Study Guide -- Child Abuse and Vulnerable Adult Abuse and Neglect Ethics, Laws, and Issues Child

Maltreatment -- maltreatment includes all forms of physical and emotional ill-treatment, sexual abuse, neglect, and exploitation that results in actual or potential harm to health, development or dignity (World Health Organization) 1) Partial history of child protective services and development of maltreatment legislation A. Prior to 1874, sporadic intervention in child maltreatment cases was provided by a small number of local and state laws B. 1875 Establishment of the New York Society for the Prevention of Cruelty to Children, the first organization devoted entirely to child protection C. 1962 Battered child syndrome is described in medical literature D. 1963 First mandated reporter laws enacted targeting physical abuse E. 1969 Publication of findings from 250 child sexual abuse cases F. 1970s Expansion of mandated reporters, inclusion of mental health care providers G. 1971 -- People v. Jackson recognition of battered child syndrome as an accepted medical diagnosis H. 1974 Child Abuse Prevention and Treatment Act -- included sexual abuse in its definition of maltreatment I. 1976 -- Tarasoff v. Regents limited confidentiality; established duty to warn individuals who are specifically being threatened by a client J. 1976 -- Landeros v. Flood -- established the basis for civil liability, essentially defining failure to diagnose battered child syndrome as malpractice K. 1978 Conceptualization of emotional abuse and psychological damage in literature L. 1980 Adoption Assistance and Child Welfare Act required states to make reasonable efforts to preserve families in the case of maltreatment M. 1983 -- People v. Stritzinger established limits to exceptions to confidentiality; found that although an initial report of child abuse was warranted, an additional report made after consultation with the abuser was in violation of the clients rights N. 1984 -- State v. Andring -- supports the legal precedent of maintaining as much of a client's confidentiality as possible, even when reports must be made O. 1988 Child Abuse Prevention, Adoption, and Family Services Act -- Inclusion of definitions for emotional maltreatment, exploitation P. 1989 -- DeShaney v. Winnebago County -- government agency's failure to prevent child abuse by a custodial parent does not violate the child's right to liberty, but acknowledges duty to protect Q. 1993 -- State v. Huss found that a number of factors can cause a child to provide questionable testimony R. 1997 Adoption and Safe Families Act focused efforts on child protection rather than preserving families; cases of chronic sexual and physical abuse are moved more swiftly toward termination of parental rights 2) Maryland laws and APA ethical standards related to reporting child maltreatment A. APA Ethical Principles of Psychologists and Code of Conduct (APA, 2010) (I) All General Principles are involved in the reporting of child maltreatment (II) 2.01 Boundaries of Competence, 2.03 Maintaining Competence, 2.04 Bases for Scientific and Professional Judgments -- Psychologists have or obtain the training, experience, consultation or supervision necessary to ensure and maintain the

(III) (IV)

(V)

(VI)

(VII)

(VIII)

(IX)

(X)

(XI)

(XII)

competence of their services, and base their work upon established scientific and professional knowledge of the discipline 3.04 Avoiding Harm -- Psychologists take reasonable steps to avoid harming their clients and to minimize harm where it is foreseeable and unavoidable. 4.01 Maintaining Confidentiality -- Psychologists have a primary obligation and take reasonable precautions to protect confidential information recognizing that the extent and limits of confidentiality may be regulated by law. 4.02 Discussing the Limits of Confidentiality -- Psychologists discuss with clients the relevant limits of confidentiality and the foreseeable uses of the information generated through their psychological activities. Unless it is not feasible or is contraindicated, the discussion of confidentiality occurs at the outset of the relationship and thereafter as new circumstances may warrant. 4.04 Minimizing Intrusions on Privacy -- Psychologists include in written and oral reports and consultations, only information germane to the purpose for which the communication is made. Psychologists discuss confidential information obtained in their work only for appropriate scientific or professional purposes and only with persons clearly concerned with such matters. 4.05 Disclosures Psychologists disclose confidential information without the consent of the individual only as mandated by law, or where permitted by law for a valid purpose. Disclosure is limited to the minimum that is necessary to achieve the purpose. 4.06 Consultations -- When consulting with colleagues, psychologists do not disclose confidential information that reasonably could lead to the identification of a client. 6.01 Documentation of Professional and Scientific Work and Maintenance of Records -- Psychologists create, and to the extent the records are under their control, maintain, disseminate, store, retain and dispose of records and data relating to their professional and scientific work. 3.10 Informed Consent, 8.02 Informed Consent to Research, 9.03 Informed Consent in Assessments, 10.01 Informed Consent to Therapy, 10.02 Therapy Involving Couples or Families In the practice of psychology, regardless of the setting, clients must be fully informed of limitations to confidentiality. Code of Maryland Regulations (COMAR) 07.02.07 Title 7 describes child protective services, defines maltreatment, and outlines expectations of mandatory reporters Family Law Article, 5-701, 5-702, 5-704, 5-708, 5-711 provide definitions of child maltreatment and mandates reporting of suspected child abuse or neglect by mental health care providers (among other professionals)

3) Child maltreatment definitions (COMAR 07.02.07.02) A. Child means an individual younger than 18 years old. B. Child abuse means one or more of the following by a parent, caretaker, or household or family member: (I) Physical injury, not necessarily visible, or mental injury of a child, under circumstances that indicate that the child's health or welfare is harmed or at substantial risk of being harmed (II) Sexual abuse of a child, regardless of whether the child has physical injuries C. Child neglect means one or more of the following by a parent or caretaker:

D. E. F. G.

(I) A failure to provide proper care and attention to a child, including leaving a child unattended, under circumstances that indicate that the child's health or welfare is harmed or placed at substantial risk of harm (II) Mental injury or a substantial risk of mental injury of a child that is caused by the failure to provide proper care and attention to a child Mental injury means the observable, identifiable, and substantial impairment of a child's mental or psychological ability to function. Failure to give proper care and attention means the omission of proper care or attention or the provision of improper care or attention; this includes leaving a child unattended. Sexual abuse means any act that involves sexual molestation or exploitation of a child. Sexual molestation or exploitation means sexual contact or conduct with a child. This includes, but is not limited to: (I) Exposure, voyeurism, sexual advances, kissing, or fondling (II) Sexual crime in any degree including rape, sodomy, or prostitution (III) Allowing, encouraging, or engaging in obscene or pornographic display, photographing, filming, or depiction of a child in a manner prohibited by law

4) High risk groups Children of parents who were abused, children who have been abused in the past, children with disabilities, children in the foster care system, and children living in underserved communities (poverty, lack of health care options) 5) Recognizing maltreatment in children A. Although self-report is the most reliable way to recognize maltreatment, it is not commonly offered by children, and may be retracted later out of fear. These signs and symptoms are not specific to maltreatment, and should be considered along with knowledge of the childs individual circumstances. B. Physical abuse frequent injuries, unexplained tissue damage, hypervigilance C. Sexual abuse trouble walking or sitting, complaints of pain in genital regions, sexual knowledge and/or behavior that is not age-appropriate D. Emotional and mental abuse withdrawal, excessive fear, extreme behaviors E. Neglect malnourishment, poor hygiene, untreated illnesses, infrequent school attendance F. Exploitation often requires report or physical evidence G. More information about recognizing child abuse and neglect 6) Necessity of mandated reporting A. Protection of vulnerable populations B. Need for offender treatment or isolation C. Association of child abuse with a wide variety of medical and psychological sequelae, including earlier onset of mental health problems and increased suicidality D. Significantly greater use of healthcare resources after abuse E. Tendency for abuse to be perpetuated in future relationships F. Correlation of child abuse with spousal and animal abuse G. Association of child abuse history with risky behaviors and law violations H. Protection from legal liability for health professionals 7) Mandated reporting A. Psychologists and other mental health service providers are among those required to report suspected abuse (COMAR 07.02.07.04)

B. Procedures for reporting abuse vary by state; most include calling a social services hotline C. Information needed for a report includes the following (Maryland Dept. of Human Resources) (I) The name and home address of the child and the parent or other individual responsible for the care of the child (II) The present location of the child (III) The age of the child (IV) Names and ages of other children in the home (V) The nature and extent of injuries or sexual abuse or neglect of the child (VI) Any information relayed by the individual making the report of previous possible physical or sexual abuse or neglect. (VII) Information available to the individual reporting that might aid in establishing the cause of the injury or neglect; (VIII) The identity of the individual or individuals responsible for abuse or neglect D. This information should be reported to local social services or child protective services if the alleged abuser is a caretaker; if not, the report should be made to the local police. E. Oral reports should be made immediately and written reports must be made within 48 hours of contact that discloses the suspected abuse or neglect (Maryland Dept. of Human Resources) F. Anyone who makes a good-faith report based on reasonable grounds is immune from liability 8) Issues A. Confidentiality therapists may believe that reporting abuse violates confidentiality, or that limitations to confidentiality stop offenders from discussing these issues in therapy B. High overlap of emotional and behavioral symptoms between maltreatment and dysfunctional family environments that do not include maltreatment C. Possible disruption of therapeutic relationship D. Perception of child protective services as ineffective or damaging E. Concern that children and offenders will not be brought in/come in for treatment F. Maltreatment vs. corporal punishment and parental choice G. Diversity considering what is usual for culture or community H. Misunderstanding scope of professional duties trying to act as an investigator and obtain substantiating evidence rather than reporting based on suspicion I. All of these may lead to confusion or resistance regarding reporting 9) Positive practices A. Read and understand laws and regulations for mandated reporting B. Incorporate mandatory reporting laws into confidentiality agreements C. Inform the individuals you are working with of all relevant mandatory reporting laws before offering services D. Deliver this information in person and create an opportunity for discussion E. Consider making disclosure information available in various accessible formats F. Understand situations in which reporting is mandated G. Document all information that leads to decision to file a report H. Remind clients of mandated reporting requirements when information is disclosed that requires a report to be filed. I. Remember that the formation and maintenance of trust in a therapeutic relationship does not require absolute confidentiality. J. When a report is warranted, try your best to fully explain your responsibilities and the need for the report, and involve the client in the process.

K. Ensure that disclosure is limited to the minimum necessary for making a report. L. Be familiar with signs, symptoms, and circumstances of maltreatment M. Always pay close attention when a client tells you about abuse, take it seriously, and gather additional information N. Be aware of high risk groups O. Correct any personal misperceptions about maltreatment (e.g., only severely ill people mistreat children, only girls are sexually abused) P. Consult with colleagues, ethics committee members, social services, or legal advisors (without disclosing identifying information) if unsure whether to report Q. Participate in Mandatory Reporting continuing education courses and seminars R. Mandated Reporter Training many states have in-person or online programs for mandated reporters (http://dc.mandatedreporter.org/ Free online program for mandated reporters in DC) S. Know reporting procedures for your area, and keep information accessible. Maryland Child Protective Services and Family Services: 410-361-2235 (available 24 hours a day)

Vulnerable Adult Maltreatment 1) Partial history of adult protective services and reporting legislation A. 1958 -- National Council on Aging -- acknowledged nationwide need for protective service for elderly people, established exploratory committee of social workers B. 1961 -- White House Conference on Aging -- recommended increased study of ways to facilitate the provision of protective services to older people C. 1965 -- Older Americans Act passed, contains definitions of elder abuse and authorizes federal funding for the National Center on Elder Abuse D. 1975 -- Title XX of the Social Security Act was passed -- states were required to provide protective services to children, elderly people, and adults with disabilities who were reported to be abused, neglected, or exploited E. 1980 -- Civil Rights of Institutionalized Persons Act enacted to protect the rights of people in state or local correctional facilities, nursing homes, mental health facilities and institutions for people with intellectual and developmental disabilities. F. 1981 -- All states had an office with responsibility to provide protective services G. 1990 -- Americans with Disabilities Act prohibited discrimination on the basis of disability H. 1991 -- 42 states had mandatory reporting laws for maltreatment of vulnerable adults I. 1993 -- All states and territories, with the exception of Puerto Rico, had enacted laws addressing maltreatment of vulnerable adults 2) Maryland laws and APA ethical standards A. APA Ethical Principles of Psychologists and Code of Conduct (APA, 2010) -- While the APA General Principles and ethical standards are similar to those described above for child maltreatment, Principle D: Justice and Principle E: Respect for People's Rights and Dignity are especially important when working with vulnerable adults. B. Mandatory reporting laws have been criticized for compromising the autonomy of elderly people and people with disabilities. Also, some people feel that health care providers who are unfamiliar with vulnerable populations may mistake some normal circumstances for abuse, or treat all vulnerable adults as if they are unable to make their own decisions regarding therapy and problem resolution. C. 3.01 Unfair Discrimination -- In their work-related activities, psychologists do not engage in unfair discrimination based on age disability, or any basis proscribed by law.

D. COMAR 07.02.16 describes maltreatment of vulnerable adults and mandates reporting E. Maryland Family Law Article, 14-101,--14-103, 14-302, 14-308, 14-309 describe Duty to Report Abuse, Neglect, Self Neglect, or Exploitation of Vulnerable Adults 3) Definitions COMAR 07.02.16.02 A. Vulnerable adult means an adult (person over 18 years of age) who lacks the physical or mental capacity to provide for the adult's daily needs. B. Disabled person means an adult who has been judged by a court for purposes of adult public guardianship of the person to be unable to provide for his daily needs sufficiently to protect his health or safety due to a mental disability, disease, habitual drunkenness, or addiction to drugs. C. Abuse means the sustaining of any physical injury by a vulnerable adult as a result of cruel or inhumane treatment or as a result of a malicious act by a person. D. Neglect means the willful deprivation of a vulnerable adult of adequate food, clothing, essential medical treatment or habilitative therapy, shelter, or supervision. E. Self-neglect means the inability of a vulnerable adult to perform activities of daily living or to provide the vulnerable adult with the services: (a) That are necessary for the vulnerable adult's physical and mental health; and (b) The absence of which impairs or threatens the vulnerable adult's well-being. F. Exploitation means any action which involves the misuse of a vulnerable adult's funds, property, or person. 4) High risk groups Elderly people with any form of dementia, people with intellectual disabilities (particularly women), people with multiple disabilities or impairments 5) Recognizing maltreatment in elderly people or people with disabilities A. Be aware of sudden changes in physical, behavioral, or financial status B. Be suspicious if access to vulnerable adult is suddenly blocked or discouraged C. Physical abuse bruises, burns, imprint injuries, fractures, bleeding D. Sexual abuse pain in genital or anal regions, torn clothing, STIs E. Emotional and mental abuse agitation, fearful behavior, withdrawal, apathy F. Neglect and self-neglect malnourishment, dehydration, bed sores, untreated injuries, overor under-medication, poor hygiene, lack of appropriate supervision G. Exploitation sudden lack of funds, complaints of missing items H. More information on maltreatment of elderly people I. More information on maltreatment of people with disabilities 6) Necessity of mandated reporting A. Protection of vulnerable populations B. Need for offender treatment or isolation C. Association with medical and psychological complications D. Decreased quality of life and ability to provide self-care E. Protection from legal liability 7) Mandated reporting A. Psychologists and other mental health service providers are among those required to report suspected maltreatment (COMAR 07.02.16.04)

B. Procedures -- make the report by telephone, direct communication, or in writing to the local social services department as soon as possible (COMAR 07.02.16.02) C. Information needed (I) The name, age, and home address of the alleged vulnerable adult (II) The name and home address of the person responsible for the care of the alleged vulnerable adult (III) The whereabouts of the alleged vulnerable adult (IV) The nature of the alleged vulnerable adult's incapacity (V) The nature and extent of the abuse, neglect, self-neglect, or exploitation of the alleged vulnerable adult, including evidence or information available to the reporter concerning previous injury possibly resulting from maltreatment or self-neglect (VI) Any other information that would help to determine the cause of the suspected abuse, neglect, self-neglect, or exploitation, and the identity of any individual responsible for the maltreatment. 8) Issues A. Confidentiality some vulnerable adults do not want to maltreatment to be reported (I) Fear of losing caregivers or angering loved ones (II) Fear of retaliation or future maltreatment (III) Perception that social services do not effectively intervene B. Many people believe that reporting may cause damage to an individuals right to autonomy, and self-determination C. Some health care professionals who work with a vulnerable adult as part of a team assume that it is someone elses responsibility to detect and report abuse. D. May lead to victims/survivors not seeking help or not returning to services E. Diversity what is considered normal in the population? F. What if the offender is a vulnerable adult? Common misperception of elderly and disabled as incapable of causing harm may not be aware of some actions, but may still cause harm 9) Positive practices A. Several are similar to practices for reporting child maltreatment B. It is especially important to have mandatory reporting information available in multiple formats to ensure that impaired clients can understand limits to confidentiality. C. Be aware of your own biases about elderly people and individuals with disabilities. D. Respect the autonomy, individuality, and right to self-determination of your client while considering the best course of action, and include them in the process. E. Be aware that immediate removal of a caretaker with no alternative plan for providing assistance may threaten a vulnerable adult's survival. F. Discuss the situation (without disclosing identifying information) with people who have knowledge of resources for the disabled community. G. If working as part of a team, do not assume that it is someone elses responsibility to detect and report maltreatment. H. Participate in continuing education efforts to increase your competence for working with elderly people and people with disabilities. I. Know reporting procedures for your area, and keep information accessible. MD Adult Protective Services Public Telephone Number: 443-423-6600, Baltimore City: 410-361-5000