation should use language that is not open to misinterpretation.

If photographs will be needed, it is a good idea to inform the child or adolescent and encourage them to participate in the process. Photographs are another form of medical documentation that can provide objective, visual documentation of abuse. There should be a protocol for releasing the photos after a formal request, and a chain of custody may be necessary as well.

REPORTING CHILD ABUSE AND NEGLECT

The government has a responsibility to protect children when parents fail to provide proper care and to intervene in cases of child maltreatment. The federal Child Abuse Prevention and Treatment Act (CAPTA) requires each state to have a system in place that requires certain individuals to report suspected child abuse and neglect. All states list the mandated reporters, responsibilities of institutions, standards for making reports, and how confidentiality of the reporting party is maintained.

Who Must Report Abuse?

Anyone may report suspected child abuse at any time and is encouraged to do so. Such reports are typically confidential and may be made anonymously by members of the public.

Nearly all states designate certain professions whose members are mandated by law to report child maltreatment. Typically, these individuals have frequent contact with children. Such persons may include:

• Social workers
• Teachers and other school personnel
• Physicians, nurses, and other healthcare workers
• Mental health professionals
• Child care providers
• Medical examiners or coroners
• Law enforcement officers

Some other professions include film or photograph processors, computer technicians, substance abuse counselors, probation or parole officers, and attorneys and clergy in certain circumstances. Domestic violence workers, animal control or humane officers, and court-appointed special advocates are also required to report in some states.

In more than one third of states, any person who suspects child abuse or neglect is required to report it. In most of those states, professionals who are mandated to report are also listed, but all persons who are aware of abuse are required to report.

It is important that all professionals be informed of the laws that pertain to the jurisdiction(s) of their own practice (CWIG, 2023).

What Situations Require That a Report Be Made?

State statutes vary, but generally a mandatory reporter must make a report when they suspect or have reason to believe that a child is abused or neglected. The reporter does not have to provide proof of the suspected abuse or neglect (CWIG, 2023).

(For state-by-state information on mandated reporting, see “Child Welfare Information Gateway” in the “Resources” section at the end of this course.)

How Is a Report Made?

In most jurisdictions, a telephone report should be made immediately and then followed by a written report. States often provide standardized forms for this purpose, and many jurisdictions offer electronic reporting.

Most healthcare facilities also have policies and procedures in place regarding the reporting of suspected child abuse. Healthcare professionals and other mandatory reporters must know what guidelines are in place at their place of employment as well as state mandates.

At the time of an oral telephone report, frequently to a state-subsidized 800 number, a Child Protective Services (CPS) specialist will typically request the following information:

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

A reporter is not required to know all of the above information in making a report; therefore, lack of complete information does not prohibit a person from reporting. However, information necessary to locate a child is crucial.

(See also “Childhelp National Child Abuse Hotline” in the “Resources” section at the end of this course.)

Mandatory Notification of Substance Exposed Infants

The CAPTA Reauthorization Act of 2003 contained legislation that called for mandated reporters to notify Child Protective Services when infants were identified as affected by substance abuse or withdrawal symptoms resulting from in-utero exposure to substances. The CAPTA Reauthorization Act of 2010 included additional legislation requiring that mandated reporters notify CPS for infants affected by fetal alcohol spectrum disorder (FASD). In 2016, further changes to CAPTA were made in response to the nation’s opioid epidemic, for instance, no longer specifying “illegal” in regard to substance abuse.

CAPTA also requires a plan of safe care, immediate screening, risk and safety assessment, and timely investigation for substance- and alcohol-affected infants. Safe care plans must address the affected caregiver as well as the infant. CAPTA also requires that states report data on affected infants and create and provide oversight systems to assure that safe care plans are implemented (U.S. DHHS, 2024).

HEALTHCARE PROVIDERS REQUIRED TO REPORT

The healthcare providers required to submit this notification vary by state but generally include licensed hospitals or healthcare facilities or persons who are licensed, certified, or otherwise regulated to provide healthcare services. These professions typically include physician, podiatrist, optometrist, psychologist, physical therapist, certified nurse practitioner, registered nurse, nurse midwife, physician’s assistant, chiropractor, dentist, pharmacist, and those accredited or certified to provide behavioral health services.

PLAN OF SAFE CARE

After notification of a child born affected by substance use or withdrawal symptoms resulting from prenatal drug exposure or a fetal alcohol spectrum disorder, a multidisciplinary team meets prior to the child’s discharge from the healthcare facility. The meeting informs an assessment of the needs of the child and the child’s parent(s) and immediate caregiver(s) to determine the most appropriate lead agency for developing, implementing, and monitoring a plan of safe care. Depending on the needs of the child and parents/caregivers, ongoing involvement of a county agency may not be required.

The child’s parents and immediate caregivers must also be engaged to identify the need for access to treatment for any substance use disorder or other physical or behavioral health condition that may impact the safety, early childhood development, and well-being of the child.

For the purpose of informing the plan of safe care, the multidisciplinary team may include public health agencies, maternal and child health agencies, home visitation programs, substance use disorder prevention and treatment providers, mental health providers, public and private children and youth agencies, early intervention and developmental services, courts, local education agencies, managed care organizations, private insurers, hospitals, and medical providers.

The intent of legislation that addresses substance-exposed newborns in recent years was to improve the care for these infants and families by involving CPS when the mother has a substance abuse disorder. A study by the Johns Hopkins University shows that reporting drug-exposed babies to CPS is often perceived as punitive and can be a deterrent to parents seeking treatment, prenatal care, or psychotherapy. It is important that providers are aware that in some states, substance use alone or a positive toxicology screen in a newborn is insufficient to generate a report to CPS, and there must be other identified concerns. Policymakers should try to improve guidance given to providers and find ways to help women with substance use disorder receive treatment early in pregnancy (McCourt et al., 2022).

Consequences for Failing to Report

Nearly every state imposes a penalty of a fine or incarceration for mandated reporters who willfully do not report suspected child abuse or neglect. Such mandated reporters may be charged with a misdemeanor or felony for the failure to report. In several states, mandated reporters can also be held liable by civil statutes for damages that result from their failure to report (CWIG, 2019).

Perhaps more importantly, failure to report can also lead to more serious consequences for the child and family. CPS cannot act until child abuse is identified and reported—that is, services cannot be offered to the family nor can the child be protected from further suffering.

Legal Protections for Reporters

CAPTA requires states to provide immunity from liability for individuals making good-faith reports of child abuse or neglect. States must comply with this mandate in order to be eligible for federal grants. In addition, the identity of the reporter is protected from disclosure to the alleged perpetrator (CWIG, 2023).

Mandatory reporting laws may recognize the right to maintain confidential communications between professionals and their clients, patients, or congregants. In order to provide protection to maltreated children, the reporting laws in most states and territories restrict this privilege for mandated reporters.

Among the requirements for receiving federal funding under CAPTA is that states must also preserve the confidentiality of all child abuse and neglect reports and records. This mandate protects the privacy of the child and their parents or guardians, except in certain limited circumstances. All jurisdictions have provisions that protect abuse and neglect records from public view, and many jurisdictions include specific provisions for this purpose (CWIG, 2022).

CONCLUSION

Child abuse and neglect negatively impact the health and well-being of society. Child victimization is not only a social problem but also a serious public health issue. Child abuse and neglect affect not only the victims while they are children but also shape the adults these children will become. Prevention of child abuse and neglect is a fundamental goal to create healthy children who will in turn become healthy adults.

Research on child abuse and neglect indicates that its incidence can be reduced and its harmful effects can be diminished through prevention and treatment. Individuals, communities, and society must provide safe environments for all children.

Mandated reporters are obligated to report suspected child abuse and neglect. Reporting suspected child abuse is their duty as professionals, but it is also an opportunity to help improve the health and well-being of children and take part in creating a healthier society.