Introduction

New York law states that a person applying on or after January 1, 1991, initially, or for the renewal of, a license, registration, certificate, or limited permit must provide documentation that he or she has completed two hours of coursework or training regarding the physical or behavioral indicators of child abuse and maltreatment. Among groups specified by law to comply with this requirement are registered nurses, physicians (including psychiatrists), chiropractors, dentists, podiatrists, optometrists, psychologists, dental hygienists, teachers, pupil personnel services professionals, school administrators and supervisors, and school district administrators. Successful completion of this self-study module satisfies this requirement for professional licensure through a separate providership granted to Nursing Spectrum Division of Continuing Education from the state of New York.

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Federal legislation — the Child Abuse and Prevention and Treatment Act of 1974 — was amended in 1996 to mandate that certain persons, including nurses, report child abuse. Minimum federal standards define child abuse and neglect as “Any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation; or an act or failure to act which presents an imminent risk of serious harm.”¹ Individual states determine the definition of maltreatment and to whom abuse is reported.

The Family Next Door

About 3,300,000 cases of alleged child maltreatment were reported to child protective services (CPS) agencies in the US in 2005; in about 30% of these cases, a child was determined to be a victim of abuse or neglect. An estimated 1,460 children died as a result of abuse or neglect in 2005, a rate of 1.9 per 100,000 children, over 76% of whom were younger than four years old.²

Children who have been abused or who have experienced other childhood adverse events  (parental domestic violence, drug use, incarceration, mental illness, divorce or death) not only have increased rates of drug use,³ depression, suicidal ideation,⁴ and teen parenthood,⁵ but also have increased rates of cardiovascular and pulmonary disease as adults.⁶ The odds are increased that youngsters who have been abused will engage in future crime or domestic violence, perpetuating the abusive cycle. For all of these reasons, it’s important to identify, protect, and offer multifaceted treatment to these children as quickly as possible.

In the eyes of the law, abuse can result from the acts of the parent or the person legally responsible for the child at the relevant time, as well as from the acts of a custodian, who may not have a legal relationship to the child but who is regularly in the same household as the child.

The Family Court Act Section 1012(e)⁷ defines an abused child as an individual less than 18 years of age whose parent or legal custodian —

• Inflicts or allows to be inflicted physical injury that could cause death, disfigurement, or impairment of health or function.
• Creates or allows to be created a substantial risk of physical injury.
• Commits or allows to be committed a sex offense against the child or permits or encourages a child to engage in acts such as incest or prostitution.

This definition also applies to children residing in group residential care facilities as well as to children older than 18 years of age with handicapping conditions.

The neglected or maltreated child is defined by the same law⁷ as a child under 18 whose physical, mental, or emotional condition has been impaired, or placed in imminent danger of impairment, by the parent or legal guardian’s failure to exercise a minimum degree of care. In other words, the parent or legal guardian —

• Has failed to provide sufficient food, clothing, shelter, education, and medical and dental care when offered reasonable means to do so.
• Has failed to provide proper supervision.
• Has inflicted excessive corporal punishment or misused drugs and/or alcohol to the extent that the child was placed in imminent danger.

An abandoned child is defined by Social Service Law 384b as one whose parent shows intent to forego parental rights and obligations as manifested by failure to visit or communicate with the child when not prohibited or physically unable to do so.

According to Family Court Act 1012, emotional abuse is defined as the impairment of good emotional health. In this situation, the impairment must be attributable to the unwillingness or inability of the caretaker to exercise a minimum degree of care toward the child in instances of failure to thrive, self-destructive impulses, and habitual truancy, for example.

Examples of emotional abuse include excessive, aggressive, or unreasonable demands, such as making a child sit still for long periods of time without moving or expecting a youngster to carry out adult responsibilities. These acts place expectations on children that tax them beyond their capacity, retard their development, and damage their sense of self-worth. Constant criticizing, belittling, insulting, rejecting, and teasing rob children of the psychological nurturing needed for normal emotional development.

Risks and Protective Factors

Certain factors put adults at risk for becoming abusers, and certain children at risk for being abused. For example, many abusive adults were victims of abuse themselves. Consider the following cases of children with special needs: A child with cerebral palsy is abandoned in a hospital lobby by his overwrought parents. A colicky infant suffers massive brain injury as a result of shaken baby syndrome at the hands of an adolescent father. His caretaker locks a hyperactive, demanding child in his room every day after school.

Here are some risk factors for child abuse⁸:

• Irritable, difficult-to-engage, high needs child
• Adolescent parents, immaturity, lack of parenting skills, or unrealistic expectations of a child
• Unmet emotional needs, isolation, or poor impulse control
• Life crises, unemployment or housing problems, divorce, or death of a loved one
• Physical or mental health problems, irrational behavior, or substance abuse
• Poverty
• Lack of social support

However, even in families with multiple stresses, there are strengths, or protective factors, which lower the risk for child abuse and maltreatment⁸:

• Healthy, intelligent, engaging child
• Organized, knowledgeable, child-focused parent
• Involvement of both parents and/or extended family support
• Religious involvement, other community group involvement
• Safe neighborhood
• Access to health care
• Adequate economic resources

While these risks and protective factors are helpful in designing prevention programs, they are not as useful in identifying individual children at risk: even healthy, engaging children from two-parent affluent families can be victims of child abuse, and yet nurses are less likely to report abuse from a white, middle-class intact family with whom they are familiar than from a single parent family, from an African-American family, a poor family, or from a family they don’t know as well.^9,10

While it is important to be aware of the possibility of child abuse and maltreatment in any clinical situation, there are some behavioral indicators and physical signs that should increase your suspicion of child abuse.

Looking for Red Flags

Abusive caretakers may have unrealistic expectations of the child’s physical and emotional needs. They may look at children as “miniature adults,” and expect them to behave that way. For example, they may feel that the child should be potty-trained before it is reasonable to expect this. When the child has an accident, the parent gets angry and abusive. Some parents consider corporal punishment as their sole option for discipline. They may view the child as bad, evil, or different. They may fail to seek health care for injuries and illnesses and may skip routine check-ups and immunizations.

Revealing Histories

Although the physical signs of child abuse vary and may be difficult to confirm, the patient’s history often yields clues. Medical records of previous admissions or ED visits for other siblings or a parent may reveal events that signal family violence. Any history of domestic violence in a family puts the children at high risk for abuse; in households where mothers are victims, the children are more likely to be abused.¹¹ Be alert for parents who are reluctant to give an account of the injury or who offer an inconsistent account of the injury. And be wary when the type of injury does not correlate with the explanation of how it occurred.

Tara’s mother reported that her child “backed into a curling iron.” However, her story was improbable, because bumping into the iron would have likely left a horizontal burn, not a vertical one. The wound was consistent with an iron that had been held against the skin, and the disparity in the story raised a red flag. The absence or presence of wounds in areas that do not correspond to the account of the accident may be a sign of abuse. For instance, if a parent says that her child slipped and fell on the cement and hit his head, the palms of the hands would probably also be scraped.

Signs of Physical Abuse

Injuries are normal and typical during childhood. Active youngsters sustain scratches, cuts, and bruises from falling off bicycles, playing on monkey bars, and running. Nurses must look for injuries consistent with abuse, remembering that no one sign or symptom alone can indicate its presence.

Bruises in the shape of handprints or other identifiable patterns, welts, and abrasions in many stages of healing should stir suspicions. Pattern injuries often indicate the instrument of abuse, such as burns that are round from cigarette butts, cylindrical from a light bulb, or triangular from the tip of an iron. Contusions from belts, rings, and sharp objects may leave obvious, identifiable impressions on a child’s skin. Injuries to either eyes or cheeks should always raise eyebrows as accidents typically cause only a unilateral injury. Linear whip marks and loop bruises may suggest the use of flexible objects, such as electrical cords. Look for “grab marks” on arms or shoulders, and check for bite marks. Absence of hair could be due to hair pulling, while tooth or frenulum injury might be a result of battering.^9,12

Burns can be a life-threatening form of abuse. Stocking burns, which occur when a child’s limb is held forcibly in a burning liquid, are delineated, circumferential scalds that are usually inconsistent with any explanation of an accidental fall into water. Burns on the buttocks and genitalia can result from being immersed in hot water.

Some medical conditions mimic skin lesions that are suggestive of child abuse. Impetigo can mimic cigarette burns, while bullous impetigo, with erythema and large blisters, or staphylococcal scalded skin syndrome, can mimic hot water or immersion burns. Erythema multiforme and Henoch-Schönlein purpura can mimic extremity bruising.¹² Some children compulsively pull out their own hair (trichotillomania).

Fractures, especially those in multiple stages of healing, are a classic injury of child abuse. Broken long bones, ribs, skull, and vertebral bodies are highly suggestive of battering. Transverse fractures are due to direct trauma. Spiral and epiphyseal fractures of the long bones come from rotational and bending forces, which may be inflicted but sometimes are due to accidental falls. Metaphyseal chip fractures are common in abuse⁹. As with all injuries, if there is a changing explanation for the trauma or one that does not coincide with the injury, abuse may be involved.

Blunt trauma can affect the gastrointestinal, cardiopulmonary, and central nervous systems. Violent force can rupture a child’s spleen or intestines and cause massive shock and death. Fractured ribs can precipitate a pneumothorax, heart contusion, and pericardial tamponade.

Retinal bleeding, with no other overt signs of abuse, may be the result of violent shaking. When a child is under two years of age, the impact on the brain can be as much as 30 times the force of gravity. The leading cause of death in child abuse is head injury. Infants or children with altered mental states, unresponsiveness, convulsions, or other neurological deficits may be victims of abuse.⁹

Parents may fabricate or induce illness in their child. This is sometimes referred to as Munchausen syndrome by proxy. Caretakers have been known to put drops of blood into their child’s urine sample, to contaminate central venous access devices, or to administer laxatives to induce diarrhea and dehydration.¹³

He May Be Telling You Something

The child’s behavior can be an indicator of abuse. You may find that the child is wary of contact with the caretaker. He or she may become apprehensive when other children cry. You may witness behavioral extremes or wild mood swings. Perhaps you’ll observe signs of self-injurious behavior. The child may even have obsessions, phobias, compulsions, or hypochondria. He or she may be afraid to go home, threaten to run away, or mention suicide.

When you suspect neglect, consider these indicators. Is the child lagging in physical, mental, or emotional development? Is there a speech disorder or failure to thrive? Is there consistent hunger, poor hygiene, inappropriate dress for the season, lack of supervision, unattended medical needs, or chronic truancy? Perhaps there will be a history of stealing food, constant fatigue, delinquency, habit disorders, neurotic traits, or alcohol/drug abuse. Has the child ever run away or attempted suicide?

One caveat here: children react to all kinds of trauma with similar behaviors and symptoms. While keeping child abuse in mind, it would be important to explore other potential forms of trauma, including death or divorce in the family, natural disasters, recent accident, or serious illness.

An estimated 12% to 25% of girls and 5% to 15% of boys are sexually abused before reaching adulthood (18 years of age). While only a small percentage of parents who maltreat their children sexually abuse them, in absolute numbers this is still the largest category of offenders.¹⁴ Up to 12% of perpetrators of sexual abuse may be women, who are estimated to abuse 5% of female victims and 20% to 25% of male victims.¹⁵ Adolescents have the highest rates of sexual abuse, more than 16% in all ages above 12 years, while children under three have the lowest rates, 2.2%.¹⁴ As with other forms of abuse, sexual abuse occurs in every ethnic, racial, social, and economic group.

The sad truth is that the vast majority of child molesters are family members or friends of the child. This makes it extremely difficult for the victim to report sexual abuse. Victims suffer shame and guilt and worry that they will be betraying a loved one. What’s so difficult for healthcare professionals is the fact that there is no one profile of a child molester. Additionally, the signs and symptoms of incest and other sexual abuse can be subtle.

Often there are no physical signs of child sexual abuse or signs that only a health professional with specialized training and experience could detect, such as changes in the genital or anal areas. Even when children are examined by an expert, there are positive physical findings in fewer than 5% of prepubertal girls, including girls with a history of penetration. A recent study of pregnant adolescents found physical evidence of penetration in only a small percentage of cases. The reasons for the lack of clear and definitive findings include the broad range of normal exams, delayed disclosures, and the remarkable capacity of mucosal injuries to heal.¹⁶ To complicate the picture even more, common respiratory and enteric pathogens, such as streptococcus and shigella species, can cause purulent and even bloody vaginal discharge in prepubertal girls.¹⁷

Some physical indicators of sexual abuse are: ¹⁸

• Acute trauma to the genital or anal area
• An acute or healed posterior tear to the hymen,
• Markedly decreased or absent hymenal tissue
• Anal bruising or injuries or alterations in anorectal tone
• Sexually transmitted diseases in the absence of consensual sexual activity of an adolescent
• Pregnancy (depending on age and circumstances)

Behavioral indicators could be as subtle as unwillingness to change for gym class. However, they may be as severe as forcing sexual acts on other children, seductive or promiscuous behavior, or prostitution. While behavioral indicators may provide the first clues to sexual abuse, they are often nonspecific indicators of trauma in general, such as withdrawal, aggression, sleep disturbances, or regression, including bedwetting and eating disorders, and in these cases the nurse should be alert to any possible trauma in the child’s life, including but not limited to abuse. Sexual play between age mates, such as young children of similar ages looking at or touching each other’s genitalia without coercion, is considered normative and not an indicator of sexual abuse. However, age differences, coercion, penetration or using objects, or putting the mouth on genitalia in children under 12 should prompt a suspicion of sexual abuse.

Sexual Abuse and Adolescents: Confidentiality and Reporting Issues

In New York State, health care for minors related to sexual activity is considered confidential, as long as the healthcare provider can ascertain that the minor is developmentally able to give informed consent. This confidentiality protection extends to treatment for sexual abuse and assault, where the minor has the right to decide whether or not to report the abuse to law enforcement officials.¹⁹ However, the nurse must make a report about sexual abuse or assault of a minor, in spite of the minor’s wishes, under the following conditions:

• Serious bodily harm has occurred during the course of the assault, such as a gunshot wound or stab wound — the injury must be reported, but the sexual assault may not be reported without the minor’s consent.²⁰
• The alleged perpetrator in the abuse was a parent or guardian, or someone acting in a custodial role.
• The parent, guardian, or custodian knowingly allowed the abuse to occur. This does not apply, for example, when a parent knows that a young adolescent is having consensual sexual relations.
• If the abuse was committed by a teacher or other school employee, such as an athletic coach, a report must be made to school authorities, but not necessarily to the Child Abuse Central Registry.

Fact or Fiction?

The interactions between the child and a parent are often most revealing when taking a history and performing a physical assessment. Watch the parent’s reaction to the child answering questions and observe the child’s response. Some abused children will cling to the abusive parent even after being injured, hoping to assure the parent that the secret is not being divulged. This behavior can also be an attempt to remain safe, to prevent further abuse, and to receive physical assurance that the abuser still loves the child. However, it is normal for children to cling to their parents in unfamiliar environments, especially if they are frightened.

Talk with the child as well as the parent or caretaker. He or she may have been coached before seeking medical attention; hence their explanation may be identical to the parents’. Although questions are routine to the physical assessment of a child, a nurse should not appear to be interrogating the parent or child. By saying, “Is there anything I should know about your child or anything in particular you are concerned about with your child’s health?” you can avoid being perceived as accusatory.

Children can enter an ED or clinic setting with signs and symptoms that suggest abuse when none has occurred. The injury may have been a legitimate accident. Although it could appear intentional, consider the child who placed both hands on a barbeque grill searching for a hot dog. You may encounter a child not yet diagnosed with osteogenesis imperfecta — a brittle bone disease characterized by bones that break easily, presenting a profile of a child who has been abused.⁹ Or, you may hear of a child with idiopathic thrombocytopenic purpura, a disease which can present with multiple bruises--misdiagnosed as a victim.

Although healthcare professionals are legally bound to report suspected abuse, good faith reporting typically protects them from prosecution if their suspicions are incorrect. However, you need to know what actions must be taken and find out about your legal responsibilities.

In New York State, almost 71,000 children were substantiated victims of child abuse and maltreatment in 2005, and 11% of these children were physically abused.² The key to differentiating between accidental and intentional injury lies in the history and physical examination of the child. Does the history explain the injuries? You may feel that it does not. But it’s easy to see why many healthcare professionals are reluctant to become involved. Abuse of a child is downright disturbing. Not only that, but dealing with abusers and victims creates anger and frustration.²¹ However, as a nurse in the state of New York, it is not only your moral obligation to step in, it’s your legal responsibility.

There are many professionals in New York State who are required by Social Services Law to report suspected child abuse, neglect, and maltreatment. The list ranges from school officials to coroners, from podiatrists to police officers, from day care workers to mental health practitioners. Among those listed are RNs and physicians as mandated child abuse reporters.

Here’s a quick pretest. You witness a child being spanked in the parking lot at the shopping mall. His mom is yelling, “Never do that again.” As an RN or physician is it your legal and professional responsibility to report it? Now you are at work in the pediatric urgent care area and you examine a toddler with a probable fractured wrist and scrapes on both knees. His father says, “He fell while he was running in the playground.” Will your license be on the line if you fail to call in a report to Child Protective Services? Shift your thinking to the ED where you assess a baby, who seems “much more sleepy than usual.” Examination reveals retinal hemorrhages and neurological changes. His adolescent mom says that she left the infant with her boyfriend last night when the baby “just wouldn’t stop crying.” Does the law tell you that you have to report a suspicion of possible abuse? The answers are no, no, and most definitely, yes!

Knowing When to Act

In order to know when you are legally obligated to report child abuse, you’ll have to understand a few terms. Here’s where some legal lingo comes in that you must commit to memory.

• Reasonable Cause: Considering what physical evidence is presented, you may feel that it is possible that the injury or condition was caused by neglect or nonaccidental means. By no means do you have to be certain.
• Suspicion: The only thing necessary for you to have suspicion of abuse is that you distrust or doubt what you observe or are being told about an injury.

The law outlines the following three situations in which you as a nurse must file a report. Legally speaking, these apply to when you are acting in your professional capacity:

1. You have reasonable cause to suspect that a child is abused.
2. A parent or person legally responsible for the child comes to you and states from personal knowledge that the child is abused.
3. A staff member suspects abuse and notifies you, as the designated supervisor. However, should the employee be mistaken about the standard of abuse, you may determine that a report need not be made.

A new law, S849-A (known as “Xcstasy’s Law”) requires social service workers to make official reports of all third-party allegations of abuse, even if that party is not legally responsible for the child.²² While not specifically changing reporting requirements for nurses, the impact of this new law is still unclear.

What to Do Next

The team meets to discuss the baby brought in by the teen mom. A diagnosis of shaken baby syndrome is beginning to surface. While the staff makes some medical decisions, you need to consider your role as a mandated reporter. But when do you have to act? In short, the answer is — immediately. Whether it is your role or that of a supervisor, a report can be made by telephone at any time of day, seven days a week. The call must be made to the New York State Central Register of Child Abuse and Maltreatment (SCR) at (800) 635-1522.

Next comes the written report, which must be completed within 48 hours of the oral report. A copy of the Mandated Reporter Form can be obtained online under Forms at www.ocfs.state.ny.us. This document, signed by the reporter, is filed with your local child protective services. Be sure to ask for the “Call ID” that a Child Protective Services (CPS) specialist will assign to your report. It’s also a good idea to keep careful notes for your own personal records indicating dates, times, places, and names of persons involved in any reporting incidents.

When filing a report of suspected abuse, you’ll need to name the “subject of the report.” This is the parent or person legally responsible for the child at the time. Of course, abuse may have been at the hands of a stranger, another child, or an acquaintance. In these situations, rather than calling in a case of suspected child abuse, law enforcement authorities need to be contacted.

Let’s say the circumstances are subtler than shaken baby syndrome. You are doing triage when a six-year-old girl is brought in with a dislocated elbow. Her mother has a feasible explanation —“She fell off the monkey bars.” But you notice bruises on the back of the girl’s neck and on her shoulder that could be “grab marks.” The child is clinging to her mother and won’t answer any of the nurse’s questions. She has been to the ED several times this year for trauma-related injuries. In each instance there were lingering questions and inconsistencies in the stories. Are you certain that this is a case of abuse? No, of course not. But you do have reasonable cause to suspect abuse. By law, you are now mandated to act.

What if it isn’t an injury at all? You may encounter a teen, who has been admitted multiple times for alcohol intoxication. He reports that he drinks in front of his mother.  There may even be times when there is just the threat of violence. A woman in your unit has been a victim of domestic violence and says that she fears her husband might hurt the children. These are all reportable situations.

After you make the initial phone call to SCR and you are ready to complete a written report, here’s what you need to include. Remember, though, that written reports are admissible as evidence in any judicial proceedings, so be sure that it is accurate, clear, and objective.

• Names and addresses of the child, parents and/or caretakers
• Child’s age, gender, race
• Nature and extent of injuries, including evidence of prior injuries or abuse to the child or siblings
• Name of person responsible for causing the injury
• Family composition
• The source of the report
• Person making the report and where to be reached
• The actions taken — x-rays, photographs, and removal or keeping of the child

Any mandated reporter may take, or cause to be taken, at public expense, color photographs of the area of trauma visible on a child. If medically indicated, mandated reporters may cause x-rays to be taken as well.

Any x-rays or photographs should be identified with the child’s name, date, and photographer’s name. It’s also helpful to list injuries by sites, and plot the location on a body diagram. These should accompany the written report or follow as soon as possible after its submission.

Any clothing torn or stained with blood, semen, or other fluids should be bagged in paper to preserve evidence and then set aside for authorities. Any lab specimens should be carefully labeled, handled by as few people as possible, and delivered directly to another department to ensure that the specimen is not tampered with or taken from the premises.

Now turn your attention to a more severe story. A 10-year-old boy is brought in by ambulance with life-threatening head injuries. He has been beaten into unconsciousness with a broomstick. His father says, “I was just so tired of his backtalk.” The police have taken Dad away, and the boy is sent to the pediatric intensive care unit. He may not live.

A child may be taken into protective custody without court order or parental consent if the parent or legal caretaker presents imminent danger to the child’s life or health. Those legally authorized to place a child into protective custody include law enforcement officials, a designated employee of the Department of Social Services, or a person in charge of a hospital, to name a few. Those individuals have to take certain actions once protective custody occurs. Unless the child is admitted to a hospital, the child must be brought to a location designated by the rules of the Family Court. Every reasonable effort must be made to inform the parent/caretaker about where the child has been taken. And written notice must be provided as well. Local child protective services will take it from there.

The Investigation

CPS uses the report itself as a starting point for an official investigation. This fact-finding process is used to determine whether evidence of abuse or maltreatment exists. The process will include interviewing, observing, and information gathering. CPS will contact the source, the child, the parents, school personnel, healthcare professionals, neighbors, and others. As the mandated reporter, your testimony may be required during court proceedings, should it come to that.

The final step in the investigation is deciding whether the report is “indicated” or “unfounded,” which must take place within 90 days of the oral report. If unfounded, all the information identifying the subjects is wiped out. Should credible evidence exist supporting abuse, the report is deemed “indicated.” In this case, the family is offered appropriate services.

In implementing a plan, CPS may arrange for and monitor services for the family. Should the parents refuse services, or their cooperation is insufficient, CPS must turn to Family Court. Few cases reach this point, but when they do, the assistance of mandated reporters is vital to presenting a case.

Legal Protections and Consequences

Would you worry about being sued if your suspicions turned out to be false? What if you make a report and it turns out that you’re wrong? Fear not, as the law affords the reporter certain legal protections from liability. Any person who in good faith makes a report, takes photographs, and/or takes protective custody, has immunity from any liability — civil or criminal — that might be a result of such actions. In addition, your identity is protected under confidentiality clauses. Social Services cannot give your name to anyone, including the subject of the report, without your written permission to do so.

Should you decide that you just don’t want to get involved, be aware that the penalty can be severe. If you willfully fail to report a case of child abuse or maltreatment, you may be guilty of a Class A misdemeanor. You may also be civilly liable for the damages caused by such failure.⁷ So don’t let the ball drop — for the sake of your license, but more important, for the sake of the child at risk.

Prevention of abuse begins with an awareness of the risk factors and the identification of early opportunities for intervention. For example, new mothers, especially adolescents, are at greater risk of abusing children; on the other hand, they are also excellent candidates for education. Before parents leave the hospital, a nurse can ask about childcare arrangements for when they return to work or school. A new mother, who has concerns about caring for the child, is likely to be responsive to assistance. If the mother has been a victim of child abuse, she may even voice fears about abusing the child. By knowing which local, state, and national agencies can offer parenting information, support groups, or special services and following up before discharge, you may stave off future abuse.

Home health nurses can have a direct effect on preventing or stopping child abuse. Several states have reported decreases in child maltreatment after instituting universal home visiting programs.²³ Prenatal visits offered the nurses a chance to educate mothers, check on their nutritional status, and ensure a healthy start for the babies. After childbirth and until the age of two years, home visits offered mothers a chance to communicate their concerns, ask questions, and voice frustrations regarding childcare. The result of the programs was a significant reduction in child abuse and neglect.

The cycle of abuse can be stopped. But it takes someone to step in. Won’t you be that someone?

Hotlines

New York State Child Abuse Hotline: (800) 635-1522 (mandated reporters)

New York State Child Abuse Hotline: (800) 342-3720 (general public)

New York State Department of Social Services: (800) 342-3715 (general information)