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NEW YORK Child Abuse Identification and Reporting for Healthcare Professionals
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CE Requirements for New York License Renewal New York mandated reporters, including those who have previously undergone child abuse recognition training, must complete an updated course that includes implicit bias, identifying adverse childhood experiences and guidelines to identify child abuse while interacting virtually. Training must be completed by April 1, 2025 . This course fulfills the requirements for training in identifying and reporting child abuse, maltreatment, and neglect in New York. Mandated Training Related to Child Abuse
Information about approved training providers can be accessed at the NYSED Website.
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©2024: All Rights Reserved. Materials may not be reproduced without the expressed written permission or consent of Colibri Healthcare, LLC. The materials presented in this course are meant to provide the consumer with general information on the topics covered. The information provided was prepared by professionals with practical knowledge in the areas covered. It is not meant to provide medical, legal or professional services advice. Colibri Healthcare, LLC recommends that you consult a medical, legal or professional services expert licensed in your state. Colibri Healthcare, LLC has made all reasonable efforts to ensure that all content provided in this course is accurate and up to date at the time of printing, but does not represent or warrant that it will apply to your situation or circumstances and assumes no liability from reliance on these materials.
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New York Mandatory Child Abuse Identification and Reporting for Healthcare Professionals, 2nd Edition 2 Contact Hours
Release Date : October 9, 2023
Expiration Date : February 28, 2025
Author Simona Pozzetto, LICSW, was born and raised in Italy, where she obtained her bachelor’s degree in psychology. After moving to Massachusetts, Ms. Pozzetto achieved her MSW and completed the Certificate Program in Jewish Communal and Clinical Social Work at Simmons College and Hebrew College in 2003. Ms. Pozzetto worked in community mental health clinics and long-term care facilities as a clinical therapist, initially focusing on children How to receive credit ● Read the entire course online or in print. ● Depending on your state requirements you will be asked to complete: ○ A mandatory test (a passing score of 75 percent is required). Test questions link content to learning objectives as a method
and adolescents, then mostly on adults and the elderly. In 2014, Ms. Pozzetto obtained her LICSW, and after a few years in management, in 2020, opened a private practice. During her career Ms. Pozzetto has specialized in trauma work, dissociative disorders, mood disorders, and end-of-life issues. Simona Pozzetto has no significant financial or other conflicts of interest pertaining to this course. to enhance individualized learning and material retention. ● Provide required personal information and payment information. ● Complete the mandatory Course Evaluation. ● Print your Certificate of Completion. Sponsorship/commercial support and non- endorsement It is the policy of Colibri Healthcare, LLC not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.
Disclosures Resolution of conflict of interest Colibri Healthcare, LLC implemented mechanisms prior to the planning and
implementation of the continuing education activity, to identify and resolve conflicts of interest for all individuals in a position to control content of the course activity. Disclaimer The information provided in this activity is for continuing education purposes only and is not meant to substitute for the independent medical
judgment of a healthcare provider relative to diagnostic and treatment options of a specific patient’s medical condition.
©2024: All Rights Reserved. Materials may not be reproduced without the expressed written permission or consent of Colibri Healthcare, LLC. The materials presented in this course are meant to provide the consumer with general information on the topics covered. The information provided was prepared by professionals with practical knowledge of the areas covered. It is not meant to provide medical, legal, or professional advice. Colibri Healthcare, LLC recommends that you consult a medical, legal, or professional services expert licensed in your state. Colibri Healthcare, LLC has made all reasonable efforts to ensure that all content provided in this course is accurate and up to date at the time of printing, but does not represent or warrant that it will apply to your situation nor circumstances and assumes no liability from reliance on these materials. Quotes are collected from customer feedback surveys. The models are intended to be representative and not actual customers.
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Implicit bias in healthcare Implicit bias significantly affects how healthcare professionals perceive and make treatment decisions, ultimately resulting in disparities in health outcomes. These biases, often unconscious and unintentional, can shape behavior and produce differences in medical care along various lines, including race, ethnicity, gender identity, sexual orientation, age, and socioeconomic status. Healthcare disparities stemming from implicit bias can manifest in several ways. For example, a healthcare provider might unconsciously give less attention to a patient or make assumptions about their medical needs based on race, gender, or age. The unconscious assumptions can lead to delayed or inadequate care, misdiagnoses, or inappropriate treatments, all of which can adversely impact Learning objectives After completing this course, the learner will be able to: Discuss the incidence and prevalence of child abuse in New York State and the U.S. Define terms related to child abuse and maltreatment. Recognize the signs and symptoms of the various types of child abuse, including in a virtual setting. Course overview This beginner-level course fulfills the requirements for training in identifying and
health outcomes. Addressing implicit bias in healthcare is crucial for achieving equity in medical treatment. Strategies to combat these biases involve education and awareness programs for healthcare professionals. These programs help individuals recognize and acknowledge their biases, fostering a more empathetic and unbiased approach to patient care. Additionally, implementing policies and procedures prioritizing equitable treatment for all patients can play a pivotal role in reducing healthcare disparities. Ultimately, confronting implicit bias in healthcare is essential to creating a more just and equitable healthcare system where everyone receives fair and equal treatment regardless of their background or characteristics. Identify risk factors associated with child abuse. Recognize the impact of trauma and Adverse Childhood Experiences (ACEs). Explain strategies to prevent child abuse. Recognize the impact of bias on mandated report decision-making. Describe the child abuse intervention and reporting process in accordance with the laws of New York State.
reporting child abuse, maltreatment, and neglect in New York.
INTRODUCTION
● Being part of a multiple birth such as twins or triplets. It is important to recognize the particular behaviors, such as the following, associated with sexual abusers (Prevent Child Abuse New York, n.d.): ● Insisting on having physical contact (hugging, kissing) with children, even though the children do not want the contact. ● Refusing to let the children set their own limits. ● Being overly interested in the sexuality of a particular child or teenager. ● Insisting on time alone with children.
Other factors put certain children at risk for being abused (Centers for Disease Control and Prevention, 2019): ● Being born prematurely: Premature babies often add emotional and financial stress to the family. They are generally hospitalized for a longer period after birth and require more expensive hospital care. They may also need special care and monitoring when they are discharged to the home. ● A physical disability. ● Below-normal intelligence. ● Developmental delays.
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Prevention So much of prevention depends on recognizing risk factors for abuse and taking steps to help defuse potentially abusive situations. The following are some strategies for social workers to take to help prevent child abuse (Centers for Disease Control and Prevention, 2019): ● Teach parents about growth and development stages, behaviors and developmental changes.
● Spending the majority of their time with children and having little interest in spending time with adults. ● Frequently offering to babysit or to take children overnight. ● Buying children expensive gifts or giving them money for no apparent reason. ● Often walking in on children or teenagers when they are in the bathroom.
Scenario 1 Leslie is a licensed social worker who works in a community hospital in upper New York State. She lives in a small, peaceful town and rejoices at the lack of violence and the neighborly good will that seems predominant in her community. However, Leslie’s complacency is about to be shattered. Leslie works as an integrated behavioral health specialist in a family medicine clinic. Leslie’s brother and his family have recently relocated from California to Leslie’s quiet town, and she is thrilled to have them nearby. Leslie is especially glad to have a chance to become reacquainted with Marie, her sister-in-law, whom she has always admired. Marie is a financial planner and has a successful home business in addition to being a mother to three children ages 5, 8, and 10. Marie has arranged to see one of the physicians at Leslie’s workplace. She has a severe upper respiratory infection. Marie arrives early, and Leslie meets her in the waiting room to chat until it is time for her appointment. Marie says, “I am just exhausted. Trying to get the house settled and keep up with my clients is almost impossible. Your brother isn’t that much help; he’s working such long hours at his new job. And trying to keep up with three children is just too much. Especially this 5-year-old here. She just needs too much attention.” It was then that a nurse opened the door to the exam rooms and announced it was time for Marie to come back. “Do you mind if I join you for your appointment? We can continue to talk until Dr. Johnson is ready for you,” Leslie offered. Marie accepted. In the examination room the nurse confirms patient identifying information and collects vitals. Leslie notices that her 5-year-old niece, Anne, huddles in a corner while her mother is speaking. Leslie and Marie continue their conversation until the physician arrives. Leslie offers to take Anne to the break room for a juice box so Dr. Johnson can conduct her examination of Marie. Although it is a warm summer day, Anne has on a long-sleeved sweater. “Anne, you seem so sad. Do you miss your old home?” Anne shakes her head and rubs her upper arms. “What’s wrong? Let me see your arms.” To her horror, Leslie finds bruises in various stages of healing over her niece’s upper arms. “Anne, can you tell me how you got hurt?” “I was a bad girl,” Anne replies. “I spilled my milk yesterday and Mommy told me I was bad and had to learn a lesson.” Leslie is shocked and frightened. She knows that such bruising is a sign of physical abuse. She also knows that as a mandated reporter, she must report her findings. “I knew that I might have to deal with this at work, but I never dreamed it would affect my family,” she thought. Leslie is facing a difficult challenge. However, her obligation is to protect the safety and welfare of the child. New York State recognizes that some professionals are particularly well qualified to be mandated reporters of child abuse, including social workers, psychologists, marriage and family therapists, and licensed mental health counselors among other medical and allied healthcare providers (New York State Consolidated Laws, Social Services Law- SOS§413). The purpose of this education program is to help behavioral health and other healthcare providers recognize signs and symptoms that indicate child abuse or maltreatment and to assist them in effectively fulfilling their roles as mandated reporters in New York State.
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Incidence and prevalence of child abuse in New York State and the United States Abuse affects children of all economic levels, ethnicities, cultures, religions, and educational backgrounds. Child abuse is never the fault of the child. The majority of adults who abuse children count on their ability to persuade
and quality adjusted life years) $2 trillion (Peterson et al., 2018). ● Perpetrator Demographics : ○ Age : 83.2% were between the ages of 18 and 44 years old. ○ Sex : 52% were women, 47.1% were men, and 0.9% were of other or unknown sex. ○ Race and ethnicity : The three largest percentages were White (48.4%), African American (20.8%), and Hispanic (20.1%); remaining race and ethnicity categories were responsible for 10.7% of abuse. ● Relationship to the child: 77.2% were a parent to the victim, 6.6% are a nonparent relative, 4.2% were in multiple relationships to the child, and 3.8% were the unmarried partner to a parent. In New York State, the Center for the Prevention of Child Abuse and the Office of Children and Family Services (2019) have provided the following statistical information about child abuse: ● In 2019, 101 children died because of abuse or neglect in New York State. ● In 2020, there were 70,754 cases of abuse, with a rate of 16.8 per 1,000 reports of child abuse in New York State. These numbers are suspected to be artificially deflated due to the COVID-19 global pandemic, which significantly reduced mandated reporters’ access to children. Child abuse occurs among people of all socioeconomic levels, cultures, and ethnicities and at all levels of education. It is important to note that many cases of child abuse are unrecognized or unreported, and some may be recognized but do not get reported.
children to be silent or to lie about the abuse by convincing them that the abuse is their fault or that they “deserved it.” Abusers may also tell the abused children that if they tell someone about the abuse, they will be punished even more harshly (Joyful Heart Foundation, 2019). New York State describes abuse as the most serious harm committed against a child. It defines an abused child as a child “whose parent or other person legally responsible for his/her care inflicts upon the child serious physical injury, creates a substantial risk of serious physical injury, or commits an act of sex abuse against the child. Not only can a person be abusive to a child if they perpetrate any of these actions against a child in their care; they can [also] be guilty of abusing a child if they allow someone else to do these things to that child” (New York State Consolidated Laws, Social Services Law-SOS§412). The following are statistics on child abuse in the United States: ● Figures : In 2020, an estimated 618,000 children were abused, with 76.1% of victims neglected, 16.5% physically abused, and 9.4% sexually abused (U.S. Department of Health and Human Services, 2022). ● Fatalities : There were 1,750 fatalities in children, with 68% being younger than 3 years of age. ● Economic Impact : In 2015, the estimated cost of child abuse and neglect in the United States overall was (actual healthcare dollars
CHILD PROTECTION LAWS IN NEW YORK
In 1973, New York passed the first child protective services act. This act mandated reporting of suspected child abuse. It also created a 24-hour, 7-day-a-week registry to receive reports. The most recent update to the child abuse and prevention law was in 2011, when an expanded list of mandatory reporters was enacted (New York State Governor’s Office,
2011). A new law titled Child Victims Act, which provides avenues for victims of child abuse (especially sexual abuse), was enacted to allow for civil charges against the perpetrators (New York State Governor’s Office, 2019). The laws that guide New York Child Protective Services today are Article 6, Title 6 of Social Services Article 10 of the Family Court Act.
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Definition of terms New York State Section 412 of the Social Services Law and Section 1012 of the Family Court Act (https://codes.findlaw.com/ny/social- services-law/sos-sect-412.html; https://codes. findlaw.com/ny/family-court-act/fct-sect-1012. html) define an abused child as a child younger than 18 years of age whose parents or other person legally responsible for care commits any of the following offenses: ● Inflicts or allows to be inflicted upon a child physical injury by other than accidental means that causes or creates a substantial risk of death, serious or protracted disfigurement, protracted impairment of physical or emotional health, or protracted loss of or impairment of the function of any bodily organ. ● Creates or allows to be created a substantial risk of physical injury to a child by other than accidental means that would be likely to cause death or serious or protracted disfigurement, protracted impairment of physical or emotional health, or protracted loss or impairment of the function of any bodily organ. ● Commits or allows to be committed a sex offense against a child as defined in the penal law; allows, permits, or encourages the child to engage in any act described in Sections 230.25, 230.30, and 230.32 of the penal law (promoting prostitution in the third, second, and first degrees); commits any act described in Section 255.25 of the penal law (incest); or allows a child to engage in any act described in Article 263 of the penal law (sexual performance by a child). Section 412 of Title 6 of the Social Services Law (https://codes.findlaw.com/ny/family-court-act/ fct-sect-1012.html) defines a neglected child as a child younger than 18 years of age whose physical, mental, or emotional condition has been impaired or is in imminent danger of becoming impaired as a result of the failure of the parent or other person legally responsible for care to exercise a minimum degree of care.
The law mandates supplying the child with adequate food, clothing, shelter, and education in accordance with the provisions of Part 1 of Article 65 of the education law. The law prohibits denying medical, dental, optometric, or surgical care if the caregiver is financially able to do so or is offered financial or other reasonable means to do so. Further, the law prohibits failing to provide the child with proper supervision or guardianship by unreasonably inflicting or allowing to be inflicted harm or a substantial risk, including the infliction of excess corporal punishment; by misusing a drug or drugs; by misusing alcoholic beverages to the extent that the parent or other person legally responsible loses self-control of their actions; or by any other acts of a similarly serious nature requiring the aid of the court. The law also prohibits abandonment by a parent or other person legally responsible for the child. Self-Assessment Quiz Question #1 The Social Services Law mandates that a child be supplied with which of the following? ( Select all that apply .) a. Food. b. Clothing. c. Shelter. d. All of the above. Self-Assessment Quiz Question #2 According to the U.S. Department of Health and Human Services (2017), the demographic with the highest percentage of perpetrators is: a. White. b. African American. c. Hispanic. d. None of the above.
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Healthcare consideration: A person who is legally responsible for a child is defined as “parent of, guardian of, or other person eighteen years of age or older legally responsible for, as defined in subdivision (g) of Section 1012 of the Family Court Act, a child reported to the statewide central register of child abuse and maltreatment who is allegedly responsible for causing injury, abuse or maltreatment to such child or who allegedly allows such injury, abuse or maltreatment to be inflicted on such child; or a director or an operator of, or employee or volunteer in, a home operated or supervised by an authorized agency, the Office of Children and Family Services, or in a family day-care home, a day-care center, a group family day-care home, a school-age child care program or a day-services program who is allegedly responsible for causing injury, abuse or maltreatment to a child who is reported to the statewide central register of child abuse or maltreatment or who allegedly allows such injury, abuse, or maltreatment to be inflicted on such child” (New York State Consolidated Laws, Social Services Law-SOS§412, 2022). Social workers must be aware that this means a wide variety of persons may commit child abuse. Also, according to New York State statutes, it is not only the person who actually harms the child that is responsible for the abuse but also the person who is aware of the abuse and lets it continue. Social workers need to be thorough in evaluating all persons who have contact with or are responsible for the child when child abuse is suspected.
Maltreatment refers to a poor quality of care that children receive from those responsible for them. Maltreatment occurs when a parent or other person legally responsible for the care of children harms or places the children in danger of harm by “failing to exercise the minimum degree of care in providing the child with any of the following: food, clothing, shelter, education, or medical care when financially able to do so" (New York State, Office of Children and Family Services, n.d.d). Maltreatment can also result from the abandonment of a child or from not providing adequate supervision for the child. Maltreatment may also occur if a parent or other legally responsible person engages in excessive
use of drugs or alcohol if doing so interferes with that person’s ability to adequately supervise the child (New York State, Office of Children and Family Services, n.d.d). Healthcare consideration: The abuse of alcohol, tobacco, prescription drugs, or illicit drugs can interfere with a caregiver’s judgment and put a child in danger of abuse. In some cases, substance abuse is considered a specific type of abuse (Kings, 2017). Social workers must always know that children whose caretakers have problems with substance abuse are at increased risk for abuse.
RECOGNIZING THE SIGNS AND SYMPTOMS OF CHILD ABUSE
Scenario 2 Martin is a social worker. He works at a large community mental health clinic that is affiliated with a major urban mental health agency in New York State. His first client of the day is Amanda, an 8-year-old girl who arrives with her mother, Helen, for an assessment of vague physical symptoms and unusual anxiety. Helen tells Martin that her daughter is complaining of headaches and stomachaches and seems to cry for no reason at all. “She doesn’t want to go to school, and she used to love school. She won’t let me out of her sight and just clings to me. I can’t get her to tell me what’s wrong. At first, I thought she was upset because her second- grade teacher recently resigned after having a baby, and Amanda just loved her. But I met the new teacher, and he seems so nice. He has an excellent reputation, and all of the other children just love him. But Amanda just keeps saying she doesn’t want to go to school, and I’m afraid that all of these stomachaches and headaches could mean she’s really sick.” Amanda sits silently through her mother’s comments but clings to her mother and sucks her thumb. Martin prepares to perform an evaluation, but he is also concerned about the possibility of abuse.
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● Difficulty or pain when sitting or walking. ● Sexually suggestive, inappropriate, or promiscuous behavior or verbalization. ● Sexual victimization of other children. Indicators of maltreatment ● Obvious malnourishment, listlessness, or fatigue. ● Stealing or begging for food. ● Lack of personal care such as poor personal hygiene, torn or dirty clothes. ● Untreated need for glasses, dental care, or other medical attention. ● Frequent absence from or tardiness to school. ● Child inappropriately left unattended or without supervision. ● The Child Welfare Information Gateway in its April 2019 publication What Is Child Abuse and Neglect? Recognizing the Signs and Symptoms and the Mayo Clinic (2019) list the following symptoms that may indicate child abuse: ○ Regression : Children often regress to an earlier developmental stage if abused. For example, 8-year-old Amanda in Scenario 2 is observed sucking her thumb, a behavior associated with much younger children. ○ Developmental problems : Children may fail to thrive socially, emotionally, or academically. They may also demonstrate delayed physical development. ○ Speech disorders : Children may develop speech disorders such as stammers or lisps. ○ Problems with attachment : Children may be uncomfortable with physical contact or developing interpersonal relationships. ○ Changes in school performance : School performance may decline in children who are abused. ○ Changes in behavior : Children may become aggressive or isolate themselves from friends and activities. ○ Changes in emotional behavior : Children may become irritable and quick to anger. ○ Crying : Children may cry more often and more easily. ○ Behavior toward the abuser : Children display a tendency to avoid, go out of their way to please, or try to ingratiate themselves with the abuser.
Self-Assessment Quiz Question #3 What signs and/or symptoms of abuse does this scenario present, if any? (Select all that apply.) a. There are no signs of abuse. b. There are vague physical symptoms and unusual anxiety. c. Amanda is complaining of headaches and stomachaches and crying for no reason. d. Amanda will not let her mom out of sight and clings to her. Healthcare consideration: In addition to signs and symptoms of specific types of abuse, social workers must be alert to more general complaints that may also be caused by abuse (Mayo Clinic, 2019). Signs of developmental regression such as thumb-sucking in an 8-year-old or bed-wetting in older children may be stress related. All social workers must be prepared to evaluate the safety and well- being of all children they encounter in their professional practices. According to New York State’s Office of Children and Family Services, Child Protective Services (n.d.d), the following are the most common signs of abuse, though the list is not all inclusive, and not all children will display all the signs. Indicators of physical abuse: ● Injuries to the eyes or both sides of the head or body—accidental injuries typically affect only one side of the body. ● Frequently appearing injuries such as bruises, cuts, and burns, especially if the child is unable to provide an adequate explanation of the cause—these may appear in distinctive patterns such as grab marks, human bite marks, cigarette burns, or impressions of other instruments. ● Destructive, aggressive, or disruptive behavior. ● Passive, withdrawn, or emotionless behavior. ● Fear of going home or fear of parents. Indicators of sexual abuse: ● Symptoms of sexually transmitted diseases (STDs). ● Injury to the genital area.
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○ Anxiety : Children may display unusual anxiety or panic behaviors. ○ Generalized physical symptoms : Children may frequently complain about vague symptoms such as stomachaches and headaches. ○ Isolation : Children may tend to spend more time alone and may attempt to isolate themselves from family and friends.
○ Clingy behaviors : Children become more dependent and cling to certain people. ○ Harm : Children may express thoughts about hurting themselves or other people. ○ Risk-taking behaviors : Children may show less regard for their own safety or
engage in more risk-taking behaviors. Examples include running in the street or climbing excessively high equipment on playgrounds. RECOGNIZING ABUSE AND MALTREATMENT IN A VIRTUAL ENVIRONMENT With the increase in telehealth and virtual technology, mandated reporters may
the professional in assessing for the safety of the child: ● Be alert to attempts by the child to communicate something without someone in the room noticing. ● Be alert to nonverbal cues or changes in the child’s demeanor when someone else is present. ● Listen for statements by the child that may be concerning. ● Observe the child for any suspicious physical injuries or emotional issues such as depression or anxiety. ● Be alert to hesitancy by the child to turn the webcam on or if they turn it off suddenly. ● Look at the environment of the child: Does it appear unsafe? Is there supervision? Are younger children supervised by older children rather than an adult? ● If you notice anything questionable, openly discuss it with the family to evaluate their perspective on the situation. When interacting through a virtual platform, stressful or difficult communications or altercations between children and adults may be observed. Assess whether the severity warrants a mandated report, and if not, use it as an opportunity to discuss safety and to provide strategies for improving communication and managing stress. Caregiver risk factors ● Alcohol abuse: The compulsive use of alcohol that is not of a temporary nature. ● Drug abuse: The compulsive use of drugs that is not of a temporary nature.
have interactions with children in a virtual environment. Your responsibilities as a mandated reporter remain the same when you are interacting with a child in your professional role even when the interaction is in a virtual space. The signs of abuse, neglect, and maltreatment that are evaluated during in-person contacts are the same for virtual contacts. Identifying those signs, however, may be more difficult due to the limited physical interaction with the child. This makes it imperative that the professional be keenly alert to even subtle signs. Virtual contact requires reliable technology with adequate sound and light, and there must be adequate privacy to be able to discuss sensitive matters. At the beginning of a virtual session, first introduce everyone who is present, confirm the child’s physical location in the event of an emergency, ensure that the child is present for at least part of the session, and provide your follow-up contact information including email, phone, text, or online as applicable. During virtual contact with the child, the following recommendations outlined by New York State Mandated Reporter (n.d.a) will assist Risk factors Risk factors for children ● Younger than 4 years of age. ● Special needs: Physical or emotional needs that may increase caregiver burden. (Centers for Disease Control and Prevention, 2019)
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Family protective factors ● Supportive family environment and social networks. ● Concrete support for basic needs. ● Nurturing parenting skills. ● Stable family relationships. ● Household rules and child monitoring. ● Parental employment. ● Access to healthcare and social services. ● Caring adults outside the family who can serve as role models or mentors. Community protective factors Communities can support parents and take responsibility for preventing abuse by providing ● Parental education. ● Adequate housing. support services such as counseling, foster parent support training and group support sessions, child abuse hotlines, and respite care. A special note : With the growing opioid crisis, more children are at risk for neglect and abuse. In New York State, statistics show an increase in adults abusing opioids and the effects on children. In Florida, in 2015, it was reported that more than 50% of all foster home placements for children 6 years or younger were because of opioid abuse, and there has been a 32% increase in the rate of removal from the home because of parental neglect related to opioid abuse (Quality Improvement Center for Research-Based Infant-Toddler Court Teams, 2018). Evidence-based practice Research has shown that the most common form of child abuse in the United States is the child being left alone at home without adult supervision. This is referred to as supervision neglect. In fact, all types of neglect account for an estimated 75% of all child abuse reports made to child welfare authorities (U.S. Department of Health and Human Services, 2017). Social workers must be especially alert to signs and symptoms of neglect, which may not be as readily apparent as the signs of physical abuse.
● Financial problems: A risk factor related to the family’s inability to provide sufficient financial resources to meet minimum needs. ● Domestic violence: Any abusive, violent, coercive, forceful, or threatening act or word inflicted by one member of a family or household on another—the caregiver may be the perpetrator or the victim of the domestic violence. (U.S. Department of Health and Human Services, 2017) Other risk factors ● Parents’ lack of understanding of children’s needs, child development, and parenting skills. ● Parental history of child abuse or neglect. ● Mental health issues, including depression in the family. ● Parental characteristics such as young age, low education, single parenthood, large number of dependent children, and low income. ● Nonbiological transient caregivers in the home, for example, mother’s male partner. ● Parental thoughts and emotions that tend to support or justify maltreatment behaviors. Family risk factors ● Social isolation. ● Family disorganization, dissolution, and violence, including intimate partner violence. ● Parenting stress, poor parent–child relationships, and negative interactions. (Centers for Disease Control and Prevention, 2019) ● Concentrated neighborhood disadvantages: High poverty and residential instability, high unemployment rates, high density of alcohol outlets, and poor social connections. Protective factors According to the Centers for Disease Control (CDC), there are protective factors that social workers should be aware of and advocate for in the social worker’s community (Centers for Disease Control and Prevention, 2019). Community risk factors ● Community violence.
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Self-Assessment Quiz Question #4 According to the Centers for Disease Control and Prevention (2019), which of the following are risk factors for abuse for children? (Select all that apply.) a. Younger than 4 years of age. b. Special needs. c. Socioeconomic status. d. Race.
Self-Assessment Quiz Question #5 Financial problems are NOT a caregiver risk factor for abuse. a. True. b. False. Self-Assessment Quiz Question #6
In New York State, statistics show an increase in adults abusing opioids and the effects on children. a. True. b. False. IMPACT OF TRAUMA AND ADVERSE CHILDHOOD EXPERIENCES (ACE)
Trauma is “The experience of serious adversity or terror or the emotional or psychological response to that experience” which threatens the person’s sense of safety. The response to the event may cause immediate and long-term reactions such as unpredictable emotions, flashbacks, strained relationships, and/or physical symptoms such as headaches, muscle tension, shallow breathing, or heart palpitations (American Psychological Association, n.d.a). Common traumatic events include: ● Exposure to family or community violence. ● Emotional abuse. ● Sexual abuse. ● Exposure to an accident or natural disaster. Adverse childhood experiences (ACEs) are events that occur in childhood and are potentially traumatic (New York State Mandated Reporter, n.d.b). ACEs include the previously listed traumatic events, but may also include more insidious events such as: ● Living in poverty. ● Neglect. ● Bullying. ● Parental mental illness. ● Loss or separation from a parent or loved one.
data has found that 63.9% of U.S. adults reported at least one ACE and 17.3% reported experience of four or more ACEs (Centers for Disease Control, 2023). With repeated or prolonged ACEs without mitigating protective factors, the child experiences prolonged toxic stress. The stress response stays activated in the child’s body, and chronic changes in concentration, short term memory, breathing, muscle tension, and heart rate may result. This may have lasting life-long effects on the child’s physical and emotional health. Research has found that adults who were exposed to ACEs have higher rates of depression, obesity, substance abuse, anxiety, smoking, and early death (New York State Mandated Reporter, n.d.c). Although experience of trauma and ACEs may not meet criteria for child abuse or maltreatment, their impact on the child’s functioning needs to be assessed and addressed. Young children who experience trauma may : ● Have trouble eating or sleeping. ● Show regression of childhood milestones. ● Demonstrate excessive fear of strangers. ● Demonstrate attachment difficulty. School-age children who experienced trauma may : ● Show aggressive behavior. ● Be unusually withdrawn. ● Re-enact trauma through play or in therapy. ● Have nightmares. ● Have difficulty concentrating.
● Discrimination. ● Incarceration. ● Substance abuse.
ACEs are common across all socioeconomic groups and may be single one-time events or ongoing repeated events. The CDC surveillance
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Adolescents who experienced trauma may : ● Be anxious or depressed or experience suicidal ideation. ● Engage in risk-taking behaviors. ● Report intense guilt, anger, or shame. ● Have a negative view of people and society as a whole. Resilience is the ability to successfully recover from life challenges and helps to reduce the long-term impact of ACEs (New York State Child Welfare and Community Services, n.d.) Resilience is strengthened by the presence of protective factors which may include: ● Exposure to supportive relationships. ● Positive social connections. ● A sense of safety at home, school, or in the community. ● Healthy lifestyle including exercise, adequate sleep, healthy diet, and mindfulness. ● Economic stability. ● Early life quality childcare and education. Trauma-informed care recognizes and responds to the impact that traumatic stress has on all parties involved, including children, families, caregivers, and service providers. The goal is to maximize physical and psychological safety, facilitate recovery of the child and family, and support their ability to thrive and succeed. It focuses on strengthening resiliency while not inadvertently retraumatizing the individual. Bartlett and Steber (2019) outline the four key elements of trauma-informed practice, which they label “The 4 R’s”:
1. Realize the impact of trauma on the child’s emotional, social, behavioral, cognitive, mental health, and physical development. Realize that the professional’s experience with trauma may have an impact on the professional’s own response and may require support to avoid secondary stress. 2. Recognize the symptoms of trauma reactions. 3. Respond by making adjustments in one’s own language and behavior in order to support the child’s recovery and resilience. 4. Resist re-traumatization by actively adjusting the child’s environment to avoid triggers (sights, sounds, smells, objects, places, or people that remind the child of the original trauma) and protect the child from further trauma. These key elements of trauma-informed practice help to strengthen resilience to trauma and, together with protective factors, improve the chance for positive child outcomes despite exposure to trauma. Healthcare consideration: Adverse childhood experiences (ACEs) are potentially traumatic and may have lifelong effects on the child. Many of the signs are similar to, and overlap with, signs of maltreatment or abuse. The presence of ACEs and their impact on functioning needs to be carefully assessed. Once identified, strategies to minimize their effects and foster and strengthen resiliency can be put into place through trauma-informed care.
PHYSICAL ABUSE
Scenario 3 Katie is 12 years old and the daughter of parents who are prominent in the community. Her father is a wealthy real estate developer, and her mother is a highly successful surgeon. They live in a beautiful home in one of the most expensive areas of Connecticut within commuting distance of New York City. Seen as an “ideal” family, they are the envy of their friends and neighbors. They are also known for setting high standards for their children, expecting them to excel at school, sports, and extracurricular activities chosen to increase the chances of their acceptance into Ivy League colleges. According to her parents, Katie is not as “successful” as her older brother and sister. Katie’s mother was a star gymnast in high school and college and expects Katie to be so too. Unfortunately, Katie seldom qualifies to place on the first competing squad and is often relegated to the sidelines, much to her mother’s chagrin. Katie’s report cards show that she achieves the highest of grades in almost all classes, with only a few exceptions.
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Scenario 3 ( continued) These exceptions disappoint and anger her parents. They tell her that they expect “only the best,” and failure to be the best will result in punishment. What people outside the family do not know is that this punishment is often physical. Katie’s friends often notice that she has bruises on her arms and legs, which she explains away by telling them she is clumsy and often gets hurt during gymnastics practices. One day, Katie’s gymnastics coach notices a laceration on Katie’s lower back that is swollen, red, and oozing pus-like draining. She sends Katie to the school’s counselor, who evaluates Kathy and starts asking her a few questions. “How did you get hurt, Katie?” the counselor asks. “I’m just clumsy.” Katie then begins to cry and pleads with the counselor not to say anything to her parents. “They will be so angry!” The counselor suspects physical abuse and prepares to report her suspicions.
Prevent Child Abuse New York (n.d.) defines physical abuse as “the non-accidental physical injury of a child inflicted by a parent or caretaker that ranges from superficial bruises and welts to broken bones, burns, serious internal injuries, and in some cases, death.” It is important to differentiate deliberate physical injury from accidental injuries. This is not always easy. However, there are some indicators of deliberate physical injury (Joyful Heart Foundation, 2022): ● Injuries to the eyes or to both sides of the head or body: In general, accidental injuries occur only on one side of the body. ● Bruises and other injuries that are in various stages of healing: This may suggest that abuse is occurring over long periods. ● Bruising, welts, or burns: Injuries that have specific shapes such as those resembling a belt buckle, a hand imprint, or round burns indicative of a cigarette burn should trigger an alarm that abuse is occurring. Bruising around the wrists and ankles may indicate that the child has been physically restrained. ● Bruising and injuries over areas of the body not normally visible: For example, bruising over the buttocks, chest, or torso may indicate that the abuser is injuring the child over areas that are not readily seen by people other than parents and other close caregivers. ● Frequent visits to the emergency department
the injuries (if the child is old enough to communicate). ● Bed-wetting in children who are already toilet trained. ● Fractures in various stages of healing or a history of repeated fractures. ● Human bite marks. Many people, including some healthcare professionals, may first think of such behaviors as striking, kicking, or shaking a child when physical abuse is committed. However, physical abuse may also include other acts (KidsHealth, 2015): ● Holding a child under water. ● Burning a child or scalding a child with hot water. ● Throwing an object at a child. ● Using an object to beat a child. ● Using physical restraints to discipline a child. Healthcare consideration: Children who have been physically abused may be seen wearing clothing that covers bruised or damaged areas of the body. For example, children may be dressed in long-sleeved clothing even in hot weather to cover bruised arms. If the child is taken to the emergency department or family physician, the abuser is usually reluctant to leave the child alone with healthcare professionals for fear that the child may talk about the abuse (Joyful Heart Foundation, 2022). Healthcare providers must be alert to any signals that the child’s safety is compromised.
because of injuries: The caregiver’s explanations of the injuries are often inconsistent with the injuries or do not coincide with the child’s explanation of
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Abusive head trauma/shaken baby syndrome Abusive head trauma (AHT)—also known as shaken baby syndrome, shaken impact syndrome, and inflicted traumatic brain injury— is used to describe a constellation of signs and symptoms (National Center on Shaken Baby Syndrome, n.d.). It usually occurs when a parent or caregiver forcibly shakes the baby, usually while the baby is crying inconsolably. The shaking causes acceleration and declaration of the brain against the skull because of the baby’s weak neck muscles, causing direct brain damage and rupture of blood vessels in the brain, which leads to hemorrhaging. AHT is primarily seen in children younger than 2, with peak incidence between 3 and 8 months (American Association of Neurological Surgeons, n.d.), AHT is the leading cause of death in child abuse cases in the United States (KidsHealth, 2015). The effects of AHT in children who survive include the following (American Association of Neurological Surgeons, n.d.): ● Partial or complete blindness.
The following are signs and symptoms of AHT (American Association of Neurological Surgeons, n.d.): ● Retinal hemorrhages. ● Skull fractures. ● Swelling of the brain. ● Subdural hematomas. ● Bruising around the head, neck, or chest. ● Cyanosis. ● Respiratory distress. ● Unequal pupil size. ● Inability to lift the head, to focus the eyes, or to track movement.
● Lethargy. ● Vomiting. ● Irritability. ● Poor sucking.
● Difficulty swallowing. ● Decreased appetite.
● Rigidity. ● Seizures. ● Diminished smiling or vocalizing.
● Developmental delays. ● Intellectual impairment. ● Cerebral palsy. ● Epilepsy or seizures. ● Paralysis. ● Intellectual disabilities.
Healthcare consideration: AHT frequently results in death and, in those children who survive, lifelong detrimental effects. It is imperative that social workers help parents and other caregivers develop child- raising skills, as well as assist them in finding ways to diminish stress.
SEXUAL ABUSE
Scenario 4 Eric is a single father raising three children alone after the death of his wife. His youngest child, 6-year-old Steven, was especially devastated by his mother’s death. Since her death, Steven has avoided his friends and is reluctant to be separated from his father. This has led to problems at school and problems interacting with his older brother and sister. Eric is relieved when new neighbors move into the house across the street. They are a young couple with two children close to Steven’s age. Steven seems to enjoy playing with the children and often talks about how nice their mother, Ellen, is. Eric is relieved that Steven seems to be “getting over” his mother’s death. One day, Eric realizes that Steven has left his backpack at the neighbor’s home, and the backpack contains the boy’s homework. Eric drops by to retrieve it. Ellen welcomes him and tells him to sit down in the family room while she finds the missing backpack. As Eric waits, he notices some papers on the floor underneath the sofa. He picks them up and realizes that they are photos. He idly begins to page through them. To his dismay, he notices that they are pictures of young children who are naked and posed in various sexual positions. One of the children is Steven. Eric realizes that Steven is the victim of sexual abuse.
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