≥ 92% of participants will know how to identify and respond appropriately to child abuse.
CEUFast, Inc. is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. ANCC Provider number #P0274.
≥ 92% of participants will know how to identify and respond appropriately to child abuse.
After completing this continuing education course, the participant will be able to:
Studies have concluded that professionals who have contact with children often report only half of the incidents that may be abuse.
Youth violence is a central public health issue. The World Health Organization (WHO) estimates that nearly 176,000 people between the ages of 15 and 29 are killed every year, making it the third leading cause of death for individuals in this age group (World Health Organization [WHO], 2023). Sexual violence is also shown to affect a significant proportion of youth as well, as evidenced by about 1 in 8 young people who report being sexually abused (WHO, 2023).
It is estimated that approximately 1 in 7 children suffer from abuse or neglect every year (Centers for Disease Control and Prevention [CDC], 2022a). This is likely underestimated because numerous cases go unreported (CDC, 2022a). In 2020 alone, more than 1,750 children died due to abuse and neglect just in the United States (CDC, 2022a).
There is a large gap between the true prevalence of child abuse and the number of cases that are brought forward to Child Protective Services (CPS) (Baker et al., 2021). Every year, CPS investigates over 3 million children and their families nationally (Rizvi et al., 2023). Of this number of families, 20% produce evidence of maltreatment that is substantiated (Rizvi et al., 2023). While males and females seem to be equally affected, the highest risk of abuse and neglect is in children who are less than three years of age and those who are African American and Native American (Brown et al., 2023; Melmer & Gutovitz, 2023). Of the number of abused children, 75% suffer neglect, 15-20% suffer physical abuse, and 5-10% endure sexual abuse (Brown et al., 2023; Melmer & Gutovitz, 2023).
Mandated Reporters make the majority of child abuse reports due to their professional experience and Mandated Reporter training (Baker et al., 2021).
For many families, having a child removed from the home and navigating a child welfare system can be traumatic events (New York State [NYS], 2022). Enduring abuse as a child is a traumatic event (Better Health Channel, 2022). Let’s discuss what trauma is and what it can look like.
Trauma is defined as a terrible event that threatens a person’s life or safety in a way that is too much for the mind to handle, initiates an emotional response, and often leaves the person powerless, in shock and denial (American Psychological Association [APA], n.d.; NYS, 2022).
Traumatic experiences include personally enduring or observing events including (NYS, 2022; Better Health Channel, 2022):
Following a distressing event, it is normal to have strong reactions. These immediate reactions often fade as the mind and body can heal and recover with time (Better Health Channel, 2022).
Trauma can cause physical reactions including (NYS, 2022; Better Health Channel, 2022):
Trauma can also cause emotional reactions that might include (NYS, 2022; Better Health Channel, 2022):
Mental reactions to trauma can involve (NYS, 2022; Better Health Channel, 2022):
Now that we have reviewed what trauma is and can look like, we will now go over Adverse Childhood Experiences. As mentioned above, we know that enduring and/or witnessing physical, mental, emotional, and sexual abuse as a child can be traumatic (Better Health Channel, 2022). That trauma can be experienced long-term.
Adverse Childhood Experiences, or ACEs, are negative experiences or events that are potentially, and often, traumatic. These events occur from birth through about 17 years of age (CDC, 2023).
ACEs can include all the following situations as listed in the following image:
Image #1:
Adverse Childhood Experiences (ACEs)
This list, however, is not fully inclusive. Additional examples of ACEs include (CDC, 2023; Cleveland Clinic, 2023; Integrative Life Center, 2021):
This list is quite similar to the one above, listing examples of traumatic experiences one might endure. As you might deduce, child maltreatment and abuse are also ACEs (NYS, 2022).
ACEs have been shown to impact a person’s functioning, physical and mental health, and overall well-being throughout their lives (CDC, 2023). These effects can then be seen well into adulthood. The CDC and Kaiser Permanente conducted the first ACE study from 1995 to 1997 (National Conference of State Legislatures [NCSL], 2022). Of the more than 17,000 adults surveyed about childhood experiences (including emotional, physical, and sexual abuse, neglect, and household dysfunctions of separation from a parent, substance use disorder, incarceration, violence, and/or mental illness), approximately two-thirds of respondents indicated a history of at least one ACE and more than 20% noted three or more (NCSL, 2022).
Other factors can intensify the effects of ACEs. These factors can include (NYS, 2022):
As mentioned above, exposure to ACEs has been correlated with increased risk for certain behavioral issues and health conditions. Additional research has determined that ACE exposure increases a child's risk of obesity, autoimmune diseases, depression, and substance use disorders (Cleveland Clinic, 2023; NCSL, 2022; Webster, 2022).
A direct correlation has been noted:
But why is this? The underlying mechanism here is associated with the "toxic stress" that ACEs are said to exert their effects on health, growth, and development (NCSL, 2022). Although some stress is normal and essential to proper growth and learning, sustained chronic, toxic stress damages both the body and the brain (NCSL, 2022). Toxic stress follows when a person experiences severe, prolonged adversity without sufficient support. Toxic stress means the body's stress response stays continuously activated (NYS, 2022). This toxic stress can build up in the body, interfere with proper neural, hormonal, and immune development, and ultimately alter DNA expression (NCSL, 2022). This change in DNA expression can result in lifelong effects on behavior, attention, decision-making abilities, and one's response to stress (NCSL, 2022). Toxic stress impacts children developmentally and behaviorally (NYS, 2022).
As we have seen,
Because ACEs can have lifelong negative effects on a child or adolescent's health and overall well-being, it is important that we do what we can to mitigate them once they have occurred or prevent them outright (CDC, 2022b).
The following strategies for mitigation and prevention have been presented by the National Conference of State Legislatures (2022) report after reviewing an extensive number of publications in the research done following the original ACE study (Bellazaire, 2018):
The CDC outlines these additional strategies for preventing ACEs altogether (CDC, 2023):
It is important to continue raising awareness of ACEs to help prevent them or work to prevent the long-term sequelae that result without adequate intervention (CDC, 2023; Webster, 2022). The focus needs to be taken off the individual and, more so, shifted onto the community to help lessen the risk of ACEs and their effects. The more children and adolescents can reach their full potential, the more the communities these future adults will live in will benefit (CDC, 2023).
Trauma-informed care (TIC) is an approach for working with individuals and families that recognizes the impact and influence trauma may have on the individuals and families you serve (NYS, 2022). The main goal of a TIC approach is to avoid the inadvertent re-traumatization of individuals through your interactions with them (Tracy & Macias-Konstantopoulos, 2023; Gaillard-Kenney et al., 2020). TIC's goal is to understand that trauma may impact a person’s behavior (Tracy & Macias-Konstantopoulos, 2023; Gaillard-Kenney et al., 2020).
This patient-centered approach focuses on the basic understanding that the trauma the patient has endured will greatly impact their life from now on (Tracy & Macias-Konstantopoulos, 2023). This approach aims to avoid any possible reinjury, focus on survivor strengths and overarching resilience, empower healing and recovery, and promote the creation of survivorship skills (Tracy & Macias-Konstantopoulos, 2023).
TIC can be applied to all patients as it simply involves the healthcare personnel's practice modification to be critically aware of the general traumatic events this specific patient has lived through (Tracy & Macias-Konstantopoulos, 2023; Gaillard-Kenney et al., 2020).
The CDC’s Office of Readiness and Response (ORR), in collaboration with SAMHSA’s National Center for Trauma-Informed Care (NCTIC), developed trauma-informed practice training that included six main principles (CDC, 2020). These principles include (CDC 2020):
Based on these principles, to be trauma-informed means asking the patient permission before completing an examination, allowing them to remain clothed per their comfort level, assessing them in a place that is comfortable to them, and informing them of the steps in what you are doing so they can know what to expect each step of the way (Tracy & Macias-Konstantopoulos, 2023). The patient should also be asked what their expectations are for your time with them and how you can help them feel as comfortable as possible throughout the proceedings, which could often mean leaving the door open slightly ajar (Tracy & Macias-Konstantopoulos, 2023). It is also helpful for these patients to identify a "safe word" or a "signal" that patients can utilize if they begin to feel unsafe or distressed during the visit (Tracy & Macias-Konstantopoulos, 2023).
Engaging in TIC is not accomplished by using a singular checklist (CDC, 2020). Instead, it requires continual attention, compassionate awareness, sensitivity, and some level of cultural change within the organization (CDC, 2020).
Employing TIC for these patients is extremely important. It helps the patient trust the healthcare personnel and best opens the communication lines (Tracy & Macias-Konstantopoulos, 2023; Gaillard-Kenney et al., 2020).
Protective factors are conditions that, when present in families and communities, can help increase the health and well-being of children and families, serving as buffers to prevent worse outcomes from actualizing (Positive Childhood Alliance, 2024). Protective factors offer support, resources, and coping strategies, allowing families to care for their children and “parent” effectively, even under stressful circumstances (Positive Childhood Alliance, 2024). Research has shown that protective factors can contribute to a lower incidence of child abuse and neglect (Positive Childhood Alliance, 2024).
The following are the five protective factors (Positive Childhood Alliance, 2024):
Resilience is the inner strength and adaptability that allows one to “bounce back” when things are not going well. Resilient parents are able to cope with the stresses of everyday life and situational crises as they arise.
Social connection features a social network of emotionally supportive family, friends, and neighbors who can assist parents with caring for a child. Parents who have reliable people they can count on to share advice, simply listen, or provide concrete support are parents who find it easier to care for their children and themselves.
Extensive research has been done on parenting skills and their effect on children. Effective parenting is strongly associated with healthy child development. Children require affection, but they also require respectful communication, listening, safe opportunities to promote independence, and consistent rules and expectations.
Research has also shown that babies who receive enough affection and nurturing from their parents have the best chances of healthy development. Young children who have a positive relationship with a caring, consistent adult have better grades, an increased ability to cope with stress, more positive interactions with peers, and overall healthier behavior and physical growth and development.
Parents who have the tools to provide their children with basic food, clothing, housing, and transportation are better equipped to provide childcare, healthcare, and mental health services. Families who have the needed tools and support are better able to ensure their children's safety and overall well-being. Sharing with parents the resources that are available in their community can be highly beneficial, especially for those who are struggling to work to prevent child maltreatment or even neglect.
A bias is a personal and sometimes unreasonable judgment against a person, place, or thing (U.S. Department of Justice, 2021). We all have our own biases. We are human beings. Our life experiences help inform our future experiences. There are two main types of bias that we will discuss here.
Implicit bias is a bias or prejudice that is present but not consciously held or recognized, so we are often unaware that it exists (U.S. Department of Justice, 2021).
Explicit bias is a personal judgment about a person, place, or thing on a conscious level or one that we are aware of (U.S. Department of Justice, 2021).
Whether these biases are implicit or explicit, they can affect our actions, beliefs, and decisions. These biases may influence our decision-making process, including how a person sounds, looks, and even where they live (NYS, 2022; U.S. Department of Justice, 2021).
Both types of bias can emerge as prejudice, discrimination, and/or oppression on individual, group, or systemic levels (NYS, 2022; U.S. Department of Justice, 2021). Individual biases are often so deeply ingrained and are born out of a long history of unequal treatment of different social groups, the person’s upbringing, cultural conditioning, discrimination, oppression, and stereotypical portrayals (NYS, 2022; U.S. Department of Justice, 2021). The influence of decisions that are rooted in biases often substantially impacts individuals, social groups, and communities (NYS, 2022; U.S. Department of Justice, 2021).
A benefit of being aware of the potential impression of your biases is that you can take the initiative in lowering their impact on your decision-making (NYS, 2022; U.S. Department of Justice, 2021).
National research demonstrates that disparities have existed historically throughout the child welfare system (Ellis, 2019). These disparities are still alive today (Ellis, 2019; National Center for Youth Law [NCYL], n.d.).
Research has also shown that the income status of families and overall socioeconomic status are significant predictors of involvement with the child welfare system (Ellis, 2019; NYS, 2022). Poverty, in and of itself, does not and should not equate to child abuse or maltreatment (Ellis, 2019; NYS, 2022). This disparity can have devastating and long-lasting effects on families and communities (NYS, 2022).
A Mandated Reporter’s decision on whether to file a report can change the whole course of the life of a child and the family. We must be aware of the tendencies of our implicit and explicit biases and be cognizant about making each of our decisions based on the present, objective facts of a situation (Ellis, 2019; NYS, 2022). We need to increase our awareness regarding our beliefs, including those hidden from our conscious thoughts (Ellis, 2019). As a professional, you must ensure that your own biases do not impact your decision to make a report.
These are important things to consider and reflect on before making the call. You should only file a report as a Mandated Reporter when you have a legal obligation (NYS, 2022).
The first phase in identifying implicit bias is reflecting on how we see the world. Bias might show up as subconscious thoughts (implicit bias), conscious thoughts (explicit bias), quick judgments, or even untrue stereotypes (NYS, 2022). Fortunately, bias can also be unlearned (NYS, 2022).
One demonstrated strategy to reduce personal bias is to think about whether the facts of the situation would lead you to the same decision if they were slightly different (Ellis, 2019; NYS, 2022). What if the family's race or religion was different? Or what about their immigration status? Or what about their gender identity? If the answers to these questions change your approach, bias may impact your decision to file a report (Ellis, 2019; NYS, 2022).
Think about situations you encounter from a different viewpoint. For example, in some cultures, beans and rice are dietary staples. One’s personal belief may not include entire meals from such a food group as nutritionally sound. Not applying one’s beliefs, values, or experiences but acting on the facts and from professional experience is a better measure of responding to suspicious incidents.
Risk factors for child abuse are the specific characteristics that can increase the chances of child maltreatment. For example, children younger than four years of age and those with special needs, were born prematurely, or have a disability are risk factors that increase a child’s chance of being maltreated or abused (CDC, 2022b; National Society for the Prevention of Cruelty to Children [NSPCC], 2024).
The following are the caregiver-related risk factors for child maltreatment and abuse (CDC, 2022b; CDC, 2022c):
Some community-related risk factors can increase the likelihood of child maltreatment and abuse. These environmental risk factors can include areas of high rates of violence and crime, limited educational and economic opportunities, high rates of unemployment, simple access to alcohol and drugs, unstable housing, quick neighborhood resident turnover, and frequent concerns around food security (CDC, 2022b).
Protective factors are the specific characteristics that have the possibility of lowering the chances of children being neglected or abused (CDC, 2022b).
Caregivers who nurture positive relationships with children, utilize parenting skills, provide emotional support, have a college degree or higher with steady employment, and are capable of meeting a child’s basic needs of food, security, shelter, healthcare, and education are known to be those who are less likely to harm the children in their care (CDC, 2022b). Families who are active and present, enforce rules in the home, monitor their children for their safety, and have a supportive environment of friends and family who can offer guidance and assistance in caring for the children are also less at risk for engaging in child abuse and maltreatment (CDC, 2022b).
Just as communities can have a negative impact on the chances of child abuse and maltreatment, they can also have a protective effect (CDC, 2022b). The following includes the factors of communities that help to decrease the likelihood of child abuse and maltreatment (CDC, 2022b; CDC, 2022c):
Types of indicators of abuse or maltreatment can include (State University of New York [SUNY], 2013):
Some Mandated Reporters see a child only once or very infrequently, whereas others see them more often. In looking for reasonable cause, you must consider what you know about the child’s normal behavior. No two children will respond the same way to the same situation.
Now, let’s review the physical indicators of child maltreatment and abuse.
What does child maltreatment and abuse physically look like?
Physical indicators of abuse can include (Mayo Clinic Staff, 2022; Moore, 2023):
Image #2:
Handprint Injury on Child’s Face
(AbuseWatch.net, n.d.)
Image #3:
Bruising of Torso, Buttocks, and Thighs
(AbuseWatch.net, n.d.)
Image #4:
Spiral Fracture of the Humerus
(AbuseWatch.net, n.d.)
Image #5:
Cigarette Burn to Finger
(AbuseWatch.net, n.d.)
Image #6:
Glove-Like Burn of the Hands
(AbuseWatch.net, n.d.)
Image #7:
Sock-Like Burn of the Feet
(AbuseWatch.net, n.d.)
Image #8:
Steam Iron Burn to the Arm
(AbuseWatch.net, n.d.)
Image #9:
Looped Cord Injury
(AbuseWatch.net, n.d.)
Let’s take a look at sites of bruising that would be considered normal for children and those that are more suspicious of possible child abuse.
Image #10:
Normal vs. Suspicious Bruising
(AbuseWatch.net, n.d.)
In addition to the bruise's location, the injury's size and shape need to be considered.
Children are susceptible to injuries in relation to their developmental stage. If a plausible explanation is offered, consider the child's age and the location of a suspicious injury when developing your thoughts about “reasonable cause to suspect.”
Suspicious injuries usually occur in areas not susceptible to accidental, age-appropriate areas, as you have seen in the image above.
Consider the size and shape of the injury, as well as the location of the injury (SUNY, 2013). Consider the relationship of the mechanism of injury (explanation of how the injury occurred) to the child’s developmental stage. For example, we have discussed that toddlers fall when they learn to walk, and young children scrape their knees when learning to ride a bicycle.
Let’s think about a specific case example:
Think about if the story that was given as an explanation for an injury would produce the physical indicators that are present. For instance, a toddler falls to the floor while walking, not striking anything when he falls. That toddler has bruises on the back of his legs. One would expect that from a fall while walking, the toddler would have bruises and scrapes on his hands, knees, and shins and not bruises on the back of his legs. This would elicit some suspicion from you.
See the image below for additional information regarding physical indicators of abuse.
Image #11:
Physical Indicators of Abuse
(AbuseWatch.net, n.d.)
As mentioned above, carefully examine any bruises, welts, or burns. Is it possible the injury is making a specific shape? Like the image of the iron burn above, many tools can create visible markings that would specify what was used on the child.
The following image gives you additional ideas of what to look out for.
Image #12:
Clues to the Mechanism of Injury
(AbuseWatch.net, n.d.)
Now, let’s review the child’s behavioral indicators of child abuse.
Caregiver behavioral indicators of physical abuse may include when they (Mayo Clinic Staff, 2022; Moore, 2023):
Emotional abuse occurs when a child is subjected to repeated negative treatment made to make them feel unloved or worthless (Kids Helpline, 2023; Morin, 2022). Emotional abuse can also be described as verbal abuse or psychological abuse (Kids Helpline, 2023; Morin, 2022). This happens to be the most common form of child abuse but is one of the most difficult to detect (Kids Helpline, 2023; Morin, 2022).
Emotional abuse can be remarkably detrimental to a child’s self-confidence and well-being (Kids Helpline, 2023; Morin, 2022). Emotional abuse can include yelling, screaming, criticism, exposure to family violence, humiliation, withholding love and support, social isolation, threatening harm, the incitation of fear, bullying, teasing, rejection, or hostility (Kids Helpline, 2023; Morin, 2022).
The physical indicators of emotional abuse that can be seen in children can include (Kids Helpline, 2023; Morin, 2022; SUNY, 2013):
The behavioral indicators of emotional abuse in children may be (Kids Helpline, 2023; Morin, 2022; SUNY, 2013):
The behavioral indicators of emotional abuse that can be seen in caregivers can include (Kids Helpline, 2023; Morin, 2022; SUNY, 2013):
The terms “child abuse” and “neglect” are often used together, seemingly implying that they are terms that can be used interchangeably. They are, however, two different things. Child abuse is behavior that harms a child, whereas neglect is more about a failure to provide a child with what they need (Carmody, 2022).
According to the Centers for Disease Control and Prevention (CDC), neglect occurs when a child’s basic physical and emotional needs are not fulfilled (CDC, 2024). Basic needs include food, clothing, housing, education, access to medical care, and emotional validation by a caregiver (CDC, 2024). Child neglect is the most common form of child maltreatment (Child Welfare Information Gateway, n.d.).
Children will often display physical indicators of neglect. These physical indicators can include (NSPCC, 2024; New York State Office of Children and Family Services [NYS OCFS], n.d.; SUNY, 2013):
Severe neglect is present when the child is not protected from severe malnutrition and is medically diagnosed with “non-organic failure to thrive” (American Society for the Positive Care of Children [American SPCC], 2024). Healthcare professionals who have a regular role in utilizing growth charts know that these are an excellent and very useful form of measurement for mapping a child’s development (American SPCC, 2024). Growth charts allow pediatric providers to compare this child’s growth with the growth in their past and the statistically relevant percentile comparisons of children of the same height, weight, and age. Failure of appropriate nutrition generally affects weight first, length second, and head circumference third (American SPCC, 2024). A child demonstrating some or all of these changes and falling off their own growth curve on their growth chart should be a cause for concern.
The following image depicts a child who has been severely neglected. He is substantially underweight and has been diagnosed with failure to thrive. The signs of his malnutrition are evident, even in this picture.
Image #13:
Neglect: Failure to Thrive
(AbuseWatch.net, n.d.)
Children can also often display behavioral indicators of neglect. These behavioral indicators can include (NSPCC, 2024; NYS OCFS, n.d.; SUNY, 2013):
In addition to behavioral signs that we can see in children if they are being neglected, the caregiver can also often display behavioral indicators of neglect. These behavioral indicators can include (NSPCC, 2024; SUNY, 2013):
As briefly mentioned above, there might be physical indicators and behavioral indicators that a child is being sexually abused (Mayo Clinic Staff, 2022; Moore, 2023; NYS, 2022). But this is not always the case. Sexual abuse is the act of sexual activities with dependent, developmentally immature children to which they are unable to provide consent (Zeanah & Humphreys, 2018). Because many individuals who sexually abuse children are family members or friends, it makes disclosure of the abuse very difficult. Often, child victims feel shame and guilt and are afraid to disclose because of what might result.
Sexual abuse occurs when a parent or caregiver of a child under the age of 18 commits or allows to be committed any of the following (Mayo Clinic Staff, 2022; Moore, 2023; Zeanah & Humphreys, 2018):
The physical indicators that might point to sexual abuse include (Moore, 2023):
Behavioral indicators that a child might be a victim of sexual abuse can include (Moore, 2023; DHS, 2024):
But what about their caregivers? There are certainly signs that a parent or caregiver might demonstrate that would point to possible sexual abuse. These caregiver behavioral signs can include (Moore, 2023; SUNY, 2013):
Abuse should never be assumed as your first and last thought. Carefully consider your previous experiences with this child and whether there is a difference between those experiences and what you currently see (NYS, 2022). It is important to make an objective evaluation, free from any bias (NYS, 2022).
Each indicator, as listed above, needs to be considered in relation to the child’s developmental age and circumstances (NYS, 2022). These indicators must be considered in relation to the child’s condition. They should be considered in the overall context of the child’s physical appearance and behavior (NYS, 2022). Sometimes, a single indicator is self-evident or points to abuse or maltreatment/neglect. Often, several indicators must be pulled together, or clusters of indicators must be used to develop a reasonable cause (SUNY, 2013).
Mandated Reporters may interact with children in a virtual setting (University of South Carolina, 2020; NYS, 2022). While interacting with children in your professional role, your responsibilities as a Mandated Reporter are the same in a virtual environment (University of South Carolina, 2020; NYS, 2022).
When assessing a child’s safety virtually, please consider all of the following (University of South Carolina, 2020; NYS, 2022):
When dealing with child abuse or maltreatment, you are not to investigate or interrogate.
Occasionally, you learn of possible abuse or maltreatment not by what you see but by what a child says to you.
When a child discloses, consider the following suggestions of what to do when talking with children.
It is important to (SUNY, 2013):
When talking with a child, stress that the situation and the behaviors are not their fault.
What about what not to do? It is important not to overreact. It is natural for us as human beings to potentially act immediately when something like this is disclosed to us. It is important that we listen, remain mindful, and do not react. We must also not make any quick judgments. We should never make any promises to the child. As mentioned above, it is not our duty to interrogate and investigate. Make sure not to do this.
Each state has specific agencies to receive and investigate reports of suspected child abuse and neglect. This is usually done by child protective services (CPS) within a Department of Social Services, Department of Human Resources, or Division of Family and Children Services. A list of state-specific contact information can be found at the end of this course.
In some states, police departments also may receive reports of child abuse or neglect. If you do not know whom to call, you can call or text Childhelp USA’s National Child Abuse Hotline at 1-800-4-A-CHILD (1-800-422-4453; TDD 1-800-2-A-CHILD). This Hotline is available 24 hours a day, seven days a week. They can tell you where to file your report and even help you make it.
Their website is also set up to allow for live chatting.
Child abuse victims frequently have contact with healthcare professionals, but only injuries are often treated. Because there is a lack of training on what to look for and how to ask about abuse, healthcare professionals can often fail to identify victims. Opportunities for intervention can be repeatedly missed, and victims continue to suffer the adverse health consequences of physical, emotional, and sexual abuse.
Healthcare professionals are often the first to observe abuse and neglect, and their careful and detail-oriented observations are crucial in substantiating that abuse has occurred. They can help by (Golonka et al., 2024; Bragança-Souza et al., 2023; Chen et al., 2022):
But what exactly does that mean?
The term “reasonable” has its’ own legal implications. In general, “reasonable” means that you have a realistic suspicion. It means someone else with your training, professional experience, and education would have the same suspicion (Krase, n.d.). It is important to note that just a “gut feeling” is not considered enough. A “gut feeling” must also be accompanied by objective observations (Mandated Reporter, 2024).
You would have reasonable cause to be suspicious of child abuse or maltreatment, based on what you have observed or been told, combined with your training and experience, if you feel that harm or imminent danger of harm to the child could result from an act or omission by the person legally responsible for the child.
Crimes committed against the child should be reported directly to law enforcement. If the child is in imminent danger, contact law enforcement immediately by calling 9-1-1. Imminent danger is when the child is placed at immediate or substantial risk of harm.
While there is general overlap and similarity, each state has its own rules for who Mandated Reporters are, how child abuse terminology is defined, what and what is not considered illegal, who/what to report to, and how to report a suspected case of child abuse or neglect. It is important that you know your own state’s requirements for these things and circumstances.
This link provides the child abuse laws state-by-state for your review
This link provides more information regarding mandatory reporting requirements for the majority of the states in the U.S.
Preventing child abuse and neglect requires a multisystem approach. Just as we discussed earlier, because ACEs, which include child abuse and neglect, can have lifelong negative effects on the health and overall well-being of a child or adolescent, it is important that we do what we can to prevent them (CDC, 2022b).
According to the American Psychological Association (APA), much research is still being done to determine the best steps in preventing child abuse. Primary prevention programs are designed to teach the public and policymakers about child abuse and the scope of problems involved to raise awareness in general (APA, 2009). Secondary prevention is aimed at focusing on populations with specific risk factors for child abuse and maltreatment (APA, 2009). Tertiary prevention is the intervention within families where abuse has occurred to try to prevent reoccurrence and lessen the impact of what has already occurred (APA, 2009).
As mentioned earlier, much of what was discussed can help to prevent ACEs from working to prevent child abuse and neglect. In addition to those points, specifically regarding child abuse and neglect, the WHO emphasizes the importance of the following preventative interventions (WHO, 2022):
Children require loving and nurturing environments to grow appropriately. They need to know that they matter and that their thoughts and feelings matter. Children need to be able to develop trust, self-esteem, and self-worth to become thriving members of society (Mayo Clinic Staff, 2022). We know that the earlier such interventions occur in the lives of children, the better off the child will be, and the more significant the benefits to the child’s growth and development and society in general will be (WHO, 2022).
Consider these questions when evaluating the following case studies (SUNY, 2013):
The correct answers follow the case studies and allow you to reflect on your answer choices.
When confronted with an incident, use these same questions to help decide if there is reasonable cause to suspect.
Your “gut” feeling serves as a warning and warrants further examination of the situation.
Emma, a 13-year-old female, has come into the emergency room with a rash in her vaginal area. She shares with you that she has been engaging in sexual intercourse with her mother’s 42-year-old boyfriend for the past four months. Emma’s mom’s boyfriend has resided in the house with the child and her mother for the past three years and is responsible for her care when the mother works as a bartender.
Tommy, a five-year-old male, came into his pediatrician’s office for a sports physical so he could play soccer at school. You notice that he has a bruise on the left side of his face with scrapes along his left arm and hand. Tommy claimed he fell off the monkey bars at school. He lives with his mother, who is a single parent. Tommy’s mother says that he is a very active child who sometimes misbehaves at school.
Pamela, a 32-year-old female, is admitted to the obstetric unit at your hospital. She delivers her child, Sarah. After 36 hours of birth, the nurse notices that Sarah has tremors and increased muscle tone. Sarah was soon diagnosed with neonatal abstinence syndrome (NAS) by the neonatologist, as she is showing signs of drug withdrawal from when Pamela was pregnant with her. When talking to Pamela, you learned she had not prepared for her baby to come home.
Seven-year-old Nick comes to the emergency room with an injured arm. His mother says he fell off the trampoline while jumping around and playing with his friend. An X-ray is ordered to assess for any breaks. When Nick’s arm is X-rayed, a spiral fracture of his humerus is identified.
Four-month-old Sabrina is brought into the emergency room for being unresponsive. Mom accompanies Sabrina. Mom indicated that Sabrina was fine until they returned home from running errands. Mom says that her boyfriend, Rick, watched her while she took a shower. She said that she heard Sabrina crying. When the crying had been continuous for ten minutes and then abruptly stopped, she heard Rick yell that he was going to pick up some cigarettes from the gas station and then slam the door. Mom finished getting dressed and returned to Sabrina’s room to check on her. Mom initially thought she was asleep in her crib, but on closer examination, she was not breathing. Mom notes that Rick has a temper and is easily frustrated with Sabrina.
Benjamin is a 19-year-old who attends the school you teach at. Benjamin is in your English class but has not attended school in a few weeks. You reach out to his mother, who tells you he is refusing to go to school, and there is nothing she can do to get him to go. She said he has a job at the local convenience store and spends all his time there.
You are discussing with the mother of a two-year-old about how much stress she currently is dealing with. She admits that she leaves her son, Elijah, at home alone at least once a week so that she can run to the corner store to buy groceries. She says he is just fine and tells her neighbors that she will be back in 15 to 20 minutes and to listen out for him.
Three-year-old Emily enters the pediatric primary care clinic for her yearly well-child examination. You notice ligature marks and bruising around both of her wrists. You ask Mom what these are from. Mom indicates that she knows her child is good but is sometimes possessed by evil spirits that make her do bad things. She tells you that in her culture, it is common practice to tie the child to their bed and restrict food to eliminate the evil spirit.
Case Study 1
What indicators are present?
Is there reasonable cause to suspect abuse or maltreatment?
Is there a parent or other person responsible for the suspected abuse or maltreatment?
Case Study 2
What indicators are present?
Is there a parent or other person responsible for the suspected abuse or maltreatment?
What are your next steps?
Case Study 3
What indicators are present?
Is there reasonable cause to suspect abuse or maltreatment?
Is there a parent or other person responsible for the suspected abuse or maltreatment?
What are your next steps?
Case Study 4
What indicators are present?
Is there reasonable cause to suspect abuse or maltreatment?
Is there a parent or other person responsible for the suspected abuse or maltreatment?
Case Study 5
What indicators are present?
Is there reasonable cause to suspect abuse or maltreatment?
Is there a parent or other person responsible for the suspected abuse or maltreatment?
What are your next steps?
Case Study 6
What indicators are present?
Is there reasonable cause to suspect abuse or maltreatment?
Is there a parent or other person responsible for the suspected abuse or maltreatment?
What are your next steps?
Case Study 7
What indicators are present?
Is there reasonable cause to suspect abuse or maltreatment?
Is there a parent or other person responsible for the suspected abuse or maltreatment?
Case Study 8
What indicators are present?
Is there reasonable cause to suspect abuse or maltreatment?
Is there a parent or other person responsible for the suspected abuse or maltreatment?
What are your next steps?
Child abuse and maltreatment are, unfortunately, quite common. With an improved understanding of what to look out for, Mandated Reporters have a unique position, due to their positions in their work roles, to file a report when they suspect a child or children are being mistreated or abused. We can all identify children in need and speak up on their behalf to protect them!
Alabama Department of Human Resources
50 North Ripley Street
Montgomery, Alabama 36130
Phone: (334) 242-1425
Email: fsd@dhr.alabama.gov
Alaska Department of Family and Community Services
Phone: (907) 465-3207
Email: ReportChildAbuse@alaska.gov
Arizona Department of Child Safety
P.O. Box 6030
Site Code CH010-23A
Phoenix, Arizona 85005-6030
Phone: (602) 255-2500
Arkansas Department of Human Services
Donaghey Plaza, PO Box 1437
Little Rock, Arkansas 72203
Phone: (501) 683-2735
California Department of Social Services
744 P Street
Sacramento, California 95814
Phone: (916) 651-8848
Email: piar@dss.ca.gov
California Ombudsman for Foster Care
744 P Street
Sacramento, California 95814
Phone: 1(877) 846-1602
Email: fosteryouthhelp@dss.ca.gov
Colorado Department of Human Services
1575 Sherman Street
Denver, Colorado 80203
Phone: (303) 866-5700
Fax: (303) 866-5563
Email: cdhs_clientservices@state.co.us
Connecticut Department of Children & Families
505 Hudson Street
Hartford, Connecticut 06106
Phone: (860) 550-6300
Email: Commissioner.dcf@ct.gov
District of Columbia Child and Family Services Agency Youth Ombudsman
200 I Street, SE
Washington, District of Columbia 20003
Phone: (202) 442-6100
Fax: (202) 727-6505
Email: cfsa@dc.gov
Florida Department of Children and Families
2415 North Monroe Street
Suite 400
Tallahassee, FL 32303-4190
Phone: (850) 487-1111
Georgia's Office of Child Advocate
2 Capitol Square SW
Atlanta, Georgia 30334
Phone: (404) 656-4200
Email: tboga@oca.ga.gov
Hawaii Office of the Ombudsman
465 South King Street, 4th Floor
Honolulu, Hawaii 96813
Phone: (808) 587-0770
Fax: (808) 587-0773
Email: complaints@ombudsman.hawaii.gov
Illinois Advocacy Office for Children and Families
406 East Monroe Street
Springfield, Illinois 62701
Phone: (217) 524-2029
Toll-Free: (800) 232-3798
Indiana Department of Child Services (DCS) Ombudsman Bureau
402 W. Washington Street
Indianapolis, Indiana 46204
Phone: (260) 458-6100
Email: DCSOmbudsman@idoa.in.gov
Iowa Office of Citizens' Aide Ombudsman
Ola Babcock Miller Building
1112 East Grand
Des Moines, Iowa 50319
Phone: (515) 281-3592
Email: ombudsman@legis.iowa.gov
Kansas Department for Children and Families
555 S Kansas Avenue
Topeka, Kansas 66603
Phone: (785) 296-3271
Kentucky Cabinet for Health and Family Services
275 East Main Street, 3E-A
Frankfort, Kentucky 40621
Phone: (502) 564-5497
Email: CHFS.Listens@ky.gov
Louisiana Department of Children & Family Services
627 North Fourth Street
Baton Rouge, Louisiana 70802
Phone: (225) 342-2297
Fax: (225) 342-2268
Email: LAHelpU.dcfs@la.gov
Maine Ombudsman Program
Maine Child Welfare Services Ombudsman
Phone: (207) 213-4773
Toll-Free: (866) 621-0758
Email: ombudsman@cwombudsman.com
Maryland Department of Human Resources
311 West Saratoga Street
Baltimore, Maryland 21201-3521
Toll-Free: (800) 332-6347
Email: dhr-help@dhr.state.md.us
Massachusetts Department of Children and Families Ombudsman
DCF Central Office
600 Washington Street, 6th Floor
Boston, Massachusetts 02211
Phone: (617) 748-2000
Michigan Office of the Child Advocate (OCA)
P.O. Box 30026
Lansing, Michigan 48909
Phone: (517) 241-0400
Fax: (517) 335-4471
Minnesota - The Office of the Ombudsperson for Families
1450 Energy Drive
Suite 106
St. Paul, Minnesota 55108
Phone: (651) 539-1257
Toll-Free: 1-888-234-4939
Fax: (651) 643-2539
Email: obff.info@state.mn.us
Mississippi Department of Human Services
200 South Lamar Street
Jackson, Mississippi 39201
Phone: (601) 359-4500
Missouri Office of Child Advocate
PO Box 809
Jefferson City, Missouri 65102
Toll-Free: (866) 457-2302
Fax: (573) 522-8683
Email: oca@oca.mo.gov
Montana Child and Family Ombudsman
PO Box 201417
Helena, Montana 59620
Phone: 1-844-252-4453
Email: DOJOMBUDSMAN@mt.gov
Nebraska Public Counsel (Ombudsman's Office)
State Capitol
PO Box 94604
Room 807, State Capitol
Lincoln, Nebraska 68509-4604
Phone: (402) 471-2035
Email: ombud@leg.ne.gov
Nevada Division of Child and Family Services
Systems Advocate
4126 Technology Way, 3rd Floor
Carson City, Nevada 89706
Phone: (775) 684-4453
Email: systems.advocate@dcfs.nv.gov
New Hampshire Department of Health and Human Services
Office of the Ombudsman
129 Pleasant Street
Concord, New Hampshire 03301-3857
Phone: (603) 271-9000
Toll-Free: (800) 852-3345
New Jersey Department of Children and Families
PO Box 729, 3rd Floor
Trenton, New Jersey 08625-0729
Phone: 1(855) 463-6323
Email: askDCF@dcf.state.nj.us
New Mexico Children, Youth & Families
PO Drawer 5160
P.E.R.A. Room 254
Santa Fe, New Mexico 87502
Phone: (505) 827-8400
Fax: (505) 827-8480
Email: harry.montoya@state.nm.us
New York State Office of Children and Families
Capital View Office Park
52 Washington Street
Rensselaer, New York 12144-2834
Phone: 518-473-7793
Email: info@ocfs.ny.gov
North Dakota Department of Human Services
600 E Boulevard Avenue, Dept. 325
Bismarck, North Dakota 58505-0250
Phone: (701) 328-2310
Email: dhslau@nd.gov
Ohio Department of Job and Family Services
Office of Constituent Affairs
30 East Broad Street
32nd Floor
Columbus, Ohio 43215-0423
Phone: (614) 466-9280
Email: legislation@jfs.ohio.gov
Oklahoma Department of Human Services
2400 N Lincoln Boulevard
Oklahoma City, Oklahoma 73105
Phone: (405) 522-5050
Oregon Governor's Advocacy/Ombudsman Office
500 Summer St, NE
4th Floor GAO
Salem, Oregon 97301
Phone: (503) 945-6904
Toll-Free: (800) 442-5238
Email: gao.info@odhs.oregon.gov
Pennsylvania Department of Human Services
625 Forester Street
Harrisburg, Pennsylvania 17120
Phone: (800) 692-7462
Rhode Island Office of the Child Advocate
6 Cherrydale Court, Cottage 43
Cranston, Rhode Island 02920
Phone: (401) 462-4300
Fax: (401) 462-4305
South Carolina State Office of Children's Affairs
Department of Children’s Advocacy
1205 Pendleton Street, Suite 471A
Columbia, South Carolina 29201
Phone: (803) 734-3176
South Dakota Department of Social Services
700 Governor's Drive
Pierre, South Dakota 57501
Phone: (605) 773-3165
Email: DSSConstituentLiaison@state.sd.us
Tennessee Commission on Children and Youth
Andrew Johnson Tower, 9th Floor
502 Deaderick Street
Nashville, Tennessee 37243-0800
Phone: (615) 741-2633
Email: tccy.info@tn.gov
Texas Department of Family and Protective Services
4900 North Lamar Boulevard
Austin, Texas 78751
Phone: (512) 929-6900
Email: oca@dfps.state.tx.us
Utah Department of Human Services
195 North 1950 West
Salt Lake City, Utah 84116
Phone: (833) 353-3447
Vermont Department for Children and Families
280 State Drive, HC 1 North
Waterbury, Vermont 05671-1080
Phone: (802) 871-3385
Virginia Department of Social Services
5600 Cox Road
Glen Allen, Virginia 23060
Phone: (800) 468-8894
Email: citizen.services@dss.virginia.gov
Washington State Office of the Family & Children's Ombuds
6840 Fort Dent Way, Suite 125
Mail Stop TT-99
Tukwila, Washington 98188
Phone: (206) 439-3870
Fax: (206) 439-3877
West Virginia Department of Health and Human Resources
Office of Client Services
350 Capital Street - Room 513
Charleston, West Virginia 25301
Phone: (304) 558-4194
Email: osaclientservices@wv.gov
Wisconsin Department of Children and Families
201 West Washington Avenue, Second Floor
PO Box 8916
Madison, Wisconsin 53703-8916
Phone: (608) 422-7000
Fax: (608) 422-7163
Email: dcfweb@wisconsin.gov
Wyoming Department of Family Services
Hathaway Building - 2300 Capitol Avenue, 3rd Floor
Cheyenne, Wyoming 82002
Phone: (800) 457-3659
Email: dfs-directorsoffice@wyo.gov
CEUFast, Inc. is committed to furthering diversity, equity, and inclusion (DEI). While reflecting on this course content, CEUFast, Inc. would like you to consider your individual perspective and question your own biases. Remember, implicit bias is a form of bias that impacts our practice as healthcare professionals. Implicit bias occurs when we have automatic prejudices, judgments, and/or a general attitude towards a person or a group of people based on associated stereotypes we have formed over time. These automatic thoughts occur without our conscious knowledge and without our intentional desire to discriminate. The concern with implicit bias is that this can impact our actions and decisions with our workplace leadership, colleagues, and even our patients. While it is our universal goal to treat everyone equally, our implicit biases can influence our interactions, assessments, communication, prioritization, and decision-making concerning patients, which can ultimately adversely impact health outcomes. It is important to keep this in mind in order to intentionally work to self-identify our own risk areas where our implicit biases might influence our behaviors. Together, we can cease perpetuating stereotypes and remind each other to remain mindful to help avoid reacting according to biases that are contrary to our conscious beliefs and values.