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Ca child abuse_prevention_handbook_2007_ada

  1. 1. CHILD ABUSEPrevention Handbook . . . and intervention guideCrime and Violence Prevention CenterCalifornia Attorney General’s Office
  2. 2. Child AbusePrevention Handbook...and intervention guide Crime and Violence Prevention Center California Attorney General’s Office
  3. 3. April 2006 Revised January 1982, August 1985, March 1993 and January 2000 This Handbook and accompanying Addenda provide general information and current laws to serveas a practical aid for those who work with children in the field of child abuse prevention and to assist mandated reporters and others in determining their reporting responsibilities. The Addenda will be updated every year. Therefore, if there are discrepancies between the Addenda and the Handbook,please use the information in the Addenda as the most current. Both publications are not intended to be and should not be considered legal advice. In the event there are questions about laws related to reporting responsibilities in a specific case, the advice of legal counsel should be sought.All revisions to the law in this handbook reflect changes through December 2005, unless otherwise noted.
  4. 4. Message from the Attorney GeneralChild abuse and neglect have both human and economic costs. For example, in 2004, the CaliforniaDepartment of Social Services estimated that 378,301 cases of abuse and neglect involving approxi-mately 713,391 children were referred for investigation. According to an audit conducted in 2002 bythe California Department of Health Services, 140 children died in the state as a result of abuse andneglect. Prevent Child Abuse-America, one of the nation’s leading child abuse prevention organiza-tions, estimates the total annual direct and indirect costs of child abuse and neglect is approximately$94 billion dollars.New research suggests that children chronically exposed to violence, either through child maltreat-ment or being raised in homes where domestic violence is present, suffer increased risk of experiencingdepression, post-traumatic stress disorder, greater alcohol and drug abuse and lower academic achieve-ment.In California, approximately one in four children are directly exposed to violence as a victim or witness.Childhood abuse and neglect increases the odds of arrest as a juvenile by 59%, as an adult by 28%and for a violent crime by 30%.In California, many communities are involved, and many more are becoming involved, in interveningin the lives of maltreated children. Child Welfare Services (CWS) recently developed an innovativeapproach to address the problems of children and families at the community level. Their vision, “Everychild living in a safe, stable, permanent home, nurtured by healthy families and strong communities,”serves as a “call to action” for communities to provide the resources necessary to intervene with fami-lies before they come to the attention of CWS. In the long term, strengthening communities and fami-lies will go a long way to reducing the number of maltreated children in our state.The Department of Justice takes a proactive role in the prevention of child abuse and neglect. Thedepartment launched Safe from the Start, a statewide effort designed to reduce children’s exposure toviolence. The Department developed a Megan’s Law CD-Rom and the California Sex Offender Informa-tion Line. The Department administers the California State Child Death Review Council which contin-ues to support local child death review teams in their efforts to prevent fatal child abuse and neglect.The purpose of this handbook is to serve as a guide for those who work with children and who aremandated to report suspected abuse under the California Child Abuse and Neglect Reporting Act. Thehandbook provides an overview of the laws, practices and procedures for the prevention, identification,reporting, treatment, investigation, and prosecution of child abuse and neglect. It has been updated toreflect current changes in law and practice. As in the past, we hope that you find its contents helpful.We cannot view the protection of children as a single person‘s or organization‘s responsibility. Only ourcollaborative efforts will ensure a healthier life for the children of California.
  5. 5. “There is no greater insightinto the future than recognizingwhen we save our children,we save ourselves.” Margaret Meade
  6. 6. Table of ContentsWhat is Child Abuse? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1The Extent of the Problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2Physical Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Physical Neglect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Sexual Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Exploitation/Child Pornography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Abuse of Children with Disabilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Cultural Differences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18What is Not Child Abuse? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Who are Child Abusers? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21The Nexus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25Reporting Child Abuse and Neglect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27The Child Abuse Reporting Act . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27Who Reports? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29Immunity from Liability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29Liability for Failure to Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30Purpose of Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30Making a Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30What Happens to the Report? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31Professional Responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35Schools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35Child Day Care Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
  7. 7. Out-of-Home Child Care Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38Medical Community . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39Child Welfare (Protective) Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41Law Enforcement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46Coordinated Investigations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49Multidisciplinary Child Death Review Teams . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54Legal Community . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56Court Appointed Special Advocates (CASA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56Probation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57Prevention, Intervention and Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59The Role of the Community . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63Victims of Crime Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69Appendix I: Child Abuse Reporting Forms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71Appendix II: Confidentiality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77Appendix III: Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82PLEASE NOTE: Addendum I – California Child Abuse and Neglect Reporting Act;Addendum II – Juvenile Dependency Proceedings; Addendum III – Child Abuse Crimes; andAddendum IV – Guidelines for Investigation of Child Abuse in Out-of-Home Care Facilities area part of this handbook but are located in a separate publication and will be updated on a yearlybasis.
  8. 8. What is Child Abuse?To many, child abuse is narrowly defined as Certain persons, known as mandated report-having only physical implications. In reality, ers, are required by law to report any knownchild abuse includes: or suspected instance of child abuse. Every-• Physical abuse; unlawful corporal punish- one else may report child abuse and neglect. ment or injury. Indicators for suspected child abuse are pre- sented in this publication to assist mandated• General and severe neglect. reporters in meeting their responsibilities• Sexual abuse; sexual assault; exploitation under the Child Abuse and Neglect Reporting• Willful harming or endangering a child; Act. (See Addendum I for a list of mandated emotional maltreatment. reporters.) One of the most important indicators forChild abuse may involve multiple categories suspecting child abuse is when a child tellsin each family. They include both (overt) acts someone that he or she has been abused.and omissions. Competent assessments and When a child tells a particular person who isinterventions must consider evaluating mul- an individual required to report child abuse,tiple categories of abuse. the communication is not privileged. That individual, by law, must report what the childThe act of inflicting injury or the failure to has related to him or her. An only exceptionact so that injury results, is the basis for is when the information is relayed duringmaking the decision to intervene. A parent “penitential communication.” A clergy mem-or caretaker may begin by inflicting minor ber who acquires knowledge or reasonableinjuries, then may increasingly cause more suspicion of child abuse during penitentialserious harm over a period of time. There- communication is not required to reportfore, detecting the initial small injuries and abuse or neglect. Penitential communicationintervening with preventive action may save a is the communication, intended to be inchild from future permanent injury or death. confidence, including but not limited to, a sacramental confession, made to a clergyPhysical injuries, neglect and malnutrition are member who, in the course of the disciplinemore readily detectable than the subtle and or practice of his or her church, denomina-less visible injuries that result from emotional tion, or organization, is authorized or accus-maltreatment or sexual abuse. However, all tomed to hear those communications, andcategories of abuse endanger or impair a under the discipline, tenets, customs, orchild’s physical and/or emotional health and practices of his or her church, denomination,development and demand attention. or organization has a duty to keep thoseChild Abuse Prevention Handbook
  9. 9. communications secret. (Pen. Code, § 11166 including the U.S. Department of Health andsubd. (c) (1)). In addition, and in the recent Human Services, the U.S. Department of Jus-past, “any custodian of records of a clergy tice and the U.S. Census. According to theirmember” were made mandated reporters conservative estimates, approximately $94and are now required to report child abuse billion is spent each year on direct (those costsand neglect. Mandated reporters who report associated with the immediate needs of abusesuspected child abuse cases have immunity, and neglected children) and indirect costboth civilly and criminally, for making reports. (those costs associated with the long-term(See “Liability for Failing to Report” page 30.) and/or secondary effects of child abuse and neglect) for child abuse and neglect.2 The probability that child abuse and neglectThe Extent of the Problem is a leading cause of childhood deaths seems to be generally accepted. The National ChildIn 2003, the National Clearinghouse on Child Abuse and Neglect Data Systems (NCANDS)Abuse and Neglect reported an estimate of reported that in 2003, there were an estimat-2.9 millions referrals concerning the welfare ed 1,500 child fatalities related to child abuseof approximately 5.5 million children were and neglect. More than three-quarters (79%)made to child protective services agencies of children who were killed were youngerthroughout the United States. Of these, than 4 years old. More than one-third ofapproximately two-thirds (1.9 million) were child fatalities were attributed to neglect.accepted for investigation for an assessment. The rate of child abuse and neglect fatalitiesMore than 60 percent of child victims expe- reported by NCANDS has increased slightlyrienced neglect. Almost 19 percent were over the past several years from 1.84 perphysically abused, 10 percent were sexually 100,000 children to 1.98 in 2002. However,abused and 5 percent were emotionally mal- experts do not agree whether this representstreated. Girls were slightly more likely to be an actual increase in child abuse and neglectvictims than boys. Pacific Islanders, Ameri- fatalities, or whether it may be attributed tocan Indian and Alaska Native, and African- improvements in reporting procedures.American children had the highest rates ofvictimization when compared to their national In California, the Department of Health Ser-population. While the rates of white victims vices estimates that 140 children died as aof child abuse or neglect were 11.0 per 1,000 result of child abuse and neglect in 2002.children, the rate for Pacific Islanders was Also in California, the Fatal Child Abuse and21.4 per 1,000 children, the rate for Ameri- Neglect Surveillance (FCANS) Program wascan Indian or Alaska Natives was 21.3 per introduced to local child death review teams1,000 children and the rate for African-Ameri- in the fall of 2002. The goal of FCANS is forcans was 20.4 per 1,000 children.1 all child deaths to be reviewed by local child death review teams and for the teams toIn addition to the enormous human costs gather relevant data to assist in reducing childof child abuse and neglect, there are huge abuse fatalities. (See page 54 for informationfinancial costs. In 2001, Prevent Child Abuse- on child death review teams)America, a leading child abuse preventionorganization, published data that represented Many researchers and practitioners believethe first attempt at documenting the nation- child fatalities due to abuse and neglectwide costs resulting from abuse and neglect. are under reported. State definition of keyData was drawn from a variety of sources, terms such as “child homicide,” “abuse” and Child Abuse Prevention Handbook
  10. 10. “neglect” vary, therefore, so do the numbers levels of government. Efforts continue toand types of child fatalities they report. In be made to develop systems that will reflectaddition, some deaths officially labeled acci- more accurately the scope and degree of childdents, child homicides and/or Sudden Infant abuse and neglect, e.g. FCANS. The numberDeath Syndrome (SIDS), might be attributed of suspected child abuse cases reported andto child abuse and neglect if more compre- investigated in California has steadily risenhensive investigations were conducted or if over the years as a result of the Child Abusethere were more consensus in the coding of and Neglect Reporting Act and the increasedabuse on death certificates.3 attention paid to the problem by profession- als and the public. For example, in 2004, theWhen addressing the issue of child maltreat- California Department of Social Services esti-ment, and especially child fatalities, preven- mated that 378,301 referrals for investigationtion is a recurring theme. Well-designed and of child abuse and neglect involving 713,391properly organized child fatality teams appear children were handled by child welfare ser-to offer hope for defining the underlying vices agencies. Of these, 17 percent werenature and scope of fatalities due to child for physical abuse, 39 percent for generalabuse and neglect. The child fatality review neglect, 1.5 percent for severe neglect, 8 per-process helps identify factors that may assist cent for sexual abuse, 4 percent for caretakerprevention professionals to prevent future absence, 9 percent for emotional abuse, anddeaths. (For more information on the Califor- 1 percent for exploitation and 21 percent fornia’s child death review process, see page 54) other. (See chart on page 5.)Although young children are more “at risk” The Department of Justice maintains a Childof abuse than adolescents, the problem of Abuse Central Index which contains dataadolescent abuse is often underestimated. from child abuse investigations submit-Unfortunately, child protective services may ted by law enforcement agencies and childdiscount adolescents because they are con- welfare services. Between 1999 and 2003,sidered to be less “at risk” than younger 189,576 child abuse investigation reportschildren, and because adolescents are seen as were received by the Department of Justice.having more options than younger children. Of these, 49 percent involved physical abuse,Because it is believed that adolescents are 24 percent involved sexual abuse, 27 percentable to leave the house until the parent/care- involved severe neglect and emotional mal-taker “calms down,” they can fight back or, treatment. (For further information on thein some cases, take the abuse with only tem- Child Abuse Central Index, see page 32.) porary discomfort, they are not considered ashelpless as younger children. However, manychild prostitutes and young people involved inalcohol and drug abuse are victims of physicalor sexual abuse and neglect at home. Many“runaways” have similar histories. Thus, ado-lescents may have more options than younger 1 National Clearinghouse on Child Abuse and Neglect children, but they are not necessarily positive Information, Child Maltreatment 2003: Summary of Key options. Adolescent abuse remains a serious Findingsproblem that deserves attention and action. 2 Prevent Child Abuse-America, Total Estimated Costs of Child Abuse and Neglect in the United States, Statistical Evidence, 2001The gathering of accurate information and 3 National Clearinghouse on Child Abuse and Neglect: statistics is recognized as a problem at most Statistics and Interventions, 2002Child Abuse Prevention Handbook
  11. 11. Physical Abuse • Knowledge that a child’s injury is unusual for a specific age group (any fracture in anPhysical abuse is any non-accidental act that infant).results in physical injury. Inflicted physical injurymost often represents unreasonably severe cor- • Unexplained injuries (parent, caretaker, orporal punishment or unjustifiable punishment. child is unable to explain reason for injury;This usually happens when a person is frus- there are discrepancies in explanation;trated or angry and strikes, shakes, or throws blame is placed on a third party; explanationsthe child. Intentional, deliberate assault, such as are inconsistent with medical diagnosis).burning, biting, cutting, poking, twisting limbs, • Parent or caretaker delays seeking careor otherwise torturing a child, is also included in for a child or fails to seek appropriatethis category of child abuse. care.Indicators of Physical Abuse Behavioral IndicatorsThese indicators are used to help distinguish Children may exhibit new or concerningaccidental injuries from cases of suspected behaviors for a number of reasons includingphysical abuse: child abuse as well as other sources of child- hood stress such as parental divorce, death in the family, etc. If a child exhibits drasticLocation and Type of Injury behavioral changes, is excessively aggressive,Padded areas as the buttocks, back of legs, violent or destructive, is cruel to animals, orgenitalia and cheeks are more concerning becomes visibly depressed or suicidal, a seri-in that it takes more force to cause bruising. ous mental health evaluation should be done.Bruises happen when the blood vessels break In addition, it may be an indication that theunder the skin. Thus children who are old child has been abused. If abuse is suspected,enough to walk often fall and have bruises the mandated reporter must inform Childover boney surfaces such as the forehead, Protective Services or law enforcement aboutknees, shins where blood vessels are break- their between two hard surfaces (the floor forexample and the underlying bone). However,simple falls and even disciplinary spanking with Types Of Injuriesan open palm should not be forceful enoughto cause bruising to the buttocks. Protected Damage To Skin and Surfaceareas such as ears, neck, and upper lip are Tissuemore concerning because it is difficult toaccidentally bump or fall on these areas. Pat-terned injuries such as loop marks, slap marks, Bruisesor grab marks are highly suspicious and in Bruises, also referred to as contusions, result-some cases indicative of inflicted trauma. ing from abuse are found on multiple surfaces of the body, particularly the buttocks, back, genitals, and face. They may appear in aHistory characteristic pattern (outline of hand, pairedThe history includes all facts about the child bruises from pinching), or they may clearlyand the injury, including: resemble an impression of an item of jewelry• Statements by the child that the injury was (a ring), or a disciplinary imprint (a paddle, caused by abuse. switch, or coat hanger). Linear bruise marks, Child Abuse Prevention Handbook
  12. 12. Number of Children Referred for Investigation in California 1991 - 2004 706,918 715,062 713,391 700,000 690,005 670,426 660,942 600,000 571,214 540,577 500,000Number of Children 400,000 300,000 200,000 100,000 1991 1993 1995 1996* 1999* 2001 2003 2004 2004 Number and Percentage of Children by Type of Abuse (Total Number of Children 713,391) Emotional Abuse Severe Neglect 62,146 (9%) 11,398 (1.5%) Physical Abuse 124,751 (17%) Other** 147,496 (21%) Sexual Abuse 58,926 (8%) Caretaker Absence/Incapacity 31,225 (4%) Exploitation 817 (1%) General Neglect 276,632 (39%) Source: California Department of Social Services, Statistical Services Branch * The caseload fall from 1996 to 1999 may be due to transitional issues relating to the implementation of the Child Welfare Services/Case Management System (CWS/CMS) ** Includes children at risk and at substantial risk of abuse and neglect.
  13. 13. strap marks, or loop marks going around a dentists, skilled evidence technicians, or othercurved body surface are almost always evi- experienced individuals. Salivary swabbingdence of abuse. should be collected, because they may be used to determine the blood type or evenIt is not possible to date bruises. The colors DNA of the biter. In penetrating bite marks,red, blue, purple or black can occur at any services of the individuals listed above shouldtime. In addition, bruises of identical age and also be obtained in order to secure accuratecause on the same person may look different impressions of the bitten area.and may resolve differently. If properly collected and analyzed by experi-In cases where bruises are suspected bite enced forensic dentists, bite mark evidencemarks, investigators should also be prepared can point to the guilt or innocence of ato seek the expertise of forensic odontolo- perpetrator suspected of involvement in thegists. physical or sexual abuse of a child.Abrasions, Lacerations BurnsAs with bruising, the multiplicity and location The location of a burn and its characteristicsof the wounds should be considered. For (shape, depth, margins, etc.) may indicateexample, lacerations under the tongue or abuse. It is important to keep in mind thatthose of a torn frenulum (the small piece of children instinctively withdraw from pain.tissue connecting the gum to the lip) could be Burns, without some evidence of withdrawal,caused by falling with an object in the mouth are highly suspect because a child will usuallyor by the use of excessive force during feed- try to escape, which will result in splashes,ing. Both are suspicious injuries when the vic- uneven burns and sometimes burns on thetim is an infant who is still unable to stand. hands.Whipping a child with a belt buckle or belts Scalding a child with hot liquid is the mostor cords that are looped may cause lacera- common abuse burn. Young infants are com-tions resembling a “C” or “U” shape or other monly scalded by immersion, and older chil-wounds with distinctive shapes. dren by having liquids thrown or poured on them.Bite MarksBite marks may be found on any part of a When children are forcibly held in hot water,child’s body. They may appear to be dough- there are often sharply demarcated burns. Ifnut shaped, double horseshoe shaped, or held in water in a “jackknife” position, onlyoval in configuration. Individual teeth or the buttocks and genitalia may be burned. Ifa blurry area with varying colorations may held down forcibly in a sitting position, thebe observed, depending on the age of the center part of the buttocks (if pressed tightlybite mark lesion. Time is of the essence in against the tub) is spared from burning, thusrecording bite marks through photography resulting in a “doughnut shaped” burn. Ifand/or video taping because some lesions will the extremities are forcibly immersed in hotbecome less distinct with time. water, “glove” or “sock” burns to the hands or feet may result. The burns are often sym-Photography, employing non-distorting cam- metric and an immersion line is readily evi-eras, with rulers or scales adjacent to the dent.lesion, should be accomplished by forensic Child Abuse Prevention Handbook
  14. 14. Abuse may also be suspected when burns are for the child’s state, head injury from possiblepointed or deeper in the middle. This indi- abuse should be considered. The caretaker’scates that hot liquid was poured on, or a hot explanation for a fall should be carefully doc-object (poker, utensil) pressed into the skin. umented as to who was present, the distance of the fall, the type of surface hit, and time ofAnother type of burn characteristic of abuse the injury.has the shape of a recognizable object evenlyburned into the victim’s skin. These burns The medical evaluation is critical but shouldindicate forced contact or “branding” with, not stand-alone. A complete evaluation, evenfor example, the grill of an electric heater, the with severe injury, includes a psychosocialelement of an electric stove, or an iron. evaluation of the family, caretakers and home, which can be completed by hospital socialCigarette burns are difficult to diagnose, but workers. In general, these evaluations shouldwhen inflicted they are often multiple and are be considered in all cases where child abuse isusually found on the palms or soles. There a searing effect, perhaps with charringaround the wound. Abusive Head Trauma Abusive head trauma, (Shaken Baby Syn-Rope “burns” appear around wrists or ankles drome), describes a constellation of signswhen children are tied to beds or other struc- and symptoms resulting from violent shakingtures. or shaking and impacting of the head of an infant. The degree of brain damage dependsDamage To Brain on the amount and duration of the shaking and the forces involved in the impact of theHead Injuries head. Signs and symptoms range on a spec-Head injuries are the most common cause of trum of neurological alterations from minorchild abuse related deaths and an important (irritability, lethargy, tremors, vomiting) tocause of chronic neurological disabilities. major (seizures, coma, stupor, death). These neurological changes are due to destructionWhenever abuse or neglect is suspected, a of the brain cells secondary to trauma, lack ofcareful examination of the child’s eyes and oxygen to the brain cells, and swelling of thenervous system should be performed to look brain. Extensive retinal hemorrhages in onefor signs of intracranial injury. For certain or both eyes are found in the vast majoritygroups of suspected victims, a full skeletal of these cases. The classic triad of subduraltrauma series may be necessary as well as tox- hematoma, brain swelling, and retinal hem-icology. Serious intracranial injury can occur orrhages are accompanied in some, but notwithout visible evidence of trauma on the all cases, by bruising of the part of the bodyface or scalp. Children with any soft tissue used as a “handle” for shaking. Fractures ofinjury to the head should be neurologically the long bones and/or of the ribs may also beassessed and have an ophthalmological evalu- seen in some cases. Rib fractures or metaphy-ation to look for retinal hemorrhages. These seal fractures (also called bucket handle orinjuries may cause brain damage or death if corner fractures) are particularly concerningundetected and untreated. in young children and if seen should prompt further investigation for a possible shakingWhen a child is in an unconscious or unre- event. In many cases, however, there is nosponsive state and there is no external evi- external evidence of trauma either to thedence of injury and no adequate explanation head or the body.Child Abuse Prevention Handbook
  15. 15. Approximately 20 percent of cases are fatal in Fractures are most suspicious for inflictedthe first few days after injury. Survivors suffer trauma when there are multiple lesions, theyfrom handicaps ranging from mild learning are in different stages of healing, and theredisorders and/or behavioral changes, to mod- are unsuspected lesions. Other fractureserate and severe, such as profound mental that raise suspicion are: metapyhseal frac-and developmental retardation, paralyses, tures (also known as corner, chip, or bucketblindness, inability to hear, or a permanent handle fractures) which are at the end of longvegetative state. bones and may be fractures from excess trac- tion, jerking, and twisting injuries; multipleA careful post mortem examination is required rib fractures, especially back rib fractures;of all infant deaths in California. These exam- and healing or healed fractures without aninations should always include evaluation for explanation revealed by x-rays. For youngsigns of intracranial bleeding, retinal hemor- victims, x-ray bone surveys are important toolsrhages, and points of impact on or within the used to diagnose suspected physical abuse.body. Evaluations of potentially suspicious Radioisotope bone scans may pick up healingcases also should include forensic lab study by fractures, subperiosteal hematomas, etc. Aprotocol, including toxicology, microscopic tis- pediatric radiologist should be consulted onsue examination (including the retina), and a all suspicious cases.full trauma x-ray series.Damage To Other Internal Organs Physical NeglectInternal Injuries Neglect is the negligent treatment or mal- treatment of a child by a parent or caretakerBlunt blows to the body can cause serious under circumstances indicating harm orinternal injuries to the liver, spleen, pancreas, threatened harm to the child’s health or wel-kidneys, and other vital organs and occa- fare. The term includes both acts of commis-sionally can cause shock and result in death. sion and omissions on the part of the respon-Internal injuries are the second leading cause sible person. The California Child Abuse andof death for victims of child abuse. Neglect Reporting Act defines two categories of physical neglect, severe neglect and gen-Detectable surface evidence of such trauma eral present only about half the time. Physi-cal indicators of serious internal injuries may Severe neglect means the negligent failureinclude distension of the abdomen, blood in of a parent or caretaker to protect the childthe urine, vomiting, and abdominal pain. from severe malnutrition or medically diag- nosed non-organic failure to thrive. It alsoDamage To Skeleton means those situations of neglect where the parent or caretaker willfully causes or permitsFractures the person or health of the child to be placedAny unexplained fracture in an infant or tod- in a situation such that his or her person ordler is cause for additional inquiry or investi- health is endangered. This includes the inten-gation. Rib fractures, especially of back ribs, tional failure to provide adequate food, cloth-are the most common fractures found in ing, shelter, or medical care.abused children and are caused from eitherblunt force (hit) or compression (squeezed). General neglect means the negligent failure of a parent or caretaker to provide adequate Child Abuse Prevention Handbook
  16. 16. food, clothing, shelter, medical care, or super- tions of harmful substances; a child caredvision where no physical injury to the child has for by another child); the child is left aloneoccurred. in the home, or unsupervised under any circumstances (left in car, street).An example of inadequate supervision is when • The conditions in the home are unsanitaryparents leave their children unsupervised dur- (garbage, animal, or human excrement);ing the hours when the children are out of the home lacks heating or plumbing; thereschool. These parents are often unable to are fire hazards or other unsafe homearrange childcare services to meet their needs. conditions; the sleeping arrangements areAlthough these parents may not regard them- cold, dirty, or otherwise inadequate.selves as “neglecting their children,” leavingyoung children without supervision may con- • The nutritional quality of food in the homestitute general neglect. Children left in these is poor; meals are not prepared; refrigera-circumstances may also be particularly vulner- tor or cupboards contain spoiled to accidents, injuries, or crime. Becausethese parents don’t see any wrongdoing, this While some of these conditions may exist inis a very complicated area that is subject to any home environment for a variety of dif-controversy regarding the age when children ferent reasons, e.g., poverty, welfare reform,should be left alone, societal and community and limitations on entitlement programs, it isresponsibilities to provide resources, and gov- the extreme or persistent presence of theseernmental requirements. factors that indicate some degree of neglect. Disarray and an untidy home do not neces-Prenatal neglect is maternal substance abuse sarily mean the home is unfit. Extreme condi-coupled with significant risk factors that indi- tions resulting in an “unfit home” constitutecate the parent’s inability to provide the child neglect that may justify protective custodywith adequate care. and dependency proceedings under Welfare and Institutions Code section 300 (see Adden- dum II), as well as criminal neglect charges.Indicators of Neglect (See Addendum III.)Neglect may be suspected if any of the fol-lowing conditions exist: Psychosocial Failure to Thrive• The child is lacking adequate medical or Infants or young children who are much dental care. smaller than would be expected at a par-• The child is often sleepy or hungry. ticular age can present a difficult diagnostic problem for physicians. After excluding those• The child is often dirty, demonstrates infants who are small because they were poor personal hygiene, or is inadequately small at birth, there remains a large group of dressed for weather conditions. infants with low weights and perhaps short• The child is depressed, withdrawn or apa- lengths and small head circumferences. Some thetic; exhibits antisocial or destructive of these children are small because of a fail- behavior, shows exaggerated fearfulness; ure to meet their nutritional needs and/or or suffers from substance abuse, or speech, failure to meet their emotional needs. These eating, or habit disorders (biting, rocking, children may also demonstrate delayed devel- whining). opment and abnormal behavior. Some of• There is evidence of poor supervision the small children, however, do have hidden (repeated falls down stairs; repeated inges- medical problems. Hospitalization may beChild Abuse Prevention Handbook
  17. 17. required to screen for significant medical ill- may be present, in varying degrees, fol-lowingness and, more important, to see if the child chronic and severe emotional abuse, especiallyresponds to adequate nutrition and a nurtur- when there is little or no environment with a rapid weight gain andmore appropriate behavior. Evaluation is more This is especially true for neonates, infantsthan weighting and measuring a baby. Chil- and toddlers. These children may becomedren who suffer neglect may also receive spo- chronically withdrawn and anxious and loseradic disconnected medial care and are likely basic social and language skills necessary foronly to be examined in emergency rooms. intimate relationships. They may becomeThey may have no ongoing measurement of developmentally delayed, socially limited, and,development except as noted by caretakers. in some cases, antisocial or chronically unableGrowth charts compare the child to other to protect themselves from others.children noting percentile size in head, bodylength and weight. Feeding failure for what- Verbal assault (belittling, screaming, threats,ever reason will generally damage weight first, blaming, sarcasm), unpredictable responses,length second, and head circumference third, continual negative moods, constant familyso it may be helpful to observe the caretaker’s discord, and chronically communicating con-feeding habits. In fact, the best environment flicting messages are examples of ways parentsto observe this is in the home. Pediatric exper- may subject their children to emotional abuse.tise is vital to access such changes but growthcharts should be kept on all infants and tod- Emotional abuse and neglect are also com-dlers who may be suffering neglect. Failure to ponents of other abuse and neglect. Sexualdocument physical growth and other markers abuse and physical abuse may be the officialof child development may prevent an accurate category for a report but emotional damagediagnosis and make it impossible to protect a also exists. Emotional abuse/neglect maychild or provide useful intervention. damage children of all ages but may be criti- cal with infants and toddlers leaving themIf left untreated, the physical and/or emotional with permanent developmental of the child may be endangered, andemotional disorders, school problems, retar- Behavioral Indicators of Childrendation, and other problems may result. Emotional abuse may be suspected if the child: • Is withdrawn, depressed and apathetic.Emotional Maltreatment • Is clingy and forms indiscriminate attachments. • “Acts out” and is considered a behaviorEmotional Abuse problem (e.g. bullies others, chronically uses profanity).Just as physical injuries can scar and incapaci-tate a child, emotional maltreatment can crip- • Exhibits exaggerated fearfulness.ple and handicap a child emotionally, behav- • Is overly rigid in conforming to instructionsiorally and intellectually. Self-esteem can be of teachers, doctors, and other adults.damaged. Severe psychological disorders have • Suffers from sleep, speech, or eating disor-been traced to excessively distorted parental ders.attitudes and actions. One of the hallmarksof emotional abuse is the absence of positive • Displays other signs of emotional turmoilinteraction (e.g. praising) from parent to their (repetitive, rhythmic movements; rocking,child. Emotional and behavioral problems whining, picking at scabs).10 Child Abuse Prevention Handbook
  18. 18. • Suffers from enuresis (bed wetting) and Suspected cases of emotional abuse that con- fecal soiling. stitute willful cruelty or unjustifiable punish-• Pays inordinate attention to details, or ment of a child are required to be reported exhibits little or no verbal or physical com- by mandated reporters. This means a report munication with others. must be made of any situation where any person willfully causes or permits any child• Unwittingly makes comments such as, to suffer, or inflicts on any child, unjustifiable “Mommy/Daddy always tells me I’m bad.” mental suffering. (Pen. Code, § 11165.3.) However, mandated reporters may also reportThe behavior patterns mentioned may, of any degree of mental suffering. While thesecourse, be due to other causes, but the suspi- cases may not always be prosecuted, report-cion of abuse should not be dismissed. ing provides the opportunity for intervention and/or therapy with the family.Behavioral Indicators of Parents/Caretakers Emotional DeprivationA child may become emotionally distressed Emotional deprivation has been defined aswhen: “. . . the deprivation suffered by children• Parents or caretakers place demands on when their parents do not provide the nor- the child that are based on unreasonable mal experiences producing feelings of being or impossible expectations or without loved, wanted, secure, and worthy.” consideration of the child’s developmental capacity. Caretakers might also provide cause for evalu-• The child is used as a “battle ground” for ation and possible reporting of a neonate at marital conflicts. risk. Withholding affection with touch, smiles and sound may be more damaging than ver-• The child is used to satisfy the parent’s/ bal and even physical assault. Children may caretaker’s own ego needs and the child is provoke assault if necessary to gain nega- neither old enough nor mature enough to tive interaction rather than suffer the pain of understand. being ignored. This may damage children of• The child victim is “objectified” by the all ages but is critical for infants and young perpetrator, the child is referred to as “it” toddlers. Intervention may include consid- (“it” cried, “it” died). eration of caretaker depression, substance• The child is a witness to domestic violence. abuse, parenting deficits, and lack of social or financial support for the caretaker. Consid- eration should be made for evaluation of theEmotional abuse can be seen as proving a caretaker for these issues as well as possibleself-fulfilling prophecy. If a child is degraded domestic violence.enough, the child will begin to live up to theimage communicated by the abusing parentor caretaker. Behavioral Indicators of Emotional DeprivationEmotional abuse cases can be extremely diffi- Emotional deprivation may be suspected if thecult to prove, and cumulative documentation child:by witnesses is imperative. Such cases should • Refuses to eat adequate amounts of foodbe referred to treatment as soon as possible. and is therefore very frail.Child Abuse Prevention Handbook 11
  19. 19. • Is unable to perform normal learned func- Sexual abuse encompasses a broad spectrum tions for a given age (walking, talking); of behavior, and it may consist of many acts exhibits developmental delays, par- over a long period of time (chronic molesta- ticularly with verbal and nonverbal social tion) or a single incident. It may progress skills. from less intimate types of sexual activity to• Displays antisocial behavior (aggression, active body contact and later to some form behavioral disruption, bullying others) of penetration. Victims range in age from or obvious “delinquent” behavior (drug younger than one year through adolescence. abuse, vandalism); conversely, is abnor- Specifically, sexual assault includes: rape, mally unresponsive, sad, or withdrawn. rape in concert, incest, sodomy, oral copula- tion, penetration of genital or anal opening• Constantly “seeks out” by a foreign object, and child and “pesters” other molestation. It also includes adults, such as teachers lewd or lascivious conduct with or neighbors, for atten- a child under the age of 14 tion and affection. years, which may apply to any• Displays exaggerated lewd touching if done with the fears. intent of arousing or gratifying• Apathy, withdrawal the sexual desires of either the and lack of response to person involved or the child; human interaction. lewd or lascivious conduct with a child 14 or 15 years of age by a person at least 10 years olderWhen parents ignore their than the child; and unlawfulchildren, whether because sexual intercourse with a minorof drug or alcohol use, under 16 years of age by a per-psychiatric disturbances, son over the age of 21 years.personal problems, outside Sexual exploitation includesactivities, or other preoccupying situations, conduct or activities related to pornographyserious consequences can occur. However, depicting minors, and promoting prostitutionreporting these situations is not mandated by minors. (See Addendum III for a detailedunless they constitute a form of legally defined review of these crimes.)abuse or neglect. Emotional neglect may beseen as a lesser form of child abuse/neglect. It The nature of sexual abuse, the guilt andmay not be reportable or may be assessed out shame of the child victim, and the possiblewith no intervention. It is, however, a central involvement of parents, stepparents, friends,issue for much of what damages children. or other persons in a child caretaker role,These children may return with more severe make it extremely difficult for children todamage and are therefore worthy of voluntary come forward to report sexual abuse. Yet,intervention and follow-up. despite these problems, reports of sexual abuse made to child protective agencies continue to increase. This increase is usuallySexual Abuse attributed to the passage of the Child Abuse and Neglect Reporting Act and the public’sAs defined in the Child Abuse and Neglect increased concern for child victims.Reporting Act, sexual abuse is a sexual assaulton, or the sexual exploitation of, a minor.12 Child Abuse Prevention Handbook
  20. 20. Sometimes a child who does seek help is • A child’s injury/disease (vaginal trauma,accused of making up stories, because many sexually transmitted disease) is unusual forpeople cannot believe that the apparently the specific age group.well-adjusted person involved could be capa- • A young girl is pregnant or has a sexu-ble of sexual abuse. If the matter does come ally transmitted disease. Pregnancy of ato the attention of authorities, the child may minor does not, in and of itself, constitutegive in to pressure from parents or caretakers the basis of reasonable suspicion of sexualand deny that any sexual abuse has occurred. abuse and should not be reported. (Pen.Even if protective attention is gained, the Code, § 11166, subd.(a).) However, otherchild may feel guilty about “turning in” the information such as statements by theabuser or breaking up the family and, con- minor, indication of coercion, or significantsequently, withdraw the complaint. This age disparity between the minors may leadprocess leads many to be skeptical of a child’s to a reasonable suspicion of sexual abusecomplaint of sexual abuse, and leaves him or that must be reported.her feeling helpless and guilty for causing somuch trouble. Behavioral IndicatorsThe sad reality of sexual abuse is that withoutthird party reporting, the child often remains Sexual Behaviors of Childrentrapped in secrecy by shame, fear, and the It is natural for children to have curiositythreats of the abuser. about their bodies, and therefore it may be difficult to tease out whether a child is act- ing sexually due to normal age appropriateIndicators of Sexual Abuse curiosity or if it is in response to sexual abuse.Sexual abuse of a child may surface through a The following list of behaviors are indicatorsbroad range of physical, behavioral and social of sexual abuse and deserve further evalu-symptoms. Some of theses indicators, taken ation with a mental health provider and/orseparately, may not be symptomatic of sexual pediatric expert.abuse. They are listed below as a guide, and • Detailed and age inappropriate under-should be examined in the context of other standing of sexual behavior (especially by behavior(s) or situational factors.4 younger children). • Inappropriate, unusual, or aggressive sexu-History al behavior with peers or toys.• A child reports sexual activities to a friend, • Compulsive indiscreet masturbation to the classmate, teacher, friend’s mother, or exclusion of normal childhood activities. other trusted adult. The disclosure may be direct or indirect (“I know someone...”; • “Excessive” curiosity about sexual matters “What would you do if...?”; “I heard or genitalia (self and others). something about somebody.”) It is not • Any coercion, force, pain in putting some- uncommon for the disclosure by children thing in genitals of self or other child. experiencing chronic or acute sexual abuse to be delayed.• Child wears torn, stained, or bloody under- 4 clothing. State Office of Criminal Justice Planning Publication (now known as the Governor’s Office of Emergency Services), Medical Protocol for Examination of Sexual Assault and Child Sexual Abuse Victims, 2001Child Abuse Prevention Handbook 13
  21. 21. This list is only meant as a very brief guideline. Incestuous/Intrafamilial AbuseAny time a mandated reporter has a “suspi- Sexual abuse of children within the family iscion” of child abuse, whether the indicator is the most hidden form of child abuse. In spitementioned in this handbook or not, they must of its taboo and the difficulty of detection,report it to the proper authority. some researchers believe this abuse may be even more common than physical abuse.Behavioral Indicators in OlderChildren and Adolescents Incest means sexual activity between certain close relatives (e.g., parents and children, siblings,As discussed previously, children may exhibit new grandparents and grandchildren); intrafamilialor concerning behaviors for a number of differ- abuse means sexual activity between persons in aent reasons including child abuse as well as other family setting (e.g., stepparents, boyfriends).sources of childhood stress such as divorce, etc.Any child who exhibits drastic behavioral chang- In most reported cases, the father or anotheres, runs away from home, becomes aggressive, man acting as the parent is the initiator. Indepressed or exhibits delinquent behavior, has some cases, the mother or another womanfrequent school absences, or has a sudden drop is the offending adult. Although girls are thein school performance, becomes fearful of home most frequent victims, boys are also victims,life, becomes withdrawn, abuses alcohol or much more often than previously believed.drugs, becomes suicidal, deserves our attention. The embarrassment and shame deter girls andIf sexual abuse is suspected, it should be reported boys alike from reporting the child protective services or law enforcement. The initial sexual abuse may occur at any age,Physical Symptoms from infancy through adolescence. Sexual abuseIf a child has physical symptoms such as geni- may be followed by guilt provoking demands fortal discharge or infection, a sexually transmit- secrecy and/or threats of terrible harm or conse-ted disease, physical trauma or irritations to quences if the secret is revealed. The child maythe anal/genital area (pain, itching, swelling, then fear disgrace, hatred, or blame for breakingbruising, bleeding, lacerations, or abrasions), up the family if the secret is revealed.they should be evaluated by a trained medicalprofessional as well as possible involvement of Regardless of how gentle or forceful, or howchild protective services and law enforcement. trivial or coincidental the first approach may have been, sexual coercion tends to beHow to Get Help repeated and to escalate over a period ofAs discussed later in this handbook, most years. The child may eventually accept thecounties have a team of nurse practitioners blame for tempting and provoking the abuser.and/or doctors who are trained specialist inthe evaluation and diagnosis of sexual abuse. The mother, who would usually be expectedThese teams are usually available 24 hours to protect the child, may purposely try toa day to evaluate acute (less than 72 hours) stay isolated from a problem of sexual abuse.sexual abuse cases, and are associated with Sometimes she is distant and uncommunica-the local emergency room. Some hospitals tive, or so disapproving of sexual matters thatalso have child abuse experts who are able to the child is afraid to speak up. Sometimesanswer questions during the day. she is extremely insecure and the potential loss of her husband or partner, and the eco- nomic security he provides, is so threatening14 Child Abuse Prevention Handbook
  22. 22. that she cannot allow herself to believe oreven to suspect that her child is or could be Exploitation/Childat risk. She may have been a victim herself of Pornographychild abuse and may not trust her judgmentor her right to challenge the male authority. Internet ExploitationSome mothers actually know their children Children have always been vulnerable toare sexually abused, but for whatever reason, victimization, but with the wide use of thethey “look the other way.” computer, a whole new danger threatens children; with so many children online, today’sUntil the victim is old enough to realize that predators can easily find and exploit them. Byincest and intrafamilial abuse are not common the end of the year 2005, 77 million childrenoccurrences, and/or the victim is strong enough were online and that number is only obtain help outside the family, there is noescape unless the abuse is reported. Unfortunately, criminals are also using mod-Extrafamilial Sexual Abuse ern technology. Today, with so many children online, the Internet provides predators a newChildren who are abused by someone out- arena (cyberspace) to target children for crimi-side their family typically know their molester. nal acts. Because of its anonymity, rapid trans-They meet them at school, youth programs, mission, and unsupervised nature, the Internetchurches, in their neighborhood, or at other rec- has become the venue of choice for predatorsreational activities. People who molest children who transmit and receive child pornography.fall into all age categories, including pre-teensand the elderly. Although there are several clas- Today, the virtual playground of cyberspacesifications of child molesters, a pedophile pres- affords these child sexual predators the opportu-ents the greatest danger to children because a nity to engage children in anonymous exchangespedophile’s main sexual interest is a child. that often lead to personal questions designed to assess whether the child can be lured into sexualPedophiles tend to be well liked by children conversation and sexual contact. The nature ofand may choose work in professions or vol- Internet crimes presents new challenges for lawunteer organizations that allow them easy enforcement with regard to the collection ofaccess to children and where they can devel- evidence, and apprehending offenders. The fol-op the trust and respect of children and their lowing are just a few statistics that highlight theparents. They sometimes believe sex with severity of the problem:children is appropriate and even beneficial.Children may be lured into sexual relation- • One in 5 youths have received a sexualships with love, rewards, promises, and gifts. approach or solicitation over the internet; • One in 17 youth was threatened orMost cases of extrafamilial sexual abuse harassed in the past year;involve a perpetrator known to the child. • Only a fraction of all episodes was report-However, cases of abuse by strangers do ed to authorities such as the police, anoccur. Typically, in these cases the stranger internet services provider, or a hotline;will entice the child (“Will you help me findmy puppy?”), convince the child that his or • In households with home internet access,her parent requested the stranger to pick up only 1/3 of parents said they had filteringthe child, or simply abduct the child. or blocking software on their computers.Child Abuse Prevention Handbook 15
  23. 23. Regardless of law enforcement’s ability to • Tell your children to never give out theirdetect and arrest child sexual predators using address.the Internet, the most effective protectionagainst child victimization is an involved and The National Center for Missing and Exploitededucated parent. The following is a set of Children’s (NCMEC) Cyber Tipline serves as aguidelines recommended for parents regard- national resource for tips and leads regardinging their children’s use of the Internet: the sexual exploitation of children. NCMEC• Help children to understand why it is is a national clearinghouse for information important that they do not give out per- on cases of abducted, runaway, and sexually sonal information, even if their new e-mail exploited youth. NCMEC does not investi- pal seems to be real friendly, or a “cool” gate such cases, but receives leads and dis- web site offers them a free gift for the seminates them to various investigative law information. enforcement agencies. In the effort to assist• Let your children know they can come to law enforcement, NCMEC offers technical you if they are receiving messages that assistance, information dissemination, and make them feel uncomfortable. Tell them advice. NCMEC can be reached through the that in such an event, they should save the Internet at or by calling messages for you to read and handle in an their toll free hotline at 1-800-843-5678. appropriate manner. The Missing Children’s Program of the Office• Set up guidelines that deal specifically of Juvenile Justice and Delinquency Program with meeting people on the Internet. Talk (OJJDP) initiated its Internet Crimes Against to your children about what to do if their Children (ICAC) task force program where new Internet “friend” asks to see them in state and local law enforcement agencies person, or wants your children to send pic- can acquire the skills, equipment and person- tures of themselves. nel resources to respond effectively to ICAC• Teach your children about “netiquette” offenses. To learn more, please visit their web- (etiquette on the Internet), so that they site at: will not accidentally offend anyone, but will still protect themselves. NOTE: All mandated reporters are required• Keep the computer in a high traffic part to report suspected sexual exploitation. (For of the house such as the living room. You further details on these laws, see Addendum can then easily monitor your children’s III.) activities without making them feel as if you are watching over their shoulders all the time. Abuse of Children with• Find web sites you think your children will enjoy and “bookmark” them. This Disabilities will help direct your children away from Children with disabilities represent approxi- using search engines, where they might mately 15% of the child population. The first find inappropriate sites. national study conducted on the incidence of abuse of children with disabilities found that• Most importantly, spend time with your they are abused at approximately twice the children talking about their experiences rate of those in the general population.6 online. Give them a chance to show you A more recent and comprehensive study what they have learned or the things they published in 2001, conducted at Boys Town like.516 Child Abuse Prevention Handbook
  24. 24. University by Dr. Patricia Sullivan, found that same, but in some cases, children with disabil-the increased rate was 3.5 times that of ities may easily bruise or fracture themselves,children, in general.7 Yet, most profession- so care must be taken to understand theals estimate that the rates are much higher, disability when assessing whether abuse hassomewhere between 4 to10 times the rate.8 occurred. Communication issues are critical. Children are frequently able to communicateChildren may acquire serious and chronic dis- the abuse, but they are often disbelieved dueabilities through abuse, and then become to prejudice against or misunderstanding ofmore vulnerable. An estimated 25 percent individuals with disabilities. Use of assistedof children with developmental disabilities communication skills may be required, or theacquired the disability as a direct result of use of an interpreter may be necessary whenabuse.9 “Developmental Disability” is a legal conducting an interview.term defined in the Welfare and Institutionscode that established a network of Regional Children with physical disabilities as wellCenters throughout California to provide for as those with psychiatric, sensory (hearing,the needs of children and adults with “devel- vision), and communication (non verbal, lan-opmental disabilities.” The main theme of guage processing impairments) disabilities,“developmental disability” is that the disabil- have all been victims of abuse. Althoughity is of such significance that it interrupts the statistics indicate that physical assault is mostnormal developmental process of the child. frequently reported, sexual abuse is recog-This category of disability represents about nized as grossly under reported. Incest and5% of all children with disabilities. Child abuse perpetrated within the family mirrorsAbuse Neglect Disability Outreach is the that which occurs in the general population.only agency that provides wrap-around ser- Emotional and verbal maltreatment is also avices to children with other disabilities. serious problem among this population.Children with developmental disabilities (those In most cases to date, the perpetrators arethat impair the developmental process, such male, with the victims nearly equally dividedas mental retardation, autism, cerebral palsyand other physical disabilities) receive servicesfrom a wide array of professionals, and thus,are vulnerable to a much higher number of 5 Daniel Armagh, A Safety Net for the Internet: Protecting trusted individuals who may abuse them. In Our Children, American Prosecutor’s Research Institute’s National Center for Prosecution of Child Abuse.this population, 99 percent of the perpetra- 6 Westat Report: National Incidence Study on Abuse of tors are known to and trusted by the child Children with Disabilities, U.S. Department of Health and and family.10 In many cases, when the per- Human Services, 1991. 7 In Focus: The Risk and Prevention of Maltreatment of petrator is an approved service provider, the Children with Disabilities, National Clearinghouse on Child abuse is not reported. However, when discov- Abuse and Neglect Information, 2001. 8ered, the perpetrator is fired and frequently 9 James Garbarino, Special Children, Special Risks, 1989. N. J. Baladerian, Ph.D., unpublished research paper, 1991, moves to new employment or a volunteer prepared for Centers for Disease Control Conference onposition and continues the abuse. Prevention of Disabilities, Washington, D.C. Compiles all studies available in literature search on abuse of children Emotional and behavioral signs of abuse in with disabilities and disability caused by abuse and neglect. (A Nation’s Shame: Fatal Child Abuse and Neglect in the children with disabilities may differ from those United States, A Report of the U.S. Advisory Board on Child exhibited by children without disabilities due Abuse and Neglect, April 1995.) 10to differences caused by the disability. For Seattle Rape Relief, Special Education Curriculum on Sexual Exploitation, Seattle, WA; Developmental Disabilities Project, example, physical signs of abuse are the 1979.Child Abuse Prevention Handbook 17
  25. 25. between boys and girls. No single category of address issues of abuse as these relate to chil-persons is identified as perpetrators. Howev- dren with, transporters (bus drivers) do appear to rep-resent a high proportion of those convicted. Cultural DifferencesSome reports indicate that child abuse report- Our ideas concerning the parenting of chil-ing soars at ages five to six, when many chil- dren may contrast greatly with other cultures.dren enter school and come into contact with Cultural differences may become evident inmandated reporters. Children with disabilities various aspects of child rearing. Cultural defi-frequently stay within the school system until nitions of child abuse and neglect are wideage 22; however, after 18, their abuse would and varied. Therefore, the professional mustbe reported to Adult Protective Services. be aware of the discrepancies between our culture and others when assessing childrenMost children with disabilities receive spe- they suspect of being abused. There arecial educational services, either on a regu- times when the professional needs to makelar school campus or a separate school. decisions regarding whether to report childAlthough they are mandated reporters, many abuse, educate the parents, or simply acceptspecial education teachers believe that “no the practice as “different” and not harm-one would abuse a child with a disability” ful. The law does give the professional someand blind themselves to signs of abuse, and guidance in this area. According to Welfaredo not report what they observe. They may and Institutions Code section 16509, “Cul-attribute physical signs or behavioral changes tural and religious child rearing practices andto the disability, rather than recognize these beliefs which differ from the general com-as potential signs of abuse. Further, because munity standards shall not in themselves cre-some disabilities result in behaviors of aggres- ate a need for child welfare services unlesssion (toward self or others) there are increas- the practice presents a specific danger to theing reports that teachers and teacher aides physical or emotional safety of the child.”abuse children in the school system through Therefore, when a professional believes thatthe misuses of restraint procedures. a practice falls within the definitions of child abuse, it must be reported. If a mandatedInformation about abuse of children with dis- reporter is unsure about a particular culturalabilities is not familiar to many in the lay or practice, it is recommended they contact theirprofessional communities, which may leave local child protective services agency and dis-these children more vulnerable to abuse. The cuss their concerns. Since cultural practicessigns of abuse they display may be ignored or are so diverse, mandated reporters are strong-mistakenly attributed to the disability. Cases ly encouraged to receive cultural diversityare less likely to be reported, thoroughly training to better understand these practices.investigated, and prosecuted. Lack of seriousattention to the needs of disabled childrenthroughout the child abuse response systemis unique when compared to any other groupof child victims, and must be addressed. Inrecent years, more attention to this popula-tion has emerged with training programs forthose who respond to child abuse calls, andmodifications of training programs for man-dated reporters are currently underway to18 Child Abuse Prevention Handbook
  26. 26. What is Not Child Abuse?Mandated reporters often have questions 16509.1 are not considered child neglect.about situations that may or may not be child Not receiving specific medical treatment forabuse. Listed below are situations or circum- religious reasons (Pen. Code § 11165.2 (b)stances that are not considered child abuse is further codified in Welfare Institutionsfor purposes of the Child Abuse and Neglect Code 16509, which states, “…religious childReporting Act: rearing practices and beliefs which differ from the general community standards shall• Children fighting. Injuries caused by not in themselves create a need for child children fighting by mutual consent. (Pen. welfare services unless the practice presents Code, § 11165.6.) a specific danger to the physical or emotional• Reasonable force. Injuries caused by safety of the child.” reasonable and necessary force used by a • Voluntary sexual activity between peace officer acting within the scope of children under the age of 14. Voluntary his or her employment. (Pen. Code, sexual conduct between children who are § 11165.6.) Injuries caused by reasonable both under the age of 14 years and who and necessary force used by public school are of similar age and sophistication is not personnel to stop a disturbance that is a crime and need not be reported under threatening physical injury to someone or the Child Abuse and Neglect Reporting damage to property, for purposes of self- Act. (People ex rel. Eichenberger v. Stock- defense, or to obtain possession of weap- ton Pregnancy Control Medical Clinic, Inc. ons or other dangerous objects within the (1988) 203 Cal.App.3d 225; Planned Par- control of a child. (Pen. Code, § 11165.4) enthood Affiliates v. Van de Kamp (1986)• Corporal punishment. Spanking is not 181 Cal.App.3d 245.) considered child abuse, however, when • Pregnancy. Pregnancy of a minor, does “any person willfully inflicts upon any child not, in and of itself, constitute the basis of a any cruel or inhuman corporal punishment reasonable suspicion of sexual abuse. (Pen. or injury resulting in a traumatic condi- Code, § 11166, subd. (1).) Pregnancy may tion,” it is considered “unlawful corporal be cause for a report if the pregnancy was punishment” and must be reported. (Pen. conceived by a female under age 16 and a Code § 11165.4) male over 21. Similar consideration should• Medical treatment. An informed and be made for other evidence of sexual activ- appropriate medical decision (Pen. Code § ity including sexually transmitted diseases 11165.2 (b) and treatment by spiritual means including Gonorrhea, Chlamydia, Genital as provided by Welfare Institutions Code Herpes, genital warts and HIV.Child Abuse Prevention Handbook 19
  27. 27. • Past abuse of a child who is an adult at and is only determined after completing an the time of disclosure. There is no duty autopsy, a death scene investigation, and a to report child abuse unless the victim is a review of the case history of both the baby child, meaning a person under the age of and the family.11 SIDS is not contagious, 18 years. (Pen. Code, § 11165.) Accord- and is not caused by immunizations, suf- ingly, past abuse of a child who is an adult focation, or by child abuse or neglect. at the time of disclosure or discovery of the abuse need not be reported. However, if a Researchers and clinicians have discovered mandated reporter has a “reasonable sus- that although SIDS cannot be predicated or picion” due to the conversation with this prevented, there are things parents and care- adult that someone under the age of 18 givers can do to lower an infant’s risk of SIDS. has been abused or is in danger of being The Back-to-Sleep campaign, a national pub- abused, it must be reported. lic health educational effort, which began in• Maternal substance abuse and positive 1994, recommends that all babies be placed toxicology screen at birth. A positive on their backs to sleep, unless otherwise toxicology screen at the time an infant is instructed by a physician. Infant care prac- delivered is not, in and of itself, a sufficient tices that should be followed by parents to basis for reporting child abuse or neglect. reduce their baby’s risk for SIDS include the However, any indication of maternal sub- following: stance abuse shall lead to an assessment • Always place your baby on his/her back to of the needs of the mother and child pur- sleep, even for naps. suant to Health and Safety Code section 123605. If other factors are present that • Never allow smoking around your baby. indicate a risk to the child, a report must • Place your baby on a firm, flat surface to be made, but a report based on risk to sleep. a child that relates solely to the parent’s • Remove all soft things such as loose bed- inability to provide the child with regular ding, pillows, and stuffed toys from the care due to the parent’s substance abuse sleep area. shall be made only to county welfare departments and not to law enforcement • Never place your baby on a sofa, water- agencies. (Pen. Code, § 11165.13.) bed, soft chair, pillow, or beanbag.• Sudden Infant Death Syndrome (SIDS). • Take special precautions when your baby is SIDS is the sudden death of an infant in bed with you. under one year of age which remains • Make sure your baby doesn’t get too hot. unexplained after a thorough case inves- • Keep your baby’s face and head uncovered tigation including performance of a com- during sleep. plete autopsy, examination of the death scene, and review of the clinical history • Share this information with everyone who (Willinger, et al., 1991). It is the major cares for your baby. cause of death infants from one month to one year of age, with most death occur- ring between two and four months. SIDS occurs quickly and quietly in seemingly healthy infants, usually during sleep and happens in all social, economic, and ethnic groups. It is a recognized cause of death 11 What is SIDS. US Department of Health and Human Services, Maternal and Child Health Bureau, 2004.20 Child Abuse Prevention Handbook
  28. 28. Who are Child Abusers?Child abuse occurs in all cultural, ethnic, Early identification, reporting, and interven-occupational, and socioeconomic groups. tion are essential and vital to protect the childAlthough many people assume that parents because people who abuse typically repeatare the only culprits, children can become the abuse and increase its frequency.victims of abuse by persons in non-parentalrelationships, such as siblings, family friends, Over the years, studies have shown that aneighbors, acquaintances, or strangers. variety of factors are associated with childThose who abuse children may also be trusted abuse. Many of these factors apply to andto care for our children, such as teachers, characterize the general population (such aschildcare providers, or foster parents. They stress, social isolation, transiency, and othermay be male or female; they may be adults, factors discussed in this section). Child abuseadolescents, or children. is seldom the result of any single factor. Rather, a combination of circumstances andAccording to recent statistics, more than 80 personality types may precipitate an act ofpercent of perpetrators were parents. Other abuse. The existence of one or more of therelatives accounted for 7 percent and unmar- following factors could trigger abusive acts: aried partners of parents accounted for 3 per- predisposition toward maltreatment (perhapscent. The remaining percent includes persons as a result of having been abused, neglected,with other relationships, e.g., camp coun- or witnessing domestic violence); emotionalselors, school employees, or unknown rela- stress, such as marital or employment prob-tionships to the child. Female perpetrators, lems; substance abuse; a lack of constructivemostly mothers, are typically younger than outlets for tension, anger, or aggression; ormale perpetrators, mostly fathers. Women poor impulse control.also comprised a larger percentage thanmen, 58 percent compared to 42 percent.12 Many people cannot understand how a par-As previously reported, child abuse fatalities ent can abuse or neglect a child. Frequently,have increased over the past several years. In abusive parents or caretakers themselves2002, one or both parents were involved in79 percent of child abuse and neglect fatali-ties. Of the other 21 percent of fatalities, 16 12 National Clearinghouse on Child Abuse and Neglect percent were the result of maltreatment by Information, Child Maltreatment: Summary of Key Findings, non-parent caretakers, and 5 percent were 2003.from unknown person or persons.13 13 National Clearinghouse on Child Abuse and Neglect, Child Abuse and Neglect Fatalities: Statistics and Interventions, 2004.Child Abuse Prevention Handbook 21