All 50 states in the United States, as well as all contiguous territories have statutes identifying persons who are required to report suspected child maltreatment to an appropriate agency (eg, child protective services [CPS], a law enforcement agency, or a state’s toll-free child abuse reporting hotline).1 Mandated reporters include healthcare workers, mental health workers, teachers, clergy, and law enforcement officers.1 The US Department of Health and Human Services provides state-by-state guidelines delineating when and how to report. Reports must include not only confirmed abuse but also the suspicion of abuse.1 Some states are even beginning to require mandatory reporting on the part of nonprofessional citizens, as well.
Types of Child Maltreatment2
- Physical abuse: Intentional use of force against a child that results in, or has the potential to result in, an injury
- Neglect: Failure by a caregiver to meet a child’s basic physical, emotional, mental/dental, or educational needs
- Sexual abuse: Any attempted or completed sexual act, sexual contact with, or sexual exploitation of a child by a caregiver
- Emotional abuse: Intentional caregiver behavior that conveys to a child that they are worthless, flawed, unloved, or valued only in meeting another person’s needs
The American Psychological Association [APA] and the American Association for Child and Adolescent Psychiatry [AACP] include reporting of child abuse in their code of ethics and conduct, and publish other forms of guidance on the subject.
However, the subject of child abuse reporting is complex and fraught with many ethical and practical dilemmas.
Can Reporting Harm the Child?
“There are some clear-cut cases that you may not feel ‘good’ about, but there are unambiguous signs of child abuse and you know that the child is in a horrible situation,” Stephanie Hartselle, MD, assistant professor of psychiatry at the Warren Alpert School of Medicine of Brown University, Rhode Island, told Psychiatry Advisor.
However, “more often than not, there are situations in which there are more complexities and ambiguities and concerns about potential harm,” said Dr Hartselle, who is also a psychiatrist in private practice in Providence, Rhode Island, and a national committee member of the American Academy of Child and Adolescent Psychiatry (AACAP).
These ambiguities can sometimes interfere with reporting. A 2017 meta-analysis of 44 articles3 found that mandatory reporters were reluctant to report abuse because of confusion regarding less-overt forms of maltreatment, including “mild” physical abuse, emotional abuse, and abuse experienced by children with disabilities. Moreover, they were reluctant to report suspicion of abuse, preferring to report only when they found actual physical evidence (eg, physical injures, bruises, broken bones, caries with corresponding lack of treatment, or “total” changes in behavior).
The researchers found that in 73% of the studies, participants mentioned negative experiences with the reporting process, including adverse child outcomes (eg, the child was not removed from harm and the abuse continued or intensified; the child was removed from harm but the foster care environment was worse than the family-of-origin environment; and child death following a report or after being removed from the family of origin).
Similar findings were obtained in a study of 15,003 child-injury visits, in which there was a suspicion of physical abuse in 1683 visits and which was reported in only 73% of visits, even when clinicians thought that the children were “likely” or “very likely” to have been abused.4 Only 24% of children with potential abuse were reported, even when the clinicians thought the children had “possibly” been abused.
Additionally, it is possible that reporting sexual abuse of a child can lead to retraumatization — especially if mandatory reporting is extended to the general public and the children are “needlessly subjected to forensic interviews and invasive medical procedures, which can be a form of child abuse in and of itself.5
“There are certainly concerns about the potential for harm,” Dr Hartselle said. For example, the reporter is not in control of the outcome of the child welfare agency’s investigation. “They [CPS] could come into the home and investigate, find the suspicion or report unfounded, and then go away with no consequence, or the agency might decide not to investigate at all. The family might not even be notified that the agency had been called,” she said.
On the other hand, “you always worry that as soon as CPS comes into the house, the child will be further abused or that the child will be insufficiently protected,” she said.
Nevertheless, these concerns do not mitigate the obligation to report.
“It comes down to this: in the end, you call CPS because you have to,” Dr Hartselle declared. This holds true whether the child presents to the emergency department or whether the clinician has been involved with the family for a long time and there is a sudden revelation or admission of abuse.
“I won’t pretend to say that we don’t hesitate, but we must do what’s mandated by law,” she emphasized.
Does Reporting Deter Abusers From Seeking Help?
One drawback of mandatory reporting is that the threat of reporting may deter many families from seeking help.6
“I’ve had some concerns that mandatory reporting may deter previously undetected adult [abusers] from coming forward and getting the help they need,” Fred Berlin, MD, PhD, associate professor of psychiatry and behavioral sciences and director of the sexual behavior consultation unit at the Johns Hopkins School of Medicine, in Baltimore, Maryland, told Psychiatry Advisor.
Psychiatrists have a duty to warn and protect others if they have become aware that a patient may constitute an imminent risk to others, but the mandate of reporting suspected child abuse “stands in marked contrast to other types of mandates such as self-disclosures about the commission of past murders, rapes, spousal abuse, and tax evasion,” said Dr Berlin, who is also director of the National Institute for the Study, Prevention, and Treatment of Sexual Trauma.
While possession and/or distribution of child pornography was previously not included in mandatory reporting, this has changed. For example, in California, therapists are now required to report a patient who has viewed child pornography online.7
“When there was no mandate to report patients who have viewed or distributed child pornography over the internet, some individuals sought treatment but would not have done so if mandatory reporting had been required,” Dr Berlin observed.
He clarified that by contrast, self-disclosures about having used a minor to produce child pornography are reportable. “I get calls from adults who want to get treatment but are afraid of divulging self-incriminating information, so they do not get the help they need,” he said.
He noted that before the change in law, an average of 7 people yearly (or 73 over a 10-year period) with attractions to children but unknown to law enforcement presented to the Johns Hopkins Sexual Disorders Clinic on their own, seeking treatment for activities involving possible child sexual abuse. On the basis of such information, clinicians were able to initiate an early intervention plan designed to prevent further problems.
“After the statutory change requiring us to report and disclose the new reporting mandate via an informed consent process, the number dropped to zero,” he recounted. “People continued to call but never came in when they found out that we would need to report them.”8
He added that a highly successful program in Germany, the Dunkelfeld project, encourages pedophiles to come forward, seek help anonymously, and receive confidential treatment to deter them from offending.9,10 “Preliminary reports suggest that it is successful and better than picking up the pieces after the fact,” he said.
He clarified that “pedophile” is not synonymous with “child molester,” and that many people who are troubled by their attractions can be stopped from acting on them and thus children are protected.
The Impact of Mandatory Reporting on the Therapeutic Relationship
Psychiatrists are often reluctant to breach confidentiality because they are concerned that doing so will compromise the therapeutic relationship with the potentially abusive parent,2 and that the act of reporting may lead to disruption of treatment in families already receiving mental health services.6
Some research suggests that compliance with mandatory reporting may actually contribute positively to the therapeutic process.”2 One study11 found that in three-quarters of cases, reporting did not ruin or significantly harm the therapeutic alliance with the parent, although almost one-quarter of patients (24%) did terminate treatment after a report was considered or filed. It is possible “that it is trust, not absolute confidentiality that is essential for the psychotherapeutic relationship. Trust may develop or be maintained even though confidentiality cannot be guaranteed or has been breached; clients can accept the disclosure of confidential communications if they feel that the therapist has no choice under the law,” the authors state.11
Children should be made aware prior to therapy that confidentiality is not absolute, and that if the therapist feels that the child is in danger, the therapist may have to disclose the information for the child’s protection. Documenting informed consent might be helpful.12
An equally serious concern can arise when an adult patient seeks therapy for abuse he or she sustained in childhood, and the psychiatrist may be required to report the information. Many patients do not wish to inform legal authorities or to have the information revealed to anyone but the therapist.
Dr Berlin noted that requirement varies by jurisdiction but was instituted in Maryland, for example.8,13 “Reporting child abuse sustained and disclosed by an adult patient over the patient’s objections can seriously damage the therapeutic relationship and also deters patients from disclosing this information to their clinicians,” he said.
He clarified that he is not “encouraging people to break the law” but emphasized that there “should be more input from mental health professionals to protect ways that well-intentioned laws are unintentionally making it worse and preventing people from seeking or receiving help.”
In Australia, reporting past child abuse disclosed by an adult patient depends on whether the perpetrator has current contact with children — a consideration that might inform the dialogue in the United States, as well.14
Tips for Approaching Reporting in Adults Who Disclose Past Childhood Abuse15
- Review your state’s mandatory reporting statute, which is probably available online, to see whether it contains time limits.
- Consult your state’s child protective agencies to see whether a report is required and thoroughly document the conversation.
- Consult a trusted colleague or an expert in law and ethics. Some local and state psychological associations provide ethics consultations. Your malpractice carrier may prove an excellent resource. Document that you have reached out for advice.
- Be mindful that mandatory reporting laws protect psychologists who make reports in good faith.
- Don’t be harsh on yourself for not knowing the answer.
Don’t Go In Alone
Dr Hartselle encourages clinicians not to figure out complex dilemmas on their own. “Consult a colleague or the leadership at your agency or institution, or obtain good supervision if you are in private practice,” she advised. She added that, although CPS is typically seen as an agent that investigates abuse and potentially removes children from the home, “part of what CPS ideally should do is also to help parents who are overwhelmed to be less overwhelmed.”
Given the underfunding of CPS and the “overuse and underuse of the system, children are dying because there is insufficient support for those who are actually trying to do this work,” she said.
Mental health professionals can play an important role not only in working with individual children and families but also in advocating for broader systemic changes.16
Helpful Resources to Guide Decision-Making in Child Maltreatment Situations
- The Child Welfare Information Gateway
- The Centers for Disease Control and Prevention: Child Abuse and Neglect Prevention
- ·The American Academy of Child & Adolescent Psychiatry Child Abuse Resource Center
- Childhelp Child Abuse Education & Prevention Resources
- Child Welfare Information Gateway. Mandatory reporters of child abuse and neglect. Washington, DC: US Department of Health and Human Services, Children’s Bureau; 2016.
- 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;39(4):691-700.
- McTavish JR, Kimber M, Devries K, et al. Mandated reporters’ experiences with reporting child maltreatment: a meta-synthesis of qualitative studies. BMJ Open. 2017;7(10):e013942.
- Flaherty EG, Sege R. Barriers to physician identification and reporting of child abuse. Pediatr Ann. 2005 May;34(5):349-356.
- Longstreth A. Analysis: mandatory reporting laws could harm children. Reuters. December 1, 2011. https://www.reuters.com/article/us-usa-crime-reportinglaws/analysis-mandatory-reporting-laws-could-harm-children-idUSTRE7B01NZ20111201. Accessed August 1, 2018.
- Melton GB. Mandated reporting: a policy without reason. Child Abuse Negl. 2005;29(1):9-18.
- Egelko B. California court upholds child porn reporting law. SF Gate. January 9, 2017. https://www.sfgate.com/news/article/California-court-upholds-child-porn-reporting-law-10846186.php. Accessed August 20, 2018.
- Berlin FS, Malin HM, Dean S. Effects of statutes requiring psychiatrists to report suspected sexual abuse of children. Am J Psychiatry. 1991;148(4):449-453.
- Connolly K. How Germany treats paedophiles before they offend. The Guardian. October 16, 2015. https://www.theguardian.com/society/2015/oct/16/how-germany-treats-paedophiles-before-they-offend. Accessed August 19, 2018.
- Beier KM, Grundmann D, Kuhle LF, Scherner G, Konrad A, Amelung T. The German Dunkelfeld project: a pilot study to prevent child sexual abuse and the use of child abusive images. J Sex Med. 2015;12(2):529-542.
- Watson H, Levine M. Psychotherapy and mandated reporting of child abuse. Am J Orthopsychiatry 1989;59(2):246-256.
- The Center for Ethical Practice. Adolescent informed consent form. http://www.centerforethicalpractice.org/Form-AdolescentConsent. Accessed August 28, 2018.
- Family law: child abuse and neglect—reporting obligation when victim of child abuse or neglect is now an adult or alleged abuser is dead—confidentiality of reports. December 3, 1993. http://www.marylandattorneygeneral.gov/Opinions%20Documents/1993/78oag189.pdf. Accessed August 20, 2018.
- Brell R. When adults report past child sexual abuse: clarifying your obligations. Avant Mutual. December 14, 2016. https://www.avant.org.au/news/when-adults-report-past-child-sexual-abuse-clarifying-your-obligations/. Accessed August 12, 2018.
- Behnke SH, Kinscherff R. Ethics rounds. American Psychological Association. May 2002; 33(5). http://www.apa.org/monitor/may02/ethics.aspx. Accessed August 28, 2018.
- Peterson MS, Urquiza AJ. The role of mental health professionals in the prevention and treatment of child abuse and neglect. US Department of Health and Human Services Administration for Children and Families Administration on Children, Youth and Families; National Center on Child Abuse and Neglect. https://www.childwelfare.gov/pubPDFs/mentlhlth.pdf. Accessed August 28, 2018.