OVERVIEW

General Principles

Child maltreatment is physical, sexual, and/or psychological maltreatment or neglect of a child.
States have their own definitions as to the details of what constitutes maltreatment, but all states require physicians and other listed professionals to report suspected child abuse or neglect to the state’s child protective services agency. State laws vary as to whether suspected abuse or neglect has to be reported if done by others than parents or caretakers, whether emotional abuse requires a report, what actually constitutes sexual abuse (e.g., maximum age difference between consenting minor and other person, minimum age for a minor to consent), and whether specific other categories are defined (e.g., medical neglect).
Therapists may feel anxious about reporting child abuse, feeling it breaks confidentiality, places them in a dual role of therapist and agent of the state, and, if the alleged perpetrator is a parent of a child in treatment, may seriously injure the therapeutic relationship with the parent and cause the parent to terminate the child’s treatment. While such feelings are understandable, they should not stop the therapist from making the report if they have a reasonable suspicion of abuse. Failure to report in such a situation is a criminal offense in most jurisdictions and may also constitute malpractice and lead to loss of licensure.
Factitious disorder by proxy, also known as Munchausen by proxy, is a rare type of child abuse in which a parent either falsely reports a child’s symptoms or intentionally causes symptoms (such as by giving toxic substances), and then brings the child for treatment.
The clinician does not have to be sure that a child has been abused in order to make a report: the usual test is whether the clinician has a reasonable suspicion of abuse or neglect. The clinician’s job is to alert the authorities to possible abuse; the state agency is responsible for investigating and determining whether abuse or neglect has actually occurred. State laws protect those who report in good faith from any liability.

CLINICAL SCENARIOS

Scenario #1: An 8-year-old girl in psychotherapy says that her 16-year-old older brother tried to get her to suck his “wee-wee.”

Sexual molestation of a young child by a person of any age is considered sexual abuse in most states, and so is reportable to Child Protective Services.

Scenario #2: A 15-year-old girl asks her doctor for “some birth control method” and reports she is having sex with her 15-year-old boyfriend.

In most states, consensual sex between adolescents close to each other in age is not considered sexual abuse. States vary as to the allowable age difference.

Scenario #3: A 28-year-old mother in individual psychotherapy reports that her husband frequently punishes their 4 year-old son by whipping him with a belt leaving black and blue marks and occasionally bleeding cuts. She says she’s asked her husband to stop, but he says, “That’s how I was raised, and it’s necessary.”

Punishment of a child that leaves signs of injury (bleeding, black and blue marks) is considered abuse and so requires a report. The therapist might well be concerned that the patient would take offense, see the report as a breach of confidentiality and trust, and terminate treatment. While this is a valid concern, a report is nevertheless required.
While a clinician could make a report without notifying the patient, and protective services will not disclose who made the report, most experts think that the patient in this case should be notified, and the therapist can discuss with the patient what is likely to happen, how to respond to Protective Services, etc. Some therapists make the telephone call to Protective Services with the patient present in the room so the patient is clear just what the report entailed.
While there is not clear data on how many patients terminate treatment in these situations, in many cases a patient will appreciate the therapist’s assistance in getting through a difficult situation, and the treatment continues. This can occur even if the patient is the abuser, and agrees to stop abusing the child. The fact that the patient is in therapy may be important in Protective Services deciding to allow the child to remain in the home and just be monitored for any further abuse.

Scenario #4: A 6-month-old female infant is seen in the emergency room for unremitting crying. As part of the work-up, a chest X-ray reveals seven posteromedial rib fractures. The mother says her daughter is learning to walk and falls down a lot.

Physical injuries that do not have a plausible explanation give rise to suspicions of abuse. Multiple posteromedial rib fractures in infants are particularly suspicious.¹
Many hospitals have a child abuse team. If the clinician notifies the team and the team makes a report, then each individual clinician does not have to make their own, individual report.

Scenario #5: A 7-year-old girl who is in the fifth percentile for weight describes that most days when she comes home from school, no adult is present in the house. She further describes that often her mother does not prepare dinner, and she is expected to eat crackers or cereal for dinner when she is hungry.

Neglect is more common than physical abuse,² and reasonable suspicion of young children being left alone, not fed, or otherwise neglected needs to be reported.

Scenario #6: A patient discloses to his treating psychiatrist that he sexually abused his stepdaughter ten years ago when she was 13. His stepdaughter never reported the abuse, and no one in the family knows. He has not had contact with his now adult step-daughter in two years. The patient is anxious that the psychiatrist will report him to the authorities.

States differ as to whether abuse of a minor who is now an adult needs to be reported. Some states have an explicit exception for abuse reported by a patient who says they abused a person who is now an adult. Since the motivation for many reporting laws is to protect minors, abuse of a minor who is now an adult may not be reportable because there is no minor to be protected. The judgement may be more complicated if there are still younger children in the home of the abuser. One option is for the psychiatrist to call Protective Services and describe the situation without providing names and then ask if the case needs to be reported. If the answer is no, the clinician should ask for the name of the Protective Services worker and document in the chart that the call was made and the clinician was told it did not require a report. Another option is for the clinician to obtain legal advice about the particular laws in the jurisdiction.

Scenario #7: The pediatric service asks for a psychiatric consultation with special attention paid to the mother of a 3-year-old who has had multiple hospitalizations for serious symptoms that remit quickly in the hospital without treatment. The mother is suspected of causing her child’s symptoms.

Making a diagnosis of Munchausen by proxy can be quite challenging, as there is no clear profile of parents who abuse their children by intentionally causing their child’s symptoms. Some hospitals contain special rooms with video surveillance that may capture actual abuse in the hospital. Treatment generally consists of removing the child from the abusing parent.

ADDITIONAL TIPS

Initial reporting to Child Protective Services is usually made by telephone. Protective Services may ask that a written form also be completed. If a report is made, the clinician should note it in the patient’s medical record. Some hospitals have a child protection team, and a clinician can report to the team who then make the report to Protective Services. If a report has been made, successive clinicians do not need to make additional reports about the same incident(s).

Special Considerations

State laws vary considerably on some details of what constitutes child abuse or neglect, so it is important for all clinicians to be familiar with the law in their state. In order to encourage reporting, Protective Service agencies will generally not reveal to parents who made the report. However, in most clinical situations it is appropriate for the clinician to inform the parent or caretaker that a report is being made.

REFERENCES

Paine CW, Fakeye O, Christian CW, Wood JN. Prevalence of Abuse Among Young Children with Rib Fractures: A Systematic Review. Pediatr Emerg Care. 2019 Feb;35(2):96-103.
U.S. Department of Health & Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. Child Maltreatment 2019; 2021. Available from: https://www.acf.hhs.gov/cb/research-data-technology/statistics-research/child-maltreatment
Yates G, Bass C. The perpetrators of medical child abuse (Munchausen Syndrome by Proxy) – A systematic review of 796 cases. Child Abuse Negl. 2017 Oct;72:45-53.

Additional Reading

Child Welfare Information Gateway. Mandatory reporters of child abuse and neglect. Washington, DC: U.S. Department of Health and Human Services, Children’s Bureau. 2016.
Christian RE, Frick PJ, Hill NL, Tyler L, Frazer DR. Psychopathy and conduct problems in children: II. Implications for subtyping children with conduct problems. J Am Acad Child Adolesc Psychiatry. 1997 Feb;36(2):233-41.
Lamb ME, Orbach Y, Hershkowitz I, Esplin PW, Horowitz D. A structured forensic interview protocol improves the quality and informativeness of investigative interviews with children: a review of research using the NICHD Investigative Interview Protocol. Child Abuse Negl. 2007 Nov-Dec;31(11-12):1201-31.
McEwan M, Friedman SH. Violence by parents against their children: reporting of maltreatment suspicions, child protection, and risk in mental illness. Psychiatr Clin North Am. 2016 Dec;39(4):691-700.

Overview | Clinical Scenarios | Additional Tips | References

By Peter Ash, MD