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Home > The Role of Mental Health Professionals in the Prevention and Treatment of Child Abuse and Neglect > The Role of Mental Health Professionals in the Prevention and Treatment of Child Abuse and Neglect: Responsibilities of the Mental Health Professional
The Role of Mental Health Professionals in the Prevention and Treatment of Child Abuse and Neglect
User Manual Series (1993)
Responsibilities Of The Mental Health ProfessionalReport Child Abuse And Neglect The requirement to report child abuse and neglect became public policy in all States by 1965 with the passage of the first child abuse reporting law, which only required physicians to report physical abuse. Since that time, neglect, emotional abuse, and sexual abuse have been recognized as injurious to a child's physical and mental health, and reporting laws were amended to include these forms of child maltreatment. Those professionals required by law to make child abuse reports also expanded over the years to include teachers, nurses, mental health professionals, social workers, school custodians, day care providers, and others who are in regular contact with children. Mental health professionals are now required by law in all States to report child abuse and neglect. The specific language of the States' reporting laws varies, but they typically cover circumstances when one acquires knowledge of or observes a child under conditions that give rise to a reasonable suspicion of child abuse and/or neglect; or, when one has knowledge of or observes a child whom he or she knows has been the victim of child abuse and neglect. "Reasonable suspicion" definitions may vary, but it is generally considered to occur when it is objectively reasonable for a person to entertain such a suspicion, based on his or her training and experience. The primary intent of these reporting laws is to protect children from abuse and neglect. The child identified in the report may not be the only victim in the family; other children may be abused or at high risk of maltreatment. The purpose of the social services and/or law enforcement investigation is to evaluate the circumstances of all children in the family. In troubled families, parents need help but may not be able to directly ask for assistance. The report of abuse may be a catalyst for bringing about change in the home environment which, in turn, may help lower the risk of abuse or neglect in the family. The majority of States require that oral reports (telephone or in-person contacts) of suspected child maltreatment be made immediately to a specified authority, usually law enforcement or child protective services (CPS). Many States require that a written report follow the oral report. In other States, written reports are only required upon request. The time frame for submission of the written report varies from within 36 hours to 5 days after making the initial oral report. Reporting laws also contain provisions to protect the identity of the person making the report and protect reporters from civil lawsuits and criminal prosecution resulting from filing a report. Civil and criminal immunity is provided as long as the report is made in "good faith." Most States have criminal and financial penalties for failure to report, and there is also a risk of civil lawsuit liability for failure to report. By requiring professionals to report suspected child abuse and neglect and by adding financial, criminal, and civil penalties for noncompliance, States and the Federal Government have made a strong policy statement that protection of children is important in our society and that there is a legal obligation attached to professionals employed in these professions. In addition to State laws, most professional codes of ethics require that their respective disciplines report child abuse and neglect to authorities. Please refer to the chapter, "How Child Abuse and Neglect Is Defined," which contains operational definitions of child abuse and neglect, and the User Manual entitled A Coordinated Response to Child Abuse and Neglect: A Basic Manual, for further discussion of child abuse reporting laws. Resistance To Child Abuse Reporting Laws Making a report of suspected child abuse may be difficult. There may be doubts about whether the circumstances merit a report, how the parents will react, what the outcome will be, and whether or not the report will put the child at greater risk from angry parents. The best way to minimize the difficulty of reporting is to be prepared for the experience, to be knowledgeable about the reporting requirements, and to be aware of the CPS agency intake criteria and the response that is initiated by making a report. The most frequent concern about reporting is whether reporting severs the trust that the client must establish in therapy. Not reporting has a greater potential to sever trust because the clients who are abusing children are showing, in action or words, that they need help. The real question is, "How can clients trust the mental health professional who fails to recognize their needs and avoids helping them?" Parents who abuse children are out of control, and parents who neglect children need education and supportive services. For various reasons, the parents' internal controls and personal resources are unavailable to them. As a result, they need as many external controls and support as possible, until they are better able to utilize their own restraints and resources. The reporting law is an opportunity to set an external control and limit that clearly states, "The abusive or neglectful behavior is unacceptable and must stop." Most abusive parents do not want to hurt their children, and hurting them affects their own self-worth by reinforcing their worst fears about themselves. As the therapist models appropriate setting of limits, the parents may become better able to do the same with themselves and with their children. Most parents will feel relief because external controls or limits have been introduced to stop abuse. Offering a matter-of-fact caring approach counters the parents' sense of secrecy and shame about the incident(s). By not responding to parents' clues or statements, the therapist gives the message that he or she does not take the abuse seriously, believes that it will go away by itself, or is willing to collude in keeping the abuse hidden. Inappropriate Interventions
Whether To Tell The Client That The Mental Health Professional Is Making A Report The law does not require mandated reporters to tell the parents that a report is being made; however, in the majority of cases, advising the client is therapeutically advisable. First, the therapist is employing clinical leverage by using authority to set a firm and necessary limit. Reporting responds to the parents' nonverbal plea for help. The therapist can reassure the clients that steps will be taken to help the parents regain control so that the abuse does not lead to serious injury or emotional trauma to the child. Second, if the therapist does not mention the report, there is secrecy and tension, which may result in the clients' feelings of suspicion, isolation, or betrayal. In some cases, reporting may elicit an extreme response from the clients. It is contra-indicated to inform parents about the report if the individual seems psychotic, has poor impulse control coupled with a history of violent behavior, has a problem with alcohol or drugs, or is likely to flee. It can be very beneficial to give clients the opportunity to make the reports themselves in the therapist's presence. A self-report, however, does not negate the therapist's mandate to report.* Refer Children For Medical Evaluations Neglected, physically abused, and sexually abused children should be referred for a medical evaluation if they have not received an examination prior to referral of the case to the therapist. Some communities have hospital-based child protection teams that perform these evaluations. Other communities rely on local hospitals or physicians in private practice. Child sexual abuse medical/evidentiary examinations have emerged as a new form of medical expertise. Some States have protocols for medical examiners to follow. The purpose of the evaluation is to examine the child for forensic evidence of recent or chronic trauma, to assess the possibility of sexually transmitted disease and pregnancy, and to provide medical treatment. If a medical/evidentiary examination is not authorized by investigative agencies, a child should still be referred for a medical examination because children frequently have concerns that their body has been irreparably damaged by the sexual contact. Reassuring sexually abused children that their bodies are healthy is an important step in the recovery process. Mental health professionals are often concerned about revictimization of the sexually abused child through an insensitive medical examination. Sometimes they have made the assumption that these examinations are traumatic and have given this information to parents and children without having inquired about how the examinations are performed. This type of communication creates anxiety for the children, increases the difficulty of examining young children, and can prevent medical examiners from performing a complete medical examination. If these concerns exist, it is important to first inquire about the quality of these exams in the community and the philosophy and practices of the medical providers. If, after making inquiry, concerns still exist, the local medical society or criminal justice and social service agencies can be notified and requested to make an inquiry into local resources and practices and compare them to established children's or university hospital-based programs with expertise in sexual abuse medical/evidentiary examinations. Prevent Sexual Abuse Of Child And Adult Clients By Therapists Sexual contact between therapists and clients is considered ethical misconduct, and, in a few States, such activity is considered a criminal act subject to prosecution. In other States, sexual misconduct with clients is subject to review by licensing boards and is grounds for revocation of licensure. Civil suits have been successfully brought against therapists by their clients. Therapists knowledgeable about sexual misconduct by other therapists have an ethical duty to report this conduct to licensing boards and investigative agencies. Acquire Knowledge, Skills, And Expertise Through Training Expertise in the area of child abuse and neglect is best acquired through a combination of clinical supervision from experienced service providers, experience in actual treatment programs prior to practicing independently in the community, and training programs. Most training on child abuse and neglect is offered through Federal, State, and local professional associations, child abuse prevention organizations, or child abuse treatment programs. Establish Quality Assurance Practices And Standards Due to Federal and State funding requirements, community mental health clinics have established quality assurance standards. Community-based organizations may or may not have developed organizationally to this point. At a minimum, policies and standards regarding client intake and evaluation procedures, establishing treatment goals and plans, charting and record-keeping requirements, client confidentiality and release of information, and maintenance of records (including length of time records are kept after a client has completed receiving services) should be established. Clinical supervision and supervisor or peer review of client charts or records should take place on a regular basis. Mental health professionals working independently of an agency or clinic should consider regular clinical consultation groups with peers to stay in the mainstream of clinical practice and the literature and to avoid working in isolation Participate On a Multidisciplinary Team The need for multidisciplinary teams emerged over 30 years ago from the realization that no one discipline can successfully intervene in cases of child abuse and neglect cases. The first teams were established in 1958 at Pittsburgh Children's Hospital, the Children's Hospital in Los Angeles, and the University Hospital in Denver. Since 1958, the number of teams has grown throughout the United States. The focus of these university hospital-based child protection teams is to review all cases referred, provide training, and initiate research. Today there are many different types of multidisciplinary teams. Some teams focus on investigation of cases and are based in a public agency rather than a hospital. These teams concentrate on discussing new cases to review findings and actions by all personnel (e.g., medical examination findings, CPS, and law enforcement initial investigation results). Prosecutors sometimes serve on these teams to report on filing decisions. The purpose of this approach is to review cases to ensure a standard quality of intervention and coordination among agencies at the initial stages of a case. If high numbers of cases (20-30) are reviewed each week, there is limited feedback in the ensuing weeks as to individual case outcomes. Lower numbers of cases make outcome information feasible to obtain and discuss. Some communities have addressed this problem by establishing teams that specialize in different types of abuse (e.g., sexual, physical, or neglect). This approach, however, necessitates specialized personnel that only investigate one form of abuse--or assignment of personnel to more than one case review meeting per week. If the team has a dual mission of case review and case planning, it will also include a public health nurse, a mental health representative from a community mental health clinic, a child abuse treatment program, or a practitioner in private practice. The focus of this team is also influenced by the number of cases. If the team reviews a high number of cases each week, the focus of the discussion is a review of decisionmaking to date, with a case planning discussion limited to recommendations. If the number of cases reviewed is more manageable, the team will have time for case planning, feedback at later sessions regarding individual case outcomes, making additional recommendations, or revising case plans. A few communities have teams that take a retrospective look at decisionmaking and randomly select past cases for review to evaluate how the child protective system is working. Cases are randomly selected from three points in the system: child abuse reports, prosecutor filing decisions, and placement of children in foster care. The review has several purposes: (1) to identify systemic or thematic problems that occur repeatedly at the time of intake, investigation filing and prosecution decisions, child protective custody and release actions, and foster placements; (2) to assess the quality of case planning; and (3) to determine whether case plans were fully or partially implemented. The focus of the review is to identify systemic or thematic problems that occur repeatedly at intake, investigation filing and prosecution decisions, child protective custody and release actions, and foster placements; review the quality of case planning; and assess whether case plans were fully or partially implemented. Two new types of specialized multidisciplinary teams that have emerged are child death review teams and perinatal substance abuse teams. The purpose of child death review teams is to review all cases of child death in a community to determine whether they were abuse-related and, if so, to identify what could have been done to prevent the death. The purpose of perinatal substance abuse teams is to review cases of newborns with positive drug screens to evaluate whether the infants are at risk of abuse or neglect and to recommend needed social services. It is commonly recommended that mental health professionals serve on multidisciplinary teams. At the same time, it must be recognized that, in many communities, these teams have evolved and changed, and their focus has become driven by the numbers of cases. Caseworkers have become service brokers securing the services of a cadre of mental health professionals in private practice, and it is not practical to include all of them on a team. The basic premise of the team is that no one professional can respond to the complexity of these cases. In recognition of these changes, it is recommended that agency-based mental health professionals form review teams within their own organization and plan case reviews involving the families' caseworkers. Clinicians in private practice should consider regular case review meetings with caseworkers and peer consultation groups.
* This section on resistance was adapted from The California Child Abuse Reporting Laws: Issues and Answers to Professionals by Eliana Gil, Ph.D.
This material may be freely reproduced and distributed. However, when doing so, please credit Child Welfare Information Gateway. |
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