#97534: Child Abuse Identification and Reporting: An Update for New York

There are several acts that may be considered abusive, and knowledge of what constitutes abuse is vital for healthcare providers and other mandated reporters. In this section, specific behaviors that fall under the category of abuse and neglect will be reviewed.

In 2021, there were 3.9 million referrals to CPS agencies in the United States [15]. More than 2 million were assessed to be appropriate for a response, and 28.7% of reports were made by health and mental or behavioral health professionals [15]. Girls tend to be victims at a slightly higher rate (8.7 per 1,000 girls) compared with boys (7.5 per 1,000 boys) [15]. More than a half (51.7%) of perpetrators are women, and the majority (83.2%) are between the ages of 18 and 44 years [15].

As of 2021, there were at least 3.5 million children referred to CPS agencies and who received an investigation and some form of response, and 8.1 of every 1,000 children in the United States were victims of abuse and/or neglect [15]. This is the unique rate, meaning each child is counted only once regardless the number of times a report may have been filed for abuse/neglect. The fatality rate for 2021 was 2.46 deaths per 100,000 children [15].

Research has shown that racial and ethnic minority children (particularly African American/Black, Native American/Alaska Native, and multi-racial children) tend to have higher rates of reported child maltreatment compared to their White counterparts (Table 1) [15]. However, the lowest reported rate is among Asian American children [15]. It is important to note the role of explicit and implicit bias in the higher rates of child abuse reports among minority populations.

In 2021, the rate of child abuse and neglect in New York State was 13.8 per 1,000 children [15]. This translates to approximately 58,760 cases of child abuse and neglect in New York in 2021, a decrease of 20.3% compared with 2017 [15]. In terms of fatalities, 126 children in New York died in 2021 as a result of child abuse and neglect—a rate of 3.06 per 100,000 children [15]. This is greater than the national rate of 2.46 per 100,000 per children [15].

Mandated reporters may have interactions with children that occur in a virtual environment. For example, children may attend school remotely, visit physicians and nurses using telemedicine, and participate in therapy sessions on virtual platforms. Those professionally interacting with children virtually have the same responsibilities as those interacting with children in person.

When assessing safety virtually, where possible:

When interacting virtually, one may observe or hear an altercation between children or adults. Even if this does not rise to a level of making a report, it may create an opportunity for a conversation about safety or managing stress

Professionals utilizing technology to provide services should always use reliable technology, with adequate lighting and sound. At the start of each visit, it is good practice to verify the child's location, in the event you need to contact emergency services. Everyone present in the video or call should be introduced, even if they enter after the visit starts. The child should be present for at least part of the visit.

The child and/or parent should be asked if there is enough privacy to discuss sensitive matters. If necessary, nonparticipating household members may be asked to move to a different room or to leave the home, if possible.

Nonverbal cues should be monitored and noted. If a child's demeanor or behavior changes when someone else enters the room, this should prompt further exploration. Similarly, if a child turns off a webcam or is very hesitant to use one, this can be a sign that they are trying to avoid confrontation or assessment.

In addition, the child's environment should be monitored for noticeable unsafe conditions. It should be clear that there is appropriate supervision for the child. One may also see that young children are being held responsible for even younger siblings.

All professionals involved in virtual contact with children should provide clear channels to reach out via e-mail, phone, chat, text, or online tool.

Trauma is an intense event that threatens a person's life or safety in a way that is too much for the mind to handle and leaves the person powerless. Trauma can trigger physical reactions, including rapid heart rate, tense muscles, or shallow breathing. Common traumatic events could be going through or seeing:

For many parents, having a child removed from the home and dealing with the child welfare system are traumatic events. As such, trauma impacts much of the work mandated reporters do.

Adverse childhood experiences (ACEs) (including abuse and maltreatment) are defined as potentially traumatic experiences that affect an individual during childhood (before 18 years of age) and increase the risk for future health and mental health problems (including increased engagement in risky behaviors) as adults [76]. These experiences are broadly common, occurring in approximately 64% of the U.S. population [82]. ACEs and trauma alone may not rise to the level of child abuse or maltreatment; it is the impact on the child that should be assessed. ACEs have a lasting impact on children, persons legally responsible for children, and mandated reporters.

Toxic stress occurs when a person experiences severe, prolonged adversity without adequate support. Toxic stress means that the stress response stays continuously activated in the body. This prolonged exposure to adversity can impact children developmentally and behaviorally.

The consequences of child abuse and neglect vary from child to child; these differences continue as victims grow older. Several factors will mediate the outcomes. These factors include [17]:

In examining some of the effects of physical abuse, it is helpful to frame the consequences along a lifespan perspective [18]. During infancy, physical abuse can cause neurologic impairments. Most cases of infant head trauma are the result of child abuse [19]. Neurologic damage may also affect future cognitive, behavioral, and developmental outcomes. Some studies have noted that, in early childhood, physically abused children show less secure attachments to their caretakers compared to their nonabused counterparts [20].

By middle to late childhood, the consequences are more notable. Studies have shown significant intellectual and linguistic deficits in physically abused children [18]. Other environmental conditions, such as poverty, may also compound this effect. In addition, a number of affective and behavioral problems have been reported among child abuse victims, including anxiety, depression, low self-esteem, excessive aggressive behaviors, conduct disorders, delinquency, hyperactivity, and social detachment [8,10,12,18].

Surprisingly, there has been little research on the effects of childhood physical abuse on adolescents [18]. However, differences have been noted in parents who abuse their children during adolescence rather than preadolescence. It appears that lower socioeconomic status plays a lesser role in adolescent abuse as compared to abuse during preadolescence [21]. In addition, parents who abuse their children during adolescence are less likely to have been abused as children themselves compared to those parents who abused their children during preadolescence [21]. It is believed that the psychosocial effects of physical abuse manifest similarly in late childhood and adolescence.

Research findings regarding the effects of childhood physical abuse on adult survivors have been less consistent. Some adult survivors function well socially and in terms of mental and physical health, while others exhibit depression, anxiety, post-traumatic stress, substance abuse, criminal behavior, violent behavior, and poor interpersonal relationships [17,18]. A 2019 meta-analysis found a robust association between five forms of child maltreatment (i.e., sexual abuse, physical abuse, emotional abuse, neglect, and exposure to intimate partner violence) and the development of mental disorders, including depressive disorders, anxiety disorders, and post-traumatic stress disorder [24]. Similar results were found in a longitudinal study that compared a child welfare cohort to a group with no child welfare involvement. The child welfare group was twice as likely to experience moderate-to-severe depression and generalized anxiety compared with the control group [25].

Although not all adult survivors of sexual abuse experience long-term psychological consequences, it is estimated that 20% to 50% of all adult survivors have identifiable adverse mental health outcomes [23]. In the Wisconsin Longitudinal Study, men who disclosed a history of childhood sexual abuse were more likely to have or develop depression, somatic symptoms, and increased levels of hostility [51]. Other possible psychological outcomes include [10,52]:

Adult male survivors of child sexual abuse are three times as likely to perpetrate domestic violence as non-victims. In addition, female survivors of child sexual abuse are more vulnerable to bulimia, being a victim of domestic violence, and being dependent on alcohol [28].

In more recent years, research has focused on the impact of ACEs in general [76]. Abuse and neglect during childhood are clear ACEs, but other examples include witnessing family or community violence; experiencing a family member attempting or completing suicide; parental divorce; parental or guardian substance abuse; and parental incarceration [76]. Adults who experienced ACEs are at increased risk for chronic illness, impaired health, violence, arrest, and substance use disorder [77,78]. It has been found that other factors can intensify the effects of ACEs, including poverty, racism, generational trauma, and frequent unintended or indirect discrimination. The effects of ACEs can be reduced by supporting children and families and increasing protective factors.

The economic costs of non-fatal child maltreatment equate to $210,012 per child victim, excluding the costs associated with adverse physical and mental health consequences and those incurred by the criminal justice and special education systems [53]. A 2017 study found a cost of more than $400,000 per child abuse victim over the course of his or her lifetime [65].

In the state of New York, certain professionals are legally required or mandated to report immediately any suspected cases of child abuse, maltreatment, and/or neglect that they encounter in their professional roles (i.e., working or volunteering in a role that requires your specific licensure or certification) to the New York Statewide Central Register (SCR) of Child Abuse and Maltreatment. Reasonable cause for suspicion is based upon behaviors that have been observed or reported that cause the professional to believe that a specific circumstance might involve child abuse or neglect [26]. Child abuse laws in New York, and in all states, do not require reporters to have absolute proof of abuse [27]. Reporting suspected cases should be done in good faith, and mandatory reporting laws give the reporter immunity from criminal and civil liability regardless of the substantiation of abuse [16]. Good faith is defined as "the reporter, to the best of his or her knowledge, has reason to believe that the child in question is being subjected to abuse or neglect" [14]. Note that poverty, in and of itself, does not equate to maltreatment or abuse.

However, if mandated reporters fail to report an incident of suspected child abuse or maltreatment, they may be charged with a Class A misdemeanor, subject to criminal penalties, and can be sued for monetary damages for any harm in a civil court [26]. It is vital to remember that mandated reporters are not required to provide absolute evidence; this is the responsibility of CPS [29]. No employer or organization is permitted to require approval prior to calling the SCR. Mandated reporters' legal obligations are personal, and organizations may not impede calling the SCR. Further, all employers and organizations are prohibited from retaliating in any way for mandated reporters' fulfilling their duties. The law also does not require multiple reports on the same incident from the same organization.

The following individuals are classified as mandated reporters in the state of New York [26]:

When mandated reporters suspect a case of child abuse or maltreatment, they must report to the SCR at 1-800-635-1522. The general public can report suspected abuse by calling 1-800-342-3720 [38]. In an emergency situation, always call 911 first.

The SCR is open 24 hours per day, 7 days per week [26]. The mandated reporter is not obligated to contact the parents or the legal guardians of the child either before or after the call to SCR [26]. Good practice dictates that the reporter either seek consent or notify the parent(s) that essential information is being (and is required to be) shared, unless doing so would put the child's health or safety at risk. However, even if the parent does not consent, the mandated reporter is still obligated to contact the SCR [26]. (Additional child abuse hotline information may be found in the Resources section of this course.)

The worker who answers the phone will attempt to accumulate as much information from you as possible. According to the New York State Office of Children and Family Services, they will ask you the following types of questions [26,38]:

Within 48 hours of reporting the suspected abuse to SCR, the reporter must also complete and sign a written report (LDSS-2221A) and submit the report to the local department of social services (LDSS) that has been assigned to the investigation [26]. The forms may be accessed on the New York State Office of Children and Family Services website at https://ocfs.ny.gov/forms/ldss/LDSS-2221/OCFS-LDSS-2221A.docx. Information required to complete the form includes:

The SCR is bound by legal criteria that dictates whether they can accept a report:

The SCR is not legally required to accept all reports from mandated reporters. The SCR staff will conduct their own interview to determine if the information you provide during the call rises to the legal level of suspected child abuse or maltreatment. If it does not rise to this level, based on the information provided, the SCR cannot accept the report. Mandated reporters have fulfilled their legal obligations even if the SCR declines to accept the report.

The CPS unit of the LDSS is required to begin an investigation of the reported abuse within 24 hours [26]. A CPS specialist will ask questions about the suspected abuse and the child and ill contact the child(ren) and alleged perpetrator. For example, the specialist will ask for the child's name, age, and home address, the name of the suspected person who inflicted the abuse, his or her address, and the nature of the abuse. The specialist should also evaluate the safety of the child named in the report as well as that of any other children in the home. If the child's safety is at risk, the specialist may take the child and other children in the home into protective custody to prevent further abuse or maltreatment. CPS has 60 days after receiving the report to determine whether it is substantiated or unsubstantiated. CPS is obligated to inform the child's parents or other subject of the report of their rights and offer potentially helpful services, according to the New York State Social Services Law, and must inform the SCR of the determination of the investigation [26]. The most common outcome of a CPS investigation is that the caseworker will work with the family to obtain necessary services or aid to alleviate problems and promote safety. However, CPS intervention is not required for parents, children, or families to obtain services.

Studies have shown that many professionals who are mandated to report child abuse and neglect are concerned and/or anxious about reporting. Identified barriers to reporting include [29,30,31,40,54,55]:

The failure to identify and report child abuse may result in continued abuse of the child and potentially severe consequences. Improved and ongoing education about child abuse and maltreatment has been shown to improve identification and reporting rates among physicians and other professionals. The education should include [32]:

Other suggestions for improving reporting include [32]:

All interactions with patients, regardless of whether or not they are potential victims of abuse, should be centered on the patient's experiences, needs, and preferences. Providing patient-centered care means that care will be respectful of and responsive to individual patient preferences, needs, and values and will reflect the patient's values. This should be considered at all stages of assessment, intervention, and continued care/follow-up.

It is important to use a trauma-informed approach when assessing and caring for potential victims, which requires that practitioners understand the impact of trauma on all areas of an individual's life. Physical, emotional, and psychological safety is at the heart of trauma-informed care. This approach allows for trust-building and continued communication, both vital to ensuring that patients receive the care and support they require.

Being trauma-informed is a strengths-based approach that is responsive to the impact of trauma on a person's life. It requires recognizing symptoms of trauma and designing all interactions with victims in such a way that minimizes the potential for re-traumatization. This involves creating a safe physical space in which to interact with survivors as well as assessing all levels of service and policy to create as many opportunities as possible for survivors to rebuild a sense of control. Most importantly, it promotes survivor empowerment and self-sufficiency. Children should have access to services that promote autonomy and are comprehensive, victim-centered, and culturally appropriate.

When assessing and providing care to children affected by trauma, it is important to consider protective factors that can lower the risk of negative health outcomes. Protective factors against child maltreatment and abuse include:

The rates of child maltreatment for children with disabilities are reportedly 1.7 to 7 times higher compared with children without disabilities [42]. In one study, researchers found that among substantiated reports of maltreatment among children, 22% of victims had some form of disability, most commonly an emotional disability [58]. A systematic review found that there was a prevalence rate of 20.4% for physical abuse, 13.7% for sexual abuse, and 26.7% for both forms of abuse combined among children with intellectual disabilities [66]. Children with disabilities can be more vulnerable to maltreatment if the parents/caregivers view the disability and its associated behaviors as "difficult," if the parents have unrealistic expectations of the child's behavior or abilities, if the parents are facing additional caregiver stress, or if the parent perceives the child as unable to defend him/herself [43]. Furthermore, they may be less likely to disclose the abuse because they not only do not realize they have been harmed or they have impaired communication skills [59].

To effectively interview a child with a disability, the practitioner should first obtain some preliminary data, including [33]:

Overall, when conducting an interview of a child with a disability or special need, the practitioner should work with someone to validate impressions or feelings about the child, develop and use a multidisciplinary resource team, be aware of the child's vulnerabilities (e.g., behavioral challenges, accompanying disabilities), and remember that he/she may be the first person able to stop the child from being further victimized [41]. When questioning the child, it is important to ask open-ended questions, as this approach maximizes recall. Some assume that children with disabilities will not be able to handle open-ended questions, but this is not strictly true [67]. When working with those with intellectual disabilities, interviewers should try shorter open-ended questions before falling back to closed-ended questions [67]. Scaffolding questions, or breaking up the tasks and gradually building up the questions with specific instructions and comprehension checks along the way, can also be beneficial [68]. Comprehension check questions can be as simple as: "Can you repeat the question I just asked?" or "I just asked you <insert question>, what does that question mean to you?" [68].

Communication with children and families regarding the signs and history of abuse is a necessary step in obtaining an accurate diagnosis. When interviewing children for whom English is not their first language, they may switch back to their first language during the interview, even if they express the wish to have the interview conducted in English [69].

There will also be many occasions when an interpreter is warranted. Without an interpreter, children may experience additional stress, struggling to find the right words in English, which can result in more feelings of fear, disempowerment, and voicelessness [44].

It may be tempting to locate a practitioner who has some language ability to speak to the child and/or family member; however, this should be avoided if at all possible [44]. When looking for an interpreter in the community, it is important to consider if the interpreter and the family are acquainted, as this can cause an uncomfortable situation [69]. The language for screening for child abuse requires precision as well as sensitivity, and professional interpreters are recommended.

In this multicultural landscape, interpreters are a valuable resource to help bridge the communication and cultural gap between patients and practitioners [33]. Interpreters are more than passive agents who translate and transmit information back and forth from party to party. When they are enlisted and treated as part of the interdisciplinary clinical team, they serve as cultural brokers, who ultimately enhance the clinical encounter. They should be familiar with both the nuances of the language and the cultural norms and value systems of the target community [44]. When providing care for children and parents for whom English is a second language, the consideration of the use of an interpreter and/or patient education materials in their native language may improve patient understanding and outcomes.

It is also vital to take into account interpreters' competence when working in the area of child abuse. Because of the sensitive nature of child abuse and the type of information being asked and recalled, interpreters should be well trained in communicating with victims and perpetrators [60].

National research shows, and OCFS data confirm, that disparities exist throughout the child welfare system presently and historically [83]. The OCFS' Disproportionate Minority Representation data show historical over-representation of children and families of color in the child welfare system. Families of color have been more likely to be involved in a report to the SCR, and children of color have been more likely to be placed in foster care and generally experience slower achievement of permanency goals.

In addition, income status of families is a significant predictor of involvement with the child welfare system. Research shows that families investigated by CPS have several poverty-related risk factors, such as unemployment, single parenthood, food insecurity, housing instability, or lack of access to childcare [83]. Families living below the poverty line are three times more likely to be substantiated for child maltreatment than those with higher income.

A mandated reporter's decision whether to call the SCR can change the course of the life of a child and the members of a family. It is important to be aware of the propensity for implicit or explicit bias and to be intentional about making decisions based on the objective facts of a situation. Part of this process involves increase our own awareness regarding our own beliefs, including those that may be hidden or unconscious. Mandated reporters should only call the SCR when they have a legal obligation to do so.

All mandated reporters should approach their responsibility with empathy, compassion, care, and curiosity. When assessing information received about a child and their family, instead of making assumptions or jumping to conclusions that a child is being maltreated or abused, consider the right analytical and evaluative questions. Evaluate whether the needs of the child and family can be met through means outside of the CPS system.

The first step in unraveling implicit bias is understanding the lens through which one views the world. By their nature, implicit biases can be difficult to recognize in oneself. The IAT can be used as a metric to assess professionals' level of implicit bias on a variety of subjects [93]. When providers are aware that implicit biases exist, discussion and education can be implemented to help reduce them and/or their impact.

Another way of facilitating awareness of providers' implicit bias is to ask self-reflective questions about each interaction with patients. Some have suggested using SOAP (subjective, objective, assessment, and plan) notes to assist practitioners in identifying implicit biases in day-to-day interactions with patients [94]. Integrating the following questions into charts and notes can stimulate reflection about implicit bias globally and for each specific patient interaction:

A proven strategy to reduce bias is to examine whether the facts of the situation would lead you to the same decision to call the SCR if the demographic information for the child or family were different. Consider if you would make the same decision if any of the following were different for the child or family:

The best tool to reduce bias is solid critical thinking. In the case of identifying possible abuse, this consists of identifying what specifically concerns you about the current situation, gathering adequate information about the current situation, analyzing that information to separate facts from assumptions, recognizing the possibility of bias, developing multiple hypotheses that could explain the situation, and determining whether you are legally required to call the SCR and, if not, whether an alternative option is better, such as connecting the individual or family to appropriate services in their community. In all cases, mandated reporters should approach the situation with humility and be open and willing to learn and consider information that might be different from first impressions and assumptions.