Recognizing and Reporting Child Abuse

from School Health Reporter, Spring 2004

Denise C. Abdoo, RN, MSN, CPNP, Senior Instructor of Pediatrics,
University of Colorado at Denver and Health Sciences Center, School of Medicine

Child abuse and neglect is a once-taboo topic brought to light in the 1960s by C. Henry Kempe’s 1962 article “The Battered Child Syndrome.” Over the last 40 years, there has been much research and work in the field of child protection and child abuse. However, child abuse remains a difficult topic.

Child abuse and maltreatment is defined as the physical or mental injury, sexual abuse or exploitation, negligent treatment or maltreatment of a child by a person who is responsible for the child’s welfare under circumstances that indicate harm or threatened harm to the child’s health or welfare (Federal Child Abuse Prevention Treatment Act. 42, United States Code 5106g (4).

As professionals in medicine, nursing, education or other disciplines working with children, we are mandated reporters of suspected child abuse.

The 1987 Child Protection Act put forth by Colorado defines child abuse as an act of omission that threatens the health or welfare of a child. This definition includes:

1. Any case where a child exhibits evidence of skin bruising, bleeding, malnutrition, failure to thrive (poor growth and development), burns, fractures, subdural hematomas, soft-tissue swelling or death, and any of the following:
   • The condition or death is not justifiably explained.
   • The history given concerning the condition is discrepant with the degree or type of such condition or death.
   • The circumstances indicate that such condition may not be the product of an accidental occurrence.
2. Any case in which a child is subjected to sexual assault or molestation, sexual exploitation or prostitution.
3. Any care in which a child is in need of services because the child’s parents, legal guardian or custodian fails to take the same actions to provide adequate food, clothing, shelter, medical care or supervision that a prudent parent would take.

Furthermore, the reporting laws for child abuse and neglect per the Colorado Children’s Code 19-3-304 state that:

• Any “suspected” or known incident of child abuse must be reported.
• Protecting patient confidentiality does not legally justify a failure to report.
• Immunity is provided for reporters “acting in good faith” (Children’s Code, 1998).

It is also important for mandated reporters to remember that child abuse is not a rare phenomenon. In 2001, according to data collected by the U.S. Department of Health and Human Services, approximately 903,000 children were the victims of maltreatment. This includes physical abuse, sexual abuse, emotional abuse and neglect.

When broken down into categories, 57 percent were victims of neglect; 2 percent medical neglect; 19 percent physical abuse; 10 percent sexual abuse; and 7 percent emotional abuse. Still the question remains: How does one recognize when a report to the Department of Social Services needs to be made?

Child physical abuse is defined as “the infliction of physical injury as a result of acts that may or may not have intended to hurt the child.” Physical injury may have occurred as a result of beating, punching, kicking, biting, burning or shaking a child (Giardino, 2003, p. 6). Specific types of injuries one may see with child physical abuse are: head injury (vomiting, irritability, seizure and lethargy), abdominal trauma (vomiting), fractures, bruises, abrasions, patterned injuries, burns, poisoning (vomiting, diarrhea, lethargy and seizure), starvation or neglect. Areas typically injured in accidents are the forehead, elbows, knees, shins and iliac crest (hip bone) (Giardino, 2003, p. 24). The injury sites on the body for possible non-accidental injury are: the scalp, behind the ears, the neck, the axillae (underarm), inner thighs, between fingers and/or toes and in the genital area. (Giardino, 2003, p. 24) When in the school setting, one has the advantage of being able to ask how an injury occurred. Any disclosure of being hit where the hitting leaves marks or being hit with an object has to be reported to Social Services.

Burns also should raise concerns for abuse. By no means are all burns caused by abuse; however, a child should be asked how he or she got the burn. Again, if a professional has the suspicion that a child may have been abused, it must be reported to Social Services.

Child sexual abuse is another area of concern. Child sexual abuse is defined as “the use of a child for sexual gratification by an adult or a person who is significantly, chronologically or developmentally older than the victim.

Sexual abuse includes molestation, exploitation for prostitution, incest or use of the child for pornographic materials.” (Destefano Lewis & Bear, 2002, p. 337). Behaviors to look for in children where sexual abuse is a concern include: excessive fear, difficulty eating, enuresis (the involuntary discharge of urine) and encopresis (involuntary defecation), sexualized behaviors, social withdrawal, aggression, depression, self-injurious acts and a decreased self-esteem (Reichert, SK, 1997, p.315). In adolescent children, one may see additional behaviors that include eating disorders, delinquency, substance abuse, suicide attempts, pregnancy, and/or a preoccupation with sexual activities. (Reichert, SK, 1997, p.315). In any case where sexual abuse is a concern, a referral to Social Services needs to be made.

In a school setting, one may witness a child perpetrating on or sexually acting out toward another child. This is concerning behavior for the offending child. A report should be made to Social Services in the context of:

1. there being concern as to where this child learned these behaviors and whether he or she has been (or is being) abused and
2. concern for mental-health issues for this child and the non-offending child.

Finally, neglect is defined as “a pattern of caregiving that does not adequately meet the needs of the developing child.” (Giardino, 2003, p. 42). Neglect may present in various manners. Neglect may be provisional, where a caregiver is unable to provide for the basic needs of a child.

Provisional neglect encompasses the lack of providing food, shelter, clothing, nurturing, schooling and healthcare. Neglect may be developmental, where caregivers do not provide a child with appropriate stimulation in the environment. Neglect also presents as supervisional neglect. When caregivers do not adequately protect a child from dangers in the environment, thus placing the child at risk for injury, this is considered supervisional neglect. (Giardino, 2003)

In summary, recognizing and reporting child abuse can be a difficult process for all professionals. The law is clear. If there is a suspicion of abuse, it must be reported to the appropriate agencies (county department of human services and the police department). Knowing when to report a suspicion of abuse is difficult to discern, in part because one does not want to be wrong when the topic of child abuse is involved. There is a fear that calling social services will result in the family of the child falsely being hassled and accused of being child abusers. Other fears are “What if I am wrong? Will I get into trouble? Will I be crying wolf? What will my relationship with this family and child be after I make the report?” All of these worries are valid.

Making a report to Social Services is not an easy task. It cannot be stated enough; professionals working with children are mandated reporters and must make a report to Social Services if there is suspicion that a child is being abused. It is not the responsibility of the reporter to prove that the child has been abused or neglected. Therefore, professionals working within the school system should be on the lookout for injuries that may not be from normal childhood play, as well as behaviors that may indicate that a child has been sexually abused.

References:

Colorado Children’s Code August 1998-1999

DeStefano Lewis, K & Bear, BJ (2002). Chapter 7: Violence. In DeStefano Lewis, K & Bear, BJ, Manual of School Health 2nd ed, pp. 327-348. Philadelphia: Saunders.

Giardino, ER (2003). Chapter 1: The problem of child abuse and neglect. In Giardino, ER & Giardino, AP (Eds.), Nursing Approach to the Evaluation of Child Maltreatment, pp. 1-16. St. Louis: G.W. Medical Publishings, Inc.

Giardino, ER (2003). Chapter 2: Presentation and Overview of the Evaluation of Child Maltreatment. In Giardino, ER & Giardino, AP (Eds.), Nursing Approach to the Evaluation of Child Maltreatment, pp. 21-45. St. Louis: G.W. Medical Publishings, Inc.

Kempe, C.H., Silverman, F.N., Steele, B.F., Droegemueller, W., & Silver, H.K. (1962). The battered child syndrome. Journal of American Medical Association, 181, 17-24.

National Clearinghouse on Child Abuse and Neglect Information, USDHHS, Child Maltreatment 2001: Summary of Key Findings, retrieved on 30 December 2003.

Reichert, SK (1997). Chapter 13: Medical Evaluation of the Sexually Abused Child. In Helfer, Me, Kempe, RS, & Krugman, RD (Eds), The Battered Child 5th ed, pp. 313-329. Chicago : The University of Chicago Press.