Child Abuse Nursing Case Study

Case Study: Legal, Ethical, and Clinical Perspectives on the Health Care Professional's Response to Child Sexual Abuse

AB, a 15 year-old recent immigrant from the Middle East, presented to her primary care provider with abdominal pain. During her exam, she disclosed sexual activity a few weeks prior by her uncle (mother’s brother), who lives in the same community as her immediate family. She was referred to Dr. Bradley, a physician in a special child abuse and neglect treatment clinic based at a local hospital for further evaluation. During her intake examination with Dr. Bradley, she strongly emphasized that she did not want her family or the police to be notified about the sexual activity. Dr. Bradley, however, felt obligated to report the situation to child protective services; child protective services would then notify the police. The teen became distraught and explained that she “could handle” her uncle, but feared what would happen if her family was alerted. She explained that it was customary in her culture for the family of an affected female child to carry out a vendetta against an abuser, which would force her mother to do something horrible to her own brother. Dr. Bradley however is concerned about the teen’s physical and emotional well being, and the risk of serious harm from continued abuse. What should Dr. Bradley do?

LEGAL ANALYSIS (NYS PERSPECTIVE)

Suspected child abuse raises several legal issues, foremost among them the mandatory reporting duties of physicians. Physicians are among the list of identified individuals who are mandated to report an instance of child abuse if having reasonable cause to believe the patient is a minor and has been abused. Actual proof of abuse is not required; reasonable suspicion is sufficient. There is no specific distinction between physical and sexual abuse in NYS law; both are covered under mandatory reporting of child abuse. Key is that the child abuse (on someone under the age of 18) results in serious risk of injury, serious or on-going injury or disfigurement, or serious or on-going impairment to physical or emotional health. It is also worth noting that NYS criminal law distinguishes between statutory rape of someone 14 or younger and sexual abuse. Law does not limit reporting to suspected abuse by family members; non-relatives may also be considered.

The law will then look to see if the suspected abuser fits certain characteristics: Did a parent, guardian, custodian or other person legally responsible inflict or let be inflicted that abuse? Custodians include someone who is routinely in the same household as the child, which may include AB’s uncle. And, other person legally responsible is defined to include a legal adult responsible for the child’s care “at the relevant time” (e.g., daycare providers or coaches). If the uncle is given this sort of responsibility by AB’s mom, he could also fit the definition. Notably, NYS law gives wide berth to physicians to report if they have reasonable cause behind their beliefs (high presumption of “good faith” reporting), without requiring extensive research. If Dr. Bradley has reasonable cause to believe this is a reportable abuse case, she must first immediately make an oral report to the local Child Protective Services agency (CPS) or to the state Central Register of Child Abuse and Maltreatment. Within 48 hours, she must also submit a written report to the local CPS.

In sum, the law places the safety of children as paramount in matters of suspected abuse; thus the “mandatory” nature of reporting. While this may seem onerous, it seeks to remove possible bias from seeping into reporting. Dr. Bradley should also consider the ability of AB to consent to STD treatment, family planning services, and to some mental health counseling, and also to confidentiality obligations that attach to such treatment.

ETHICAL OBLIGATIONS

Both the primary physician and the consulting pediatrician, by virtue of establishing doctor-patient relationships with AB, owe her respect for her privacy and compliance with her wishes for confidentiality, unless her actions lead to harm to herself or specific others. If either physician were to talk with AB’s mother or uncle against AB’s wishes, AB might not seek medical care in the future, such as evaluation of physical trauma, evaluation and treatment for STDs, and prenatal care if she becomes pregnant. Regarding AB’s future well being, both physicians should offer or arrange counseling about safe sex, contraception, options for pregnant teens, and community shelters/resources such as Vera House.

While teens may exaggerate the harms from parental notification, more needs to be learned about AB’s family and culture: her concerns should not be minimized or ignored. AB should be told that child abuse requires reporting and what the consequences of reporting may be, such as legal action against her uncle for abuse. If there are concerns about any discretion in reporting a particular case, hospital social work should be consulted. Physicians caring for children usually require parental consent for treatment. Some physicians will not see minors without parental consent, although the law in New York State does not require parental notification or consent for the evaluation of STDs, pregnancy, medical and mental health emergencies and treatment of drug abuse.

Since parents generally have the well-being of their children at heart and children may not have the maturity/capacity to truly understand complex medical scenarios, physicians have dual responsibilities to both their minor patients and their patients’ parents. In sum, to the degree possible allowed by the law, AB’s privacy and confidentiality must be protected, while striving to minimize any future harm through patient education and mandated reporting.

CLINICAL COMMENTARY

In some cases as in the above example, the investigation itself may become a concern due to the potential for creating a negative impact on the child and family. The primary care provider’s role is to work with the child abuse specialist and the various agencies to anticipate problems and to assist the family in reaching the best possible outcome for the child or adolescent.In the situation described, AB was referred by her primary care provider to another MD, a child abuse specialist, prior to anyone’s reporting to the state hotline. It is actually the legal responsibility of the primary care provider to report suspicions to child protective services prior to referral for a medical child abuse evaluation. Referral does not eliminate the obligation of the primary care provider to ensure that a report is made when there are suspicions.

Occasionally, situations arise like the above where the ethical and legal concerns may seem to contradict each other and hospital social workers or further evaluation by a child abuse specialist may be helpful. However, the physician who willfully does not report a suspicion of abuse (no matter how small) is guilty of a Class A misdemeanor. Physicians often feel they need to have a diagnosis of abuse. However, reporting of child abuse does not require a diagnosis of abuse, but merely a suspicion of abuse. Further investigation and the final determination should be left to the authorities.

—Amy T.Campbell, Joel Potash, Ann Botash

About Bioethics in Brief

Bioethics in Brief is a newsletter of the Center for Bioethics and Humanities. The Center, established through the generous support of the Medical Alumni Association, is committed to promoting clinical health care and health policy which is patient-centered, compassionate, and just.

Editorial Staff

Deirdre Neilen, PhD
Robert S. Olick, JD, PhD
Lauren Zahn, MA

Opinions expressed in the newsletter are those of the authors and do not represent the position of the Center. Information about sources used in the newsletter can be obtained by calling us at 315-464-5404.

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Reporting Numbers Resource List is from Child Welfare Information Gateway (2016): Information Updated as of Thursday, May 26, 2016 unless otherwise noted.

Alabama Department of Human Resources

50 North Ripley Street

Montgomery, Alabama 36130

Phone: (334) 242-1325

Email: fsd@dhr.alabama.gov

 

Alaska Department of Health and Social Services

130 Seward Street

Suite 400

Juneau, Alaska 99811

Phone: (907) 465-3548

Email: hss.ocscommunications@alaska.gov

 

Alaska Office of the Ombudsman

PO Box 102636

Anchorage, Alaska 99510-2636

Phone: (907) 269-5290

Fax: (907) 269-5291

 

Arizona Ombudsman-Citizens' Aide

3737 N. 7th Street

Suite 209

Phoenix, Arizona 85014

Phone: (602) 277-7292

Toll-Free: (800) 872-2879

Fax: (602) 277-7312

Email: ombuds@azoca.gov

 

Arizona Department of Economic Security

CPS Family Advocate

Phone: (602) 364-0777

Toll-Free: (877) 527-0765

 

Arkansas Department of Human Services

Client Advocate

Donaghey Plaza, PO Box 1437

Little Rock, Arkansas 72203

Phone: (501) 683-2735

 

California Department of Social Services

744 P Street, M/S 3-90

Sacramento, California 95814

Phone: (916) 651-8100

 

California Ombudsman for Foster Care

744 P Street, MS 8-13-25

Sacramento, California 95814

Toll-Free: (877) 846-1602

Email: fosteryouthhelp@dss.ca.gov

 

Colorado Department of Human Services

1575 Sherman Street

Denver, Colorado 80203

Phone: (303) 866-4511

Fax: (303) 866-5563

Email: cdhs.communcations@state.co.us

 

Office of the Child Protection Ombudsman

Phone: (303) 864-5111

 

Connecticut Department of Children & Families

Ombudsman Office

505 Hudson Street

Hartford, Connecticut 06106

Phone: (860) 550-6301

Toll-Free: (866) 637-4737

Fax: (860) 560-7086

 

District of Columbia Child and Family Services Agency Youth Ombudsman

200 I Street, SE

Washington, District of Columbia 20003

Phone: (202) 442-6100

Fax: (202) 727-6505

Email: cfsa@dc.gov

 

Florida Department of Children and Families

County Client Relations’ Coordinators

Phone: (850) 487-1111

 

Georgia's Office of Child Advocate

270 Washington Street S.W.

8th Floor, Suite 8101

Atlanta, Georgia 30334

Phone: (404) 656-4200

Fax: (404) 656-5200

Email: tboga@oca.ga.gov

 

Hawaii Office of the Ombudsman

465 South King Street, 4th Floor

Honolulu, Hawaii 96813

Phone: (808) 587-0770

Fax: (808) 587-0773

 

Illinois Advocacy Office for Children and Families

406 East Monroe Street

Springfield, Illinois 62701

Phone: (217) 524-2029

Toll-Free: (800) 232-3798

TTY: (800) 513-4980

 

Indiana Department of Child Services (DCS) Ombudsman Bureau

402 W. Washington, W479

Indianapolis, Indiana 46204

Phone: (317) 234-7295

Email: DCSOmbudsman@idoa.in.gov

 

Iowa Office of Citizens' Aide Ombudsman

Ola Babcock Miller Building

1112 East Grand

Des Moines, Iowa 50319

Phone: (515) 281-3592

Toll-Free: (888) 426-6283

 

Kansas Department of Children and Families - Foster Parent and Youth Ombudsman

Toll-Free: (844) 279-2306

Email: fosterparent@dcf.ks.gov

 

Kentucky Cabinet for Health and Family Services

Office of the Ombudsman

275 East Main Street, 1E-B

Frankfort, Kentucky 40621

Phone: (502) 564-5497

Toll-Free: (800) 372-2973

Email: AndreaT.Day@ky.gov

 

Louisiana Department of Children & Family Services

627 North Fourth Street

Baton Rouge, Louisiana 70802

Phone: (225) 342-2297

Fax: (225) 342-2268

 

Maine Ombudsman Program

Maine Child Wel­fare Ser­vices Ombuds­man

Phone: (207) 213-4773

Toll-Free: (866) 621-0758

Email: ombudsman@cwombudsman.com

 

Maryland Department of Human Resources

State Constituent Services

311 West Saratoga Street

Baltimore, Maryland 21201-3521

Toll-Free: (800) 332-6347

Email: dhr-help@dhr.state.md.us

 

Massachusetts Department of Children and Families Ombudsman

24 Farnsworth Street

Boston, Massachusetts 02210

Phone: (617) 748-2444

 

Michigan Office of Children’s Ombudsman

P.O. Box 30026

Lansing, Michigan 48909

Phone: (517) 373-3077

Toll-Free: (800) 642-4326

Fax: (517) 335-4471

Email: childombud@michigan.gov

 

Minnesota - The Office of the Ombudsperson for Families

1450 Energy Drive

Suite 106

St. Paul, Minnesota 55108

Phone: (651) 603-0058

Toll-Free: 1-888-234-4939

Fax: (651) 643-2539

 

Mississippi Department of Human Services

Office of Consumer Services

750 North State Street

Jackson, Mississippi 39202

Phone: (601) 359-4414

Toll-Free: (800) 345-6347

Email: consumer.services@mdhs.ms.gov

 

Missouri Office of Child Advocate

PO Box 809

Jefferson City, Missouri 65102

Toll-Free: (866) 457-2302

Fax: (573) 522-6870

Email: oca@oca.mo.gov

 

Montana Child and Family Ombudsman

Helena, Montana 59604

Toll-Free: (844) 252-4453

Email: DOJOMBUDSMAN@mt.gov

 

Nebraska Public Counsel (Ombudsman's Office)

Public Counsel (Ombudsman's Office)

PO Box 94604

Room 807, State Capitol

Lincoln, Nebraska 68509-4604

Phone: (402) 471-2035

Toll-Free: (800) 742-7690

Email: ombud@leg.ne.gov

 

Nevada Division of Child and Family Services

Systems Advocate

4126 Technology Way, 3rd Floor

Carson City, Nevada 89706

Phone: (775) 684-4453

Email: systems.advocate@dcfs.nv.gov

 

New Hampshire Department of Health and Human Services

Office of the Ombudsman

129 Pleasant Street

Concord, New Hampshire 03301-3857

Phone: (603) 271-6941

Toll-Free: (800) 852-3345

Fax: (603) 271-4632

 

New Jersey Department of Children and Families

Office of Advocacy

222 South Warren Street

PO Box 729, 3rd Floor

Trenton, New Jersey 08625-0729

Toll-Free: (877) 543-7864

Email: askDCF@dcf.state.nj.us

 

New Mexico Children, Youth & Families

PO Drawer 5160

P.E.R.A. Room 254

Santa Fe, New Mexico 87502

Phone: (505) 827-7606

Fax: (505) 827-4053

Email: harry.montoya@state.nm.us

 

New York State Office of Children and Families

New York City Only

Office of Advocacy/ACS Parents' and Children's Rights Unit

150 William Street - 18th Floor

New York, New York 10038

Phone: (212) 676-9421

 

North Dakota Department of Human Services

Appeals Supervisor, Legal Advisory Unit

600 E Boulevard Avenue, Dept. 325

Bismarck, North Dakota 58505-0250

Phone: (701) 328-2311

Toll-Free: (800) 472-2622

Email: dhslau@nd.gov

 

Ohio Department of Job and Family Services

Office of Constituent Affairs

30 East Broad Street

32nd Floor

Columbus, Ohio 43215-0423

Phone: (614) 466-9280

Email: legislation@jfs.ohio.gov

 

Oklahoma Department of Human Services

Office of Client Advocacy

PO Box 25352

Oklahoma City, Oklahoma 73125-0352

Phone: (405) 525-4850

Fax: (405) 525-4855

 

Oregon Governor's Advocacy/Ombudsman Office

500 Summer St, NE

4th Floor GAO

Salem, Oregon 97301

Phone: (503) 945-6904

Toll-Free: (800) 442-5238

Email: dhs.info@state.or.us

 

Oregon Foster Care Ombudsman

500 Summer St. NE E-17

Salem, Oregon 97301

Fax: (855) 840-6036

Email: fco.info@state.or.us

 

Pennsylvania Department of Human Services

Rhode Island Office of the Child Advocate

Louis Pastor Building 4th Floor

57 Howard Avenue

Cranston, Rhode Island 02920

Phone: (401) 462-4300

Fax: (401) 462-4305

 

South Carolina State Office of Children's Affairs

Office of Children's Affairs

1200 Senate Street, Suite 104

Columbia, South Carolina 29201

Phone: (803) 734-5049

Fax: (803) 734-0799

 

South Dakota Department of Social Services

Constituent Liaison

700 Governor's Drive

Pierre, South Dakota 57501

Toll-Free: (800) 597-1603

Email: DSSConstituentLiaison@state.sd.us

 

Tennessee Commission on Children and Youth

Andrew Johnson Tower, 9th Floor

710 James Robertson Parkway

Nashville, Tennessee 37243-0800

Phone: (615) 532-1572

Toll-Free: (800) 264-0904

Fax: (615) 532-1591

 

Texas Department of Family and Protective Services

Office of Consumer Affairs

PO Box 149030

Austin, Texas 78714-9030

Toll-Free: (800) 720-7777

Fax: (512) 339-5892

Email: oca@dfps.state.tx.us

 

Texas Health and Human Services Commission

Office of the Ombudsman

PO Box 13247 -- MC H-700

Austin, Texas 78711-3247

Toll-Free: (877) 787-8999

TDD: (888) 425-6889

Fax: (888) 780-8099

 

Utah Department of Human Services

Office of Child Protection Ombudsman

120 North 120 200 West

Room 422 - PO Box 45500

Salt Lake City, Utah 84145-0500

Phone: (801) 538-4589

Toll-Free: (800) 868-6413

Fax: (801) 538-3942

 

Vermont Department for Children and Families

Consumer Concerns Team

103 South Main Street - 2nd Floor, 5 North

Waterbury, Vermont 05671-5920

Phone: (802) 871-3385

 

Virginia Department of Social Services

801 East Main Street

Richmond, Virginia 23219-3301

Phone: (804) 726-7011

Fax: (804) 726-7015

Email: comm@dss.virginia.gov

 

Washington State Office of the Family & Children's Ombuds

6720 Fort Dent Way, Suite 240

Mail Stop TT-99

Tukwila, Washington 98188

Phone: (206) 439-3870

Toll-Free: (800) 571-7321

Fax: (206) 439-3877

 

West Virginia Department of Health and Human Resources

Office of Client Services

350 Capital Street - Room 513

Charleston, West Virginia 25301

Toll-Free: (800) 642-8589

 

Wisconsin Department of Children and Families

201 East Washington Avenue, Second Floor

PO Box 8916

Madison, Wisconsin 53708-8916

Phone: (608) 267-3905

Fax: (608) 266-6836

Email: dcfweb@wisconsin.gov

 

Wyoming Department of Family Services

Complaint Resolution/Ombudsman

Hathaway Building - 2300 Capitol Avenue, 3rd Floor

Cheyenne, Wyoming 82002

Phone: (307) 777-6031

Toll-Free: (800) 457-3659

Fax: (307) 777-7747

Email: Kristie.langley@wyo.gov

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