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Child Maltreatment Nursing CE Course

2.0 ANCC Contact Hours

About this course:

The purpose of this 2-hour course is to ensure nurses understand the New York State (NYS) laws about child maltreatment and their role in identifying and reporting potential cases of maltreatment.

Course preview

If you are licensed in New York State or applying for a New State license, please reach out to our support team at [email protected] for your official NYS completion certificate. 

Disclosure Form

The purpose of this 2-hour course is to ensure nurses understand the New York State (NYS) laws about child maltreatment and their role in identifying and reporting potential cases of maltreatment. 

After this activity, learners will be prepared to:

  • Define child maltreatment, child abuse, and child neglect as recognized by NYS laws
  • Consider the incidence and prevalence of child maltreatment and abuse in NYS and the US
  • Identify the risk factors that contribute to child maltreatment and abuse
  • Recognize the behaviors and physical indicators of child maltreatment and abuse
  • Discuss mandatory reporting of suspected cases of child maltreatment and abuse
  • Review the legal protection for mandatory reporting and consequences for failing to report suspected child maltreatment and abuse

The government, healthcare workers, teachers, family, friends, and parents are all partners in children's growth, development, and safety. In a perfect world, all these components would work together for the good of each child, but statistics demonstrate that children are often victims of maltreatment and abuse. Children have a right to protection from harm, as reflected in current legal standards. When persons who are legally responsible for children fail to deliver proper care, legal consequences are imposed. Laws protect caregivers' ability to raise their children as they view appropriate and hold them accountable for maintaining each child's safety and protecting them from abuse or neglect. The US Constitution outlines this right to families in the 14th Amendment, “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 each individual to establish a home and raise their children (Laws, 2020). 

While the US Constitution noted the parental right 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 determined that the government must ensure children were protected from abuse. Congress formed the Children's Bureau, which has focused on improving the lives of children and their families (Children's Bureau, 2021).

The goal of governmental programs and child abuse laws is 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, n.d.-a). New York passed its first child protective services act in 1973, which mandated reporting suspected child abuse and a 24-hour, 7-day-per-week registry to receive reports. 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 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 to include an expanded list of mandatory reporters. The Child Victim's Act, providing alternatives for justice for victims of child abuse or sexual abuse, was enacted to allow civil charges against perpetrators. 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.-a, 2021). This module will focus on the NYS Consolidated Laws and mandatory child abuse identification and reporting for healthcare professionals.

Definitions

In NYS, an abused child is defined as anyone under 18 years of age who experiences any of the following from a caregiver or another adult legally responsible for their care (New York Consolidated Laws, Family Court Act - FCT § 1012, n.d., subsection e; New York Social Services Law - SOS § 412, n.d.): 

  • “(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.” 

Child maltreatment refers to the quality of care any child receives from the person responsible for their care. Maltreatment can occur when a responsible person harms a child, places a child in imminent danger through failure to deliver the minimum level of care, or fails to provide a 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.-a).

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

A neglected child is a child under 18 years of age (New York Consolidated Laws, Family Court Act - FCT § 1012, subsection f, n.d.):

  • “(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 s

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upervision 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.” 
  • 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 daycare home, a daycare 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 Social Services Law - SOS § 412, subsection 4, n.d.)Epidemiology

    According to the HHS (2020), over 3.9 million children were subjects of investigation, and approximately 618,000 were determined to be victims of maltreatment, decreasing from 678,000 in 2018. This number equates to a victim rate of 8.4 per 1,000 children. Of these, neglect was experienced by 76.1%, physical abuse by 16.5%, sexual abuse by 9.4%, and multiple types of maltreatment by over 15%. Due to abuse and neglect, child fatalities increased in 2020 to an estimated 1,750 children, a rate of 2.38 per 100,000 children. Of these child fatalities, 46.4% were younger than 1 year. Boys have higher fatality rates (2.99 per 100,000 boys) than girls (2.05 per 100,000 girls). African American children have a 3.1-times greater fatality rate than Caucasian children and a 3.6-times greater rate than Hispanic children (Administration for Children and Families, 2020).

    According to the Centers for Disease Control and Prevention (CDC, 2021d), 1 in 7 children has experienced abuse across the US in the past year. Children who live in poverty experience abuse rates 5 times higher than their higher-socioeconomic counterparts. The lifetime economic burden associated with child abuse was estimated at over $428 billion in 2015 and is comparable to high-cost diseases such as type 2 diabetes and stroke (CDC, 2021d). 

    The following are additional national statistics on child abuse (Administration for Children and Families, 2020; Child Welfare Information Gateway, 2021):

    • In 2019, approximately 70.3% of deaths related to abuse involved children under 3 years of age.
    • Children under 1 year of age have the highest victimization rate at 25.1 per 1,000 children nationwide. 
    • Girls have a higher victimization rate (8.9) than boys (7.9) per 1,000 children. 
    • Native American or Alaska Native children have the highest victimization rate (15.5), and African American children have the second-highest rate (13.2) per 1,000 children. 
    • In 2019, parents—either individually or with another parent—were responsible for 79.7% of child abuse or neglect fatalities, with 29.2% committed by the mother alone; 14.2% were committed by the father alone, and 22.6% involved both parents. Relatives, a partner of a parent, or childcare providers were responsible for 16.6% of child fatalities, and unknown perpetrators caused 3.7% of child abuse deaths in 2019.

    The 2018 Bright Spots Child Protective Services (CPS) Report noted that 45.9 children of every 1,000 (203,127 cases statewide) were named as an alleged victim of abuse or maltreatment, and 15.2 of every 1,000 (67,124 cases statewide) children were confirmed as a victim in at least one CPS report in New York (OCFS, 2018). NYS statistics on child abuse include the following (OCFS, 2020):

    • The total verified deaths related to child maltreatment and abuse in 2018 were 89 across New York. There were 326 deaths of children that OCFS reviewed in 2018, and 70 were undetermined/unknown due to insufficient evidence to classify otherwise. 
    • In 2017, 73 deaths were due to unsafe sleep environments for children under 12 months of age and were not included in those caused by abuse or maltreatment. 
    • Child abuse occurred amongst people of all socioeconomic levels, cultures, ethnicities, and levels of education of the perpetrator.

    Long-Term Effects

    Child abuse and neglect leave a long-lasting impact on survivors; Figure 1 highlights the potential concerns with adverse childhood experiences (ACE) over a lifetime:

    Abuse and neglect cause physical changes in children's brains. Poor impulse control, an inability to experience pleasure, or antisocial behaviors can stem from previous abuse and neglect. A child that lives in an unstable environment with constant stress or violence is more likely to develop learning disabilities, anxiety, or even physical illness, including cancer, diabetes, and early death. Children exposed to violence are more likely to have poor school performance and develop substance abuse disorders and a variety of emotional and physical health concerns. In addition, they may have difficulty with interpersonal relationships with peers in the present and the future (Bellis et al., 2017). 

    Studies have shown a direct correlation between psychopathic traits of adults and exposure to violence as a child (Bellis et al., 2017; Dargis & Koenigs, 2017). Exposure to violence in children (under the age of 18) was assessed during the National Survey of Children's Exposure to Violence, or NatSCEV, a joint effort of the CDC and the US Department of Justice. Most (67.5%) of respondents had witnessed violence or abuse directly or indirectly in the last year (when a crime was included in the definition of violence or abuse). Even more troubling was that 41% had multiple exposures in the past year, which could be trauma-inducing if not identified and adequately addressed. Up to 10% of the respondents reported six or more direct exposures in the last year, making them highly vulnerable to adversities and distress, or "polyvictims." Exposure to violence can cause many of the same emotional and psychological effects as direct maltreatment if not managed appropriately. In addition, NatSCEV found that exposure to violence increased the risk of other types of violence/maltreatment as well (Finkelhor et al., 2015).

    Risk and Protective Factors

    Certain characteristics (direct or indirect) are associated with a greater likelihood of child abuse and maltreatment (CDC, 2021c). These risk factors occur in 3 main categories: (a) risk factors for victimization, (b) risk factors for perpetration, and (c) community risk factors (i.e., social determinants of health [SDOH]). Although child maltreatment can affect all races, ethnicities, sexes, and socioeconomic groups, research demonstrates that some of these characteristics are associated with an increased likelihood of abuse (Joyce et al., 2021). Therefore, identifying and understanding these risk factors is essential to developing potential preventative initiatives (CDC, 2021b). The risk factors for abuse in children include:

    • age 4 years old or younger, particularly premature babies
    • special needs (emotionally or physically) that can increase the caregiver burden (CDC, 2021c)

    Risk factors that contribute to child abuse or neglect perpetrated by a family or caregiver children include:

    • domestic violence in the home, including abusive, coercive, forceful, or threatening acts or words by a member of the household to another (the caregiver may be the perpetrator or victim of the domestic abuse) or other violence, including a caregiver’s personal history of child abuse or neglect
    • financial problems within the family leading to an 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)
    • caregiving stress or negative interactions/caregiver-child relationships
    • divorce, family break-ups, or social isolation
    • a caregiver’s lack of understanding regarding the needs or development of their child 
    • a lack of parenting skills
    • family mental health issues, including depression
    • specific caregiver characteristics, including young age, low education, single parenthood, many dependent children, or low income
    • transient, non-biological caregivers in the home, such as a caregiver’s significant other or partner (CDC, 2021c)

    Community risk factors that contribute to child maltreatment include:

    • violence within the community
    • neighborhood disadvantages (i.e., high poverty rates, residential instability, high unemployment rates, poor social connections, and a high density of alcohol outlets; CDC, 2021c)

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

    • supportive family environments and social networks
    • basic needs met, including housing, food, and safety
    • readily available parenting skills education
    • stability in family relationships
    • caregiver education and employment 
    • access to health care and social services
    • caring adults outside the home who serve as role models or mentors (CDC, 2021c)

    The goal is to prevent abuse and neglect before it happens. Among the preventative techniques is strengthening economic support to families through a family-friendly work policy or household financial security. Social norms and educational campaigns that focus on positive parenting and coaching are effective. Children should have quality care and education during their toddler, preschool, and early elementary years. These can be encouraged through state licensing and accreditation of daycare centers and early childhood programs. Initiatives such as early childhood programs and home visits can promote parenting skills and healthy child development. Finally, pediatricians and primary care providers should monitor for and intervene in high-risk situations where future abuse and neglect are suspected to minimize the effects and avoid future concerns (CDC, 2021d).

    Indicators of Abuse/Maltreatment

    Physical Abuse

    Physical abuse or bodily injury is a "non-accidental injury to a child by a parent or caretaker” that can include “frequent and unexplained bruises, burns, cuts or injuries; 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 and purposeful physical injuries 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 by previously toileting 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 or handprint, round burns from cigarettes, or marks around the wrist or ankles indicating that the child was restrained and struggling
    • multiple bruises or other injuries in various stages of healing
    • injuries to the eyes or both sides of the head or body, as most accidental injuries are unilateral (Child Welfare Information Gateway, 2019; OCFS, n.d.-c)

    Providers should remember that abuse is not always limited to hitting or injuring with associated bruising or visible injuries. Other acts of bodily injury can include burns such as with hot water, holding a child underwater, throwing objects at a child, physically restraining a child as a form of discipline, and using an object such as a paddle, belt, cord, limb from a tree (switch), or shoe to beat a child (Child Welfare Information Gateway, 2019; OCFS, n.d.-c). Adolescents can be screened for potential abuse using the Conflict Tactics scale. This scale was developed in 1972 based on the conflict theory. It examines specific acts or events used in a conflict and considers that abusers seek power and control over the victim. Warning signs of abuse may also include asthma, stress-related illnesses, anxiety/panic attacks, vague aches and pains, chronic diarrhea, abdominal pain, bladder/kidney infections, joint pain, or muscle pain (Ronzon-Tirado et al., 2019).

    Pediatric AHT 

    Pediatric AHT results from caregiver abuse and was previously termed shaken baby syndrome. This severe form of child abuse can lead to serious brain injury or death. It often occurs due to an infant's prolonged crying, causing the caregiver to become angry, shake or throw the child down, and ultimately cause a head injury. Bleeding can occur around the brain or on the internal layer of the eyes. Pediatric AHT is the leading cause of death in children under 5 years of age in the US, with babies under a year old at the highest risk, and it accounts for more than one-third of all child maltreatment deaths in the US. Long-term consequences of pediatric AHT can include vision problems, developmental delays, physical disabilities, and hearing loss (CDC, 2021a). Please see the NursingCE course entitled Pediatric Abusive Head Trauma for more information.

    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, or 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 their 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 behaviors toward other children
    • signs (verbal or physical) of age-inappropriate knowledge of sexual acts or information (Child Welfare Information Gateway, 2019; OCFS, n.d.-c)

    The child may describe sexual actions or act them out, although they are often threatened or intimidated into keeping the activity secret (Child Welfare Information Gateway, 2019; OCFS, n.d.-c). 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
    • causing pregnancy
    • producing, owning, or sharing pornographic images, movies, or online materials of children
    • any sexual conduct 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 a refusal/reluctance to change clothes in front of others (e.g., gym class). The child may refuse to participate in sports or otherwise entertaining activities. They may withdraw from friends and family and have an unusual or sophisticated knowledge of sexual behaviors. Other symptoms can include anxiety, anger, depression, promiscuity in older children, internalized symptoms (e.g., upset stomach, headaches), or nondescript symptoms. Some children may not exhibit any indication that they have been exposed to sexual abuse, making recognition by their healthcare provider more difficult (Schaefer et al., 2018).

    Child Sex Trafficking

    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" (National Center for Missing and 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 foster care, child protective services, or the courts
    • children with SUD or those who live in a household with persons with SUD 
    • children identifying as LGBTQ who have been kicked out of their home (NCMEC, n.d.)

    In 2018, approximately 23,000 children were considered runaways, and 1 child in 7 was 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 behavioral and physical red flags that healthcare providers should know 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, or argumentative or appears coached in 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 traveling 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 who 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 mentions traveling opportunities and jobs such as modeling, singing, dancing, or acting
    • a child with specific tattoos or burn marks, which are considered branding
    • a child with unaddressed medical issues who 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 resists help from others even when offered (NCMEC, n.d.; OCFS, n.d.-b)

    The federal Preventing Sex Trafficking and Strengthening Families Act was signed into law in 2014 with two purposes: "to protect and prevent at-risk children and youth from becoming victims of sex trafficking and to improve the safety, permanency, and wellbeing outcomes of children and youth in the child welfare system" (OCFS, 2015, p. 2). NYS 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 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 damage a child's developing brain. It can lead to long-term learning difficulties, an 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, as it can be subtle and seem like a particular parenting style (Prevent Child Abuse America, n.d.-b). However, the actions constitute 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
    • isolating 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 and 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 safe or 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 beyond their ability to achieve (Prevent Child Abuse America, n.d.-b)

    The causes of emotional abuse are multifaceted. A child and their caregiver, community, or society may be involved at several levels. For example, a caregiver could have a mental illness such as depression or SUD, or the child may have a disability such as dyslexia. The caregivers 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 can create more lifelong trauma than physical abuse (Prevent Child Abuse America, n.d.-b).

    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 wellbeing are threatened with harm” (New York City Administration for Children’s Services, [NYCACS] n.d., para. 3). Examples of neglect 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 
    • a child is subjected to fear, verbal terror, extreme criticism, or humiliation
    • a child receives corporal punishment 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 a caregiver
    • a caregiver who uses drugs cannot care for the child (NYCACS, n.d.)

    Signs of each type of neglect will be unique. For example, 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 as follows:

    • inappropriate growth for age
    • weight gain or obesity
    • poor hygiene (dirty hair, skin, or body odor)
    • inappropriate clothing or a 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 to bring to siblings
    • taking food or money without permission
    • showing a lack of appropriate dental, medical, or mental health care or failing to follow up (Mayo Clinic, 2021)

    SUD in a caregiver often contributes to the neglect or abuse of children. For example, a child may accidentally ingest drugs, or their caregiver may be too impaired to care for the child, leading to neglect. In addition, older children are sometimes made responsible for younger siblings and cannot provide adequate care. Therefore, healthcare providers should be aware of the possibility of neglect and respond appropriately (Mayo Clinic, 2021).

    Factitious Disorder Imposed on Another (FDIA)

    FDIA, also known as Munchausen syndrome by proxy (MSP), is abuse involving an intentional production of illness in another person to assume the sick role by proxy. The proxy is usually a parent who intentionally makes a child ill or fabricates symptoms to gain attention. The diagnosis and treatment of this health disorder are complicated. Victims are typically under 6 years of age, and the cases are usually undiagnosed; FDIA wastes medical services and can lead to significant morbidity and mortality in children. Invasive diagnostic tests or treatments are often ordered, and the caregiver fabricates symptoms for various dysfunctional reasons. FDIA abusers have different motives, 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 [AAFP], 2021).  

    Someone suffering from FDIA may purposely make their child sick by withholding food, poisoning, or suffocating the child, giving inappropriate medications, or withholding prescribed medications. The caregivers knowingly expose the child to risky and painful medical procedures, including surgery (AAFP, 2021). Some common illnesses that caregivers seek medical help for FDIA victims can include:

    • nausea, vomiting, and diarrhea
    • failure to thrive
    • seizures
    • infections
    • fevers of unknown origin
    • allergic reactions
    • breathing difficulties (AAFP, 2021) 

    Mandatory Reporting

    Nurses should be highly familiar with the policies and procedures in their workplace based on applicable state laws. In NYS, these laws direct handling suspected child abuse or maltreatment. If an organization's policies and procedures are not aligned with the state laws and directives, nurses are still obligated to follow the law. If nurses fail to report suspected abuse, they are subject to prosecution for neglect or omission of duty. The NYS OCFS maintains the Statewide Central Registry for Child Abuse and Maltreatment (SCR), also known as the "hotline" for reporting suspected or confirmed abuse and maltreatment according to the Social Services Law (see the website for phone numbers; OCFS, n.d.-d). This hotline is available 24 hours per day, 7 days per week. After a call reaches the SCR, local CPS is contacted to initiate an investigation and determine whether there is a history of child abuse or maltreatment reports. 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 whether 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 a list of all children in the household, the basis of suspicion, any medical examination information, photographs, radiographs, or any images obtained during the child's assessment. Any information from the child or caregiver 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 caregivers before or after the report to SCR. Often, alerting caregivers could jeopardize the child’s welfare and hinder the investigation (OCFS, 2021). Nurses must report suspected child abuse and maltreatment and are considered mandated reporters. Mandated reporters can include the following (see the website for the full list): 

    • medical and hospital personnel
    • school officials
    • social service workers
    • childcare workers
    • residential care workers and volunteers
    • law enforcement personnel (OCFS, n.d.-d)

    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” (New York Social Services Law - SOS § 413, subsection 1, n.d.).

    Failure to report suspected abuse could result in severe consequences for the child. Thus, nurses who fail to report suspected child abuse are at risk of a Class A misdemeanor, are subject to criminal penalties, and can be sued in civil court for monetary damages that may arise from harm caused by the failure to report to the SCR (OCFS, 2021). 

    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 it but still have a moral obligation to report. Reasonable cause is based on the nurse's professional training and experience, observation, or suspicions that imminent danger of harm by a caregiver to a child exists. NYS law protects nurses 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 child’s wellbeing, 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" (New York Social Services Law - SOS § 413, subsection 1, n.d.). 

    Conclusion

    Adverse experiences in childhood impact not only the child's mental and physical development but also future violence victimization and perpetration. In addition, abuse and maltreatment affect a child's lifelong mental and physical health and opportunities. Nurses can protect children from further harm through early intervention and identification and allow entire families to live with safe, stable, and nurturing relationships that extend to future generations (CDC, 2021b). 


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