Iowa Mandatory Reporter: Child and Adult Dependent Abuse

2 Contact Hours

Syllabus

Purpose

The purpose of the child abuse and dependent adult abuse is to provide comprehensive information in accordance with Iowa regulations for mandatory reporters who shall complete two hours of training relating to the identification and reporting of child abuse and dependent adult abuse within six months of initial employment or self-employment. The person shall complete at least two hours of additional child abuse and dependent adult abuse identification and reporting training every five years. If the person is an employee of a hospital or similar institution, or of a public or private institution, agency, or facility, the employer shall be responsible for providing the child abuse identification and reporting training. If the person is self-employed, the person shall be responsible for obtaining the child abuse and dependent adult abuse identification and reporting training (DHS, 2018).  Note: These requirements do not apply to a physician whose professional practice does not regularly involve providing primary health care to adults. The goal of this education to encourage reporting of suspected child and adult dependent abuse. It is important to note that no employer can impose any rules or policies that limit or prohibit the ability report.

Objectives

At the completion of this module, you will be able to:

  • Identify the Iowa Mandatory Training Expectations
  • Describe the definitions of child abuse and dependent adult abuse according to Iowa Code and categories.
  • Describe the categories of abuse (child and dependent adult)
  • Describe the physical, emotional, and environmental indicators for abuse.
  • Explain the reporting requirements and process, including documentation.
  • Identify mandatory reporter in Iowa
  • Describe reporting confidentiality, immunity and penalties for failure to review.
  • Identify possible indicators related to child and dependent adult abuse.
  • Identify the state agency that investigates allegations of child maltreatment.
  • Describe barriers that contribute to under recognition and underreporting of suspected cases of child maltreatment.
  • Describe the role of the sexual assault nurse examiner.
  • Define the terms, medical neglect, educational neglect, emotional neglect, economic abuse, and abandonment.
  • Explain how parent substance use disorder affects the child.
  • Identify risk factors for child maltreatment.
  • Identify protective factors that reduce the risk of child abuse
  • Describe actions the nurse should take when assessing a child when abuse is suspected.
  • Explain how to document the care of a child who has a physical injury and physical abuse is suspected.
  • Identify the components of primary, secondary, and tertiary prevention levels of intervention.
  • Discuss actions for the nurse to take when experiencing moral distress.
  • Locate the Iowa Resources to report suspect abuse.  


Background

Child abuse is now recognized as a problem of epidemic proportions.  Child abuse has serious consequences that may remain as indelible pain throughout a person’s lifetime.  The violence and negligence of parents and caretakers serve as a model for children as they grow up. The child subjected to abuse today, without protection and treatment, may become the child abusers of tomorrow.

As with any social issue, child abuse is a problem for the entire community.  Achieving the goals of protective services requires the coordination of many resources.  Each professional group and agency involved with a family assumes responsibility for specific elements of the child protective service process.

Iowa Statistics

The Iowa Department of Public Health provides the following statistics for the types of abuse for confirmed or founded abuse for calendar year 2017. (Iowa DPH, 2018)

  • Denial of Critical Care 11,431

  • Exposure to Manufacture of Methamphetamine 4

  • Mental Injury 40

  • Physical Abuse 1,521

  • Presence of Illegal Drug in Child’s System 1,581

  • Sexual Abuse 1,992

  • Cohabiting with registered sex offender 1

  • Allows access by registered sex offender 148

  • Dangerous Substance 1,992

Child Abuse Iowa Response.  Iowa’s child abuse reporting law, Iowa Code sections 232.67 through 232.75, was initially enacted in 1978 and has been amended several times since then. The intent of the law is to identify children who are abused.  The law also provides for a professional assessment to determine if abuse has occurred. Accompanying the assessment are protective services designed to protect, treat, and prevent further maltreatment. (Iowa DHS, 2010).

The purpose of the Iowa law is to provide the greatest possible protection to children by encouraging the reporting of suspected child abuse.  The state respects the bond between parent and child. However, the state does assert the right to intervene for the general welfare of the child when there is a clear and present danger to the child’s health, welfare, and safety.  The state does not intend to interfere with reasonable parental discipline and child-rearing practices that are not injurious to the child (Iowa DHS, 2010).

According to Iowa statute, the Department of Human Services (DHS) has the responsibility to assess reports of suspected child abuse. DHS is the agency designated by law to receive reports of suspected child abuse and neglect.

Dependent Adult Abuse Iowa Response. Researchers estimate that only 1 in 14 incidents of elder abuse come to the attention of law enforcement or human service agencies.  Elder abuse is one of the most under-recognized and under-reported social problems in the United States. It is far less likely to be reported than child abuse because of the lack of public awareness.  Nationally, it is estimated that over 55% of elder abuse is due to self-neglect. Such abuse can happen anywhere… in private homes, at health care facilities and in the community at large (Iowa DHS, 2004).

Iowa has an increasing proportion of people who are aged 60 and over.  The group that is 80 and over is increasing more rapidly than any age group.  Iowa’s proportion of older adults in the population exceeds that of the United States.

The Dependent Adult Abuse Law, Iowa Code Section 235B, was initially enacted effective January 1, 1983 and has been amended yearly since then.  This legislation authorizes the Department of Human Services (DHS) to accept reports of suspected dependent adult abuse, evaluate reports, complete an assessment of needed services, make appropriate referrals for services, and maintain a central registry (Iowa DHS, 2004).

Who is a vulnerable elder? 

Vulnerable elder is defined as “a person sixty years of age or older who is unable to protect himself or herself from elder abuse as a result of age or a mental or physical condition.”

What is included in the definition of elder abuse? 

Elder abuse under the new law includes:

  • Physical injury, unreasonable confinement, punishment or assault
  • Sexual offense, 
  • Neglect - which is deprivation of necessary care by a caretaker, and 
  • Financial exploitation

Additionally, dependent adult abuse may be a crime.  Often times the DHS worker and law enforcement work together.  Criminal laws provide for the prosecution of alleged perpetrators in cases where a criminal act has been committed.  Other laws provide other means of protection for dependent adults, including guardianships and conservatorships, and, when necessary, the involuntary commitment of adults for substance abuse or mental health reasons (Iowa DHS, 2004).


Section 1: Child Abuse

The definitions for child and child abuse are provided in Iowa Code 232.67 and reference below.

Child 
Any person under the age of eighteen years.

Sexual abuse 
Iowa Code section 232.68(2)(a)(3) defines “Sexual Abuse” as the commission of a sexual offense with or to a child pursuant to Iowa Code chapter 709, section 726.2, or section 728.12(1), as a result of the acts or omissions of the person responsible for the care of the child or of a person who resides in a home with the child.

Child abuse includes 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., clergy, coach, or teacher). Under Iowa Law this includes: (1) physical abuse, (2) mental injury, (3) sexual abuse, (4) child prostitutions, (5) presence of illegal drugs in a child’s body, (6) denial of critical care, (7) dangerous substance, (8) bestiality in the presence of a child, (9) access to a registered sex offender, (10) access to obscene materials and (11) sex trafficking.  The Iowa law explicitly outlines the following:

  1. Any nonaccidental physical injury, or injury which is at variance with the history given of it, suffered by a child as the result of the acts or omissions of a person responsible for the care of the child.

  2. Any mental injury to a child's intellectual or psychological capacity as evidenced by an observable and substantial impairment in the child's ability to function within the child's normal range of performance and behavior as the result of the acts or omissions of a person responsible for the care of the child, if the impairment is diagnosed and confirmed by a licensed physician or qualified mental health professional as defined in section 622.10.

  3. The commission of a sexual offense with or to a child pursuant to chapter 709, section 726.2, or section 728.12, subsection 1, as a result of the acts or omissions of the person responsible for the care of the child. Notwithstanding section 702.5, the commission of a sexual offense under this paragraph includes any sexual offense referred to in this paragraph with or to a person under the age of eighteen years.

  4. The failure on the part of a person responsible for the care of a child to provide for the adequate food, shelter, clothing or other care necessary for the child's health and welfare when financially able to do so or when offered financial or other reasonable means to do so. A parent or guardian legitimately practicing religious beliefs who does not provide specified medical treatment for a child for that reason alone shall not be considered abusing the child, however this provision shall not preclude a court from ordering that medical service be provided to the child where the child's health requires it.

  5. The acts or omissions of a person responsible for the care of a child which allow, permit, or encourage the child to engage in acts prohibited pursuant to section 725.1. Notwithstanding section 702.5, acts or omissions under this paragraph include an act or omission referred to in this paragraph with or to a person under the age of eighteen years.


Child Physical Abuse
The State of Iowa defines “child abuse” as “any non-accidental physical injury, or injury which is at variance with the history of, suffered by a child as the result of the acts or omissions of person responsible for the care of the child” (232.68).

Child Mental Injury 
“Any mental injury to a child’s intellectual or psychological capacity as evidence by an observable and substantial impairment in the child’s ability to function within the child’s normal range of performance and behavior as the result of the acts or omissions of a person responsible for the care of the child, if the impairment is diagnosed and confirmed by a licensed physician or qualified mental health professional”.  For more information on these diagnoses go to Iowa Code, section 622.10.

Child Sexual Abuse 
Sexual abuse is defined as any sex act between persons is sexual abuse by either of the persons when the act is performed with the other person in any of the following circumstances: (1) The act is done by force or against the will of the other. If the consent or acquiescence of the other is procured by threats of violence toward any person or if the act is done while the other is under the influence of a drug inducing sleep or is otherwise in a state of unconsciousness, the act is done against the will of the other, (2) Such other person is suffering from a mental defect or incapacity which precludes giving consent, or lacks the mental capacity to know the right and wrong of conduct in sexual matters, and (3) Such other person is a child (Iowa Code, 709.1). There are several subcategories of sexual abuse: (1) First degree sexual abuse, (2) Second degree sexual abuse, (3) Third degree sexual abuse, (4) Lascivious acts with a child, (5) Indecent exposure, (6) Assault with intent to commit sexual abuse, (7) Indecent contact with a child , (8) Lascivious conduct with a minor , (9) Incest, (10) Sexual exploitation by a counselor or therapist, (11) Sexual exploitation of a minor, (12) Sexual misconduct with offenders and juveniles, (13) Invasion of privacy, and (14) nudity.

Behavioral indicators of sexual abuse could include things such as excessive knowledge of sexual matters beyond their normal developmental age or seductiveness.  Physical indicators of sexual abuse could include things such as bruised or bleeding genitalia, venereal disease, or even pregnancy.

A first-degree sexual abuse is when in the course of committing sexual abuse the person causes another serious injury. A second degree sexual abuse is when the person commits sexual abuse under any of the following circumstances: (1) during the commission of sexual abuse the person displays in a threatening manner a dangerous weapon, or uses or threatens to use force creating a substantial risk of death or serious injury to any person, (2) the other person is under the age of twelve, (3) the person is aided or abetted by one or more persons and the sex act is committed by force or against the will of the other person against whom the sex act is committed. This is considered a class “B” felony.  Third degree sexual abuse is when the person performs a sex act under any of the following circumstances: (1) The act is done by force or against the will of the other person, whether or not the other person is the person’s spouse or is cohabiting with the person, (2) The act is between persons who are not at the time cohabiting as husband and wife (see additional details, 709.4), (3) The act is performed while the other person is under the influence of a controlled substance, which may include but is not limited to flunitrazepam (see additional details, 709.4) and (4) The act is performed while the other person is mentally incapacitated, physically incapacitated, or physically helpless.  This is considered a class “C” felony (Iowa Code, 709.2, 709.3, 709.4).

Caretaker of a Child
A person responsible for the care of a child is defined in Iowa Code section 232.68 as:  (1) Parent, guardian, or foster parent, (2) A relative or any other person with whom the child resides and who assumes care or supervision of the child, without reference to the length of time or continuity of such residence, (3) An employee or agent of any public or private facility providing care for a child, including an institution, hospital, health care facility, group home, mental health center, residential treatment center, shelter care facility, detention center, or child care facility, (4) Any person providing care for a child, but with whom the child does not reside, without reference to the duration of the care.  A person who assumes responsibility for the care or supervision of the child may assume such responsibility through verbal or written agreement, or implicitly through the willing assumption of the care-taking role.

Rape 
An act of forced sexual intercourse a nonconsensual activity that involves penetration of the vagina or anus or oral cavity by a body part or inanimate object. Both men and women can be raped. However, statistics show that the highest risk is for females under the age of 34, in a low-income bracket and live in a rural community.  

Sexual Assault Nurse Examiner (SANE) 
A sexual assault examiner is a register nurse who has special training to conduct sexual assault evidentiary examination for rape victims. The SANE is also qualified to serve as an expert witness in court. Be prepared to assist the SANE with the physical examination and support the client during the examination. Sexual assault evidence kits are used for collecting blood, oral swabs, hair samples, nail swabs, or scrapings and genital, anal, or penile swabs.

Child prostitution 
According to Iowa Code (725.1), a person who is responsible for the child who allow, permit, or encourage the child to engage in sex or proposition is prohibited and considered child prostitution. The child does not have to engage in a sex act to be considered prostitution, this alone is sufficient for a report of this type of child abuse.  The offer does not have to be made by the child’s caretaker. The caretaker can be reported as being responsible for child abuse simply for “allowing, permitting, or encouraging” the child’s exploitation as a prostitute by someone else (DHS, 2018).

Children Born Positive for Illegal Substance 

Abuse of drugs or alcohol by parents and other caregivers can have negative effects on the health, safety, and well-being of children. Approximately 47 States, the District of Columbia, Guam, and the U.S Virgin Islands have laws within their child protection statutes that address the issue of substance abuse by parents. Two areas of concern are the harm caused by prenatal drug exposure and the harm caused to children of any age by exposure to illegal drug activity in their homes or environment (Child Welfare Information Gateway, 2016).  

The Child Abuse Prevention and Treatment Act (CAPTA) requires States to have policies and procedures in place to notify child protective services (CPS) agencies of substance-exposed newborns (SENs) and to establish a plan of safe care for newborns identified as being affected by illegal substance abuse or having withdrawal symptoms resulting from prenatal drug exposure (Child Welfare Information Gateway, 2016).  

The Comprehensive Addition and Recovery Act (CASA) is a multifaceted legislative act that addresses the opioid epidemic. Section 501 provides funds to treat opioid addiction in pregnant and postpartum women and their children. Section 203 calls for the expansion of disposal sites for unwanted medications to prevent access to them by children and adolescents. (Summary of the Comprehensive Addition and Recovery Act 2016)

Several States currently address this requirement in their statutes. Approximately 19 States and the District of Columbia have specific reporting procedures for infants who show evidence at birth of having been exposed to drugs, alcohol, or other controlled substances; 14 States and the District of Columbia include this type of exposure in their definitions of child abuse or neglect (Child Welfare Information Gateway, 2016).  

There is increasing concern about the negative effects on children when parents or other members of their households’ abuse alcohol or drugs or engage in other illegal drug-related activity, such as the manufacture of methamphetamines in home-based laboratories. Many States have responded to this problem by expanding the civil definition of child abuse or neglect to include this concern (Child Welfare Information Gateway, 2016).

Iowa Law states the "presence of illegal drugs" is defined as occurring when an illegal drug is present in a child's body as a direct and foreseeable consequence of the acts or omissions of the person responsible for the care of the child.  Note: "Illegal drugs" are defined as cocaine, heroin, amphetamine, methamphetamine, other illegal drugs (including marijuana), or combinations or derivatives of illegal drugs which were not prescribed by a health practitioner (DHS, 2018).

Child Denial of Critical Care 

"Denial of critical care" is defined as the failure on the part of a person responsible for the care of a child to provide for the adequate food, shelter, clothing or other care necessary for the child's health and welfare when financially able to do so or when offered financial or other reasonable means to do so (DHS, 2018).

 A parent or guardian legitimately practicing religious beliefs who does not provide specified medical treatment for a child for that reason alone shall not be considered abusing the child. However, this does not preclude a court from ordering that medical service be provided to the child where the child's health requires it.

 Denial of critical care includes the following seven sub-categories:

  1. Failure to provide adequate food and nutrition to such an extent that there is danger of the child suffering injury or death.

  2. Failure to provide adequate shelter to such an extent that there is danger of the child suffering injury or death.

  3. Failure to provide adequate clothing to such an extent that there is danger of the child suffering injury or death.

  4. Failure to provide adequate health care to such an extent that there is danger of the child suffering serious injury or death.

  5. Failure to provide the mental health care necessary to adequately treat an observable and substantial impairment in the child's ability to function.

  6. Gross failure to meet the emotional needs of the child necessary for normal development evidenced by the presence of an observable and substantial impairment in the child's ability to function within the normal range of performance and behavior.

  7. Failure to provide proper supervision of a child which a reasonable and prudent person would exercise under similar facts and circumstances, to such an extent that the child was directly harmed or placed at risk of harm (DHS, 2018).

Withhold Medical Treatment

Failure to respond to the infant's life-threatening conditions by failing to provide treatment which in the treating physician's judgment will be most likely to be effective in ameliorating or correcting all conditions. This subcategory or the denial of critical care abuse type is also known as withholding of medically indicated treatment. The type of treatments included are appropriate nutrition, hydration and medication. The term does not include the failure to provide treatment other than appropriate nutrition, hydration and medication to an infant when in the treating physician's medical judgment, any of the following circumstances apply:

  1. The infant is chronically and irreversibly comatose.

  2. The provision of treatment would merely prolong dying, not be effective in ameliorating or correcting all of the infant's life-threatening conditions, or otherwise be futile in terms of the survival of the infant.  

  3. The provision of the treatment would be virtually futile in terms of the survival of the infant and the treatment itself under the circumstances would be inhumane (DHS, 2018).

Dangerous Substance 
“Dangerous substance" occurs when the person responsible for the care of a child did any of the following in the presence of a child: (1) Unlawfully used, possessed, manufactured, cultivated, or distributed a dangerous substance, (2) Knowingly allowed use, possession, manufacture, cultivation, or distribution of a dangerous substance by another person, (3) Possesses a product with the intent to use the product as a precursor or an intermediary to a dangerous substance. Additionally, it is unlawful in the child’s home, on the premises, or in a motor vehicle located on the premises (even if a child was not present) to use, possess, manufacture, cultivate, or distribute amphetamine, methamphetamine, or a chemical or combination of chemicals that poses a risk of causing an explosion, fire, or other danger to the life or health of persons who are in the vicinity while the chemical or combination of chemicals is used or intended to be used in the manufacturing of an illegal or controlled substance (DHS, 2018).

For the purposes of this definition, "in the presence of a child" means in the physical presence of a child, or occurring under other circumstances in which a reasonably prudent person would know that the use, possession, manufacture, cultivation, or distribution may be seen, smelled, ingested, or heard by a child (DHS, 2018).

For the purpose of this definition, "dangerous substance" means any of the following amphetamine, methamphetamine, cocaine, heroin, opium, opiates and their salts, isomers, or any chemical or combination of chemicals that poses a reasonable risk of causing an explosion, fire, or other danger to the life or health of people who are in the vicinity while the chemical or combination of chemicals.  The process of manufacturing an illegal or controlled substance or an intermediary in the manufacturing of an illegal or controlled substance is illegal (DHS, 2018).

Bestiality in the Presence of a Minor 
Bestiality is defined as the commission of a sex act with an animal in the presence of a minor as defined (Iowa Code 717C.1) by a person who resides in a home with a child, as the result of the acts or omissions of a person responsible for the care of the child.  Animal is defined as any nonhuman vertebrate, either dead or alive.

Access to Sex Offenders 
Iowa Law states that allowing unsupervised access to a child or minor by a custodial or person responsible for child to a known registered sex offender after knowing the person’s offense status is a violation (726.6).

Access to Obscene Material 
Child abuse also includes that act of knowingly allowing access, exhibiting or disseminating obscene material to a child.

Human Trafficking 
The term 'human trafficking' means participating in a venture to recruit, harbor, transport, supply provisions, or obtain a person for the purpose of forced labor or service that results in involuntary servitude, peonage, debt bondage, or slavery. The term 'forced labor or services' means labor or services that are performed or provided by another person and that are obtained or maintained through any of the following:

  • Causing or threatening to cause serious physical injury to any person

  • Physically restraining or threatening to physically restrain another person

  • Abusing or threatening to abuse the law or legal process

  • Knowingly destroying, concealing, removing, confiscating, or possessing any actual or purported passport or other immigration document, or any other actual or purported government identification document, of another person

The term 'involuntary servitude' means a condition of servitude induced by means of any scheme, plan, or pattern intended to cause a person to believe that if the person did not enter into or continue in such condition, that person or another person would suffer serious harm or physical restraint or the threatened abuse of legal process. The term 'services' means an ongoing relationship between a person and the actor in which the person performs activities under the supervision of or for the benefit of the actor, including commercial sexual activity and sexually explicit performances (DHS,710A.1).

Sex Trafficking of Minors 
Iowa defines “Child Sex Trafficking” as the recruitment, harboring, transportation, provision, obtaining, patronizing, or solicitation of a child for the purpose of commercial sexual activity as defined in Iowa Code section 710A.1

Human trafficking also means knowingly purchasing or attempting to purchase services involving commercial sexual activity from a person engaged in human trafficking. The term 'commercial sexual activity' means any sex act or sexually explicit performance for which anything of value is given, promised to, or received by any person and includes, but is not limited to, prostitution, participation in the production of pornography, and performance in strip clubs. The term 'sexually explicit performance' means a live or public act or show intended to arouse or satisfy the sexual desires or appeal to the prurient interest of patrons. The term 'services' means an ongoing relationship between a person and the actor in which the person performs activities under the supervision of or for the benefit of the actor, including commercial sexual activity and sexually explicit performances (DHS, 710A.1).

Suspected Child Abuse Mandatory Reporters 
Iowa law defines classes of people who must make a report of child abuse within 24 hours when they reasonably believe a child has suffered abuse.  These “mandatory reporters” are professionals who have frequent contact with children, generally in one of six disciplines: (1) health professionals, (2) education, (3) child care, (4) mental health, (5) law enforcement, and (6) social workers. Health professionals includes (1) licensed physicians and surgeons, (2) physician assistants, (3) dentists, (4) licensed dental hygienists, (5) optometrists, (6) podiatrists, (7) chiropractors, (8) residents or interns in any of the professions listed above, (9) registered nurses, (10) licensed practical nurse, and (11) basic and advanced emergency medical care providers.

School Sector 
Additionally, any of the following persons who, in the scope of professional practice or in their employment responsibilities, examines, attends, counsels, or treats a child (1) an employee or operator of a public or private health care facility (Iowa Code section 135C.), (2) a certified psychologist, (3) a licensed school employee, certified paraeducator, or holder of a coaching authorization issued under Iowa Code section 272.31, or an instructor employed by a community college (DHS, 2018).

Community Sector
An employee or operator of a licensed child care center, registered child development home, Head Start program, Family Development and Self-Sufficiency Grant program under Iowa Code section 216A.107, or Healthy Opportunities for Parents to Experience Success – Healthy Families Iowa program under Iowa Code section 135.106; this includes (1) an employee or operator of a licensed substance abuse program or facility license, (2) an employee of an institution operated by DHS (Iowa Code section 218.1), (3) an employee or operator of a juvenile detention or juvenile shelter care facility approved under Iowa Code (section 232.142; (4) an employee or operator of a foster care facility licensed or approved under Iowa Code Chapter 237, (5) an employee or operator of a mental health center, (6) a peace officer, (7) a counselor or mental health professional, and  (8) an employee or operator of a provider of services to children funded under a federally approved medical assistance home- and community-based services waiver.

The employer or supervisor of a person who is a mandatory reporter shall not apply a policy, work rule, or other requirement that interferes with the person making a report of child abuse.

Spiritual Sector
Clergy members are not considered to be mandatory reporters unless they are functioning as social workers, counselors, or another role described as a mandatory reporter.  If a member of clergy provides counseling services to a child, and the child discloses an abuse allegation, then the clergy member is mandated to report as a counselor. (The counseling is provided to a child during the scope of the reporter’s profession as a counselor, not clergy.)

Health Service Professionals
The recognition and treatment of child abuse, including the recognition of the abuse, reporting the suspected abuse, crisis intervention, and long-term treatment are within the roles of health service professionals who are often the first line of defense in the early detection of child abuse.  Most health professionals who treat children are required to be mandatory reporters of child abuse. Health care professionals are often called upon to work collaboratively with many other disciplines, including social work, education, law enforcement, and the courts to ensure a multi-disciplinary approach to the recognition and treatment of child abuse (Iowa DHS, 2005)

A health care practitioner may, if medically indicated, take or cause to be taken, a radiological examination, physical examination, or other medical test of the child or take photographs, which would provide medical indications for the child abuse assessment. A physician has the authority to keep a child in custody without a court order and without the consent of a parent, guardian, or custodian, provided that the child is in a circumstance or condition that presents an imminent danger to the child’s life or health.  However, the physician must orally notify the court within 24 hours. The ability to take or keep a child in custody is unique to physicians and peace officers (Iowa DHS, 2005).

Others Required to Report
Some employers may have specific policies that require certain training and reporting procedures regarding child abuse for their staff, even when they are not by law considered mandatory reporters.  Reporters who by law are not considered mandatory reporters will be considered permissive reporters regardless of the employer’s requirements. Iowa Administrative Code 441--175.23(2) mandates certified adoption investigators and DHS income maintenance workers to report suspected abuse.  Income maintenance workers and certified adoption investigators are “mandated,” not mandatory reporters. As such, they are not required to make a written report, although they may do so if they wish. They receive the same information and notices as permissive reporters. They are not entitled to written notification that the assessment has been completed nor to a copy of information placed on the Registry.  However, they may receive a copy of the report if they have another role with the child that allows access to the summary (Iowa DHS, 2005).

Iowa Mandatory Suspected Child Abuse Reporting Law
According to Iowa Code section 232.70, if you are a mandatory reporter of child abuse and you suspect a child has been abused, you need to report it to the Department of Human Services.  The law requires you to report suspected child abuse to DHS orally within 24 hours of becoming aware of the situation. You must also make a report in writing within 48 hours after your oral report.  The employer or supervisor of a person who is a mandatory or permissive reporter shall not apply a policy, work rule, or other requirement that interferes with the person making a report of child abuse. As a mandatory reporter, you are also required to make an oral report to law enforcement if you have reason to believe that immediate protection of the child is necessary. The law requires the reporting of suspected child abuse.  It is not the reporter’s role to validate the abuse. The law does not require you to have proof that the abuse occurred before reporting. The law clearly specifies that reports of child abuse must be made when the person reporting “reasonably believes a child has suffered abuse.” (Iowa DHS, 2010).

Suspected Child Abuse Reporting Procedure and Form

The Iowa Suspected Child Abuse Reporting Form may be used as the written report which the law requires all mandated reporters to file with the Department of Human Services following an oral report of suspected child abuse.  If your agency has a report form or letter format which includes all of the information requested on this form, you may use the agency format in place of this form. Fill in as much information under each category as is known.  Submit the completed form within 48 hours of making the oral report to the Centralized Intake Unit, PO Box 4826, Des Moines, Iowa 50305. To make a report of suspected child abuse in Iowa, call the toll-free 24-hour hotline: 1-800-362-2178.

Forms for reporting suspected child abuse and suspected dependent adult abuse can be downloaded from this web site https://dhs.iowa.gov/dhsforms.  Examples of the form are provided at the end of this module for your review, please go the official website for reproduction and use.

If you see a child that is in imminent danger, immediately contact law enforcement, to provide immediate assistance to the child.  Law enforcement is the only profession that can take a child into custody in that situation.  After you have notified law enforcement, then call DHS.

Oral and written reports should contain the following information, if it is known: (1) the names and home address of the child and the child’s parents or other persons believed to be responsible for the child’s care, (2) the child’s present whereabouts, (3) the child’s age, (4) the nature and extent of the child’s injuries, including any evidence of previous injuries, (5) the name, age, and condition of other children in the same household, (6) any other information that you believe may be helpful in establishing the cause of the abuse or neglect to the child, (7) the identity of the person or persons responsible for the abuse or neglect to the child, (8) your name and address (Iowa DHS, 2010).

The DHS decision on whether to accept or reject a report of child abuse is to be made within a 1-hour or 12-hour time frame from receipt of the report, depending on the information which is provided and the level of risk to the child. When a report indicates that the child has suffered a “high-risk” injury or there is an immediate threat to the child, the Department acts immediately to address the child’s safety.  The decision to accept the report of child abuse is made within one hour from receipt of the report (Iowa DHS, 2010).

Confidentiality

State child protective services agencies are required to maintain records of the reports of suspected child abuse and neglect that they receive. These reports include identifying information about the child, the child’s family, conditions in the child’s home environment, the nature and extent of the child’s injuries, and information about other children in the same environment. Agency records also may include other information submitted by the reporter, including photographs and medical records, as well as the results of any assessments or investigations completed by the agency. These records are maintained by state child protection or social services agencies to aid in the investigation, treatment, and prevention of child abuse and to maintain statistical information for staffing and funding purposes. In many states, these records and the results of investigations are maintained in databases, which often are called central registries. The type of information retained in central registries and agency records and access to this information vary from state to state (Child Welfare Information Gateway, 2016).

Among the requirements for receiving federal funding under the Child Abuse Prevention and Treatment Act (CAPTA) is that states must preserve the confidentiality of all child abuse and neglect reports and records to protect the privacy rights of the child and of the child’s parents or guardians, except in certain limited circumstances (Child Welfare Information Gateway, 2016).

State statutes indicate who may access child abuse and neglect records, the specific kinds of information that will be made available, and under what circumstances the information will be made available. In general, individuals and entities are granted access to a case because they have a direct interest in the case, direct interest in the child’s welfare, or have an interest in providing protective or treatment services. Typically, individuals entitled to access the records are physicians and medical examiners; researchers; police; judges and other court personnel; the person who is the subject of a report; a person who was an alleged suffered from child abuse (Child Welfare Information Gateway, 2016).

Waiver of Confidentiality 
The issues of confidentiality and privileged communication are often areas of concern for mental health and health service professionals.  Rules around confidentiality and privileged communication are waived during the child abuse assessment process (once a report of child abuse becomes a case). Iowa Code section 232.71B indicates that the Department may request information from any person believed to have knowledge of a child abuse case.  County attorneys, law enforcement officers, social services agencies, and all mandatory reporters (whether or not they made the report of suspected abuse) are obligated to cooperate and assist with the child abuse assessment upon the request of the Department (DHS, 2010).

It is a good idea to let your clients know your status as a child abuse reporter at the onset of treatment.  This will help establish an open relationship and minimize the client’s feelings of betrayal if a report needs to be made.  Making a child abuse referral does not necessarily mean that your relationship with the child and family will end, especially when you are able to support the family during the assessment process (DHS, 2010).

When possible, discuss the need to make a child abuse report with the family.  However, be aware that there are certain situations where if the family is warned about the assessment process, the child may be at risk for further abuse, or the family may leave with the child (DHS, 2010).

Immunity from Liability 
The Iowa Code (section 235.B.3) protects individuals that report and cooperate with the investigation, such actions are considered good faith those individuals have immunity from liability, civil or criminal, which might otherwise be incurred or imposed based upon the act of making the report or giving the assistance.  The department may request further information from those who may have further knowledge of the case. Furthermore, it is unlawful for an employee to be discharged, disciplined, or suspended as a result of reporting or cooperating based solely upon the person’s reporting or assistance relative to the instance of dependent adult abuse. The protects health care professional when conducting medically relevant tests and includes: (1) making a report, (2) photographs, x-rays, (3) assisting in an assessment of a child abuse report, and (4) performing tests that produce reliable results of exposure to dangerous substances (illegal drugs).

Sanctions for Failure to Report Child Abuse 
Iowa Code section 232.75 provides for civil and criminal sanctions for failing to report child abuse.  Any person, official, agency, or institution required by Iowa to report a suspected case of child abuse who knowingly and willfully fails to do so is guilty of a simple misdemeanor.  Any person, official, agency, or institution required by Iowa Code section 232.69 to report a suspected case of child abuse who knowingly fails to do so, or who knowingly interferes with the making of such a report in violation of section 232.70, is civilly liable for the damages proximately caused by such failure or interference (DHS, 2010).

Sanctions for Reporting False Information
The act of reporting false information regarding an alleged act of child abuse to DHS or causing false information to be reported, knowing that the information is false or that the act did not occur, is classified as simple misdemeanor under Iowa Code section 232.75, subsection 3 (DHS, 2010).


Indicators of Possible Child Abuse

The following physical and behavioral indicators are listed as signs of possible child abuse for you to consider in making your report.  These indicators need to be evaluated in the context of the child’s environment. The presence of one or more of these symptoms does not necessarily prove abuse.  These lists are examples and are not all-inclusive.

Physical Indicators

  • Bruises and welts on the face, lips, mouth, torso, back, buttocks, or thighs in various stages of healing
  • Bruises and welts in unusual patterns reflecting the shape of the article used (e.g., electric cord, belt buckle) or in clusters indicating repeated contact
  • Bruises on infant, especially facial bruises
  • Subdural hematomas, retinal hemorrhages, internal injuries
  • Cigarette burns, especially on the soles, palms, backs or buttocks
  • Immersion burns (sock-like, glove-like, doughnut-shaped) on buttocks or genitalia
  • Burns patterned like an electric element, iron or utensil
  • Rope burns on arms, legs, neck or torso
  • Fractures of the skull, nose, ribs or facial structure in various stages of healing
  • Multiple or spiral fractures
  • Unexplained (or multiple history for) bruises, burns or fractures
  • Lacerations or abrasions to the mouth, frenulum, lips, gums, eyes or external genitalia
  • Bite marks or loss of hair
  • Speech disorders, lags in physical development, ulcers
  • Asthma, severe allergies or failure to thrive
  • Consistent hunger, poor hygiene, inappropriate dress
  • Consistent lack of supervision; abandonment
  • Unattended physical or emotional problems or medical needs
  • Difficulty in walking or sitting
  • Pain or itching in the genital area
  • Bruises, bleeding or infection in the external genitalia, vaginal or anal areas
  • Torn, stained or bloody underclothing
  • Frequent urinary or yeast infections
  • Venereal disease, especially in pre-teens
  • Pregnancy
  • Substance abuse – alcohol or drugs
  • Positive test for presence of illegal drugs in the child’s body (DHS, 2010)

Behavior Indicators  

  • Afraid to go home; frightened of parents
  • Alcohol or drug abuse
  • Apprehensive when children cry, overly concerned for siblings
  • Begging, stealing or hoarding food
  • Behavioral extremes, such as aggressiveness or withdrawal
  • Complaints of soreness, uncomfortable movement
  • Constant fatigue, listlessness or falling asleep in class
  • Delay in securing or failure to secure medical care
  • Delinquent, runaway or truant behaviors
  • Destructive, antisocial or neurotic traits, habit disorders
  • Developmental or language delays
  • Excessive seductiveness or promiscuity
  • Extended stays at school (early arrival and late departure)
  • Extreme aggression, rage, or hyperactivity
  • Fear of a person or an intense dislike of being left with someone
  • Frequently absent or tardy from school or drops out of school or sudden school difficulties
  • History of abuse or neglect provided by the child
  • Inappropriate clothing for the weather
  • Massive weight change
  • Indirect allusions to problems at home such as, “I want to live with you”
  • Lack of emotional control, withdrawal, chronic depression, hysteria, fantasy or infantile behavior
  • Lags in growth or development
  • Multiple or inconsistent histories for a given injury
  • Overly compliant, passive, undemanding behavior; apathy
  • Poor peer relationships; shunned by peers
  • Poor self-esteem, self-devaluation, lack of confidence or self-destructive behavior
  • Role-reversal behavior or overly dependent behavior; states there is no caretaker
  • Suicide attempts
  • Unusual interest in or knowledge of sexual matters, expressing affection in inappropriate ways
  • Wary of adult contacts, lack of trust, uncomfortable with or threatened by physical contact or closeness  (DHS, 2010).

Indicators of Sexual Abuse

Child Welfare Information Gateway (CWIG) provides information about possible indications of sexual abuse displayed by the child: 

  • Has difficulty walking or sitting
  • Experiences nightmare
  • Wets the bed
  • Refuses to change clothes for gym
  • Demonstrates bizarre, sophisticated or unusual sexual knowledge or behavior
  • Becomes pregnant or acquires asexually transmitted infection
  • Attaches quickly to strangers

CWIG also provides information about possible indications of sexual abuse displayed by the caregiver: 

  • Is unduly protective of the child or severely limits the child’s contact with other children, especially of the opposite sex
  • Is secretive and isolated
  • Is jealous or controlling with family members.

Newborn Haven Act. Iowa has joined 30 other states in creating safe havens for infants.   The Newborn Haven Act (Iowa Code Chapter 233) is a law that allows parents (or another person who has the parent’s authorization) to leave an infant up to 14 days old at a hospital or health care facility without fear of prosecution for abandonment. For more information go to: http://www.dhs.iowa.gov/Consumers/Safety_and_Protection/Safe_Haven.html


Section 2: Dependent Adult Abuse

Iowa Code 235B (4) and (5) provide the definition dependent adult and dependent adult abuse.

Dependent adult
Person eighteen years of age or older who is unable to protect the person's own interests or unable to adequately perform or obtain services necessary to meet essential human needs, as a result of a physical or mental condition which requires assistance from another, or as defined by departmental rule.

Dependent adult abuse 
A dependent adult who experiences any of the following as a result of the willful or negligent acts or omissions of a caretaker:

  1. Physical injury to, or injury which is at a variance with the history given of the injury, or unreasonable confinement, unreasonable punishment, or assault of a dependent adult.

  2. The commission of a sexual offense under chapter 709 or section 726.2 with or against a dependent adult.

  3. Exploitation of a dependent adult which means the act or process of taking unfair advantage of a physical or financial resource for one's own personal or pecuniary profit, without the informed consent of the dependent adult, including theft, by the use of undue influence, harassment, duress, deception, false representation, or false pretenses.

  4. The deprivation of the minimum food, shelter, clothing, supervision, physical or mental health care, or other care necessary to maintain a dependent adult's life or health.

  5. The deprivation of the minimum food, shelter, clothing, supervision, physical or mental health care, and other care necessary to maintain a dependent adult's life or health as a result of the acts or omissions of the dependent adult.

  6. Sexual exploitation of a dependent adult who is a resident of a healthcare facility, as defined in section 135C.1, by a caretaker providing services to or employed by the health care facility, whether within the health care facility or at a location outside of the health care facility.

Sexual exploitation
Any consensual or non-consensual sexual conduct with a dependent adult for the purpose of arousing or satisfying the sexual desires of the caretaker or dependent adult, which includes but is not limited to kissing; touching of the clothed or unclothed inner thigh, breast, groin, buttock, anus, pubes, or genitals; or a sex act, as defined in section 702.17. Sexual exploitation does not include touching which is part of a necessary examination, treatment, or care by a caretaker acting within the scope of the practice or employment of the caretaker; the exchange of a brief touch or hug between the dependent adult and a caretaker for the purpose of reassurance, comfort, or casual friendship; or touching between spouses.

Family or household member 
Spouse, a person cohabiting with the vulnerable elder, a parent, or a person related to the vulnerable elder by consanguinity or affinity, but does not include children of the vulnerable elder who are less than eighteen years of age.

Fiduciary
Person or entity with the legal responsibility to make decisions on behalf of and for the benefit of a vulnerable elder and to act in good faith and with fairness. “Fiduciary” includes but is not limited to an attorney in fact, a guardian, or a conservator.

Emergency shelter services
Includes, but is not limited to, secure crisis shelters or housing for victims of dependent adult abuse.

Immediate danger to health or safety
Situation in which death or severe bodily injury could reasonably be expected to occur without intervention.

Individual employed as an outreach person 
A natural person who, in the course of employment, makes regular contacts with dependent adults regarding available community resources.

Recklessly
When a person acts or fails to act with respect to a material element of a public offense, when the person is aware of and consciously disregards a substantial and unjustifiable risk that the material element exists or will result from the act or omission. The risk must be of such a nature and degree that disregard of the risk constitutes a gross deviation from the standard conduct that a reasonable person would observe in the situation.

Serious injury
A disabling mental illness, or a bodily injury which creates a substantial risk of death or which causes serious permanent disfigurement, or protracted loss or impairment of the function of any bodily member or organ.

Person Responsible for Dependent Adult Abuse
A perpetrator of dependent adult abuse must occur as the result of the willful or negligent acts or omissions of a caretaker to qualify as dependent adult abuse. 

Caretaker
Iowa Code section (235B.2) defines “caretaker” as a related or nonrelated person who has the responsibility for the protection, care, or custody of a dependent adult as a result of assuming the responsibility voluntarily, by contract, through employment, or by the order of the court (DHS, 2018).

Dependent Adult Physical abuse
Physical injury to, or injury which is at a variance with the history given of the injury, or unreasonable confinement, unreasonable punishment, or assault of a dependent adult committed by a caretaker.

Dependent Adult Sexual Abuse
The commission of a sexual offense with or against a dependent adult. This includes the following sub-categories: 

  • First degree sexual abuse
  • Second degree sexual abuse
  • Third degree sexual abuse
  • Detention in a brothel
  • Indecent exposure
  • Assault with intent to commit sexual abuse and incest
  • Sexual exploitation by a counselor or therapist
  • Sexual exploitation of a dependent adult who is a resident of a healthcare facility, as defined in Iowa Code 135C.1, by a caretaker providing services to or employed by the health care facility, whether within the health care facility or at a location outside of the health care facility (DHS, 2007).

Personal Degradation
According to Section 1. Section 235E.1 subsection 5, paragraph a, Code 2017, is amended by adding the following new subparagraph includes personal degradation of a dependent adult.  Personal degradation is a willful act or statement by a caretaker intended to shame, degrade, humiliate, or otherwise harm the personal dignity of a dependent adult, or where the caretaker knew or reasonably should have known the act or statement would cause shame, degradation, humiliation, or harm to the personal dignity of a reasonable person. “Personal degradation” includes the taking, transmission, or display of an electronic image of a dependent adult aby a caretaker, where the caretaker’s actions constitute a willful act or statement intended to shame, degrade, humiliate, or otherwise harm the personal dignity of the depend adult, or where the caretaker knew or reasonably should have known the act would cause shame, degradation, humiliation, or harm to the personal dignity of a dependent adult for the purpose of reporting dependent adult abuse to law enforcement, the department or other regulatory agency that oversees caretakers or enforces abuse or neglect provisions, or for the purpose of treatment of diagnosis or as part of an ongoing investigation.  “Personal degradation” also does not include the taking, transmission, or display of an electronic image by a caretaker in accordance with the facility’s or program’s confidentiality policy and release of information or consent policies

Dependent Adult Financial Exploitation
The act or process of taking unfair advantage of a physical or financial resource for one’s own personal or pecuniary profit, without the informed consent of the dependent adult, including theft, by the use of undue influence, harassment, duress, deception, false representation or false pretenses. Financial exploitation to a vulnerable elder is when a person stands in a position of trust or confidence with the vulnerable elder and knowingly and by undue influence, deception, coercion, fraud, or extortion, obtains control over or otherwise uses or diverts the benefits, property, resources, belongings, or assets of the vulnerable elderly.

Dependent Adult Sexual exploitation
Any consensual or non-consensual sexual conduct with a dependent adult which includes but is not limited to kissing; touching of the clothed or unclothed inner thigh, breast, groin, buttock, anus, pubes, or genitals; or a sex act, is considered sexual exploitation. (Iowa Code, 702.17).    This offense includes the abuse of electronic images such as the transmission, display, taking of electronic images of the unclothed breast, groin, buttock, anus, pubes, or genitals of a dependent adult by a caretaker for a purpose not related to treatment or diagnosis or as part of an ongoing assessment, evaluation, or investigation (DHS, 2018).

The exclusions to the definition are the following:

  • Sexual exploitation does not include touching which is part of a necessary examination
  • Treatment, or care by a caretaker acting within the scope of the practice or employment of the caretaker
  • The exchange of a brief touch or hug between the dependent adult and a caretaker for the purpose of reassurance, comfort, or casual friendship; or touching between spouses (DHS, 2018).

Dependent adult abuse does not include any of the following:

(1)  Circumstances in which the dependent adult declines medical treatment if the dependent adult holds a belief or is an adherent of a religion whose tenets and practices call for reliance on spiritual means in place of reliance on medical treatment;

(2)  Circumstances in which the dependent adult's caretaker, acting in accordance with the dependent adult's stated or implied consent, declines medical treatment if the dependent adult holds a belief or is an adherent of a religion whose tenets and practices call for reliance on spiritual means in place of reliance on medical treatment;

(3)  The withholding or withdrawing of health care from a dependent adult who is terminally ill in the opinion of a licensed physician, when the withholding or withdrawing of health care is done at the request of the dependent adult or at the request of the dependent adult's next of kin or guardian pursuant to the applicable procedures under chapter 125, 222, 229, or 633;

(4) Good faith assistance by a family or household member or other person in managing the financial affairs of a vulnerable elder at the request of the vulnerable elder or at the request of a family member, guardian, or conservator of the vulnerable elder.


Dependent Adult Denial of Critical Care
According to the Iowa Dependent Adult Protection Handbook (2016), dependent adults are vulnerable to denial of critical care.

The deprivation of the minimum food, shelter, clothing, supervision, physical or mental health care, medical care, failure to provide proper supervision, or other care necessary to maintain a dependent adult’s life or health. Consider the following factors:

  • A medical chart which documents a pattern or weight gain or loss, accompanied with observation by a credible person of the dependent adult’s diet over the corresponding time period.

  • A medical diagnosis provided by a credible person showing that the medical condition resulted from dietary deficiencies.  The presence of the condition is circumstantial evidence.

  • There is immediate or potential danger to health or safety, or injury to or death of the dependent adult.  Credible evidence could include a medical chart or diagnosis showing a medical condition or death resulting from diet deficiencies.

  • The caretaker or the dependent adult has financial means or has been offered financial means to provide adequate food.

  • The dependent adult does not have adequate shelter.  Evidence must be from a credible person. Credible evidence could include power company records to show a pattern of lack of provision of heat, with corresponding weather records and medical estimates of effects on the dependent adult, to illustrate immediate or potential danger to the dependent adult.

  • The failure to provide adequate shelter has resulted in the dependent adult being in immediate or potential danger to health and safety, which could result in injury or death.  Evidence must be from a credible person. Credible evidence could include:

  • Medical records showing actual or potential danger to the dependent adult.

  • Health department records showing actual or potential danger to the dependent adult.

  • The caretaker or the dependent adult has financial means or has been offered financial means to provide adequate shelter.

  • The dependent adult does not have adequate clothing necessary for the dependent adult’s health and welfare.  Credible evidence may include:

  • Observation and documentation by a credible person of the dependent adult’s manner of dress which indicates that the clothing provided was not adequate to meet the dependent adult’s needs.

  • Documentation of weather records which would confirm weather conditions from which the dependent adult’s manner of dress would not adequately protect the dependent adult.

  • There is immediate or potential danger of injury to or death of the dependent adult.  Evidence must be from a credible person. Credible evidence could include observations by a credible person as to the lack of adequate clothing, weather reports, and medical estimates of potential or actual danger because of lack of adequate clothing in this situation.

  • The caretaker or the dependent adult has financial means or has been offered financial means to provide adequate clothing.

  • There is evidence that the dependent adult does not have adequate medical care.  Evidence must be from a credible person. Credible evidence could include failure to follow through with necessary medical treatment as directed by a licensed physician. 

  • There is documentation of the immediate or potential danger of injury or death of the dependent adult.  Evidence must be from a credible person. Credible evidence could include the medical chart plus a doctor’s statements to show how the medical condition could or did lead to serious illness or death because of failure to seek or follow through with necessary medical treatment.

  • The caretaker or the dependent adult has financial or other means to provide adequate medical care.

  • The failure to provide medical care is not based on the dependent adult’s religious beliefs

  • The dependent adult has a serious mental health condition.  Evidence must be from a credible person. Credible evidence could include a diagnosis from a credible mental health professional.

  • Statements from credible witness as to behavior of the dependent adult which suggests a serious mental health condition.

  • Evidence that the caretaker, if there is one, knows of or should reasonably know that the dependent adult has a serious mental health condition.

  • The responsible caretaker or dependent adult refuses to obtain a mental health evaluation or treatment.  Credible evidence could include written documentation from a mental health professional or physician showing that a recommendation for evaluation or treatment was made.  Use credible evidence to show that the caretaker or dependent adult failed to act on the recommendations.

  • The caretaker or the dependent adult has financial or other means to provide adequate mental health care.

  • The dependent adult has gross functioning abnormalities resulting from a failure to meet the emotional needs of the dependent adult.  Evidence must be from a credible person. Credible evidence could include observations and documentation by a physician or mental health professional to establish existence of the condition.

  • The dependent adult has suffered mental or emotional injury resulting from the failure to meet the adult’s emotional needs.  Evidence must be from a credible person.

  • The responsible caretaker or the dependent adult has the financial means or has been offered the financial means to provide proper supervision.

  • The dependent adult was not provided proper supervision which a reasonable and prudent person would exercise under similar facts and circumstances.  Credible evidence could include evidence that the dependent adult does not have the ability to remove him or herself from emergency which might occur.

  • Evidence that a caretaker was selected who was known to be incapable of ensuring the safety of the dependent adult.

  • Evidence that a dependent adult was abandoned.

  • The dependent adult is in immediate or potential danger in a given situation.  Evidence must be from a credible person. Credible evidence could include evidence that the dependent adult was left unattended in a bath tub, near an open flame, or in some other precarious situation.

  • The caretaker or the dependent adult has the financial means or has been offered the financial means to provide proper supervision.

  • The dependent adult does not have adequate physical care.  Evidence must be from a credible person. Credible evidence could include failure to bathe resulted in skin breakdown.

  • The dependent adult was repeatedly dropped or mishandled, resulting in injury.

  • There is documentation of the immediate or potential danger or injury to or death of the dependent adult.  Evidence must be from a credible person. Credible evidence could include the medical chart plus the physician’s statement to show how lack of physical care could or did lead to serious illness, injury or death.

  • The caretaker or the dependent adult has financial or other means to provide adequate physical care.


Dependent Adult Self-Denial of Critical Care
According to the Iowa Dependent Adult Protection Handbook (2016), to establish that the dependent adult is responsible for self-denial of critical care, the following should be described in the report conclusions:

  1. A pattern of the dependent adult being denied essential food, shelter, clothing, supervision, physical or mental health care, or other care necessary for the dependent adult’s health and welfare.

  2. The significant event that occurred that brought the dependent adult’s situation to the attention of the reporter (especially if there is not a pattern of self-denial of critical care).

To determine self-denial of critical care, the conclusions must include a statement that the dependent adult is financially able to purchase services or has been offered financial and other reasonable means to provide services. A dependent adult has the right to make unhealthy choices if they are not deprived of the minimum standard to maintain life or health.  Living in a dirty house or eating junk food, in and of itself, is not self-denial of care.


Personal Degradation
“Personal degradation” means a willful act or statement by a caretaker intended to shame, degrade, humiliate, or otherwise harm the personal dignity of a dependent adult, or where the caretaker knew or reasonably should have known the act or statement would cause shame, degradation, humiliation, or harm to the personal dignity of a reasonable person. “Personal degradation” includes the taking, transmission, or display of an electronic image of a dependent adult aby a caretaker, where the caretaker’s actions constitute a willful act or statement intended to shame, degrade, humiliate, or otherwise harm the personal dignity of the depend adult, or where the caretaker knew or reasonably should have known the act would cause shame, degradation, humiliation, or harm to the personal dignity of a dependent adult for the purpose of reporting dependent adult abuse to law enforcement, the department or other regulatory agency that oversees caretakers or enforces abuse or neglect provisions, or for the purpose of treatment of diagnosis or as part of an ongoing investigation.  “Personal degradation” also does not include the taking, transmission, or display of an electronic image by a caretaker in accordance with the facility’s or program’s confidentiality policy and release of information or consent policies.

Dependent Adult Abuse Exclusion
There are several exclusions in the definition of dependent adult abuse that pertains to patient’s rights include the following:

  1. Circumstances in which the dependent adult declines medical treatment if the dependent adult holds a belief or is an adherent of a religion whose tenets and practices call for reliance on spiritual means in place of reliance on medical treatment.

  2. Circumstances in which the dependent adult’s caretaker, acting in accordance with the dependent adult’s stated or implied consent, declines medical treatment if the dependent adult holds a belief or is an adherent of a religion whose tenets and practices call for reliance on spiritual means in place of reliance on medical treatment.

  3. The withholding or withdrawing of health care from a dependent adult who is terminally ill in the opinion of a licensed physician, when the withholding or withdrawing of health care is done at the request of the dependent adult or at the request of the dependent adult’s next of kin, attorney in fact, or guardian pursuant to the applicable procedures under (Iowa Code, chapter 125, 144A, 144B, 222, 229, or 633, DHS, 2018).


Dependent Adult Abuse Mandatory Reporters
Mandatory reporters are the same for child and dependent adult and are categorized into six general disciplines: 

  1. Health
  2. Education
  3. Child Care
  4. Mental Health
  5. Law Enforcement
  6. Social Workers  

Registered nurses are mandatory reporters for suspected child and adult dependent abuse to the Iowa Department of Health Services. There are many other mandated reporters as well, according to the Iowa Code section 235B.3, reporters include a(n): 

  1. Social Worker
  2. Employee/employer of public or private health care facility
  3. Counselor or mental health professional
  4. Licensed school employee, paraeducator or coach
  5. Psychologist
  6. Instructor at a community college
  7. Employee or operator of a licensed child care center or registered child care home
  8. Employee or operator of a substance abuse program or facility licensed
  9. Employee of a department of human services institution listed
  10. Employee or operator of a juvenile detention or juvenile shelter care facility
  11. Employee or operator of a foster care facility licensed or approved
  12. Employee or operator of a mental health center
  13. Peace officer
  14. Basic and advanced emergency medical care providers
  15. Residents or interns in any profession listed above a dental hygienist
  16. Counselor, or mental health professional
  17. Clergy member that are functioning in the role of social worker, counselor or therapist are considered mandatory reports
  18. Clergy who provide counseling services (employed in the role of a counselor) to a child, and that child discloses abuse, then the clergy is mandated to report as a counselor


Dependent Adult Reporting Process and Documentation

The mandatory report must complete the form within 48 hours after the oral report has been given to the department.  The reporter shall forward one copy to the protective services unit. Additional copies may be prepared for the reporter’s records and for the evaluator’s files. The reporter shall attach any collateral information on the report to the form. Collateral contacts are individuals who have knowledge of the alleged abuse or incident.  

The report should contain the following information, or as much of it as you are able to furnish:

  1. The names and home addresses of the dependent adult, appropriate relatives, caretakers, and other people believed to be responsible for the care of the dependent adult
  2. The dependent adult’s present whereabouts, if not the same as the address given
  3. The reason the adult is believed to be dependent
  4. The dependent adult’s age
  5. The nature and extent of the adult abuse, including evidence of previous adult abuse as well as the existence of alleged adult abuse
  6. Information concerning the suspected adult abuse of other dependent adults in the same residence
  7. Other information which you believe might be helpful in establishing the cause of the abuse or the identity of the people responsible for the abuse or helpful in assisting the dependent adult, and
  8. Your name and address (DHS, 2007).

A report that meets the criteria will be accepted whether or not it contains all of the information listed. Common reasons for rejections of dependent adult abuse reports includes: 

  1. The subject of the report is not a dependent adult
  2. Alleged perpetrator is not a caretaker
  3. The allegations do not constitute abuse
  4. The information provided is insufficient to suspect abuse or duplicate information to prior report (DHS, 2007).

Forms for reporting suspected child abuse and suspected dependent adult abuse can be downloaded from this web site https://dhs.iowa.gov/dhsforms.  Examples of the form are provided at the end of this module for your review, please go the official website for reproduction and use.

Indicators of Possible Dependent Adult Abuse

Mandated reports are required to report a suspected case of dependent adult abuse and those who knowingly and willfully fails to do so commits a simple misdemeanor or who interferes with the making of a dependent adult abuse report or applies a requirement that results in a failure to make a report, is civilly liable for the damages proximately caused by the failure.  The following physical, behavioral, and environmental indicators are outlined as signs of possible dependent adult abuse for you to consider in making your report (DHS, 2007).

Environment

  • No food in the house or rotted, infested food
  • Lack of proper food storage
  • Special dietary foods not available
  • Inadequate cooking facilities or equipment
  • Clothes extremely dirty or uncared for
  • Not dressed appropriately for the weather
  • Inadequate or ill-fitting clothing, not dressing
  • Wearing all of one’s clothing at once
  • Structure dilapidated or in poor repair
  • Fallen steps, high grass, rotted porch, leaking roof
  • Utilities cut off or lack of heat in winter
  • Doors or windows made out of cardboard
  • Unvented gas heaters, chimney in poor repair
  • ehNo fuel for heating or fuel stored dangerously
  • Lack of water or contaminated water
  • Gross accumulation of garbage, papers, and clutter
  • Lack of access to essential rooms
  • Lack of access to community resources
  • Lives on the street
  • Large number of pets with no apparent means of care
  • No income, unpaid bills
  • Out of money by second week of the month
  • Income does not meet monthly expenditures
  • Signs checks over to others
  • Sudden change in money management habits
  • Sudden withdrawals or closing out of bank accounts
  • No TV, radio, telephone, newspapers, magazines
  • No friends or family visits
  • No means of transportation
  • Not physically able to get out and shop, pay bills, etc. (DHS, 2007).

Physical Condition

  • Lack of medical care
  • Lack of personal cleanliness and grooming, body odors
  • Swollen eyes or ankles, decayed teeth or no teeth
  • Bites, fleas, sores, lesions, lacerations
  • Multiple or repeated or untreated injuries
  • Injuries incompatible with explanation
  • haveBruises, broken bones or burns
  • Untreated pressure sores
  • Signs of confinement (tied to furniture, locked in a room, etc.)
  • Obesity, malnourishment or dehydration
  • Tremors
  • Difficulty in communication
  • Broken glasses frames or lenses
  • Drunk, overly medicated
  • Lying in urine, feces, old food
  • No use of limbs, lack of mobility (DHS, 2007).

Behavior

  • Intentional physical self-abuse, suicidal statements
  • Persistent liar
  • Does not follow medication directions
  • Refuses needed medical attention
  • Refuses to accept services offered by others
  • Threatens or attacks others physically or verbally
  • Refuses to accept presence of visitor
  • Refuses to open door
  • In total darkness
  • Denies obvious problems (medical conditions, etc.)
  • Increased depression, anxiety or hostility
  • Withdrawn, reclusive, suspicious, timid, unresponsive
  • Refuses to discuss the situation
  • Lack of trust in family as well as in others
  • Refuses to take medication
  • Denies any wrongdoing, medically or otherwise
  • Unjustified pride in self-sufficiency
  • Procrastination
  • Turns off hearing aid
  • Hallucinations, confusion or delusions
  • Disorientation as to place and time
  • Forgetfulness, losing things, not shutting stove off
  • Loneliness, anger, or fearfulness
  • Diminished mental capacity
  • Vague health complaints
  • Longing for death (DHS, 2007).

Iowa Evaluation/Assessment of Abuse Cases
DHS may request information from any person believed to have knowledge of a case of child abuse or dependent adult abuse.  This includes but is not limited to a county attorney, a law enforcement agency, a multidisciplinary team, a social services agency in the state, or any person who is required to report dependent adult abuse, whether or not the person made the specific dependent adult abuse report.  The person shall cooperate and assist in the evaluation upon the request of DHS.

County attorneys, law enforcement agencies, multidisciplinary teams, and social services agencies in the state shall cooperate and assist in the evaluation or assessment upon the request of DHS.  County attorneys and law enforcement agencies shall also take any other lawful action necessary or advisable for the protection of children and the dependent adult.


Reporting of Child and Dependent Adult Abuse

Permissive Reporters for child and dependent adult
Individuals who are not required by law to report child and dependent adult abuse are permissive reported.

A permissive reporter will not receive written notification that an assessment has been completed by DHS. There are two employment positions (income maintenance workers and certified adoption investigators) who are “mandated by Iowa Administrative Code 441—175.23(2), but are not mandatory reporters, and therefore employers may require training and reporting procedures regarding child abuse for their staff even when they are not by law considered mandatory reporters.

As such, employers or supervisors cannot apply a work rule, policy or other requirement that interferes with an employee making a report of child abuse and employers must inform employees the first month of employment of the training requirements. 

Definitions

Incapacitation
A person is disabled or deprived of ability, as follows:

  1. “Mentally incapacitated” means that a person is temporarily incapable of appraising or controlling the person’s own conduct due to the influence of a narcotic, anesthetic, or intoxicating substance
  2. “Physically helpless” means that a person is unable to communicate an unwillingness to act because the person is unconscious, asleep, or is otherwise physically limited
  3. “Physically incapacitated” means that a person has a bodily impairment or handicap that substantially limits the person’s ability to resist or flee. (Iowa Code, 709.1A).

Neglect
The failure on the part of the caregiver to provide physical, medical, educational, financial or emotional needs.

Physical Neglect
The failure to provide food, shelter, hygiene or appropriate supervision.

Medical Neglect
The failure to provide needed medical care including untreated medical or mental health conditions, or dental care.

Educational Neglect
The failure to provide education for the child, including special education when needed.

Emotional Neglect
The failure to provide a child the love and support needed to thrive and to develop into a healthy adult.

Economic Abuse
The failure to provide for the needs of the child when adequate funds are available.  

Abandonment
Occurs when the parent leaves the child behind and his or her whereabouts are unknown.  Some states identify abandonment as a form of neglect.

Possible Indicators for Child Abuse

  • Children younger than 4 years of age

  • Special needs that may increase caregiver burden (e.g., disabilities, mental retardation, mental health issues, and chronic physical illnesses)

Possible Indicators for Perpetrators of Abuse

Individual Risk Factors

  • Parents’ lack of understanding of children’s needs, child development and parenting skills

  • Parents’ history of child maltreatment in family of origin

  • Substance use disorder and/or mental health issues including depression in the family

  • Parental characteristics such as young age, low education, single parenthood, large number of dependent children, and low income

  • Nonbiological, transient caregivers in the home (e.g., mother’s male partner)

  • Parental thoughts and emotions that tend to support or justify maltreatment behaviors

Family Risk Factors

  • Social isolation

  • Family disorganization, dissolution, and violence, including intimate partner violence

  • Parenting stress, poor parent-child relationships, and negative interactions

Community Risk Factors

  • Community violence

  • Concentrated neighborhood disadvantage (e.g., high poverty and residential instability, high unemployment rates, and high density of alcohol outlets) and poor social connections



Prevention of Child or Dependent Adult Abuse

It is important to learn the process of identifying, assessment and reporting all suspected child abuse and dependent adult abuse cases, however, prevention is extremely important to reduce and eliminate the awful acts of abuse.

Primary Prevention

  • Teach alternative methods of conflict resolution, anger management, and coping strategies in community settings.

  • Organize parenting classes to provide anticipatory guidance of expected age-appropriate behaviors, appropriate parental responses, and forms of discipline.

  • Educate clients about community services that are available to provide protection from violence.

  • Assist in removing or reducing factors that contribute to stress by referring caretakers to respite services, assisting an unemployed parent in finding employment, or increasing social support networks for socially isolated families.

  • Teach individuals that no one has a right to touch or hurt another person, and make sure they know how to report cases of abuse.

Secondary Prevention

  • Identify and screen those at risk for abuse and individuals who are potential abusers.

  • Assess and evaluate any unexplained bruises or injuries of any individual.

  • Screen all pregnant women for potential abuse. This might be the one time in some women’s lives that they can access the health care system on a regular basis.

  • Refer sexual assault or rape survivors to a local emergency department for assessment by a SANE/sexual assault abuse team. Caution the client not to bathe following the assault because it will destroy physical evidence.

  • Assess and counsel anyone contemplating suicide or homicide, and refer the individual to the appropriate services.

  • Support and educate the offender, even though a report must be made.

  • Assess and help offenders address and deal with the stressors that can be causing or contributing to the abuse, such as mental illness or substance use disorder.

  • Alert all involved about available resources within the community.

  • Advocate for legislation designed to assist caregivers and to increase funding for programs that supply services to low-income, at-risk individuals.

Tertiary Prevention

  • Establish parameters for long-term follow-up and supervision.

  • Make resources in the community available to survivors of violence (telephone numbers of crisis lines and shelters).

  • If court systems are involved, work with parents while the child is out of the home (in foster care).

  • Refer to mental health professionals for long-term assistance.

  • Provide grief counseling to families following the death of a family member to suicide or homicide.

  • Develop support groups for caregivers and survivors.

Reporting Barriers

Even though nurses have an opportunity to act when there is a reason to suspect child maltreatment, several barriers contribute to under recognition and underreporting of suspected cases of child maltreatment.  Health care providers, including nurses, have an inadequate understanding of what child maltreatment is, how to identify at risk children, and how to intervene. Often, health care workers are unfamiliar with the statues in their state or jurisdiction that set out the mandatory reporter obligations. The health care provider may lack the confidence to function in the role of mandatory reporter as well as be afraid of litigation or being sued for reporting suspected maltreatment. It is critical that all health care providers who work with children have the requisite knowledge and skills to recognize and report to act when there are indications of child maltreatment.


Protective Factors for Child Abuse

Protective factors buffer children from being abused or neglected. These factors exist at various levels. Protective factors have not been studied as extensively or rigorously as risk factors. However, identifying and understanding protective factors are equally as important as researching risk factors. There is scientific evidence to support the following protective factors:

Family Protective Factors

  • Supportive family environment and social networks

  • Several other potential protective factors have been identified. Research is ongoing to determine whether the following factors do indeed buffer children from maltreatment.

  • Nurturing parenting skills

  • Stable family relationships

  • Household rules and child monitoring

  • Parental employment

  • Adequate housing

  • Access to health care and social services

  • Caring adults outside the family who can serve as role models or mentors

Community Protective Factors

  • Communities that support parents and take responsibility for preventing maltreatment

Possible Indicators of Individual Risk Factors for Violence

  • History of being abused or exposure to violence

  • Low self-esteem

  • Fear and distrust of others

  • Poor self-control

  • Inadequate social skills

  • Minimal social support/isolation

  • Immature motivation for marriage or childbearing

  • Weak coping skills

Social and Community Violence Risk Factors

  • Work stress

  • Unemployment

  • Media exposure to violence

  • Crowded living conditions

  • Poverty

  • Feelings of powerlessness

  • Social isolation

  • Lack of community resources (playgrounds, parks, theaters)


Nursing Assessment of a Child when Maltreatment is Suspected

  1. Hold the interview in a private setting.

  2. Be understanding and attentive.

  3. Avoid using terminology that might place the parent on the defensive for example, abuse or violence.

  4. When abuse is suspected, let the parent know a report will be made to child protective services.

  5. Initially interview the parent and the child together.

  6. Ask the parent about injuries to the child’s body.

  7. If abuse is suspected, the nurse should ask the parent to speak with the child in private. Refusal could mean there is a problem.

  8. Ask the parent if the child’s behavior has changed or if he/she has voiced new physical complaints.

  9. Observe the infant for excessive crying or fussiness.

  10. Observe the child for developmental delays.

  11. For preschool children, observe how they play or what they draw.

  12. Ask the child who takes care of them.

  13. Ask the child what he/she does for fun.

  14. Ask older children to tell you what worries them.

  15. Ask older children if they are experiencing pain.

  16. Ask what happens when someone in the household gets angry.

Sufficient Documentation
It is always important for the nurse perform accurate and complete documentation. Accurate, complete documentation provides the nurse, the nurse’s coworkers and the agency legal protection. Good documentation is the best defense against malpractice. Know your agencies policies regarding documentation and follow the policies diligently in all situations and especially in high-risk situations such as when there is suspicion of abuse. Include a description of the client’s medical history, the family’s psychosocial history, and observations you made regarding interaction among family members. Document direct quotes regarding when the injury occurred and who caused it. Document physical injuries in narrative form as well as in pictorial form such as a body map.


Family Violence

According to the U.S. Department of Justice intimate partner violence (IPV), also known as domestic violence is the use of behavior that is used by an intimate partner to gain control or to maintain power and control of the other intimate partner. IVP can be physical, sexual, emotional, economic, or psychological actions or threats of actions that influence another person. This includes any behaviors that intimidate, manipulate, humiliate, isolate, frighten, terrorize, coerce, threaten, blame, hurt, injure, or wound someone.

Children who live in a home where there is violence may witness the violence first hand, come home to find the after effects of violence or see the perpetrator removed from the home by the police. IPV is associated with many long-term adverse effects including depression, low self-esteem, antisocial behavior, academic difficulty, seductive behavior, and difficulty with the law. Older children may attempt to run away from home.

Nurses who provide care for victims of abuse can support the victim and offer resources for assistance. The nurse should:

  • Start by establishing rapport with the victim. Reassure her that she did nothing wrong.

  • Allow the victim to tell the story without interruption.

  • Ask the victim to tell what happened.

  • Encourage the victim to work with a counselor who can direct her to resources and assist her to decide her plan of action.

  • Direct the victim to support groups to minimize her feelings of isolation.

Caring for Clients Who Experience Violence.

  • Build trust and confidence with a client.

  • Focus on the client rather than the situation.

  • Assess for immediate danger.

  • Provide emergency care as needed.

  • It is NOT the job of the nurse to interrogate or investigate; reasonable cause is all that is needed to report to the agencies who will investigate. 

  • If you suspect with reasonable cause that abuse may have occurred, complete mandatory reporting, following state and agency guidelines.


Conclusion

Despite mandatory reporting statutes, child maltreatment is considerably unrecognized and unreported. In fact, there is evidence that shows only one in three children who experience maltreatment is identified and reported to child protective services.

It is especially important for nurses to serve as advocates for children who are maltreated. Nurses are frequently the first health care professional to encounter a child and his or her family and in that case, should be the one to identify a potential incidence of child maltreatment. Plus, nurses who work in an inpatient setting have lengthy interactions with children and their families which provides them the opportunity to identify indications of abuse or neglect.

Although nurses who work with children should always be aware of indications of neglect or abuse, a pediatric emergency room nurse states three important points to following: (1) If the story doesn’t fit the injury then be suspicious (2) always perform a head-to-toe assessment, and (3) child maltreatment occurs in all social, economic, racial and ethnic groups.

Iowa Contact Information

For suspected child abuse or neglect of a child 18 years or younger, contact the Child Abuse Hotline at 1-800-362-2178 is available 24 hours a day and 7 days a week.  If there is imminent danger of the child, reports must escalate the level of intervention by calling 911 immediately.

To report suspected dependent adult abuse, contact your county Department of Human Services office during regular office hours. Reports may also be made at any time by calling the toll-free 24-hour hotline at: 1-800-362-2178.Reporting Forms.  Forms for reporting suspected child abuse and suspected dependent adult abuse can be downloaded from this web site https://dhs.iowa.gov/dhsforms.  Examples of the form are provided at the end of this module for your review, please go the official website for reproduction and use. 

Iowa Department of Human Services - Report of Suspected Child Abuse

Iowa Department of Human Services - Report of Suspected Adult Dependent Abuse


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Child Welfare Information Gateway (2015). Parental drug use as child abuse.

Department of Human Services (2018). Child Abuse.

Department of Human Services (2017). Dependent Adult Abuse Statistical Report. 

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Department of Human Services (2011). Child abuse: a guide for mandatory reporters.

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