Child Maltreatment Nursing CE Course

2.0 ANCC Contact Hours AACN Category B

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NY State Education Department Approval Letter

Please note: This course does not meet the Pennsylvania Board of Nursing's requirements for Child Abuse reporting. For our Pennsylvania-approved course, please click here.

If you are licensed in New York you must contact NursingCE.com's Customer Support to receive an official NYS completion certificate after you complete your purchase for the contact hours. Please contact [email protected] or call 800-683-6758 after completing the post-course assessment.

By the completion of this activity, the nurse will be able to:

  1. Define child maltreatment, child abuse, and child neglect as recognized by the laws of New York State. 
  2. Consider the incidence and prevalence of child maltreatment and abuse in New York and the US.
  3. Identify the risk factors that contribute to child maltreatment and abuse.
  4. Recognize the behaviors and physical indicators of child maltreatment and abuse.
  5. Discuss mandatory reporting of suspected cases of child maltreatment and abuse.
  6. Review the legal protection for mandatory reporting and consequences for failing to report suspected child maltreatment and abuse.

Child Maltreatment and Abuse

First Lady Hilary Clinton noted that "it takes a village to raise a child" in her 1996 book, bringing attention to the enormous responsibility of raising children (Clinton, 1996). The government, healthcare workers, teachers, family, friends, and parents are all partners in the growth, development, and safety of children. In a perfect world, all these components would work together for the good of the child, but statistics prove that children are often victims of maltreatment and abuse. Children have a right to protection from harm, and when persons who are legally responsible fail to deliver proper care, the government has laws that protect them. Laws protect parents' ability to raise their children as they view appropriate, but also hold them accountable for maintaining the child's safety and protecting them from abuse or neglect. The US Constitution gives this right to families in the 14th Amendment, which states, “no state shall deprive any person of life, liberty, or property without due process of law.” The US Supreme Court also defined "liberty," in the 14th Amendment as freedom from bodily restraint and the right of the individual to establish a home and raise their children (Laws, 2019).  While the US Constitution updated the parental rights to have children, there were no laws to protect children initially. The first laws protecting children were established in 1874 through a nongovernmental agency in New York, The Society for the Prevention of Cruelty to Children (NYSPCC). Federal child protection did not occur until 1912 when Congress noted that the government must assure children had protection from abuse. They formed the Children's Bureau, which focused on improving the lives of children and their families (Children's Bureau, 2019b).

The goal of governmental programs and child abuse laws are to develop and maintain a comprehensive child protection system that supports families, children, and their communities to prevent the occurrence of maltreatment (Prevent Child Abuse America, 2020b). New York passed its first child protective services act in 1973, which mandated reporting suspected child abuse and a 24-hour, seven day per week registry to receive reports (New York State Governor's Office, 2011). The first federal law to protect children and improve the response to child abuse and neglect was The Child Abuse and Treatment Act of 1974, which was not enacted until the year 2000. This act authorized law enforcement to implement child abuse and neglect laws and promoted child abuse prevention programs. It also developed a system to track suspected child abuse offenders (US Department of Health and Human Services [HHS], 2014).  In 2011, the child abuse and prevention law in New York was updated along with an expanded list of mandatory reporters (New York State Governor's Office, 2011). The Child Victim's Act, providing alternatives for justice for victims of child abuse or child sexual abuse, was enacted to allow for civil charges against perpetrators (New York State Governor’s Office, 2019). Laws guiding the New York Child Protective Services today include Title 6 of the Social Services Law (specifically sections 411-428) and Article 10 of the Family Court Act (specifically section 1012; New York State Office of Children and Family Services [OCFS], n.d.b). This module will focus on the New York State Consolidated Laws and mandatory child abuse identification and reporting for healthcare professionals.

Definitions

The New York State Section 412 of the Social Services Law and Section 1012 of the Family Court Act defines an abused child as anyone under 18 years of age whose parent or another adult legally responsible for their care commits any of the following: 

“(i) inflicts or allows to be inflicted upon such child physical injury by other than accidental means which causes or creates a substantial risk of death, or serious or protracted disfigurement, or protracted impairment of physical or emotional health or protracted loss or impairment of the function of any bodily organ, or

(ii) creates or allows to be created a substantial risk of physical injury to such child by other than accidental means which would be likely to cause death or serious or protracted disfigurement, or protracted impairment of physical or emotional health or protracted loss or impairment of the function of any bodily organ, or

(iii) (a)commits, or allows to be committed an offense against such child defined in Article 130 of the penal law;  (b) allows, permits or encourages such child to engage in any act described in sections 230.25 , 230.30 , 230.32 and 230.34-a of the penal law (promoting prostitution in the first, second or third degree);  (c) commits any of the acts described in sections 255.25 , 255.26 and 255.27 of the penal law (incest);  (d) allows such child to engage in acts or conduct described in Article 263 of the penal law (sexual performance by a child); or (e) permits or encourages such child to engage in any act or commits or allows to be committed against such child any offense that would render such child either a victim of sex trafficking or a victim of severe forms of trafficking in persons pursuant to 22 USC. 7102 as enacted by public law 106-386 or any successor federal statute” (New York Consolidated Laws, Family Court Act - FCT § 1012, n.d.b, subsection e; Social Services Law - SOS § 412, n.d.a).

The term child maltreatment refers to the quality of care any child receives from the person responsible for their care. Maltreatment can occur when the responsible person harms the child, places the child in imminent danger through failure to deliver the minimum level of care, or fails to provide the child with shelter, food, clothing, medical care, or education when financially able to do so. Abandonment or failure to provide supervision is further evidence of maltreatment (OCFS, n.d.b).

Child abuse refers to the most severe type of harm to children. A parent or responsible individual(s) inflicts or creates a significant risk of severe physical injury or commits sexual abuse acts against the child as defined by the New York laws above (OCFS, n.d.b).

A neglected child is a child under 18 years of age:

“(i) whose physical, mental or emotional condition has been impaired or is in imminent danger of becoming impaired as a result of the failure of his parent or another person legally responsible for his care to exercise a minimum degree of care

  (A) in supplying the child with adequate food, clothing, shelter or education in accordance with the provisions of part one of article sixty-five of the education law, or medical, dental, optometrical or surgical care, though financially able to do so or offered financial or other reasonable means to do so, or, in the case of an alleged failure of the respondent to provide education to the child, notwithstanding the efforts of the school district or local educational agency and child protective agency to ameliorate such alleged failure prior to the filing of the petition; or

  (B) in providing the child with proper supervision or guardianship, by unreasonably inflicting or allowing to be inflicted harm, or a substantial risk thereof, including the infliction of excessive corporal punishment; or by misusing a drug or drugs; or by misusing alcoholic beverages to the extent that he loses self-control of his actions; or by any other acts of a similarly serious nature requiring the aid of the court; provided, however, that where the respondent is voluntarily and regularly participating in a rehabilitative program, evidence that the respondent has repeatedly misused a drug or drugs or alcoholic beverages to the extent that he loses self-control of his actions shall not establish that the child is a neglected child in the absence of evidence establishing that the child's physical, the mental or emotional condition has been impaired or is in imminent danger of becoming impaired as set forth in paragraph (i) of this subdivision; or 

  (ii) who has been abandoned, in accordance with the definition and other criteria set forth in subdivision five of section three hundred eighty-four-b of the social services law, by his parents or another person legally responsible for his care.” (New York Consolidated Laws, Family Court Act - FCT § 1012, subsection f, n.d.b). 

The subject of the report is “any parent of, guardian of, or other person eighteen years of age or older legally responsible for, as defined in subdivision (g) of section one thousand twelve of the family court act, a child reported to the statewide central register of child abuse and maltreatment who is allegedly responsible for causing injury, abuse or maltreatment to such child or who allegedly allows such injury, abuse or maltreatment to be inflicted on such child; or a director or an operator of, or employee or volunteer in, a home operated or supervised by an authorized agency, the office of children and family services, or in a family day-care home, a day-care center, a group family day care home, a school-age child care program or a day-services program who is allegedly responsible for causing injury, abuse or maltreatment to a child who is reported to the statewide central register of child abuse or maltreatment or who allegedly allows such injury, abuse or maltreatment to be inflicted on such child” (New York Consolidated Laws, Social Services Law - SOS § 412, subsection 4, n.d.a).

Epidemiology

According to the HHS (2018), over 3,534,000 children were subjects of investigation, and approximately 678,000 determined to be victims of maltreatment, increasing from 674,000 in 2017. Of these, neglect was involved with 60.8%, physical abuse with 10.7%, sexual abuse with 7.0% of the victims, and over 15% were victims of two or more types of maltreatment. Due to abuse and neglect, child fatalities increased in 2018 to an estimated 1,770 children, up from 1,710 in 2017 (Administration for Children & Families, 2020). The 2018 Bright Spots Child Protective Services (CPS) Report noted that 45.9 children out of every 1,000 (203,127 cases statewide) were named as an alleged victim of abuse or maltreatment, and 15.2 out of every 1,000 (67,124 cases statewide) children were confirmed as a victim in one or more CPS reports (OCFS, 2018a). 

The following are national statistics on child abuse:

  • In 2017, approximately 71% of deaths related to abuse were under three years of age (Children's Bureau, 2019a).
  • In 2017, parents either individually or with another parent were responsible for 80.1% of child abuse or neglect fatalities, with 30.5% committed by the mother alone. 15.5% were committed by the father alone, and 20.2% by both parents. Relatives, a partner of one of the parents, or childcare providers were responsible for 15.2% of child fatalities, and unknown perpetrators were responsible for 4.7% of the total deaths in 2017 (Children's Bureau, 2019a).
  • The estimated cost of child abuse and maltreatment in 2015 in the US was $2 trillion (Peterson et al., 2018).

The Centers for Disease Control and Prevention (CDC, 2020b) reports that 1 in 7 children have experienced abuse across the US in the past year, and children who live in poverty experience abuse rates five times higher than their higher socioeconomic counterparts. The lifetime economic burden associated with child abuse was estimated at over $428 billion in 2015 and comparable to high-cost diseases such as type 2 diabetes and stroke (CDC, 2020b). 

New York State statistics on child abuse include:

  • The total verified deaths related to child maltreatment and abuse in 2017 were 87 across the entire state of New York. There were 304 deaths in children that were reviewed by OCFS in 2017, and 40 were noted as undetermined/unknown due to insufficient evidence to classify otherwise. 
  • In 2017, 85 deaths were due to unsafe sleep environments for children under 12 months of age and not included in those caused by abuse or maltreatment. 
  • Child abuse occurred amongst people of all socioeconomic levels, cultures, ethnicities, and all levels of education of the perpetrator (OCFS, 2018b).

Risk Factors

As noted by the CDC (2019), the risk factors for abuse in children include:

  • The child is four years old or younger, particularly premature babies, or
  • The child has special needs, either emotionally or physically, that can increase the caregiver burden (CDC, 2019).

Risk factors for a family or caregiver to abuse or neglect children include:

  • Violence: domestic violence in the home including abusive, coercive, forceful, or threatening acts or words by one member of the household to another (the caregiver may be the perpetrator or victim of the domestic abuse), or other violence, including a parent’s personal history of child abuse or neglect,
  • Financial problems within the family can lead to the inability to provide appropriate resources to meet the minimum needs of the children and family,
  • Alcohol use disorder (compulsive and chronic use of alcohol), 
  • Substance use disorder (SUD, the chronic, compulsive use of either prescription or illegal drugs),
  • Parenting stress or negative interactions/parent-child relationships,
  • Divorce, family break-ups, or social isolation,
  • A parent’s lack of understanding regarding the needs or development of their child, 
  • A lack of parenting skills,
  • Family mental health issues including depression,
  • Specific parent characteristics including young age, low education, single parenthood, a high number of dependent children, or low income, or
  • Transient, non-biological caregivers in the home such as the mother’s male partner (CDC, 2019; HHS, 2017).

Community risk factors that contribute to child maltreatment include:

  • Violence within the community, or
  • Neighborhood disadvantages including high poverty rates, residential instability, high unemployment rates, poor social connections, and a high density of alcohol outlets (CDC, 2019).

Protective factors or those that decrease the risk of child maltreatment and abuse include:

  • Supportive family environments and social networks,
  • Basic needs met including housing, food, and safety,
  • Parenting skills education readily available,
  • Stability in family relationships,
  • Parental education and employment, 
  • Access to healthcare and social services, or
  • Caring adults outside the home serving as parental role models or mentors (CDC, 2019).

Indicators of Abuse/Maltreatment

Physical abuse is a "non-accidental injury to a child by a parent or caretaker…and may include frequent and unexplained bruises, burns, cuts or injuries, and the child may be overly afraid of the parent's reaction to misbehavior" (Prevent Child Abuse: New York, n.d., para. 1). Differentiating between accidental injuries and purposeful physical injury and abuse can be challenging for nurses. Indicators of deliberate physical injuries or abuse include:

  • Human bite marks,
  • Fractures in multiple stages of healing or a history of repeated fractures,
  • Bedwetting in previously toilet-trained children,
  • Repeated ED visits due to physical injuries,
  • A caregiver’s report that is inconsistent with the child’s explanation of the injury,
  • Bruising or injuries on areas of the body that would not typically be visible through clothing such as the chest, torso, or buttocks,
  • Bruising, burns, or welts with specific shapes such as a belt buckle, handprint, round burns from cigarettes, or those around the wrist or ankles indicating that the child was restrained and struggling,
  • Multiple bruises or other injuries in various stages of healing, or
  • Injuries to the eyes or both sides of the head or body, as most accidental injuries are unilateral (OCFS, n.d.c).

It is important to remember that abuse is not always limited to hitting or injuring, resulting in bruising or visible injuries. Other acts of physical abuse can include burns such as with hot water, holding a child underwater, throwing objects at children, using an object such as a paddle, belt, cord, limb from a tree (switch), or shoes to beat a child, or physically restraining a child as a form of discipline (OCFS, n.d.c). 

Pediatric Abusive Head Trauma

Pediatric abusive head trauma is the result of parental abuse and was previously termed shaken baby syndrome. It is a severe form of child abuse that may end with serious brain injury or death. This injury often occurs due to an infant's prolonged crying, causing the parent or caregiver to become angry, shaking or throwing the child down, and ultimately causing a head injury. Bleeding can occur around the brain or on the internal layer of the eyes. Pediatric abusive head trauma is the leading cause of death in children under five years of age in the US, with babies under a year old at the highest risk, and accounts for more than one-third of all child maltreatment deaths in the US. Long-term consequences of pediatric abusive head trauma can include vision problems, developmental delays, physical disabilities, and hearing loss (CDC, 2020a). For more information on this topic, please see the NursingCE course entitled Pediatric Abusive Head Trauma.

Sexual Abuse

Sexual abuse of a child occurs when a "parent or caretaker commits a sexual offense against a child or allows a sexual offense to be committed such as rape, sodomy, engaging a child in sexual activity, engaging a child in, or promoting a child's sexual performance" (Prevent Child Abuse: New York, n.d., para. 5). A child who is a victim of sexual abuse may exhibit sexual behavior beyond the child's age or may have a change in toileting habits, such as frequent urination or difficulty with defecation. The child may also have itching, pain, bleeding, or bruising in the genital area. Other symptoms of sexual abuse may include:

  • Sexually transmitted disease symptoms,
  • Pain or discomfort when trying to sit or walk,
  • Sexual victimization of other children, or
  • Verbalization or actions of age-inappropriate knowledge of sexual acts or information (OCFS, n.d.d).

The child may describe the actions or may act them out, although they are commonly threatened or intimidated into keeping the activity secret (OCFS, n.d.d). Sexual abuse is not limited to touching or penetrating the child. It can also include acts intended to arouse the abuser sexually (The National Child Traumatic Stress Network [NCTSN], n.d.). Other acts considered sexual abuse involve:

  • Sexual interactions between two children or an adult and child,
  • Fondling,
  • Voyeurism (looking at a child’s naked body),
  • Masturbation in the presence of a minor or forcing the minor to masturbate,
  • Exposing oneself to a minor (exhibitionism),
  • Text messages, online interactions, or sexually suggestive phone calls,
  • Sex trafficking,
  • Pregnancy,
  • Producing, owning, or sharing pornographic images, movies, or online materials of children, or 
  • Any sexual conduct that is harmful to a child’s emotional, mental, or physical welfare (NCTSN, n.d.).

Behavioral indicators of sexual abuse in children may include regression to earlier developmental stages such as bedwetting or refusal/reluctance to change clothes in front of others (i.e., gym class). The child may refuse to participate in sports or otherwise entertaining activities, they may withdraw from friends and family, and have unusual or sophisticated knowledge of sexual behaviors. Other symptoms may include anxiety, anger, depression, sexualized behaviors or promiscuity in older children, internalized symptoms (i.e., upset stomach, headache), or more nondescript symptoms. Some children may not exhibit any indication that they have been exposed to sexual abuse, making recognition by the healthcare provider more difficult (Schaefer et al., 2018).

Child sex trafficking is the "recruitment, harboring, transportation, provision, obtaining, or advertising of a minor child for a commercial sex act, which involves the exchange of anything of value, such as money, drugs, or a place to stay, for sexual activity" (The National Center for Missing or Exploited Children, [NCMEC] n.d., para. 1). Any child can be targeted for sex trafficking, but the NCMEC (n.d.) lists the following groups as being especially vulnerable: 

  • Runaway or missing children;
  • Children with a history of abuse, including sexual abuse, and particularly if the child was removed from the home after the event;
  • A child who is involved with government systems such as the foster system, child protective services, or the courts;
  • Children with SUD or those who live in a household with persons with SUD; or 
  • Children identifying as LGBTQ whose families disapprove of their lifestyle that have been kicked out of their home.

In 2018, approximately 23,000 children were considered runaways, and 1 in 7 were likely the victim of sex trafficking. The average age of runaways is 15 years. There are many indicators of sex trafficking in children, but no single indicator confirms that a child is a victim of trafficking. The NCMEC (n.d.) lists several red flags, both behavioral and physical, that healthcare providers should be aware of when caring for children.

Behavioral and physical indicators could include:

  • A significant change in behavior, such as increased use of technology or a new group of friends;
  • A child who allows others to talk for them, avoids answering questions when asked, or looks to others when asked a question;
  • A child who seems scared, resistant, argumentative, or may appear coached with responses to law enforcement;
  • A child who lies about their age or identity; 
  • A child who uses terminology that is specific to child trafficking, such as trick, the game, or the life,
  • A child who is preoccupied with obtaining money; 
  • A child with several cell phones or electronic devices;
  • A child with no ID, or an ID in someone else’s possession;
  • A child with large amounts of cash or pre-paid credit cards;
  • Multiple children present with unrelated adults;
  • A child with unexplained sexual paraphernalia such as condoms, lubricant, etc.; 
  • A child with hotel room keys, receipts, or other items from hotels;
  • A child who refers to travelling to other cities or states, does not typically live in their current location, or cannot recite their existing travel plans or location;
  • An older boyfriend or girlfriend present that appears to control the child;

A child that is recovered or found at a truck stop, hotel, or strip club;

  • A child with items or an appearance that is not congruent with their current situation, such as a homeless child with new clothes, shoes, or expensive electronics;
  • A child with a notebook or slips of paper with names, phone numbers, addresses, and dollar amounts;
  • A child who talks about online classified ads or escort websites;
  • A child who talks about traveling opportunities and jobs such as modeling, singing, dancing, or acting;
  • A child with specific tattoos or burn marks, considered branding;
  • A child with unaddressed medical issues that presents to an ED or clinic without an adult, or with an adult that is not related and appears overly controlling;
  • A child who may not identify as a victim and may resist help from others even when offered (NCMEC, n.d.). 

The federal Preventing Sex Trafficking and Strengthening Families Act was signed into law in 2014 with two purposes; those are "to protect and prevent at-risk children and youth from becoming victims of sex trafficking and to improve the safety, permanency, and well-being outcomes of children and youth in the child welfare system" (OCFS, 2015, p. 2). New York State laws reflect the federal focus on decreasing the sex trafficking of children and improving the foster care system, including a Bill of Rights for children in Foster Care (OCFS, 2015).

Emotional Abuse

Prevent Child Abuse New York (n.d.) identifies emotional abuse as “parents' or caretakers' acts or omissions that cause or could cause serious conduct, cognitive, affective, or other mental disorders such as torture, close confinement, or the constant use of verbally abusive language. Emotional abuse includes emotional neglect, [which is] withholding physical and emotional contact to the detriment of the child's normal emotional or even physical development” (para. 7). Emotional abuse can cause damage to a child's developing brain. It can lead to long-term learning difficulties, increased risk of mental health issues, and problematic behaviors or acting out. Emotional abuse can be much more challenging to recognize than other types of abuse. It may be subtle at times and seem a part of a particular parenting style (Prevent Child Abuse America, 2020a). However, the actions become abuse if there are ongoing patterns of behaviors that include any of the following:

  • Rejection of a child wherein the caregiver refuses to recognize the child’s worth and their needs;
  • Isolation, or cutting a child off from typical social experiences such as friendships, making the child believe they are alone in the world;
  • Terrorizing a child, creating an atmosphere of fear, or bullying a child, making them feel the world is hostile;
  • Ignoring a child or depriving them of essential stimulation and responsiveness;
  • Corrupting a child, or encouraging the child to engage in destructive or antisocial behaviors that are not socially appropriate; 
  • Verbally assaulting a child by humiliating them with name-calling, shaming, or sarcasm that injures the child emotionally;
  • Over-pressuring a child or having expectations that are beyond the child’s ability to achieve (Prevent Child Abuse America, 2020a).

The causes of emotional abuse are multifaceted. The child, parent, community, or society may be involved at several levels. For example, a parent could have a mental illness such as depression or SUD, or the child may have a disability such as dyslexia. The parents may be upset about the child's school performance, and begin to shame, verbally assault, or respond to them with negativity. Emotional abuse can lead to depression, low self-esteem, separation from family, troubled relationships, or a lack of empathy for others. Emotional abuse may lead to more lifelong trauma than physical abuse (Prevent Child Abuse America, 2020a).

Child Neglect

Child neglect is the “failure of a parent or caretaker to provide needed food, clothing, shelter, medical care, or supervision to the degree that the child’s health, safety, and well-being are threatened with harm” (New York City: Administration for Children’s Services, [NYCACS] n.d., para. 3). Examples of neglect might include: 

  • A child's educational needs are not met by either keeping the child at home during school time for unexcused reasons or failure to follow-up with a child's educational needs after school outreach to the caregiver;
  • Adequate clothing, food, or shelter is not provided;
  • Adequate medical or mental healthcare is not provided;
  • Adequate supervision is not provided, such as being left home alone without supervision;
  • A child is subjected to fear, verbal terror, extreme criticism, or humiliation;
  • A child has corporal punishment applied to the point of physical or emotional harm;
  • A child is exposed to family violence;
  • A child is in the presence of keeping, manufacturing, or selling drugs, or is given drugs by the caregiver; or
  • A parent or caregiver who uses drugs and is therefore incapable of caring for the child (NYCACS, n.d.).

Signs of each type of neglect will be unique. For instance, if a child does not have adequate food, they may be severely underweight for their age and height. It is not uncommon for multiple types of neglect to occur simultaneously. Some general signs of child neglect are:

  • Inappropriate growth for age;
  • Weight gain or obesity;
  • Poor hygiene (dirty hair, skin, or body odor);
  • Inappropriate clothing, or lack of clothing and supplies for physical needs;
  • Extreme fatigue or falling asleep in class;
  • Demanding constant attention or affection in school or elsewhere;
  • Hiding food for later or for siblings;
  • Taking food or money without permission;
  • A lack of appropriate dental, medical, or mental healthcare or failure to follow-up (Mayo Clinic, 2018).

SUD in parent(s) or caregiver(s) often contributes to the neglect or abuse of children. For instance, the child may ingest drugs accidentally, or the caregiver may be too impaired to adequately care for the child, leading to neglect. At times, older children are responsible for younger siblings and are unable to provide adequate care. Healthcare providers should be aware of the possibility of neglect and respond appropriately (Mayo Clinic, 2018).

Munchausen Syndrome by Proxy

Munchausen syndrome by proxy (MSBP) is a serious form of child abuse involving an intentional production of illness in another person to assume the sick role by proxy. The proxy is usually a mother who intentionally makes a child sick or fabricates symptoms to gain attention. Diagnosis and treatment of this health disorder are complicated. Victims are typically under six years of age, and the cases are usually undiagnosed; MSBP wastes medical services and can lead to significant morbidity and mortality in the children. Invasive diagnostic testing or treatments are often ordered, and the caregiver fabricates symptoms for various dysfunctional reasons. In a case study by Gehlawat et al. (2015), a father and uncle brought in a 9-year-old boy who presented with complaints of "fit-like episodes and hematemesis for one year." The child appeared normal, labs and other diagnostics including an upper GI endoscopy, fiberoptic laryngoscopy, and bronchoscopy were all unremarkable. The child had two episodes of "fit-like seizures," as reported by nursing, and two episodes of hematemesis, and each time the father collected samples which he presented to the doctors. The samples were sent to the lab with no clotting for two to three days; the samples did not contain blood. Eventually, the child was separated from his father and uncle, placed in a pediatric psychiatric unit, and his mother remained at his side. There were no further behavioral or symptomatic issues, and the child finally admitted his father gave him betadine before obtaining the emesis. The mother admitted to the doctors that her family was going through a difficult time and having financial issues. She was working, while the father and uncle were home with nothing to do. She felt their dysfunctional family situation lead his father to fabricate her son's illness (Gehlawat et al., 2015). MSBP is a serious mental illness, and abusers may participate in the behavior for various reasons, including attention-seeking, manipulation, satisfaction from deceiving others, or gaining a sense of control. The prognosis for the child depends on the severity of the damage done by the abuser (American Academy of Family Physicians, 2018).  

Mandatory Reporting

Nurses should be familiar with the policies and procedures in their workplace that are based on the laws in the state they are working in. In New York State, the laws direct how to handle suspected child abuse or maltreatment. If an organization's policies and procedures are not aligned with the state laws and directives, the nurse is still obligated to follow the law. If the nurse fails to report suspected abuse, they are subject to prosecution for neglect or omission of duty. The New York State Office of Children and Family Services maintains the Statewide Central Registry for Child Abuse and Maltreatment (SCR), also known as the "hotline" for reporting suspected or actual abuse and maltreatment according to the Social Services Law (OCFS, n.d.e).

This hotline is available 24-hours per day, seven days per week for mandated reporters and the general public. After a call comes into the SCR, local CPS is contacted to initiate an investigation and determine if there is a previous history of child abuse or maltreatment reports. The local CPS will initiate an investigation within 24 hours. The reporter must complete and sign a written report within 48 hours of the initial phone call to the hotline and mail this to the local CPS office. The caseworker may take the child into protective custody if the child is in danger. CPS has 60 days to determine if the report is indicated or unfounded. The written report may become part of future court proceedings and should be thoroughly completed. The form should include all children in the household, the basis of suspicion, any medical examination information, photographs, radiographs, and any images obtained during the child's assessment. Any information from the child or parent should be explicitly stated and accurately quoted. Appropriate medical care should be provided during the visit and documented in the report. Nurses are not required to notify the parents or other legally responsible caregivers of the child before or after the report to SCR. It is possible that alerting parents or caregivers could jeopardize the child’s welfare and hinder the investigation (OCFS, 2019). Nurses must report suspected child abuse and maltreatment and are considered mandated reporters. Additional mandated reporters include: 

  • Medical and hospital personnel,
  • School officials,
  • Social service workers,
  • Childcare workers,
  • Residential care workers and volunteers, or
  • Law enforcement personnel (OCFS, n.d.e).

The standards for making a report per the Social Services Law - SOS § 413 are as follows:

“A report is required when the reporter has reasonable cause to suspect:

  • A child coming before him or her in his or her professional or official capacity is an abused or maltreated child. 
  • The parent, guardian, custodian, or another person legally responsible for the child comes before the reporter and states from personal knowledge facts, conditions, or circumstances that, if correct, would render the child an abused or maltreated child” (Social Services Law - SOS § 413, subsection 1).

Failure to report suspected abuse could result in severe consequences for the child. Nurses who fail to report suspected child abuse are at risk of a Class A misdemeanor and subject to criminal penalties and can be sued in civil court for monetary damages that may arise from harm caused by the failure to make the report to the SCR (OCFS, 2019). 

Legal Protections for Mandatory Reporting

Nurses who are on duty are required to report any suspicion of abuse. If a nurse is off duty and suspects child abuse while not in their professional capacity, they are not legally obligated to report the abuse, but still have a moral obligation to report. Reasonable cause is based on the nurse's professional training and experience, or observation or suspicions that imminent danger of harm by a caregiver to a child exists. New York State law protects the nurse and provides immunity from liability for mandated reporting. The Social Services Law assures confidentiality for mandated reporters and all sources of maltreatment or abuse reports. Reports and all associated information may be shared with police, court officials, and district attorneys under certain circumstances. When reports are made in good faith, out of sincere concern for the good of the child, the reporter is immune from criminal or civil liability. Section 413 of the Social Services Law specifies that "no medical or other public or private institution, school, facility, or agency shall take any retaliatory personnel action against an employee who made a report to the SCR" (Social Services Law - SOS § 413, subsection 1). 

Conclusion

Adverse experiences in childhood not only impact the child's mental and physical development but also impact future violence victimization and perpetration. Abuse and maltreatment affect a child's lifelong mental and physical health and opportunities. Through early intervention and identification, nurses can protect children from further harm and give the entire family an opportunity to live a life with safe, stable, and nurturing relationships that extend to future generations (CDC, 2020b). 


References

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