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Child Abuse

2 Contact Hours
Not approved for Iowa, New York, or Pennsylvania requirements.
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This peer reviewed course is applicable for the following professions:
Advanced Practice Registered Nurse (APRN), Athletic Trainer (AT/AL), Certified Medication Assistant (CMA), Certified Nurse Midwife, Certified Nurse Practitioner, Certified Nursing Assistant (CNA), Certified Registered Nurse Anesthetist (CRNA), Clinical Nurse Specialist (CNS), Home Health Aid (HHA), Licensed Nursing Assistant (LNA), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Medical Assistant (MA), Medication Aide, Midwife (MW), Nursing Student, Occupational Therapist (OT), Occupational Therapist Assistant (OTA), Other, Physical Therapist (PT), Physical Therapist Assistant (PTA), Registered Nurse (RN), Registered Nurse Practitioner, Respiratory Care Practitioner, Respiratory Therapist (RT)
This course will be updated or discontinued on or before Wednesday, June 3, 2026

Nationally Accredited

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.


BOC
CEUFast, Inc. (BOC AP#: P10067) is approved by the Board of Certification, Inc. to provide education to Athletic Trainers (ATs).

FPTA Approval: CE24-536793. Accreditation of this course does not necessarily imply the FPTA supports the views of the presenter or the sponsors.
Outcomes

≥ 92% of participants will know how to identify and respond appropriately to child abuse.

Objectives

After completing this continuing education course, the participant will be able to:

  1. Define child abuse.
  2. Outline the impact of trauma on children and the importance of Trauma-Informed Care (TIC).
  3. Appraise the impact of adverse childhood experiences (ACEs) on children and families.
  4. Identify the mitigating effects of the five protective factors on trauma.
  5. Criticize the impact of bias on decision-making.
  6. Recognize the indicators associated with child abuse.
  7. Evaluate situations to determine reasonable cause to suspect child abuse.
CEUFast Inc. and the course planners for this educational activity do not have any relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

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    To earn a certificate of completion you have one of two options:
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    Author:    Alyssa King (DNP, APRN, CPNP-PC, PMHNP-BC, CLC, CNE)

    Why is this Training so Important?

    Studies have concluded that professionals who have contact with children often report only half of the incidents that may be abuse. Historically, this low report rate has been due to confusion or misunderstanding about the laws and procedures and a lack of knowledge or awareness of warning signs. It has also been shown that personal beliefs, values, and past experiences might be partially to blame for someone not coming forward.

    Statistics

    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).

    Definition

    Each state defines child abuse and neglect within the civil and criminal context. Civil laws, or statutes, describe the circumstances and conditions that mandate reporters to report known or suspected cases of abuse. They also provide definitions necessary for juvenile/family courts to take custody of a child alleged to have been maltreated. Criminal statutes define the criminally punishable forms of maltreatment. All states require healthcare personnel, school personnel, daycare providers, and law enforcement personnel to report child abuse. Some states have a longer list of those designated as Mandated Reporters. Failure to report is a crime.

    Child abuse and neglect are, at a minimum (Office of the Law Revision Council, 2024):

    • Any recent act or failure to act on the part of a parent or caretaker that results in death, serious physical or emotional harm, sexual abuse, or exploitation
    • An act or failure to act that presents an imminent risk of serious harm

    Understanding Trauma

    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):

    • Natural disasters (hurricanes, earthquakes, floods, etc.)
    • Life-threatening illnesses
    • Serious accidents
    • Mass shootings
    • Family violence
    • Sexual abuse
    • Emotional abuse
    • Neglect
    • Violence/crime in the community

    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). Depending on many things like the way a person reacts to trauma, what type of trauma it is, the severity of the traumatic event, the amount of support that is available following the event, other current stressors in the person’s life, the person’s level of resilience, and the person’s previously suffered traumatic experiences, all have a part in determining how a person will react to this new source of trauma (Better Health Channel, 2022).

    Trauma can cause physical reactions including (NYS, 2022; Better Health Channel, 2022):

    • Rapid heart rate
    • Nausea
    • Vomiting
    • Dizziness
    • Tense muscles
    • Exhaustion
    • Shallow breathing

    Trauma can also cause emotional reactions that might include (NYS, 2022; Better Health Channel, 2022):

    • Anxiety
    • Fear
    • Panic
    • Detachment (feeling numb)
    • Shock (trouble believing what has happened, feeling confused)

    Mental reactions to trauma can involve (NYS, 2022; Better Health Channel, 2022):

    • Confusion
    • Disorientation
    • Intrusive thoughts, specifically of the event(s)
    • Reduced memory
    • Decreased concentration

    Understanding Adverse Childhood Experiences (ACEs)

    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)

    graphic showing adverse childhood experiences

    This list, however, is not fully inclusive. Additional examples of ACEs include (CDC, 2023; Cleveland Clinic, 2023; Integrative Life Center, 2021):

    • Experiencing violence or neglect
    • Experiencing physical, sexual, or emotional abuse
    • Witnessing violence occurring in the community
    • Having a family member attempt or die by suicide
    • Having a family member who has a mental health problem
    • Experiencing divorce/custody battles
    • Experiencing natural disasters
    • Experiencing bullying

    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).

    Research on ACEs

    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):

    • Racism
    • Poverty
    • Generational trauma
    • Repetitious unintended or indirect discrimination

    What are the Consequences of Exposure to ACEs?

    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:

    The more ACEs one is exposed to, the greater the risk for negative effects.

    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, ACEs can have a lasting impact not only on children but also on caregivers and Mandated Reporters.

    How Can We Prevent ACEs?

    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):

    • Achieving strong physical health: Obtaining adequate sleep, eating well, and exercising regularly.
    • Building resilience: Increasing positive parenting skills and creating safe, stable relationships in the home.
    • Incorporation of home visits: State-employed nurses, social workers, and teachers trained to visit family homes during pregnancy and early childhood to teach and provide support services.
    • Offering early childcare services: Expanding access to early childhood programs to bolster learning, social and emotional development, and self-confidence.
    • Supporting the reduction of parental stress: Consider providing economic support, family-friendly workplaces, paid family and/or sick leave, and affordable housing.
    • Increasing mental health screening and treatment: Expand access to and coverage for comprehensive health and mental health services.

    The CDC outlines these additional strategies for preventing ACEs altogether (CDC, 2023):

    • Promoting social norms: Advertising public education campaigns, legislative approaches, and bystander approaches to teach and inform in a manner that helps to protect against violence and adversity.
    • Teaching vital skills: Prioritizing social-emotional learning, safe dating, healthy relationship building, family relationships, mentoring programs, and after-school programs.
    • Intervening early and often: Engaging children in primary care, family therapy when needed, individual therapy when needed, and family-centered treatment for households with someone suffering from a substance use disorder. 

    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).

    Understanding Trauma-Informed Care (TIC)

    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).

    TIC will assist you in identifying when your own past trauma or life experiences may influence the way you evaluate an incident you encounter in your professional role (NYS, 2022).

    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).

    Key Elements of Trauma-Informed Care

    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):

    1. Safety
    2. Peer support
    3. Trustworthiness & Transparency
    4. Collaboration & mutuality
    5. Cultural, historical, & gender issues
    6. Empowerment & choice

    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 on Trauma & Child Abuse

    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):

    • Parental resilience

    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 connections

    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.

    • Parental knowledge of child development and parenting skills

    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.

    • Social and emotional competence of children

    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.

    • Concrete support for parents

    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.

    Understanding Bias

    Implicit Bias in Decision-Making

    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).

    Understanding the Impact of Implicit Bias on Child Welfare

    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.).

    Data illustrates a historical overrepresentation of children and families of color in the child welfare system (Ellis, 2019; NCYL, n.d.). Children of color have been more likely to be placed in foster care than nonminority children (NYS, 2022; Ellis, 2019; NCYL, n.d.). In fact, in one study, African American children were over two times more likely to be placed in foster care when compared to white children (Ellis, 2019).

    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).

    Biases’ Impact on Filing Reports

    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).

    Strategies to Reduce Implicit Bias

    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).

    Another tool to identify and call our biases is simply gathering all the facts and analyzing them methodically. As a Mandated Reporter, you must ensure that you have reviewed all information and legal requirements before calling in a report. Approach each situation with humility, openness, and a willingness to learn, and recognize that we do not know everything about the family and their current situation (Ellis, 2019; NCYL, n.d.; NYS, 2022). We need to consider that our first impressions and assumptions might not be true (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 of Child Maltreatment & Abuse

    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):

    • Use of drugs or alcohol excessively
    • History of mental health conditions
    • Previous exposure to abuse or neglect as children themselves
    • Low socioeconomic status (lower income, lower levels of education)
    • High levels of stress
    • Not the biological child’s parent
    • Caring for children with special needs that they do not understand
    • Self or family members in jail/prison
    • Violence within the family
    • High level of conflict within the household
    • Isolated from extended family, friends, and/or neighbors

    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 of Child Maltreatment & Abuse

    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):

    • Access to safe housing
    • Access to high-quality schooling and childcare
    • Engaging after-school activities available
    • Access to good medical care
    • Access to mental health services
    • Economic/financial help resources
    • Workplaces that prioritize families and their needs

    Recognition of Child Abuse

    Indicators of abuse warn the Mandated Reporter to pay more attention to a particular situation. Sometimes, there are no visible indicators present even though the child is being abused.

    Types of indicators of abuse or maltreatment can include (State University of New York [SUNY], 2013):

    1. Physical indicators
    2. Child behavioral indicators
    3. Caregiver behavioral indicators 

    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.

    Physical Indicators

    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):

    • Unexplained bruises:
      • Bruising of the torso, buttocks, and thighs
      • Bruising in various stages of healing
      • Clustered bruises forming regular patterns that might reflect the shape of the article used to inflict the injury
      • Bruising on several different parts of the body
      • Bruises regularly appear after absence, weekend, or vacation
      • Suspicious bruising that does not match the story that was told as to how it was obtained
    • Unexplained fractures:
      • To the nose, skull, or facial structure
      • In various stages of healing
      • Multiple or spiral fractures
    • Unexplained burns:
      • Cigar, and cigarette burns, especially on the soles of the feet, palms, back, and buttocks
      • Immersion burns that are often appearing sock-like, glove-like, or even doughnut-shaped on the buttocks or genitalia
      • Pattern-like burn in the shape of an electric burner or an iron
      • Rope burns on the arms, legs, neck, or torso
    • Unexplained welts
    • Unexplained lacerations:
      • To the mouth, lips, gums, or eyes
      • To external genitalia
      • On the back of the arms, legs, or torso
      • Human bite marks
    • Unattended physical problems, medical, or dental needs
    • Pain or itching in the genital area
    • Difficulty in walking or sitting
    • Pregnancy, especially in the early adolescent years
    • Sexually transmitted disease (especially in pre-adolescent children)
    • Delays in physical development or growth
    • Frequent injuries that are accidental or unexplained

    Image #2:
    Handprint Injury on Child’s Face

    photo of handprint injury

    (AbuseWatch.net, n.d.)

    Image #3:
    Bruising of Torso, Buttocks, and Thighs

    photo showing bruising on torso, buttocks and thighs

    (AbuseWatch.net, n.d.)

    Image #4:
    Spiral Fracture of the Humerus

    photo of spiral fracture x-ray

    (AbuseWatch.net, n.d.)

    Image #5:
    Cigarette Burn to Finger

    photo of cigarette burn on finger

    (AbuseWatch.net, n.d.)

    Image #6:
    Glove-Like Burn of the Hands

    photo of glove like burn of the hands

    (AbuseWatch.net, n.d.)

    Image #7:
    Sock-Like Burn of the Feet

    photo of sock like burn of the feet

    (AbuseWatch.net, n.d.)
    Image #8:
    Steam Iron Burn to the Arm

    photo of steam iron injury

    (AbuseWatch.net, n.d.)

    Image #9:
    Looped Cord Injury

    photo of looped cord injury

    (AbuseWatch.net, n.d.)
     

    As mentioned above, injury or bruising that is most suspicious for child abuse is that in which (Mayo Clinic Staff, 2022; Moore, 2023):

    • The place/body part of the injury may be abnormal
    • The injury does not match with the child’s current developmental level
    • The explanation given regarding the injury does not add up
    • The laceration or bruise is shaped like a specific object (like a handprint, looped cord, or belt)

    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

    graphic showing normal and suspicious bruising areas

    (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.”

    Accidental injuries usually involve injury to the bony prominences of the body, i.e., shins, elbows, and knees. For example:

    • Toddlers fall while learning to walk.
    • Young children “skin” elbows and knees when learning to ride a bicycle or playing on playground equipment.

    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

    graphic showing 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

    graphic showing 11 clues to the mechanism of injury

    (AbuseWatch.net, n.d.)
     

    Child Behavioral Indicators

    Now, let’s review the child’s behavioral indicators of child abuse.

    The behavioral signs that might be questionable for possible child abuse include (Mayo Clinic Staff, 2022; Moore, 2023):

    • Avoiding physical contact or touch
    • Being afraid and trying to avoid going home
    • Acting on edge, on high alert always
    • Withdrawing from friends
    • Withdrawing from extracurricular activities
    • Wearing clothing that does not match the current weather (long sleeves to cover wounds)
    • Using drugs or alcohol
    • Stealing or asking for food
    • Self-destructive behaviors
    • Loss of self-confidence
    • Delayed emotional development
    • Depression
    • Declining school performance

    Caregiver Behavioral Indicators

    Caregiver behavioral indicators of physical abuse may include when they (Mayo Clinic Staff, 2022; Moore, 2023):

    • Seem unconcerned about the child
    • Take an unusual amount of time to obtain medical care for the child
    • Offer inadequate or inappropriate explanations for the injury
    • Give different explanations for the same injury (the story changes)
    • Misuse drugs or alcohol
    • Discipline the child too harshly considering the child’s age or what the child has done wrong
    • Describe the child as bad or evil
    • Have a history of abuse as a child
    • Attempt to conceal the child’s injury
    • Take a child to a different hospital or doctor for each injury (so as not to be identified)
    • Have poor impulse control
    • Expect the child to provide them attention and care
    • Limit the child’s contact with others

    Emotional Abuse

    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):

    • Fighting in school
    • Rocking
    • Sucking fingers
    • Neurotic disorders such as speech disorders
    • Trouble sleeping
    • Psychoneurotic reactions such as phobias, hysterical reactions, compulsions, or hypochondria
    • Delays in physical development

    The behavioral indicators of emotional abuse in children may be (Kids Helpline, 2023; Morin, 2022; SUNY, 2013):

    • Antisocial behaviors
    • Demanding or destructive behaviors
    • Overly adaptive behavior (such as inappropriately adult-like or infantile)
    • Developmental delays
    • Extremes of behavior (compliance, passiveness, aggressiveness)
    • Self-injurious behavior
    • Suicide attempt
    • Seeking attention from other adults
    • Loss of interest in their activities
    • Drug or alcohol use
    • Decline in schoolwork

    The behavioral indicators of emotional abuse that can be seen in caregivers can include (Kids Helpline, 2023; Morin, 2022; SUNY, 2013):

    • Treats children in the family unequally
    • Does not seem to care much about the child’s problem
    • Blames or belittles the child
    • Seems cold and rejecting
    • Inconsistent behavior toward the child

    Maltreatment/Neglect

    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):

    • Being alone, lack of supervision
    • Poor hygiene, smelling or appearing dirty
    • Wearing tattered or dirty/unwashed clothing
    • Wearing clothing that is inappropriate for the weather (heavy jacket in the summer)
    • Consistently being hungry
    • Being low-weight or extremely low-weight (malnourished)
    • Lack of personal care
    • Dental caries/obvious lack of dental health
    • Untreated medical needs
    • Not having glasses, if needed for vision
    • Unresolved Skin issues (sores, rashes, flea bites, ringworm, scabies)
    • Poor language or social skills

    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

    photo of child demonstrating 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):

    • Begging for or stealing food
    • Arriving at school early and desiring to stay as late as possible
    • Often falls asleep in class
    • Frequent absences from school
    • Missed doctor’s appointments
    • Taking on the role of the caregiver in the home
    • Becoming clingy
    • New aggression signs
    • Changes in eating habits
    • Showing signs of self-harm behaviors
    • Utilizing drugs or alcohol
    • Becoming newly more withdrawn or depressed

    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):

    • Hard to find or cannot be found/contacted
    • Has a disorganized home life
    • Misuses drugs and/or alcohol
    • Has a history of neglect as a child
    • Is not prepared to care for a child
    • Demonstrates evidence of a limited intellectual capacity
    • Is apathetic and feels like nothing will ever change
    • Exposes a child to unsafe living conditions

    Sexual Abuse

    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):

    • Physical touching of the child’s genitals, buttocks, breasts, mouth, or other private parts for the sexual gratification of the other individual
    • Engaging in intercourse or sodomy
    • Forcing children to engage in sexual intercourse
    • Exposing children to sexual activity for the sexual gratification of the other individual
    • Utilizing a child in a sexual performance within a video, photograph, play, or dance

    The physical indicators that might point to sexual abuse include (Moore, 2023):

    • Difficulty walking or sitting down
    • Torn, stained, or bloody underclothing
    • Painful or itchy genitalia
    • Pregnancy
    • Sexually transmitted diseases/infections

    Behavioral indicators that a child might be a victim of sexual abuse can include (Moore, 2023; DHS, 2024):

    • The child is not willing to change to participate in physical education (PE) class at school
    • Self-injurious behavior, suicide attempts
    • Poor peer relationships
    • Withdrawn
    • Fantasy behavior
    • Fire-starting
    • Bedwetting
    • Sleep disturbances
    • Excessive or injurious masturbation
    • Cruelty to animals or other people
    • Age-inappropriate sexual play and/or drawings
    • Sexual promiscuity
    • Regressive, infantile behavior
    • Aggressiveness
    • Delinquency, running away, school truancy
    • Reports of sexual assault by caretakers
    • Exaggerated fear of closeness or physical contact

    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):

    • Protective or jealous of the child
    • Misuses alcohol or drugs
    • Has low self-esteem
    • Encourages the child to engage in things not appropriate for age
    • Is geographically isolated or lacking in social and emotional contacts outside of the family

    Discussion About Indicators of Abuse

    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). It is important to remember NOT to view indicators in isolation(NYS, 2022).

    Assessing for Child Abuse in a Virtual Environment

    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):

    • Does the child’s behavior seem different when someone else enters the room?
    • Does the child appear anxious or depressed?
    • Are there any signs the child is trying to say something to you without someone else noticing?
    • Has the child made any worrisome comments to you, siblings, or their friends?
    • While trying to observe the child’s body, even if you can only see the child’s face, neck, shoulders, and chest, is there anything that seems questionable, such as bruises, welts, or burns?

    Talking with Children

    When dealing with child abuse or maltreatment, you are not to investigate or interrogate. You are responsible for assessing for reasonable cause to suspect and making the necessary report immediately.

    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):

    • Find a private place
    • Remain calm
    • Be honest, open, up-front, supportive
    • Be an advocate
    • Listen to the child
    • Report the situation immediately

    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.

    Reporting Suspected Child Abuse

    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):

    • Conducting thorough medical and social histories of patients and their families
    • Taking notice of family unit risk factors of concern
    • Documenting abuse thoroughly in the medical record with specifics
    • Utilizing child abuse-specific screening tools within their organization and electronic medical records (EMRs)
    • Protecting evidence
    • Providing medical advice, referrals, and safety planning
    • Showing empathy and compassion
    • Identifying the somatic signs and symptoms of abuse
    • Evaluating the plausibility of explanations given for common injuries and conditions
    • Providing expert testimony
    • Assessing the cognitive status and health factors that affect it
    • Treating injuries or health problems that result from abuse
    • Performing abuse screenings
    • Encouraging clinics, hospitals, health maintenance organizations, or other medical providers to develop or adopt protocols for screening and responding to abuse
    • Providing referrals to legal and social services
    • Learning more about child abuse and neglect
    • Reporting suspected cases of child abuse to Children's Protective Services

    What Is Reasonable Cause to Suspect Abuse or Maltreatment?

    As we have discussed, every state has its requirements for how to report and who is responsible for reporting suspected child abuse. In most cases and as briefly alluded to in the course text so far, Mandated Reporters are expected to have a “reasonable cause to suspect” that a child is being abused or neglected, necessitating the filing of a report (Mandated Reporter, 2024).

    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.

    State-Specific Requirements

    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.

    Prevention

    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):

    • Implementation and enforcement of laws to protect children and punish those who harm them
    • Education and life skills training for families to teach children how to advocate for themselves and to build resilience
    • Caregiver support services to help train families how to provide nurturing, non-violent parenting (especially for those who experienced abuse as a child themselves; the cycle can be broken!)
    • Support services to capture early cases of child abuse and intervene
    • “Norms” training for caregivers to teach about the social and gender norms that relate to raising children, gender equality, and the role of the modern-day father

    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).

    Case Study Learning Examples

    Consider these questions when evaluating the following case studies (SUNY, 2013):

    1. What indicators are present?
    2. Is there reasonable cause to suspect abuse or maltreatment/neglect?
    3. If so, who is responsible for abuse or maltreatment/neglect?
    4. What are your next steps?

    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.

    Case Study 1

    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.

    1. What indicators are present?
    2. Is there a reasonable cost to suspect abuse or maltreatment?
    3. Is there a parent or other person responsible for the suspected abuse or maltreatment?
    4. What are your next steps?

    Case Study 2

    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.

    1. What indicators are present?
    2. Is there a reasonable cost to suspect abuse or maltreatment?
    3. Is there a parent or other person responsible for the suspected abuse or maltreatment?
    4. What are your next steps?

    Case Study 3

    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.

    1. What indicators are present?
    2. Is there a reasonable cost to suspect abuse or maltreatment?
    3. Is there a parent or other person responsible for the suspected abuse or maltreatment?
    4. What are your next steps?

    Case Study 4

    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.

    1. What indicators are present?
    2. Is there a reasonable cost to suspect abuse or maltreatment?
    3. Is there a parent or other person responsible for the suspected abuse or maltreatment?
    4. What are your next steps?

    Case Study 5

    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.

    1. What indicators are present?
    2. Is there a reasonable cost to suspect abuse or maltreatment?
    3. Is there a parent or other person responsible for the suspected abuse or maltreatment?
    4. What are your next steps?

    Case Study 6

    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.

    1. What indicators are present?
    2. Is there a reasonable cost to suspect abuse or maltreatment?
    3. Is there a parent or other person responsible for the suspected abuse or maltreatment?
    4. What are your next steps?

    Case Study 7

    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.

    1. What indicators are present?
    2. Is there a reasonable cost to suspect abuse or maltreatment?
    3. Is there a parent or other person responsible for the suspected abuse or maltreatment?
    4. What are your next steps?

    Case Study 8

    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.

    1. What indicators are present?
    2. Is there a reasonable cost to suspect abuse or maltreatment?
    3. Is there a parent or other person responsible for the suspected abuse or maltreatment?
    4. What are your next steps?

    Case Study Answers

    Case Study 1

    What indicators are present?

    • Sexual abuse and verbal disclosure

    Is there reasonable cause to suspect abuse or maltreatment?

    • Yes 

    Is there a parent or other person responsible for the suspected abuse or maltreatment?

    • The 42-year-old boyfriend is an adult living in the home, acting as a caregiver when the mother is working.

    What are your next steps?

    • Report.

    Case Study 2

    What indicators are present?

    • Bruises, scrapes

    Is there reasonable cause to suspect abuse or maltreatment?

    • No, the story is consistent with a playground injury. Injuries sustained in an accidental fall would be along one side of the child’s body.

    Is there a parent or other person responsible for the suspected abuse or maltreatment?

    • No

    What are your next steps?

    • Prioritize the treatment of the child’s injury. You do not need to report this.

    Case Study 3

    What indicators are present?

    • Neonatal drug withdrawal and no plan for when the baby comes home from the hospital

    Is there reasonable cause to suspect abuse or maltreatment?

    • Yes

    Is there a parent or other person responsible for the suspected abuse or maltreatment?

    • Mother

    What are your next steps?

    • Consult your workplace's policies and procedures. You may have the ability and responsibility to report.

    Case Study 4

    What indicators are present?

    • Spiral fracture, the explanation for the injury is not plausible.

    Is there reasonable cause to suspect abuse or maltreatment?

    • Yes

    Is there a parent or other person responsible for the suspected abuse or maltreatment?

    • Mother

    What are your next steps?

    • Report.

    Case Study 5

    What indicators are present?

    • Mom’s boyfriend was taking care of the baby, Sabrina was fine one minute and then not breathing the next, reported to the ER for unconsciousness, boyfriend has a temper, boyfriend left suspiciously for cigarettes

    Is there reasonable cause to suspect abuse or maltreatment?

    • Yes

    Is there a parent or other person responsible for the suspected abuse or maltreatment?

    • Mother’s boyfriend, Rick

    What are your next steps?

    • This case is suspicious of shaken baby syndrome and should be worked up as such in the ER. Consult the policies and procedures of your workplace. You could have the ability and responsibility to report.

    Case Study 6

    What indicators are present?

    • Benjamin is not going to school anymore.

    Is there reasonable cause to suspect abuse or maltreatment?

    • No, it seems Mom has tried. Additional attention can be given specifically to Benjamin to confirm Mom’s story.

    Is there a parent or other person responsible for the suspected abuse or maltreatment?

    • No

    What are your next steps?

    • Most states have a compulsory attendance law to explicitly determine the ages at which a child must attend school regularly. For example, in Pennsylvania, children between the ages of six and eighteen are required to attend school regularly (Pennsylvania Department of Education, 2024). In New York, the ages are between six and sixteen. Take a look at the requirements in your state. Depending on those age determinations, you might or might not need to report.

    Case Study 7

    What indicators are present?

    • Mom is under a lot of stress; she also admits to leaving two-year-old Elijah home alone while she runs to the store.

    Is there reasonable cause to suspect abuse or maltreatment?

    • Yes

    Is there a parent or other person responsible for the suspected abuse or maltreatment?

    • Mother

    What are your next steps?

    • Some states have specific laws about the age to leave a child alone. Others do not. In New York, a child left alone in a residence must have the knowledge and skills to respond to a potential emergency properly and care for themselves (NYS, 2022). Also, just because an individual child may be left alone safely does not mean that that child can supervise other children (NYS, 2022). Take a look to see if your state has such stipulations. Generally, this would be considered inadequate supervision (Cumberland County, Pennsylvania, n.d.). Mom should not do this. Someone must be physically present with Elijah while she is out in case of an emergency. Report.

    Case Study 8

    What indicators are present?

    • Ligature marks around the risks, mom’s admission that she ties the child up to her bed and denies her food

    Is there reasonable cause to suspect abuse or maltreatment?

    • Yes

    Is there a parent or other person responsible for the suspected abuse or maltreatment?

    • Mother

    What are your next steps?

    • Although this appears to be a cultural practice, it might be illegal to use these means to deal with a child's misbehavior. Make sure to consult the specific rules outlining the use of cultural practices for punishment in your state. Some states, like New York, indicate that this cultural practice would be illegal and considered child abuse. Other states allow more freedom in the practices of raising children if this would qualify as possible child abuse in your state, report.

    Conclusion

    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!

    Child Abuse Reporting Contact Information by State

    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 

    Select one of the following methods to complete this course.

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    Implicit Bias Statement

    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.

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