- » The Role of Professional Child Care Providers in Preventing and Responding to Child Abuse and Neglect
- » Recognizing Child Abuse or Neglect
The Role of Professional Child Care Providers in Preventing and Responding to Child Abuse and Neglect
Office on Child Abuse and Neglect, Children's Bureau. Karageorge, Kathy, Kendall, Rosemary|
|Year Published: 2008|
Recognizing Child Abuse or Neglect
Child abuse and neglect is a problem that affects children, families, and communities throughout the United States and is an issue that child care providers may encounter in their work. According to the National Child Abuse and Neglect Data System (NCANDS), which provides the most current statistics on child abuse and neglect, in 2006:
- An estimated 905,000 children were victims of abuse or neglect.
- An estimated 3.3 million referrals of abuse or neglect, concerning approximately 6 million children, were received by child protective services (CPS), which is the agency designated to receive and to act upon reports of suspected child abuse and neglect in most States. About 62 percent of those referrals were accepted for investigation or assessment.
- Nationally, 66.3 percent of child victims experienced neglect (including medical neglect), 16.0 percent were physically abused, 8.8 percent were sexually abused, and 6.6 percent were psychologically maltreated. Additionally, 15.1 percent of victims experienced "other" types of maltreatment, including abandonment and threats of harm to the child. (Note: the percentages total more than 100 percent because a child may have experienced more than one type of maltreatment.)
- Child care providers reported nearly one percent of all child abuse and neglect cases.3
In addition to the initial harm, repeated maltreatment can have permanent effects on children as they mature, such as:
- Low self-esteem;
- Behavioral problems;
- Learning difficulties;
- Abusiveness toward others;
- Inability to establish healthy sexual relationships as an adult;
- Promiscuity or prostitution;
- Increased incidences of running away from home;
- Increased rates of suicide;
- Involvement in criminal activity.
Given that child care providers spend a large portion of their day with children, they are in a good position to observe potential indicators of maltreatment. They may notice bruises, signs of malnutrition, aggressive behaviors, or other physical or behavioral indicators. This chapter is intended to help child care providers recognize possible child abuse and neglect, as well as the cultural differences regarding maltreatment.
Parents have a fundamental right to raise their children as they see fit, and society presumes that parents will act in their children's best interest. When parents fail to protect their children from harm or fail to meet their basic needs—as with cases of child abuse and neglect—society has a responsibility to intervene to protect the health and welfare of these children. Any intervention into private family life on behalf of young children must be guided by Federal and State laws, as well as sound professional and ethical standards.
The key principles guiding child protection are based largely on Federal statutes, primarily through the Child Abuse Prevention and Treatment Act (CAPTA) (P.L. 93-247) and the Adoption and Safe Families Act (ASFA) (P.L. 105-89). CAPTA was signed into law in 1974 and has been reauthorized by Congress every 5 years. It was reauthorized most recently on June 25, 2003, as part of the Keeping Children and Families Safe Act of 2003 (P.L. 108-36). CAPTA provides definitions and guidelines regarding child maltreatment issues.
ASFA was signed into law in 1997 and built upon earlier laws and reforms to promote the safety and well-being of maltreated children. ASFA promotes three national goals for child protection:
In addition, ASFA stresses the importance of the accountability of service delivery systems in achieving positive outcomes for children and families related to each of these goals.
Types of Maltreatment
There are four major categories of maltreatment: physical abuse, sexual abuse, psychological maltreatment, and neglect. Although each form of maltreatment can occur by itself, children are often the victims of more than one type of maltreatment. Maltreatment may result from extreme discipline or from punishment that is inappropriate for the child's age or condition or from parental immaturity or stress. When the caregiver knows a child's family is experiencing significant stressors, such information may be relevant and helpful to provide to CPS when maltreatment is suspected and a report made. The legal and professional requirements for making a report to CPS, as well as how to make a report, are discussed in Chapter 3, Reporting Suspected Child Abuse or Neglect.
The signs of maltreatment discussed throughout this chapter are only indicators of possible maltreatment and do not necessarily signify that maltreatment has occurred. Only a thorough investigation by CPS or other authorities can determine if a case of maltreatment is founded. Additionally, it is important to remember that the possible signs of maltreatment also can be signs of other problems, such as a child's medical condition, a reaction to divorce, or the witnessing of domestic violence.
Physical abuse of children includes any nonaccidental physical injury caused by the child's parent or a nonparental caregiver. It may include injuries sustained from being burned, beaten, kicked, punched, bitten, or hit, or from other types of physical attack. While the injury is not an accident, neither is it necessarily the intent of the child's parent or caregiver to injure the child. Children younger than 5 years of age are at the highest risk for injury or death resulting from physical abuse because their bodies are not fully developed.5
Children typically receive bruises or other injuries during the normal course of play or while being active; additionally, some children are less coordinated than others and may have more bruises, cuts, or scrapes. The areas that are bruised most commonly during normal play include the leading or bony edges of the body, such as knees, elbows, forearms, or brows. The soft tissue areas, such as cheeks, buttocks, and thighs, are not normally injured in such circumstances. Additionally, bruises received during the normal course of childhood activity rarely are in distinct shapes, such as a hand, belt buckle, or adult teeth marks. Bruises in soft tissue areas or in distinct shapes may be indicative of physical abuse.6
There often are physical or behavioral cues that a child is being abused. The physical signs of possible physical abuse include:
- Extensive bruises, especially in areas of the body that are not normally vulnerable;
- Frequent bruises, particularly on the head or face, the abdomen, or midway between the wrist and elbow;
- Bruises in specific shapes, such as handprints or belt buckles;
- Marks that indicate hard blows from an object like an electrical cord;
- Bruises on multiple parts of the body;
- Bruises or welts in various stages of healing;
- Unexplained or repetitive dental injuries;
- Unexplained or multiple broken bones;
- Major head injuries (e.g., severe skull fracture);
- Extreme sensitivity to pain or complaints of soreness and stiffness;
- Bald spots from hair pulling;
- Adult-sized human bite marks;
- Burns from objects such as an iron, cigarettes, or rope;
- Immersion burns from having certain body parts held in very hot water (e.g., sock- or glove-like burns on the child's feet or hands).7
Abuse directed to the abdomen or the head often is undetected because many of the injuries or their effects, such as dizziness, internal bleeding, or swelling of the brain, may not be externally visible. For example, the effects of shaken baby syndrome, which is the violent shaking of a child, can cause severe damage in children, but may not be immediately apparent.
The behavioral signs that children possibly are being physically abused include:
- Being aggressive, oppositional, or defiant;
- Cowering or demonstrating fear of adults;
- Exhibiting destructive behaviors toward oneself or others;
- Repeatedly being reluctant to go home, which may indicate a possible fear of abuse at home;
- Being described as "accident prone;"
- Wearing clothing that may be inappropriate for the season (e.g., long-sleeve shirts and pants in summer) to conceal injuries;
- Having persistent or repetitive physical complaints, such as a headache or a stomachache, of an unclear cause;
- Disliking or shrinking from physical contact.8
When making reports to CPS or law enforcement, child care providers should acknowledge if they have witnessed or know if any of the following behaviors have occurred:
Case Example of Suspected Physical Abuse
Justin, aged 2 years, arrived at his child care program with multiple burn marks on his back and legs. Justin was active and occasionally came to child care with bumps and bruises. However, the burns were of particular concern because of their size and number. When the caregiver asked the father about the burns, he said that Justin bumped into the space heater at home, which caused the burn marks. The caregiver realized that the burns did not look like those that might have occurred from bumping into a space heater. Given the extensiveness of Justin's burns, the caregiver determined that a call must be made to CPS to report the suspected abuse.
Sexual abuse is defined as adult sexual behavior with a child. It can include fondling a child's genitals, making the child fondle the adult's genitals, intercourse, incest, rape, sodomy, exhibitionism, sexual exploitation, or exposure to pornography. Sexual abuse may be committed by a person younger than age 18 when that person is either significantly older than the victim or when the perpetrator is in a position of power or control over the child. Sexual abuse may take place within the family (referred to as incest), by a parent's boyfriend or girlfriend, or by an adult caretaker outside the family (e.g., a family friend, a babysitter). Contrary to the common assumption that sexual abuse is perpetrated most often by strangers, the abusers usually are known to the children and have relationships with them.10 Victims and perpetrators also come from all races, creeds, and socioeconomic backgrounds.
The impact of sexual abuse on a child depends upon many factors, such as the identity of the perpetrator, the amount of force or betrayal involved, the duration and the frequency of the abuse, and the child's age and individual personality. When children know the perpetrator, the feelings of betrayal when they realize that they have experienced abuse may be more disturbing than the abuse itself. Boys are as vulnerable to sexual abuse as girls, although they are not as likely to report the abuse.11 One problem in detecting sexual abuse is that its warning signs also may be indicative of other issues, such as an illness or a response to a difficult family situation. There are a number of physical indicators of possible sexual abuse, including:
- Difficulty or pain in walking, running, or sitting;
- Recurrent urinary tract infections;
- Problems with urination;
- Frequent yeast infections;
- Pain, itching, bruises, bleeding, or discharges in the genital, vaginal, or anal areas;
- Venereal diseases;
- Unexplained gagging;
- Torn, strained, or bloody underwear.12
In addition to physical signs, there are a number of behavioral signs that might indicate possible sexual abuse in children, including:
- Compulsive interest in sexual activities;
- Exceptional secrecy;
- Being overly compliant or withdrawn;
- Engaging in destructive behavior to self or to others;
- Fear of the abuser or an inordinate fear of a particular gender;
- Regressive behaviors, such as bedwetting, soiling, and thumb sucking;
- Reported sleep problems or nightmares;
- Showing fear or resistance at naptime;
- Sudden fearful behavior;
- In-depth or unusual sexual knowledge or behavior with peers that is developmentally inappropriate;
Other psychological and emotional symptoms common among children who have been sexually abused may include acting confused, withdrawn, fearful, or depressed. Sexually abused children may complain of psychosomatic symptoms, such as headaches, stomachaches, or a lack of appetite, and they may exhibit extreme mood changes.
Child care providers should be aware of other indicators of possible sexual abuse, such as children drawing unusual pictures involving children with no mouths or hands or explicit drawings of genitalia or sexual acts. Additionally, many children are so overwhelmed in dealing with their conflicts over the abuse that they may lack the energy to play or to participate in normal activities.
Sexually abused children may keep the abuse secret for many reasons. Some victims, such as infants and toddlers, are so young that they cannot communicate anything about the abuse nor understand what is happening to them. Slightly older children may have better verbal skills, but may be so afraid, confused, or conflicted about the abuse that they are unsure of whom to tell or of what to say. Many times, the perpetrator may have threatened them, their families, or their pets. Finally, many children may not say anything because they feel they are to blame for the situation or fear that no one will believe them if they do say something.
Sexually abused children may "tell" of their abuse by sexually acting out. Children, even very young ones, who are being or have been sexually abused will sometimes be sexually inappropriate or abuse their peers or younger children. This may be their way of trying to make sense of the abuse they have received. They are mimicking the behavior they have learned. By learning that they can often receive attention through sexualized behavior, they may also approach adults in this manner by assuming that this is what all adults want from them.
Case Example of Suspected Sexual Abuse
Cindy, a 4-year-old, often wants to play games involving sexual activities. Most recently, she sat on top of one of her classmates and imitated sexual intercourse. Her child care provider has noticed how often Cindy wants to play kissing games and doctor and nurse games, but initially thought that this was part of normal child curiosity. However, Cindy's sexual behavior continues to mimic that of adults and is becoming more aggressive. Cindy's child care provider is concerned that Cindy is being exposed to sexual activity or material or otherwise being sexually abused and reports the suspected abuse to CPS.
Psychological maltreatment, also called emotional abuse or maltreatment, includes belittling, rejecting, isolating, terrorizing, or ignoring a child.14 When adults constantly criticize, stigmatize, or belittle their children, it can have a negative effect on the children's behaviors, feelings, and thoughts.15 This type of maltreatment typically is accompanied by other types of maltreatment and rarely occurs as a one-time incident.16 It is possible for some children to internalize psychological maltreatment so thoroughly that its effects show up through developmental lags, psychosomatic symptoms, phobias, and other effects, but psychological maltreatment is most often indicated by the children's behavior.
Some of the physical indicators of possible psychological maltreatment include:
- Eating disorders;
- Self-abusive behaviors (e.g., head banging, pulling one's hair);
- Sleep disorders (e.g., nightmares);
- Developmentally inappropriate bedwetting;
- Speech disorders;
- Failure to thrive due to nonmedical causes.
The behavioral indicators of possible psychological maltreatment may include:
- Extremes in behaviors (e.g., very aggressive or passive);
- Excessive dependence on adults;
- Fear of a parent or generalized fearfulness;
- Belief that the maltreatment is their own fault;
- Habit disorder (e.g., excessive sucking, biting, rocking);
- Depression or crying easily;
- Withdrawal or decreased social interaction with others;
- Numerous "I can't" statements;
- Running away from home;
- Aggression or unexplained temper tantrums;
- Blank or empty facial expression a great deal of the time.17
It is important to note that psychological maltreatment and poor parenting or caregiving are not the same.18 Any parents and caregivers may behave at some point in a way that is psychologically hurtful to children in their care. Psychological maltreatment, however, usually occurs when the hurtful behavior becomes a consistent or chronic caregiving style.
Case Example of Suspected Psychological Maltreatment
Edward, a 3-year-old, recently started at a new child care program. His mother is 23 years old and single, and Edward is her only child. Each day when Edward's mother drops him off, she tells him to behave or else she will not pick him up in the afternoon. Also, while Edward was present, she recently told one of the child care providers that he must be "stupid" because she has tried to potty train him, but he "can't get the hang of it." She added that life would be so much better if Edward had never been born.
In this example, Edward's mother believes that he cannot do anything right. Edward runs the risk of developing depression and low self-esteem if other adults in his life do not intervene and assist the mother in understanding her behaviors and how they may affect her young son. The child care provider talked with the program director, and together they called a parenting education service provider to discuss how best to proceed with the mother.
CPS is paying increased attention to children who witness or who are exposed to domestic violence. Some jurisdictions recognize and identify this as a form of child maltreatment. According to the National Center for Children Exposed to Violence, at least 3 million children each year witness domestic violence.19 Research has shown that children exposed to domestic violence are at an increased risk of being abused or neglected. Although it can be difficult to detect a child's exposure to domestic violence, child care providers should be mindful of the following characteristics in a child:
For more information on the relationship between child maltreatment and domestic violence, refer to the User Manual Series publication Child Protection in Families Experiencing Domestic Violence.
Because neglect typically leaves no visible scars, it is more difficult to detect than physical abuse. Child neglect usually is defined as omissions in care resulting in significant harm or in the risk of significant harm to children.21 Neglect involves the caregiver's inattention to the basic needs of a child, such as food, clothing, shelter, medical care, and supervision. While physical abuse tends to be episodic, neglect tends to be chronic. Neglect is the most common type of maltreatment that children experience and has consequences that can be just as serious as physical abuse.22 Approximately two-thirds of maltreatment victims were neglected, and it is the leading cause of fatalities due to child maltreatment.23 When children die from neglect, it is often because they have been without proper nourishment, medical treatment, or supervision.24 Additionally, acute instances of neglect, such as leaving a young child unsupervised in a bath tub, near a pool, in a room with a loaded gun, or in some other potentially dangerous environment, may lead to a child's death.25
Caregivers may not provide proper care for a variety of reasons, including a lack of knowledge or understanding about meeting the child's needs, an inadequate bonding with the child, or an impairment due to substance abuse or mental illness. Although there are cases of co-occurring maltreatment and poverty, living in poverty, in and of itself, does not mean that a child is being neglected.
There are numerous categories of neglect, including physical, emotional, educational, developmental, medical, prenatal, environmental, or nutritional.26 While most of these types of neglect are associated with parents or guardians, some types, such as environmental, also may be applicable to child care providers. Maltreatment in child care programs is addressed in more depth in Chapter 4, Minimizing the Risk of Maltreatment in Child Care Programs.
The physical signs of possible neglect include:
- Height or weight that is significantly below the accepted standards of physical development;
- Wearing inappropriate clothing for the weather;
- Poor physical hygiene;
- Scaly skin and dark circles under the eyes;
- Fatigue or listlessness.28
Behavioral signs of possible neglect include:
- Refusal to go home;
- Stealing, begging, or hoarding food;
- Dependency on teachers or alternate caregivers to meet basic needs;
- Withdrawal and depression;
- Intense feelings of inferiority, guilt, embarrassment, shame, or anger.
A specific category of physical neglect is nonorganic (i.e., no medical basis) failure-to-thrive. Nonorganic failure-to-thrive occurs when the parent or the caretaker fails to provide the nurturing atmosphere the child needs to grow and to do well.29 Signs and symptoms that a child may have nonorganic failure-to-thrive include:
- Being thin and emaciated;
- Having limp, weak muscles;
- Having cold, dull, pale, or splotchy skin;
- Seeming to be tense and miserable or apathetic and withdrawn;
- Appearing to be insensitive to pain or having self-inflicted injuries;
- Wetting the bed at a developmentally inappropriate age;
- Eating or drinking from the garbage can, toilet bowl, or a pet's dish;
- Experiencing insomnia or disrupted sleep, typically due to hunger.30
Children with nonorganic failure-to-thrive may require repeated hospitalizations to determine whether they can gain weight and thrive when cared for by alternate caregivers, such as the hospital personnel. If the children are at risk for harm due to a lack of nourishment, they may be placed in foster care until the families can provide these basic needs.
|For more information on neglect, refer to the user manual Child Neglect: A Guide for Prevention, Assessment, and Intervention.|
Case Example of Suspected Neglect
Janet is 8 months old, and her child care provider has been increasingly concerned about Janet's diaper rash. Janet's mother has not provided diapers for Janet as required. In addition, the provider has noticed that Janet's diaper is very heavy when she is dropped off in the morning. For the past month, Janet has had a severe diaper rash that has not improved. When the child care provider discussed the diaper rash with Janet's mother, the mother replied that it would go away on its own and that she did not have the time or the money to treat it. When the diaper rash continued to get worse, the child care provider discussed the matter with her supervisor, and together they began to implement the established policies for reporting child abuse and neglect.
This example is a case of neglect in which the child's basic needs are not being met. Factors that may affect the mother's lack of attention to Janet's rash include: the mother may have a developmental delay, a mental illness, or a substance abuse problem; may never have learned how to care properly for her child; or may not have the money to pay for additional diapers or diaper rash ointment. After being contacted, CPS will meet with the mother to determine the cause of her inaction and provide services accordingly.
Some cultures follow practices that may physically hurt children to the point of what some might consider abuse. Many of these cultural practices are steeped in tradition and are considered normal by that culture. Cultural practices that may physically hurt children include moxibustion (an Asian folkloric remedy using a burning cone or stick that may cause the skin to burn) and coining (in which the body is rubbed vigorously with a coin, which causes bruising, in an effort to treat a particular illness).31
It is important that caregivers learn about any of the cultural groups represented in their homes or child care centers.32 In responding to suspected physical abuse in ethnic minorities, caregivers and CPS caseworkers should take cultural practices into account. For example, a child in a family that recently immigrated to the United States might be disciplined by being struck in the back of the legs with a stick, which leaves a mark; this practice is common in the family's native country. In the United States, however, it is generally regarded as maltreatment—and should be reported as such—but other factors, such as the family's culture, ethnicity, awareness of the different standards of discipline and care, and openness to change, should be considered when determining which interventions are most appropriate.33
Even when cultural values conflict with State laws, the child care provider is still legally mandated to report the suspected abuse. Where certain culturally based behaviors are seen as abusive, it usually is the practice of CPS to try to educate the parents about the laws and to work with them. Since States vary in their view of certain cultural practices, it is the responsibility of the proper authority (e.g., CPS, law enforcement) to determine if a practice is defined as abuse.
|For more information on cultural competency, visit Child Welfare Information Gateway at http://www.childwelfare.gov/systemwide/cultural/.|
Case Example of Cultural Differences
Huong, a 4-year-old female of Malaysian descent, showed her child care provider the bruising pattern on her back from a recent coining. Huong told her that the coining was to help her heal from a stomach illness that she had recently. The caregiver was upset by the bruising, but understood and respected the cultural significance of coining. Because there was a concern about this practice hurting the child, however, the caregiver was legally mandated to report the case to CPS for a professional assessment.
Observation is basic to everything that child care providers do in their work. It helps them learn about children so that they can measure each child's progress and acquisition of skills.34 Over time, the written records of these observations provide a history of the children's lives in child care, as well as an insight into their development, strengths, needs, and interests. If a child's behavior changes suddenly, reviewing the records might help the providers to understand the causes for this shift in behavior. Since these records can be subpoenaed if there is a child abuse or neglect investigation, they should be concise and objective.
Child care providers should observe the children at different times of the day, when the children are alone and with other children, and in different settings. Children may behave quite differently during a diaper change compared to when they are playing or listening to a song. When taking notes, the child care provider should be as objective as possible so that facts, rather than opinions, are recorded. Rather than writing, "Jill was very selfish when she stole Tammy's toy," the provider should note, "Jill took Tammy's stuffed animal while Tammy was playing with it." Although child care providers have busy schedules, it is important for them to find time to go over their observations and to discuss their thoughts and concerns with colleagues and supervisors.
In addition to being used in planning, in evaluating, and in reporting to parents the child's behavior and activities throughout the day, these records can be used to identify possible signs that a child has been abused or neglected. For example, if a child care provider observes potential signs of abuse or neglect, the provider can review notes from previous observations to see if the child's behaviors follow a certain pattern. This may also assist CPS, if it becomes involved.
In addition, caregivers may want to explore the causes of changes in behavior. For example, if a normally at-ease child recently has been throwing temper tantrums during mealtimes and cries hysterically during diaper changes, the caregiver might want to understand what may be happening at home that could cause this sudden change in behavior.
This material may be freely reproduced and distributed. However, when doing so, please credit Child Welfare Information Gateway.