Ethical Considerations in Identifying and Reporting Child Abuse

Child abuse is a crucial ethical issue for mental health practitioners to understand and be competent in addressing. According to Childhelp (2018), a nonprofit organization dedicated to the prevention and treatment of child abuse, child abuse occurs when a parent or caregiver, whether through action or failing to act, causes injury, death, emotional harm or risk of serious harm to a child (para. 1). In certain instances, child abuse can also be committed by peers or siblings. There are four distinct forms of child abuse, including physical abuse, sexual abuse, emotional abuse, and neglect.

Physical abuse is the most common form of child abuse, with approximately 28.3% of adults reporting experiences of physical abuse in childhood (Childhelp, 2018). Physical abuse involves physical injury to a child, such as bruises, blisters, burns, cuts, scratches, broken bones, sprains, dislocation of joints, internal injuries, brain damage, or death, resulting from striking, kicking, burning, biting, hair pulling, choking, throwing, shoving, whipping or any other action that injures a child (Childhelp, 2018, para. 2). Physical abuse does not include acts of physical discipline, given that the action does not injure or impair the child. Signs of physical abuse to a child can be both physical and behavioral. Physical signs may include visible or severe injuries, any injury to a child who is not yet crawling, injuries at different stages of healing, unexplained injuries, injuries explained in a way that do not make sense, injuries with distinctives shapes, and/or patterns in frequency, timing, or history of injuries, such as after weekends, vacations, or school absences (Childhelp, 2018). Behavioral signs of physical abuse include aggression towards peers, pets, or other animals; being fearful of parents or other adults; withdrawal, depression, or anxiety; wearing long sleeves out of season; violent themes in art or fantasy; sleep disruptions such as insomnia or nightmares; reports of injury or severe discipline; immaturity, acting out, or other behavioral extremes; and/or self-destructive behavior or attitudes (Childhelp, 2018). Parents and caregivers may also show signs of committing physical abuse, including refusal or inability to explain the child's injury, explaining the injury in a way that does not make sense, aggression towards the child, appearing overly anxious about the child's behavior, delaying or preventing medical care for the child, taking the child to different doctors or hospitals, isolating the child from social activities, and/or having a history of violence or abuse (Childhelp, 2018).

The second most prevalent form of child abuse is sexual abuse. Sexual abuse involves using a child in sex acts or for sexual gratification (Childhelp, 2018). This may take place in the form of non-contact or contact abuse. Non-contact abuse involves making a child view a sex act, making a child view or show sex organs, or talking to a child inappropriately about sex. Contact abuse includes fondling, oral sex, penetration, forcing the child to perform a sex act, or involving the child in prostitution or pornography. According to Childhelp (2018), one in every five adults reports being sexually abused as a child. Physical signs of sexual abuse in children may be more apparent to medical practitioners but may also be observed by mental health practitioners working in an integrative care setting. These signs include difficulty sitting or walking; bowel problems; torn, stained, or bloody undergarments; bleeding, bruising, pain, swelling, or itching of the genital area; frequent urinary tract or yeast infections; and/or any sexually transmitted disease or related symptoms (Childhelp, 2018). Behavioral signs of sexual abuse may include not wanting to change clothes (i.e.: for P.E.); withdrawn, depressed, or anxious affect; eating disorders or preoccupation with one's body; aggression, delinquency, or poor peer relationships; poor self-image; poor self-care; lack of confidence; sudden absenteeism or decline in school performance; substance use, running away, reckless behavior, or suicide attempts; sleep disturbances, such as fear of bedtime, nightmares, or bedwetting at an advanced age; acting out sexually or excessive masturbation; unusual or repetitive self-soothing behaviors; advanced or unusual sexual behavior or knowledge; and/or reports of sexual abuse (Childhelp, 2018). Caregivers may also exhibit signs of being sexually abusive towards a child, including failing to supervise the child, acting as an unstable adult presence in the child's life, appearing jealous or possessive, having troubled or dysfunctional sexual relationships, and/or relying on the child for emotional support (Childhelp, 2018).

Child maltreatment can also take place in the form of emotional abuse, which occurs when a parent's or caregiver's actions [harm] a child's mental and social development, or [cause] severe emotional harm (Childhelp, 2018, para. 4). This may occur as a single incident, but generally involves a pattern of behavior that causes damage over time. Emotional abuse includes rejecting or ignoring a child by telling them that they are unwanted/unloved, invalidating the child's feelings, breaking promises, interrupting the child in conversation, or not providing affection; shaming or humiliating a child by calling them names, criticizing, berating, or mocking the child, or attacking the child's sense of self-worth; terrorizing a child by accusing, threatening, manipulating, or yelling at the child, or setting the child up for failure; isolating a child by depriving them of social contact, confining them to small spaces, or depriving them of play or stimulation; and/or corrupting a child by involving them in criminal activity or encouraging misbehavior (Childhelp, 2018, para. 4). According to Childhelp (2018), 10.6% of adults report being emotionally abused in childhood. Signs that a child may be experiencing emotional abuse include developmental delays; wetting their bed or pants; speech disorders; health problems like ulcers or skin disorders; obesity and weight fluctuation; habits like sucking, biting, or rocking; learning disabilities; being overly compliant or defensive, exhibiting extreme emotions, aggression, or withdrawal; anxiety or phobias; sleep disorders; destructive or anti-social behaviors, such as violence, cruelty, vandalism, stealing, cheating, or lying; exhibiting behavior that is inappropriate for their age; and/or suicidal thoughts or actions (Childhelp, 2018). Signs that a caregiver may be emotionally abusive include routinely ignoring, criticizing, yelling at, or blaming the child; playing favorites with one sibling over another; exhibiting poor anger management or emotional regulation; having unstable relationships with other adults; disrespecting authority; having a history of violence or abuse; and/or having an untreated mental illness or addiction (Childhelp, 2018).

The fourth type of child maltreatment, neglect, often requires a pattern of behavior over time and can occur in the form of physical, emotional, medical, and educational neglect. Physical neglect involves depriving a child of adequate supervision, clothing, food, and shelter. This may include leaving the child with an inadequate caregiver, leaving the child in another person's custody for an extended period of time, failing to provide a child with healthy food and drink, failing to ensure adequate personal hygiene, or exposing the child to unsafe or unsanitary environments or situations (Childhelp, 2018). Emotional neglect occurs when a parent or caregiver does not provide adequate affection and attention for a child to feel loved and supported (Childhelp, 2018). This may include isolating the child from friends and loved ones, exposing the child to severe or repeated violence (especially domestic violence), allowing a child to abuse substances or engage in criminal activity, or not seeking treatment for a child showing signs of a psychological illness (Childhelp, 2018). Medical neglect occurs when a parent does not provide a child with appropriate treatment for injuries or illness or deprives a child of basic preventive medical or dental care (Childhelp, 2018). Lastly, educational neglect occurs when a parent limits a child's opportunities for academic success by allowing the child to miss too much school, not enrolling the child in school, or preventing the child from obtaining necessary special education services. Signs that a child may be experiencing neglect include wearing clothing that is the wrong size, tattered, dirty, or not appropriate for the weather; being hungry, stockpiling and seeking food, or showing signs of malnutrition (i.e.: distended abdomen, protruding bones); having a very low body weight and height for their age; often appearing tired or listless; displaying poor hygiene; talking about caring for younger siblings or not having a caregiver at home; having untreated medical or dental problems or incomplete immunizations; and/or truancy, frequently incomplete homework, or frequent school changes (Childhelp, 2018). Caregiver signs of neglect include indifference towards the child; depression, apathy, drug or alcohol abuse, or other mental health challenges; denying having problems with the child or blaming the child for their problems; viewing the child negatively; and/or relying on the child for their own care and well-being (Childhelp, 2018).

Prevalence and Outcomes

According to Childhelp (2018), more than 3.6 million referrals involving more than 6.6 million children are made to child protective agencies each year, and in 2014, state agencies identified an estimated 1,580 children who died as a result of abuse and neglect. On average, this indicates that between four and five children die each day due to maltreatment, but this statistic is likely higher than this due to the underreported nature of these crimes. Of the child maltreatment fatalities that are reported, 80% of them involve at least one parent as the perpetrator (Childhelp, 2018).

Research suggests that individuals who experience adverse childhood experiences, including child abuse, are at a greater risk for a variety of negative outcomes, including depression and anxiety, hallucinations, substance use, risky sexual behavior, impaired memory, obesity, sleep disturbances, somatic complains, and comorbid psychological disorders (Anda et al., 2005). Additionally, children who experience abuse and neglect are approximately nine times more likely to become involved in criminal activity and are at an increased risk for a variety of health issues, including decreased life expectancy, Ischemic heart disease (IHD), Chronic obstructive pulmonary disease (COPD), and liver disease (Childhelp, 2018). Experiences of current or past child abuse are especially prevalent within the mental health care system. According to a study by Silverman, Reinherz, and Giaconia (1996), 80% of 21-year-olds who reported childhood abuse met the criteria for at least one psychological disorder. Additionally, Swan (1998) found that as many as two-thirds of those in treatment for drug abuse reported being abused or neglected as children. Researchers hypothesize that this association between childhood trauma and abuse and negative health outcomes may be explained in part by the neurobiological changes that occur as a result of these adverse experiences (Anda et al., 2005). According to Anda et al. (2005), traumatic events experienced in childhood alter both the structure and functioning of various regions of the brain, including the amygdala, hippocampus, prefrontal cortex, and hypothalamic-pituitary-adrenal (HPA) axis. This indicates that child abuse is a major risk factor for psychological challenges and that most, if not all, practitioners will likely encounter clients with experiences of current or past abuse, regardless of their population of interest.

History of Child Protection

Prior to 1874, parents were generally considered to have ownership and absolute authority over their children. As a result of this attitude, children were often abused, neglected, and even sold into slavery without intervention by the state (Lawrence & Robinson Kurpius, 2000). Child protection first gained legal traction in 1874, when a court ruled that Mary Ellen Wilson, age 9, was afforded protection from abuse under laws related to animal cruelty. Following this ruling, the New York Society for the Prevention of Cruelty to Children (NYSPCC) was founded and become the first organization dedicated exclusively to child protection. Subsequently, in 1875, legislation was passed requiring police officers and courts to aid in the prevention of cruelty to children. By 1922, more than 300 non-governmental child protective entities, such as the NYSPCC, existed across the United States. However, over the next four decades this responsibility shifted to the state, and by 1967 nearly all states had laws making the government responsible for child protection. As of 1963, four states had enacted mandated reporting laws related to child abuse, and by 1968, all states had laws mandating that health care professionals report physical abuse and neglect of children. It was not until 1976 that all states also required professionals to report sexual abuse. Since the enactment of these child welfare laws, the responsibility of the state to protect children has been legally challenged. In the case of DeShaney v. Winnebago County Department of Social Service, a four-year-old boy was severely beaten after being returned to his father's custody by Child Protective Services (CPS). The court ruled that CPS had no legal obligation to protect the boy, thereby allowing the state to abdicate its responsibility to protect minors from parental abuse (Myers, 2008).

As the responsibility of child protection shifted from non-governmental agencies to the state, the federal government passed several acts related to child welfare. In 1974, Congress passed the Child Abuse Prevention and Treatment Act (CAPTA), which designated federal funds to improve the state response to child abuse, especially in the domains of investigation and reporting. Congress then passed the Indian Child Welfare ACT (ICWA) in 1978, mandating that child abuse cases regarding children permanently residing on a reservation be decided by the tribal court. It also mandated that tribes be notified of child abuse cases regarding children not living on the reservation and afforded tribes the right to intervene in these cases. The goal of this legislation was to reduce the disproportionately high number of Native American children being removed from their homes, often without sufficient cause.

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