Child Maltreatment Recognition and Reporting in New York State Nursing CE Course

t 1 of article 65 of the education law, or medical, dental, optometrical, or surgical care, though financially able to do so or offered financial or other reasonable means to do so, or, in the case of an alleged failure of the respondent to provide education to the child, notwithstanding the efforts of the school district or local educational agency and child protective agency to ameliorate such alleged failure prior to the filing of the petition; or

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

(ii) who has been abandoned, in accordance with the definition and other criteria set forth in subdivision 5 of section 384-b of the social services law, by his parents or another person legally responsible for his care.”

The subject of the report is “any parent of, guardian of, or other person 18 years of age or older legally responsible for, as defined in subdivision (g) of section 1012 of the family court act, a child reported to the statewide central register of child abuse and maltreatment who is allegedly responsible for causing injury, abuse or maltreatment to such child or who allegedly allows such injury, abuse or maltreatment to be inflicted on such child; or a director or an operator of, or employee or volunteer in, a home operated or supervised by an authorized agency, the office of children and family services, or in a family daycare home, a daycare center, a group family day care home, a school-age child care program or a day-services program who is allegedly responsible for causing injury, abuse or maltreatment to a child who is reported to the statewide central register of child abuse or maltreatment or who allegedly allows such injury, abuse or maltreatment to be inflicted on such child” (New York Social Services Law - SOS § 412, subsection 4, 2022).

Nursing alert: Many individuals may be involved in the abuse or maltreatment of a child. According to the NYS statutes, the perpetrator of abuse is responsible, and any person who is aware and allows the abuse to continue, including healthcare workers. Therefore, nurses must be vigilant in identifying and reporting suspected child abuse or maltreatment (New York Social Services Law - SOS § 412, subsection 4, 2022).

Epidemiology

According to the HHS (2023), over 3.9 million children were subjects of investigation in 2021, and approximately 600,000 were determined to be victims of maltreatment, decreasing from 678,000 in 2018. This number equates to a victim rate of 8.1 per 1,000 children. Of these, neglect was experienced by 76.1%, physical abuse by 16%, sexual abuse by 10.1%, and sex trafficked by 0.2%. Due to abuse and neglect, child fatalities increased in 2021 to an estimated 1,820 children, a rate of 2.46 per 100,000 children. Of these child fatalities, 45.6% were younger than 1 year, a rate of 24.39 per 100,000 children in that age range. Boys have higher fatality rates (3.01 per 100,000 boys) than girls (2.15 per 100,000 girls). Black children have a 5.6 times greater fatality rate than White children and a 3.9 times greater rate than Hispanic children (Administration for Children and Families [ACF], 2023).

According to the Centers for Disease Control and Prevention (CDC, 2022a), 1 in 7 children has experienced abuse across the US in the past year. Children who live in poverty experience abuse rates 5 times higher than their higher socioeconomic counterparts. The lifetime economic burden associated with child abuse was estimated at over $592 billion in 2018 and is comparable to high-cost diseases such as type 2 diabetes and stroke (CDC, 2022a).

The following are additional national statistics on child abuse (ACF, 2023):

• It is estimated that 70.3% of deaths related to abuse involved children under 3 years of age.
• Children under 1 year of age have the highest victimization rate at 25.3 per 1,000 children nationwide.
• Girls have a higher victimization rate (8.7) than boys (7.5) per 1,000 children.
• American Indian or Alaska Native children have the highest victimization rate (15.2), and African American children have the second-highest rate (13.1) per 1,000 children.
• In 2021, parents—either individually or with another parent—were responsible for 76.8% of child abuse or neglect fatalities, with 29.2% committed by the mother alone, 14.2% committed by the father alone, and 22.6% involved both parents. Relatives, partners of parents, or childcare providers were responsible for 16.6% of child fatalities, and unknown perpetrators caused 3.7% of child abuse deaths in 2021.
• More than half of perpetrators are female (51.7%), while 47.2% are male. Most perpetrators are between 18 and 44 years of age (83.2%). The largest percentage of perpetrators identified was White (48.0%), followed by Black (21.0%) and Hispanic (20.9%).

The 2018 Bright Spots Child Protective Services (CPS) Report noted that 45.9 children out of every 1,000 (203,127 cases statewide) were named as an alleged victim of abuse or maltreatment, and 15.2 of every 1,000 (67,124 cases statewide) children were confirmed as a victim in at least one CPS report in New York (OCFS, 2019). NYS statistics on child abuse include the following (OCFS, 2021b):

• The total number of verified deaths related to child maltreatment and abuse in 2021 was 102 across New York, with 48% of these children in families that had no prior history of contact with the New York City’s Administration of Children’s Services (NYCACS).
• In 2021, 20 fatalities occurred in families known to ACS due to sleep-related injuries or unsafe sleep conditions.
• Child abuse occurs among people of all socioeconomic levels, cultures, ethnicities, and levels of education of the perpetrator.

 

Long-Term Effects

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

Figure 1

The Adverse Childhood Experiences (ACE) Pyramid

(CDC, 2021)

ACEs can include experiencing violence, abuse, or neglect or witnessing violence in the home or community. Approximately 64% of adults in the US reported experiencing at least one ACE before the age of 18. The child’s environment can also have a significant impact on their sense of safety, stability, and bonding. The presence of mental health problems, substance misuse problems, or parental separation in a household can all negatively impact the children within the household physically and mentally. Abuse and neglect cause physical changes in children's brains. Poor impulse control, an inability to experience pleasure, or antisocial behaviors can stem from previous abuse and neglect. A child who lives in an unstable environment with constant stress or violence is more likely to develop learning disabilities, anxiety, and even physical illness, including cancer, diabetes, and early death. Childhood maltreatment has also been associated with increased episodes and severity of depression and an increased risk of suicide attempts. Children exposed to violence are more likely to have poor school performance and develop substance misuse disorders and a variety of emotional and physical health concerns. In addition, they may have difficulty with interpersonal relationships with peers in the present and the future (Bellis et al., 2017; CDC, 2023; Lippard & Nemeroff, 2019).

Studies have shown a direct correlation between the psychopathic traits of adults and exposure to violence as a child (Bellis et al., 2017; Dargis & Koenigs, 2017). Exposure to violence in children (under the age of 18) was assessed during the National Survey of Children's Exposure to Violence, or NatSCEV, a joint effort of the CDC and the US Department of Justice. Most (67.5%) of respondents had witnessed violence or abuse directly or indirectly in the last year (when a crime was included in the definition of violence or abuse). Even more troubling was that 41% had multiple exposures in the past year, which could be trauma-inducing if not identified and adequately addressed. Up to 10% of the respondents reported six or more direct exposures in the last year, making them highly vulnerable to adversities and distress, or "polyvictims." Exposure to violence can cause many of the same emotional and psychological effects as direct maltreatment if not managed appropriately. In addition, NatSCEV found that exposure to violence increased the risk of other types of violence/maltreatment as well (Finkelhor et al., 2015). In a more recent literature review, di Giacomo and colleagues (2021) found a relationship between trauma and psychopathy, with emotional neglect and physical abuse being the types of abuse with the strongest relationship to the development of psychopathy. Sexual abuse did not show a significant relationship to psychopathy in most of the studies reviewed (di Giacomo et al., 2021).

HCPs play an important role in the prevention and identification of ACEs. Understanding what constitutes an ACE and the risk factors associated with ACEs is key to prevention and appropriate care for children who are at risk of or experienced an ACE. Research has shown that many HCPs do not routinely ask about or screen for ACEs due to a lack of training on how to screen and talk with families about ACEs. Incorporating training for HCPs and developing protocols and guidelines for screening for ACEs will help identify children at risk of or who have experienced an ACE. HCPs should talk with caregivers about creating a safe, stable, and nurturing environment while addressing negative caregiving techniques and reinforcing positive caregiving techniques. Formal programs such as the Safe Environment for Every Kid can be used to screen for ACE exposures and should be routinely incorporated into practice (Jones et al., 2020).

Since the COVID-19 pandemic, many changes occurred in the delivery of healthcare services, including the increased use of telemedicine or virtual visits. HCPs must remain vigilant in screening for and identifying signs and symptoms of child abuse and maltreatment even when they are interacting in a virtual environment. Several strategies can be employed by HCPs when interacting in a virtual environment, including:

• utilizing a standardized approach to screening for child abuse or maltreatment
• observe caregiver/child interactions (e.g., does the child seem afraid of the caregiver)
• observe non-verbal cues (i.e., expressions of pain, visible marks)
• consider known risk and protective factors when interacting with a child and family
• observe the background (i.e., safety hazards, yelling by family members)
• ask probing questions (i.e., what does a day at home look like)
• evaluate suspicious injuries by requesting photos using a secure message
• listen to how the caregiver describes interactions with the child (North Central Missouri Children’s Advocacy Center, 2020)

Risk and Protective Factors

Certain characteristics (direct or indirect) are associated with a greater likelihood of child abuse and maltreatment (Boos, 2023; CDC, 2022d). These risk factors occur in three main categories: (a) risk factors for victimization, (b) risk factors for perpetration, and (c) community risk factors (i.e., social determinants of health [SDOH]). Although child abuse and maltreatment can affect all races, ethnicities, sexes, and socioeconomic groups, research demonstrates that some of these characteristics are associated with an increased likelihood of abuse (Joyce et al., 2023). Therefore, identifying and understanding these risk factors is essential to developing potential preventative initiatives (CDC, 2022c). 

The risk factors for abuse and maltreatment in children at the individual and environmental level include:

• age 4 years old or younger, particularly premature babies
• special needs (emotional or physical) that can increase the caregiver's burden
• failure to thrive
• attention deficit disorder with hyperactivity in children
• prematurity and low birth weight
• unplanned pregnancy
• unwanted child
• domestic violence in the home, including abusive, coercive, forceful, or threatening acts or words by a member of the household to another (the caregiver may be the perpetrator or victim of the domestic abuse) or other violence, including a caregiver’s personal history of child abuse or neglect
• animal cruelty
• financial problems within the family, leading to an inability to provide appropriate resources to meet the minimum needs of the children and family
• caregiving stress or negative interactions/caregiver-child relationships
• divorce, family break-ups, or social isolation
• living in poverty
• family mental health issues, including depression
• transient, non-biological caregivers in the home, such as a caregiver’s significant other or partner (Boos, 2023; CDC, 2022d)

Caregiver risk factors that contribute to child abuse or maltreatment include:

• alcohol use disorder (compulsive and chronic use of alcohol)
• substance use disorder (SUD, the chronic, compulsive use of either prescription or illegal drugs)
• specific caregiver characteristics, including young age, low education, single parenthood, many dependent children, or low income
• unrealistic expectations for the child; a caregiver’s lack of understanding regarding the needs or development of their child
• a lack of parenting skills
• poorly controlled psychiatric illness (e.g., psychosis, depression, impulse disorder; (Boos, 2023; CDC, 2022d)

Community risk factors that contribute to child abuse and maltreatment include:

• violence within the community
• neighborhood disadvantages (i.e., high poverty rates, residential instability, high unemployment rates, poor social connections, and easy access to drugs and alcohol; Boos, 2023; CDC, 2022d)

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

• supportive family environments and social networks
• basic needs met, including housing, food, and safety
• readily available parenting skills education
• stability in family relationships
• caregiver education and employment
• access to health care and social services
• caring adults outside the home who serve as role models or mentors (CDC, 2022d; Gonzalez et al., 2023)

The goal is to prevent abuse and neglect before it happens. Among the preventative techniques is strengthening economic support to families through a family-friendly work policy or household financial security. Social norms and educational campaigns that focus on positive parenting and coaching are effective. Children should have quality care and education during their toddler, preschool, and early elementary years. These can be encouraged through state licensing and accreditation of daycare centers and early childhood programs. Initiatives such as early childhood programs and home visits can promote parenting skills and healthy child development. Finally, pediatricians and primary care providers should monitor for and intervene in high-risk situations where future abuse and neglect are suspected to minimize the effects and avoid future concerns (CDC, 2022c).

Indicators of Abuse/Maltreatment

Case Study 1: A nurse working in a pediatric emergency department (ED) and is caring for a 4-year-old who has a fractured right arm. They are clinging to their caregiver and crying throughout the assessment. The nurse notices that the child has a long-sleeved shirt on, even though it is the middle of summer. When the nurse rolls back the sleeve, the child has multiple bruises; some are yellow, while others are blue and black. The child’s caregiver notices that the nurse is assessing the child’s arm and begins explaining that the child is "clumsy" and falls all the time. The child looks down when the caregiver talks about their injuries. The nurse asks to take the child to the radiology department for an x-ray, hoping to find time alone with the child. The caregiver refuses to allow the nurse to take the child away, stating that they will go with them. What red flags related to abuse should the nurse recognize in this scenario? How should the nurse proceed? Considerations: The child has a fractured arm, they have long sleeves on even though it is summertime, and they have bruises in multiple stages. The nurse should initiate a call to the abuse hotline and make a report. Children who are victims of abuse may dress inappropriately to cover injuries, such as wearing long sleeves in the summer. Other signs of abuse in the ED can include caregivers who refuse to leave the child's side, fearing the child may discuss their injuries with the HCP. Nurses should be alert to these situations that indicate the child could be in danger or a victim of abuse (Boos, 2023; Gonzalez et al., 2023; OCFS, n.d.-c).

  

 

Physical Abuse

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

• human bite marks
• fractures in multiple stages of healing or a history of repeated fractures
• bedwetting by previously toileting children
• repeated ED visits due to physical injuries
• a caregiver’s report that is inconsistent with the child’s explanation of the injury
• bruising or injuries on areas of the body that would not typically be visible through clothing, such as the chest, torso, or buttocks
• bruising, burns, or welts with specific shapes such as a belt buckle or handprint, round burns from cigarettes, or marks around the wrist or ankles indicating that the child was restrained and struggling
• multiple bruises or other injuries in various stages of healing
• a non-ambulatory infant with an injury
• injury in a nonverbal child
• mechanism of injury not plausible
• caregiver is unconcerned about the injury
• unexplained delay in seeking care
• injuries to the eyes or both sides of the head or body, as most accidental injuries are unilateral (Boos, 2023; Gonzalez et al., 2023; OCFS, n.d.-c)

Providers should remember that abuse is not always limited to hitting or injuring with associated bruising or visible injuries. Other acts of bodily injury can include burns with hot water, holding a child underwater, throwing objects at a child, physically restraining a child as a form of discipline, and using an object such as a paddle, belt, cord, limb from a tree (switch), or shoe to beat a child (Boos, 2023; Gonzalez et al., 2023; OCFS, n.d.-c). Adolescents can be screened for potential abuse using the Conflict Tactics scale. This scale was developed in 1972 based on the conflict theory. It examines specific acts or events used in a conflict and considers that abusers seek power and control over the victim. Warning signs of abuse may also include asthma, stress-related illnesses, anxiety/panic attacks, vague aches and pains, chronic diarrhea, abdominal pain, bladder/kidney infections, joint pain, or muscle pain (Ronzon-Tirado et al., 2019).

Case Study 2: A pediatric nurse is admitting a 6-month-old infant. The infant is with their caregiver's significant other since the caregiver is at work. The significant other reports that the infant fell off the bed after they both fell asleep. They further state that "the baby just wanted their parent and cried themselves to sleep." The significant other seems nervous and is texting on their phone in the corner while the nurse assesses the baby. The infant's right pupil is dilated, and they are extremely irritable with a high-pitched cry. The infant is inconsolable with a bottle or pacifier. What should the nurse do next? Considerations: The nuse should first ensure the infant is safe and provide immediate medical attention for potentially devastating or life-threatening brain injuries. The nurse should suspect abusive head trauma (AHT) and initiate a call to the abuse hotline. The nurse should also discuss their concerns with the primary HCP and determine whether the child should be placed in protective custody. It may be necessary to call 911 in this instance for the protection of the child.

 

Pediatric AHT 

Pediatric AHT results from caregiver abuse and was previously termed shaken baby syndrome. This severe form of child abuse can lead to serious brain injury or death. It often occurs following an infant's prolonged crying, causing the caregiver to become angry, shake or throw the child down, and ultimately cause a head injury. Bleeding can occur around the brain or on the internal layer of the eyes. Pediatric AHT is the leading cause of death in children under 5 years of age in the US, with babies under a year old at the highest risk, and it accounts for more than one-third of all child maltreatment deaths in the US. Long-term consequences of pediatric AHT can include vision problems, developmental delays, physical disabilities, and hearing loss (CDC, 2022b; Christian, 2022). Please see the NursingCE course entitled Pediatric Abusive Head Trauma for more detailed information.

Case Study 3 A nurse is dropping off their young child at school when their first-grade teacher asks to step into their office for advice. The teacher states that the information must be kept confidential, but that they need someone to help make the right decision. The teacher says that one of the children in the class missed 2 days of school last week, then came back to school unable to sit still. The child repeatedly asked to go to the bathroom and seemed uncomfortable sitting. The child has not been able to concentrate and seems distracted during activities they had previously enjoyed. The teacher further noted that the child had extremely chapped lips and reported that their mouth was hurting. The student’s personality had recently changed since one parent started a night shift job, and their other parent is watching them. The student’s caregivers reported that the child is having a hard time transitioning to their new routine. The teacher is worried that the child may be a victim of sexual abuse. The student’s parents are both professionals, and one is a nurse. What must the nurse do? Consideration: The nurse should report if they have any verifiable details or information regarding the child's identity. The teacher is a mandatory reporter, and the nurse should remind the teacher of their responsibility to report this case.

 

Sexual Abuse

Sexual abuse of a child occurs when a "parent or caretaker commits a sexual offense against a child or allows a sexual offense to be committed, such as rape, sodomy, engaging a child in sexual activity, or engaging a child in or promoting a child's sexual performance" (Prevent Child Abuse New York, n.d., para. 5). Sexual abuse is not limited to touching or penetrating the child. It can also include acts intended to arouse the abuser sexually (The National Child Traumatic Stress Network [NCTSN], n.d.). Other acts considered sexual abuse involve:

• sexual interactions between two children or an adult and a child
• fondling
• voyeurism (looking at a child’s naked body)
• masturbation in the presence of a minor or forcing the minor to masturbate
• exposing oneself to a minor (exhibitionism)
• text messages, online interactions, or sexually suggestive phone calls
• sex trafficking
• causing pregnancy
• producing, owning, or sharing pornographic images, movies, or online materials of children
• any sexual conduct harmful to a child’s emotional, mental, or physical welfare (NCTSN, n.d.)

A child who is a victim of sexual abuse may exhibit sexual behavior beyond their age or may have a change in toileting habits, such as frequent urination or difficulty with defecation. The child may also have itching, pain, bleeding, or bruising in the genital area. Other symptoms of sexual abuse may include:

• sexually transmitted illnesses (STIs)
• pain or discomfort when trying to sit or walk
• sexual behaviors toward other children
• signs (verbal or physical) of age-inappropriate knowledge of sexual acts or information (Bechtel & Bennett, 2022; OCFS, n.d.-c)

The child may describe sexual actions or act them out, although they are often threatened or intimidated into keeping the activity secret (Bechtel & Bennett, 2022; OCFS, n.d.-c). Behavioral indicators of sexual abuse in children may include regression to earlier developmental stages, such as bedwetting or a refusal/reluctance to change clothes in front of others (e.g., gym class). The child may refuse to participate in sports or otherwise entertaining activities. They may withdraw from friends and family. Other symptoms can include anxiety, anger, depression, promiscuity in older children, internalized symptoms (e.g., upset stomach, headaches), or nondescript symptoms. Some children may not exhibit any indication that they have been exposed to sexual abuse, making recognition by their HCP more difficult (Melmer & Gutovitz, 2023; Schaefer et al., 2018).

Case Study 4 A 12-year-old transgender adolescent is currently in foster care. Their parents threw them out of their home after the adolescent revealed that they are transgender. The adolescent has been in four foster homes and is now having difficulty in school. The adolescent is currently attending their third school in the same year. What should the nurse be concerned about as potential risks for this adolescent? Considerations: The adolescent is at risk for child abuse as well as child sex trafficking. The nurse should provide resources for them, including a referral for mental health services, and discuss these concerns with the primary HCP.

 

Child Sex Trafficking

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

• runaway or missing children
• children with a history of abuse, including sexual abuse, particularly if the child was removed from the home after the event
• a child who is involved with government systems such as foster care, CPS, or the courts
• children with SUD or those who live in a household with persons with SUD
• children identifying as LGBTQ who have been kicked out of their homes (NCMEC, n.d.; Tracy & Macias-Konstantopoulos, 2023)

In 2022, NCMEC received more than 19,000 reports of possible sex trafficking. In addition, the NCMEC has received reports for over 25,000 cases of children who were reported missing, and 1 in 6 of those children were likely victims of child sex trafficking. There are many indicators of sex trafficking in children, but no single indicator confirms that a child is a victim of trafficking. The NCMEC (n.d.) lists several behavioral and physical red flags that HCPs should know when caring for children. Behavioral and physical indicators could include:

• a significant change in behavior, such as increased use of technology or a new group of friends
• a child who allows others to talk for them, avoids answering questions when asked, or looks to others when asked a question
• a child who seems scared, resistant, or argumentative or appears coached in responses to law enforcement
• a child who lies about their age or identity
• a child who uses terminology that is specific to child trafficking, such as trick, the game, or the life
• a child who is preoccupied with obtaining money
• a child with several cell phones or electronic devices
• a child with no ID or an ID in someone else’s possession
• a child with large amounts of cash or pre-paid credit cards
• multiple children present with unrelated adults
• a child with unexplained sexual paraphernalia such as condoms, lubricants, etc.
• a child with hotel room keys, receipts, or other items from hotels
• a child who refers to traveling to other cities or states, does not typically live in their current location, or cannot recite their existing travel plans or location
• an older boyfriend or girlfriend present that appears to control the child
• a child who is recovered or found at a truck stop, hotel, or strip club
• a child with items or an appearance that is not congruent with their current situation, such as a homeless child with new clothes, shoes, or expensive electronics
• a child with a notebook or slips of paper with names, phone numbers, addresses, and dollar amounts
• a child who talks about online classified ads or escort websites
• a child who mentions traveling opportunities and jobs such as modeling, singing, dancing, or acting
• a child with specific tattoos or burn marks, which are considered branding
• a child with unaddressed medical issues who presents to an ED or clinic without an adult or with an adult who is not related and appears overly controlling
• a child who may not identify as a victim and resists help from others even when offered (NCMEC, n.d.; OCFS, n.d.-b; Tracy & Macias-Konstantopoulos, 2023)

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

Case Study 5 Caregiver A is a highly respected nurse educator at a university. They graduated at the top of their class, have a PhD and a DNP, and are often called an "overachiever" by their friends. They have a teenager who is at the top of their class and participates in several sports, excelling at all of them. Today, Caregiver A is bringing their teen to the family practice office for a cough, nasal drainage for 4 days, and a fever. The nurse checks them in and asks the patient to step on the scale. They hesitate, and the caregiver chides them, saying, "get on the scale. You know you have gained weight, so let's see." The teen looks down and steps on the scale, crying silently. The caregiver continues to belittle the patient until their phone rings, and excuses themself while the teen is being examined. When the caregiver leaves the room, the nurse asks the patient if they are ok. The patient says, "I just need to suck it up. I am fat.” The nurse is worried that the teen may be experiencing emotional abuse. What should the nurse do next? Considerations: Attempt to discuss the situation with the teen and allow them to voice their concerns. This family would likely benefit from counseling and mental health services.

 

Emotional Abuse

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

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

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

Case Study 6 A newly graduated nurse working on a pediatrics unit received a report on a 3-year-old child. The patient has been neglected, was removed from the home, and is now living with foster parents. The nurse assumes that neglect means the child was deprived of food, shelter, or basic needs; however, the nurse discovers that this child was taken from their home because the caregivers failed to obtain needed medical services for a brain tumor. Due to their religious beliefs, the caregivers did not obtain medical care for the child, so the state removed the child from the home and mandated treatment for the tumor. The nurse recognizes that they may not fully understand neglect and decides to research the topic online. What other aspects of neglect might the nurse find in this search? Considerations: Neglect can include caregivers who fail to get medical care for their child along with failing to provide the basic needs of food, shelter, or clothing.

Child Neglect

Child neglect is the “failure of a parent or caretaker to provide needed food, clothing, shelter, medical care, or supervision to the degree that the child’s health, safety, and wellbeing are threatened with harm” (NYCACS n.d., para. 3). Examples of neglect include:

• a child's educational needs are not met by either keeping the child at home during school time for unexcused reasons or failure to follow up with a child's educational needs after school outreach to the caregiver
• adequate clothing, food, or shelter is not provided
• adequate medical or mental healthcare is not provided
• adequate supervision is not provided, such as being left home alone
• a child is subjected to fear, verbal terror, extreme criticism, or humiliation
• a child receives corporal punishment to the point of physical or emotional harm
• a child is exposed to family violence
• a child is in the presence of keeping, manufacturing, or selling drugs or is given drugs by a caregiver
• a caregiver who uses drugs cannot care for the child (Gonzalez et al., 2023; Harper & Foell, 2023; NYCACS, n.d.)

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

• inappropriate growth for age
• weight gain or obesity
• poor hygiene (dirty hair, skin, or body odor)
• inappropriate clothing or a lack of clothing and supplies for physical needs
• extreme fatigue or falling asleep in class
• demanding constant attention or affection in school or elsewhere
• hiding food for later or to bring to siblings
• taking food or money without permission
• showing a lack of appropriate dental, medical, or mental health care or failing to follow up (Gonzalez et al., 2023; Harper & Foell, 2023; NYCACS, n.d.)

SUD in a caregiver often contributes to the neglect or abuse of children. For example, a child may accidentally ingest drugs, or their caregiver may be too impaired to care for the child, leading to neglect. In addition, older children are sometimes made responsible for younger siblings and cannot provide adequate care. Therefore, HCPs should be aware of the possibility of neglect and respond appropriately (Gonzalez et al., 2023; Harper & Foell, 2023; NYCACS, n.d.).

Case Study 7 A 28-year-old single parent whose significant other comes in and out of their life brings their 2-year-old child into the clinic stating that the child had a temperature of 103 °F throughout the night. The significant other is also the co-parent of the child. Today, the toddler is afebrile. They further report that the child had blood in their urine a few days prior. The nurse obtains a urine specimen that is clear. The nurse sees throughout the child’s medical record that they are frequently brought to the office by their caregivers; many tests have been run on the child, most of which are negative. The provider decides to admit the child for observation and obtain further labs. The nurse takes a cup to the parent and asks them to get a urine specimen the next time they take the child to the restroom. After leaving the room, the nurse hears the patient crying and goes in to find the parent trying to stick the child with a needle; the urine cup is open with a specimen on the bedside table. What should the nurse do? Considerations: This parent may be suffering from factitious disorder imposed on another (FDIA). The nurse should vocalize their concerns to the primary HCP and question the parent about these events.

 

Factitious Disorder Imposed on Another (FDIA)

FDIA, previously Munchausen syndrome by proxy (MSP), is abuse involving an intentional production of illness in another person to assume the sick role by proxy. The proxy is usually a parent/caregiver who intentionally makes a child ill or fabricates symptoms to gain attention. The diagnosis and treatment of this health disorder are complicated. Victims are typically under 6 years of age, and the cases are usually undiagnosed; FDIA wastes medical services and can lead to significant morbidity and mortality in children. Invasive diagnostic tests or treatments are often ordered, and the caregiver fabricates symptoms for various dysfunctional reasons. FDIA abusers have different motives, including attention-seeking, manipulation, satisfaction from deceiving others, or gaining a sense of control. The prognosis for the child depends on the severity of the damage done by the abuser (American Academy of Family Physicians [AAFP], 2023; Roesler & Jenny).

Someone suffering from FDIA may purposely make their child sick by withholding food, poisoning or suffocating the child, giving inappropriate medications, or withholding prescribed medications. The caregiver may knowingly expose the child to risky and painful medical procedures, including surgery (AAFP, 2023; Roesler & Jenny). Some common illnesses that caregivers seek medical help for FDIA victims can include:

• nausea, vomiting, and diarrhea
• failure to thrive
• seizures
• infections
• fevers of unknown origin
• allergic reactions
• breathing difficulties (AAFP, 2023; Roesler & Jenny)

Mandatory Reporting

Nurses should be highly familiar with the policies and procedures in their workplace based on applicable state laws. In NYS, these laws direct the handling of suspected child abuse or maltreatment. If an organization's policies and procedures are not aligned with the state laws and directives, nurses are still obligated to follow the law. Nurses must report suspected child abuse and maltreatment and are considered mandated reporters. Mandated reporters can include the following (see the website for the full list):

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

The NYS OCFS maintains the Statewide Central Registry for Child Abuse and Maltreatment (SCR), also known as the "hotline" for reporting suspected or confirmed abuse and maltreatment according to the Social Services Law (see the website for phone numbers; OCFS, n.d.-d). This hotline is available 24 hours per day, 7 days per week. After a call reaches the SCR, local CPS is contacted to initiate an investigation and determine whether there is a history of child abuse or maltreatment reports. Local CPS will initiate an investigation within 24 hours. The reporter must complete and sign a written report within 48 hours of the initial phone call to the hotline and mail this to the local CPS office. The caseworker may take the child into protective custody if the child is in danger. CPS has 60 days to perform an investigation and determine whether the report is indicated or unfounded. The written report may become part of future court proceedings and should be thoroughly completed. The form should include a list of all children in the household, the basis of suspicion, any medical examination information, photographs, radiographs, or any images obtained during the child's assessment. Any information from the child or caregiver should be explicitly stated and accurately quoted. Appropriate medical care should be provided during the visit and documented in the report. Nurses are not required to notify the caregivers before or after the report to SCR. Often, alerting caregivers could jeopardize the child’s welfare and hinder the investigation (OCFS, 2021a).

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

“Persons and officials required to report cases of suspected child abuse or maltreatment:

• when they have reasonable cause to suspect that a child coming before them in their professional or official capacity is an abused or maltreated child; or
• when they have reasonable cause to suspect that a child is an abused or maltreated child where the parent, guardian, custodian, or another person legally responsible for the child comes before them in their professional or official capacity and states from personal knowledge facts, conditions, or circumstances that, if correct, would render the child an abused or maltreated child” (New York Social Services Law - SOS § 413, subsection 1, 2023).

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

Legal Protections for Mandatory Reporting

Nurses who are on duty are required to report any suspicion of abuse. If a nurse is off duty and suspects child abuse while not in their professional capacity, they are not legally obligated to report it in New York but still have a moral obligation to report it. Reasonable cause is based on the nurse's professional training and experience, observation, or suspicions that imminent danger of harm by a caregiver to a child exists. NYS law protects nurses and provides immunity from liability for mandated reporting. The Social Services Law assures confidentiality for mandated reporters and all sources of maltreatment or abuse reports. Reports and all associated information may be shared with police, court officials, and district attorneys under certain circumstances. When reports are made in good faith, out of sincere concern for the child’s wellbeing, the reporter is immune from criminal or civil liability. Section 413 of the Social Services Law specifies that "no medical or other public or private institution, school, facility, or agency shall take any retaliatory personnel action against an employee who made a report to the SCR" (New York Social Services Law - SOS § 413, subsection 1, 2023).

Strategies to Reduce Implicit Bias

HCPs are responsible for identifying the signs and symptoms of child abuse and maltreatment and have a duty to report any suspicion of abuse or maltreatment. Healthcare organizations must ensure that standardized protocols and guidelines are in place to ensure the care provided in these situations is delivered fairly and equitably to all patients regardless of age, gender, race, ethnicity, religious or cultural background, sexual identity, or physical disability. Implicit bias refers to the attitudes or stereotypes that unconsciously affect our actions, understanding, and decisions. These biases can include favorable and unfavorable assessments of another person and are activated involuntarily without individual awareness or intentional control. The decision to report suspected child abuse and maltreatment can be difficult for HCPs to make, and implicit bias can occur, resulting in inequity based on socioeconomic status. Overreporting of child abuse and maltreatment occurs for families of lower socioeconomic status, while underreporting occurs with families of higher socioeconomic status. Numerous individual and community factors contribute to the risk of child abuse and maltreatment. HCPs may interpret social risk factors and apply them in ways that perpetuate bias. Black children are more likely than White children to have CPS cases opened and are at greater risk of being placed out of the home. Strategies to reduce implicit bias include universally implementing validated screening tools, clinical guidelines, and electronic health record alerts to support clinical decision-making regarding child abuse and maltreatment. HCPs should participate in effective and comprehensive implicit bias training on a regular and ongoing basis. Building diverse, multidisciplinary teams can also minimize bias in medical decision-making (Letson & Crichton, 2023; Palusci & Botash, 2021).

Conclusion

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

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