Reporting isn’t a choice—Here’s how to do it

If you suspect child abuse, then you are obligated by law to report it, says Michael Altieri, MD, FACEP, an ED physician at Fairfax Hospital in Falls Church, VA. "The law doesn’t give you wiggle room. If you see the injury and the story doesn’t fit, you don’t have a choice. You have broken the law if you don’t report it."

Here are some things to consider about reporting child abuse:

You must report any unexplained injuries. "It’s important to know you cannot be sued for libel if you report. If you a file bonafide report, then you are protected by law," says Altieri. "You’re still obligated to report if in your heart you feel it’s not abuse, but in your head you can’t justify an injury."

For example, if a 2-year-old child comes in with a broken leg and the parents don’t know what happened, you must report it. "If after an interaction you feel the child must have climbed on the table and hurt himself, but the parents say they have no idea how it happened, you must report it. Sometimes you are wrong and they do the long bone series of x-rays and find more fractures."

If there is a difference of opinion, there is still a requirement to report. Nurses are mandated reporters, even if the physician they’re working with does not want them to report, stresses Altieri. "If the nurse suspects abuse, and after the physician examines the child, [he or she] doesn’t think it’s abuse, the law is clear," he says. "If the nurse still suspects abuse, she is still obligated to report."

Failing to report when abuse is suspected carries legal risks, notes Elizabeth Nicholson, MS, SW, LISW, director of Care House, a child advocacy center at the Children’s Medical Center in Dayton, OH. "It’s a very difficult thing when you are working on a case and suspect abuse and a doctor says, I will take care of it, there is no need to report,’" she says. "In the state of Ohio, the law is clear that whoever suspects abuse is responsible, so the nurse is held liable if [he or] she suspects and fails to report."

Err on the side of caution. "You may have known a family for 10 years and think they couldn’t possibly abuse their kid, but there are certain stresses that come into play that can cause somebody [to] abuse their kids," says Altieri.

If a child is being abused and you don’t report it, you are putting that child at significant risk to be abused further, says Altieri. "The stakes are high, so when you are not sure, you need to err on the safe side," he notes. "The parents should appreciate that you are doing this, because you are acting as an advocate for their child."

One study showed that a child has a 50% chance of coming back to the ED dead if abuse wasn’t recognized and there was no intervention, Altieri says. "It is potentially life threatening if kids fall through the cracks, so it’s better to err on the safe side if you’re not sure," he stresses.

Don’t feel you need to make the decision about abuse. "Calling law enforcement actually lessens the pressure on medical professionals to make a decision," says Julie Ann Cantlon, BSN, manager of the Children at Risk Evaluation Services (CARES) at St. Luke’s Regional Medical Center in Boise, ID. "Then you can use the team to come to a consensus."

Realize you don’t know the entire story, stresses Cantlon. "We need to let go of the notion that medical people have the whole picture," she says. "In fact, we need child protective services (CPS) to know that within this family, there have been arrests related to this issue with other children. That is information we don’t have unless we contact CPS."

Don’t assume the family will get in trouble. "There is a false perception that children get removed the minute any report is made, but in fact only 5% of children get removed for suspicion of abuse," notes Cantlon. "Typically, what happens is the family receives a service such as counseling. They may have to answer some questions, but that is usually it."

Don’t set out to punish the family. "The spirit of the reporting law is of a non-punitive nature. If nurses feel that they will rescue this child from terrible parents and blow the whistle, then we’re missing the boat," says Nicholson. "In fact, children don’t want to be rescued from their parents."

The goal is to get the family help so children can be safe in their care, says Nicholson. "As Hillary Clinton said, it takes a village to raise a child.’ Nurses need to see themselves as part of a larger child protection system."

Let parents know you are going to report. "The law says you have the right to remain anonymous as a reporter. But it’s important you tell people you are reporting, although a lot of nurses find this very threatening," says Nicholson. "It is setting a bad precedent for a family to see you acting caring and concerned, then go to the nurses station and call children’s services without telling them. That sets up a pattern of distrust."

This should be done as a team, Nicholson recommends. "Do it in conjunction with physician or social worker you are working with," she says. "I think it’s very important to let parents know that you are concerned and want what is best for their children. Explain that you are going to involve some folks at this point who are going to try and help their family."

Families may ask you not to report. "You can expect families to be scared and ask you not to do this, saying, we just came here for health care,’" says Nicholson. "Your message back should be, I care what is happening to you. I’ll do everything I can to make sure they understand what the concerns are, so there is an appropriate response.’"

Be empathetic when appropriate. "When I inform a parent that I am going to make a report to protective services, sometimes I’ll say, I don’t think you did anything wrong, but our job is to advocate for the child, and that is why the law makes us report it," says Altieri. "Ninety-nine times out of 100, the parent understands that."

If the parent becomes upset, do not attempt to keep them. "Every once in awhile you’ll get somebody who is either afraid or guilty, who wants to leave before you make the report," says Altieri. "In that case, the best thing to do is let the police or protective services know, and not start an altercation. I have seen nurses physically hurt trying to stop people from leaving, and that is not our job. You can get yourself killed that way if [you are] trying to detain the wrong person."