A 16-year-old presents for a follow-up for attention-deficit/hyperactivity disorder medication and tells you that an adult family member has been sexually abusing her for the past year.
An unresponsive 4-month-old presents to the emergency department and is found to have bilateral subdural hematomas and multiple rib fractures.
A medically complex 8-year-old has missed three of his last appointments with you. A record review shows he also has missed several appointments with subspecialists.
Each of these cases raises the question of whether the child should be reported for concerns of maltreatment.
Pediatricians in all 50 states, Washington, D.C., and U.S. territories are mandated to report concerns for child maltreatment to child protective services (CPS) or other relevant investigative agencies. Many states have fines or other penalties for mandated reporters who fail to make a report when one is indicated.
The decision to report, however, can be nuanced and difficult, as the concerns may not be clear and the consequences of reporting may be great.
Awareness of sentinel injuries
All clinicians should be aware of the evidence-based entity of sentinel injuries, which are superficial and medically mild injuries in infants and toddlers who are too developmentally immature to have sustained them on their own. These injuries can include bruises in unusual locations such as the face, neck, genitals, abdomen, buttocks or back; patterned bruises that match the shape of an object; and limb injuries in children too young to cruise.
These injuries may indicate abusive behavior, and further investigation may lead to the discovery of more severe injuries such as fractures. Unless a reasonable explanation is offered for such an injury, these concerning injuries or findings must be reported.
Consulting a child abuse pediatrician, or pediatrician trained in child abuse evaluations, can be helpful when faced with a difficult decision about whether to report.
Protections for good-faith reporting
An additional concern that many pediatricians, including child abuse pediatricians, face is that some parents or caregivers have sued pediatricians who have reported concerns for child maltreatment under 42 U.S. Code §1983 for violating their perceived right to discipline their child as they see fit. These “1983 suits” are civil lawsuits that may not be covered by a pediatrician’s malpractice insurance.
While 1983 suits remain a potential concern for reporters, federal law provides protection for good-faith reporting of a suspected or known instance of child abuse or neglect.
In 2018, Congress enacted amendments to the Child Abuse Prevention and Treatment Act (CAPTA) by passing the Victims of Child Abuse Reauthorization Act. These amendments, which include language reviewed by child abuse pediatricians, are codified at 34 U.S. Code § 20342. They ensure that pediatricians who make a good faith report of child abuse or neglect shall not be subject to civil liability or criminal prosecution.
Dangers of overreporting
While underreporting is a serious concern, overreporting can have unintended consequences for families.
Statutes for mandated reporters typically require them to notify their local CPS agency when they have a “reasonable suspicion” or “reasonable cause” of child maltreatment.
This language, which is common in legal settings, is imprecise from a medical standpoint and does not have a standard meaning. This vague threshold of concern has led to an increased number of reports to social services, which disproportionately target Black and brown populations.
While they may be well-intended, these reports can be harmful to families. Children may be separated from caregivers, which may not improve their safety. In addition, caregivers may have difficulty complying with safety plans and may not receive needed support.
Balancing over- and underreporting
Balancing the duty to report concerns for child maltreatment with apprehension about overreporting emphasizes the importance of ensuring that reports are accurate, timely and reported in language that investigators can understand and act on.
The safety of the child should be paramount, and fear of consequence should not prevent a pediatric provider from making a report.
It also is important to ensure that the child can access appropriate medical care and that safety needs are met. When available, a child abuse pediatrician familiar with local practices can help identify safety needs, which can be nuanced, and provide guidance on how to report.
Following are ways pediatricians can balance concerns for underreporting child maltreatment with concerns for overreporting:
- Involve a child abuse pediatrician whenever feasible.
- Ensure documentation is objective, accurate, timely and within your scope of training and experience.
- Review your personal or institutional malpractice policies to determine if civil actions such as 1983 suits are covered.
- If involved in a lawsuit, ensure that your lawyer is aware of civil and criminal liability protections under CAPTA’s 34 U.S. Code § 20342, and encourage your lawyer to include these arguments in the first legal pleading.
Dr. Northrop is a member of the AAP Committee on Medical Liability and Risk Management. Andrea Asnes, M.D., FAAP, a member of the AAP Council on Child Abuse and Neglect Executive Committee, contributed to this article.
