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Psychiatr Serv 50:27-29, January 1999
© 1999 American Psychiatric Association
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Column

Law & Psychiatry: Child Abuse Reporting Laws: Time for Reform?
Paul S. Appelbaum, M.D.

  Introduction

TOP
Introduction
References

Nothing should be less controversial than protecting children from
abuse. As the prevalence of the "battered child syndrome" came to
popular attention in the 1960s, every state in the country required
certain classes of professionals to report their suspicions of abuse
to a child protection agency (1). In 1974 Congress passed the Child
Abuse Prevention and Treatment Act, which provided financial
assistance to states that met federal standards, and it established
the National Center for Child Abuse and Neglect to further these
efforts. But mandatory reporting of suspected child abuse has turned
out not to be a simple matter, especially not for mental health
professionals.

The best estimates suggest that the scope of the child abuse problem
is substantial. About 1.6 million children a year are thought to be
exposed to physical, sexual, or emotional abuse or to substantial
neglect (2), with more than 1,000 deaths each year attributed to these
causes (3). The incidence of serious abuse increased an estimated 67
percent between 1986 and 1993, the latest year for which comparable
data are available (2). Sequelae of child abuse can include lifelong
psychiatric and emotional problems, such as depression and
posttraumatic stress disorder. Persons who were abused as children are
at higher risk of later perpetrating abuse themselves or committing
other acts of violence (4).

Because the alarm over battered children was first raised by
physicians who saw the effects of abuse in emergency rooms and on
pediatric units (5), the model adopted for combating the problem
echoed the casefinding approach used for infectious diseases, gunshot
wounds, and other public health problems. Statutes initially focused
on requiring physicians and other medical personnel to report cases to
a state agency that would investigate the complaints and initiate
appropriate action.

The scope of the statutes was soon widened, however, to include a
broad variety of people who might, in the course of their work, become
aware of child abuse (1). Massachusetts is typical in including, among
other categories, physicians, psychologists, dentists, nurses, public
and private school teachers, educational administrators, guidance
counselors, family counselors, probation officers, social workers,
police officers, and even firefighters (6). Some states require anyone
becoming aware of abuse to report the situation (7).

Although reporting statutes are superficially similar from state to
state, they actually vary significantly (7). (An on-line compilation
of all state child abuse reporting statutes can be found at the Web
site of the National Clearinghouse on Child Abuse and Neglect
Information at www.calib. com/nccanch.) The statutes generally require
a report to be made when a mandated reporter has a "reasonable
cause" (or some similar term) to suspect abuse, and they often impose
time limits, such as 48 hours, within which contact with the agency
must take place.

But some states' language limits the obligation to professionals who
have actually seen the abused child—those "who have reason to
believe ... that a child coming before them is a victim of child
abuse"—whereas others impose the duty regardless of how the
professional learns of the suspected abuse (8). In addition, laws may
focus on the effects of abuse, requiring reporting if the child "is
suffering serious physical or emotional injury resulting from
abuse" (6). Others may require disclosure whenever a suspicion is
raised that abuse has occurred (7,9).

Based on these requirements, approximately 2 million reports of child
abuse are filed in the United States each year (3). Most states impose
sanctions, ranging from civil fines to criminal penalties, on mandated
reporters who fail to act in accord with the statutes (7). Although
prosecutions for failure to report are rare, they do occur, and
criminal convictions have been handed down (10). One might therefore
expect that most mental health professionals would be punctilious
about reporting their suspicions of abuse in cases that come to their
attention. In fact, this is far from what occurs.

By now a substantial body of studies agree that it is not uncommon for
clinicians to ignore reporting requirements. In one review of 12
studies, an average of 40 percent of psychologists acknowledged that
they had failed to report at least one case of suspected child abuse,
with the figure ranging as high as 66 percent in one survey (11).
There is no reason to believe that the numbers are different for the
other mental health professions. Although ignorance of reporting
statutes is surprisingly high in some studies, rates of nonreporting
remain elevated even when clinicians are aware of the laws in their
states. Overall, child protective agencies in 1993 are estimated to
have investigated only 28 percent of cases of children harmed by abuse
or neglect, with a substantial part of the remainder accounted for by
cases that are never reported to the agencies (3).

Why are clinicians reluctant to report cases in which they suspect
that abuse might have occurred? Studies have shown that abuse that is
recent or ongoing, that is of greater severity, that involves younger
victims, and about which the mental health professional feels more
certain has a greater likelihood of being reported (11). On the other
hand, cases are less likely to be reported if clinicians believe that
an intervention will do more harm than good (12). Thus mental health
professionals insist on exercising some degree of discretion in
decisions to report, shying away in particular from cases in which
some doubt exists about the occurrence of abuse.

These consistent findings cause no end of consternation among many
experts on child abuse. Reporting statutes are designed specifically
to require reporting whenever some reasonable suspicion of abuse is
present. Clinicians, this argument goes, are poorly situated to
perform investigations to verify whether abuse has in fact occurred—
precisely the task of the child protective agencies. Legislators have
made a judgment that a low threshold should apply to decisions to
report, recognizing that some degree of overreporting is inevitable in
these circumstances, and accepting that risk. What right do mental
health professionals have to decide otherwise?

Although one cannot gainsay the validity of these contentions, more
than three decades of resistance by mental health professionals to
these arguments suggests that they are giving equal weight to other
considerations. Many clinicians who have reported suspicions of child
abuse have had disappointing experiences with the child protective
agencies (1). Investigations may be highly intrusive, and decisions
made abruptly or on the basis of limited evidence. Children removed
from households do not always end up in placements that seem
preferable, especially when it is not clear that abuse has occurred,
or when abuse has taken place in the past but is not ongoing (13).

Having learned that child abuse reporting does not always lead to
benign outcomes, it is hardly surprising that therapists are reluctant
to file reports unless they have a high degree of certainty that a
child is at risk and will benefit from the intervention. Even the
threat of criminal penalties fails to overcome this adherence to what
clinicians believe is their patients' best interests.

Without doubt, another major consideration for clinicians is the
likelihood that a child abuse report will be disruptive to treatment.
This concern is particularly relevant when the patient is the abuser,
rather than the victim. When a person who has abused a child seeks
treatment, the therapist will usually be required under the mandatory
reporting law immediately to report any abuse that is disclosed. Many
clinicians have a reasonable fear, supported by case reports and
empirical data, that patients who have not been deterred from seeking
treatment already, perhaps because they are ignorant of the law's
requirements, will be forced from treatment if therapists report their
behavior (9,14,15). The problem is compounded by the common
requirement that reports be made within 48 hours, which limits the
time available to discuss these issues with patients.

Understandably, clinicians feel torn between their obligation to do
what is best for their patients and their duty to protect actual and
potential victims of child abuse. A variety of suggestions have been
made for ameliorating the situation (1,13,14). The least radical
changes would involve narrowing the definitions of reportable
circumstances to ensure that only the occurrence or threat of serious
harm is covered. Less serious, perhaps arguable, instances of neglect
or abuse, especially emotional abuse, might clearly be excluded under
such a proposal (1).

Somewhat more dramatically, some commentators have suggested exempting
all therapists who are treating perpetrators of abuse from mandatory
reporting, while permitting them to report voluntarily if that seemed
essential for the protection of a child (14). This approach would
permit therapy to continue in circumstances that the clinician judged
to be low risk, for example, if the abuser no longer has contact with
children. Victims of abuse who are in treatment might be given some
limited right to block therapists' reporting, out of privacy concerns
or for other reasons, as long as no one was immediately in danger.
Other persons who become aware of abuse would still be covered by the
reporting statutes.

Perhaps the most innovative suggestion advocates adoption of the Dutch
system, whereby confidential investigations take place when a report
is made, without the immediate threat of coercive interventions (13).
The primary goal of case workers is to provide treatment and support
for families and children. Only if these interventions fail, or if
parents are uncooperative, would consideration be given to removing
the child from the home.

The data on reporting by mental health professionals, characterized as
it is by frequent failure to comply with existing laws, suggest that
little might be lost and a good deal gained by considering alternative
approaches. Were, for example, therapists working with patients who
had been abusive in the past given discretion about reporting,
treatment would likely be facilitated. A positive outcome in such
cases would be better for abuser and victim alike, compared with the
intrusive and often ineffective techniques employed today. Moreover,
the terribly overburdened child protective agencies, their caseloads
reduced by elimination of some proportion of cases where the threat to
children is less imminent, might be better able to concentrate on more
serious cases of abuse.

When laws are ignored systematically, it is usually because they do
not make sense to those who are subject to them. There is good
evidence that this is the case with child abuse reporting statutes.
The possibility that there is wisdom in the intuitive responses of so
many clinicians ought to be considered.

  Footnotes

Dr. Appelbaum, editor of this column, is A. F. Zeleznik professor and
chair of the department of psychiatry of the University of
Massachusetts Medical School. Address correspondence to him at the
Department of Psychiatry, University of Massachusetts Medical School,
55 Lake Avenue North, Worcester, Massachusetts 01655.

  References

TOP
Introduction
References

Hutchinson ED: Mandatory reporting laws: child protective case finding
gone awry? Social Work 38:56-63, 1993
Sedlak AJ, Broadhurst DD: Executive summary, in The Third National
Incidence Study of Child Abuse and Neglect. Washington, DC, National
Center on Child Abuse and Neglect, Sept 1996
US Department of Health and Human Services: Child Maltreatment 1996:
Reports From the States to the National Child Abuse and Neglect Data
System. Washington, DC, US Government Printing Office, 1998
Widom CS: The cycle of violence. Science 244:160-166, 1989[Abstract/
Free Full Text]
Kempe C, Silverman F, Steele B, et al: The battered child syndrome.
JAMA 181:17-24, 1962
Massachusetts General Laws, Chpt 119, Sec 51A
Child Abuse and Neglect State Statute Series, Vol 1: Reporting Laws.
Washington, DC, National Clearinghouse on Child Abuse and Neglect
Information, 1997
Kalichman SC, Brosig CL: The effects of statutory requirements on
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Berlin FS, Malin HM, Dean S: Effects of statutes requiring
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MacDonald D, Hill AD, Li CD: Confidentiality and the duty to report
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