Mandated Reporting

Health care providers are mandated reporters of child maltreatment to protect child welfare, certain infectious diseases to protect public health, and some noninfectious diseases such as cancers to monitor prevention and control programs. Primary care providers are often the front line to identify child abuse and neglect as well as index patients for infectious diseases. Statutes related to mandated reporting such as training requirements for mandatory reporters, standard format for reporting, and confidentiality protections of reporters differ by state and jurisdiction. For current and complete information regarding reporting requirements of diseases, health care providers should check the websites of their local or state health department.As many as 1 in 4 children have experienced personal child maltreatment. Of those children who have suffered maltreatment, slightly over 2 of every 1000 will die due to their maltreatment. Maltreatment includes physical, emotional, and sexual abuse; exploitation; neglect; or negligence that results in actual or potential harm to a child. Physical abuse includes, but is not limited to, hitting, shaking, burning, and other forms of interaction that inflict a physical injury, whether external or internal. Emotional, sometimes called psychological, abuse includes actions or statements intended to scare, marginalize, or humiliate a child. Sexual abuse includes engaging a child in oral, anal, or vaginal acts that the minor cannot understand or consent to. It also includes exposing a minor to sexually explicit materials or acts. Exploitation includes employing, using, persuading, or coercing a minor to engage or assist in sexually explicit conduct for the purpose of producing a visual depiction of that conduct. Neglect involves not providing the necessary food, shelter, safety, health care, education, or other reasonable facets of life that protect and provide basic needs for a child to survive and thrive. Negligence refers to a broader definition of failure to provide reasonable care, which ultimately leads to harm to a child.Child maltreatment can be difficult to recognize in the clinical setting, and detailed descriptions of how to identify it are outside the scope of this article. In brief, taking a detailed history, performing a thorough physical examination, and having a high index of suspicion for stereotypical presentations are keys to identifying physical abuse. Fractures, bruises, and burns can be seen in a normally developing child who is not a victim of abuse or neglect. As such, certain features of a patient’s history can be critical in determining whether abuse or neglect contributed to the injury. Child maltreatment should be considered when presentation for care is delayed or when fractures, bruises, burns, or injuries are patterned, repetitive, unexplainable, or indicative of outside forces not consistent with the presenting story and timeline. Having a medical disability, a chronic illness, multiple missed health maintenance examinations, or a caregiver with a history of illicit drug use can also signal that abuse or neglect may be present.Certain fractures, bruises, burns, and head traumas should always raise suspicion for child maltreatment. Suspicious fractures include fractures in a nonmobile infant, multiple fractures in various stages of healing, metaphyseal corner fractures (bucket-handle fractures), and rib, femur, or skull fractures in a child younger than 18 months old. Suspicious burns include those that are symmetric, spare skin creases, lack splash patterns, have well-demarcated borders, or have a grazing pattern. Suspicious bruises include bruises in noncruising infants, bruises that are patterned, or bruises located on the buttocks, genitals, ears, or neck. One widely used mnemonic for common manifestations of physical abuse is TEN-4-FACESp (Figure 1).Mandated reporting is based upon having a reasonable suspicion of abuse, neglect, or both. Once there is a reasonable suspicion, providers must report the case to child protective services. For a database of state laws and contact information to report abuse and neglect to child protective services, US-based clinicians can consult the Child Welfare Information Gateway (www.childwelfare.gov), a service provided by US Department of Health and Human Services. Additionally, the Childhelp National Child Abuse Hotline (1-800-4-A-CHILD [1-800-422-4453]) is available via phone call or text 24 hours a day for assistance in referrals in an emergency. Utilizing this resource does not replace mandatory reporting to child protective services.It is important to note that implicit and explicit bias and racism can play a role in the fundamental element of reasonable suspicion when it comes to reporting child maltreatment. Compared to children of white race, children of Hispanic ethnicity or Asian race are underrepresented in child maltreatment reporting in the United States, whereas children of Black race are overrepresented. Black children are 2 times as likely as white children to have reports made and are also more likely to have their cases accepted for investigation. Being aware of these biases can help health care providers self-monitor to ensure they are including child maltreatment in the differential diagnosis equally for all children who present with injuries or histories that are potentially concerning for maltreatment.Health care providers are required to report certain sexual, respiratory, and gastrointestinal diseases, as well as cancers to their local or state public health department in a timely manner. Reporting these diseases is vital to surveillance and prevention of widespread outbreaks. Each state or territory has its own specific list of diseases that must be reported. In turn, a subset of reportable diseases and conditions are voluntarily reported by local and state public health officials to the Centers for Disease Control and Prevention based on national priorities. Some conditions common to many states’ lists of reportable diseases include COVID-19, tuberculosis, gonorrhea, and syphilis.The obligation to report communicable diseases to local or state officials falls to the provider who makes the diagnosis, although hospitals and laboratories sometimes assume this obligation on the provider’s behalf. Reporting of some diseases in some states must be done via phone call from the provider within 24 hours of diagnosis, whereas reporting of others can be accomplished by a hospital or laboratory via electronic reporting.Despite the importance of and requirement for reporting, infectious diseases are underreported by health care providers. The causes for underreporting include provider knowledge gaps as to why it is important to report, which diseases must be reported, how to make a report, and to whom reports should be made. Providers cite additional attitudinal barriers such as dislike of time-intensive reporting procedures and concern that reporting communicable diseases will negatively affect the patient-doctor relationship by sacrificing the patient’s right to privacy.Whether it is of child maltreatment, communicable diseases, or conditions under national surveillance, the goal of mandated reporting is prevention of ongoing harm and potential death. Adhering to the mandate of reporting is vital to administering health care consistent with 2 driving tenants of medical practice, namely nonmaleficence and beneficence.In the practice of pediatrics, although children are our patients, their caregivers are our partners on whom we rely to carry out our prevention and treatment recommendations. Filing a maltreatment report might feel like we are breaching an important alliance, perhaps making us inclined to doubt our assessments, to want more evidence before filing. This is why it is so important to use objective criteria in deciding when to report a suspected case of maltreatment to child protective services. Besides reducing biased reporting and underreporting, using objective criteria allows pediatricians to assure caregivers that we report every case that presents in the same manner as their child. It is important for us to keep in mind that our mandate is to report all suspected, not just likely, cases of child maltreatment. If 100% of our reported cases are true maltreatment, we are almost certainly underreporting.Linda Y. Fu, MD, MSAssociate Editor, In Brief