HSC Important Issues

HSC Important Issues

Child abuse/neglect

Child abuse can occur in any family, regardless of socio-economic status, religion, education, ethnic background, or other factors. There are four basic areas in which abuse may be revealed: (1) environmental problems (e.g., extreme dirt or filth affecting health), (2)Parental clues (e.g., parent uses “out of control” discipline), (3) Physical indicators (e.g., facial injuries, malnutrition – bloated stomach, extremely thin), (4) Behavioral indicators (e.g., destructive and self-destructive, precociously sexualized behavior, running away, unable to make choices).

Would the researcher see signs of child abuse or neglect? Surprisingly, such signs are often quite open, and adults in the household are oblivious to them or to the fact that observers from outside would notice them. For example, a training program for family counselors discontinued having its students do home visits because of the legal implications of observing quite blatant signs of child abuse. In one instance, a student who had done supervised counseling of family members arranged with the family to do a home interview. She noted that a 4 year old girl, dressed in a short ballerina’s tutu with no underpants, tripped flirtatiously around the males in the household, sat in laps, and put one man’s hands on her genitals. What would a researcher do who observed such a scene?

Before discussing the challenge to researchers, and possibly appropriate responses of researchers to signs of child abuse, it is useful for researchers to understand the legal background of this issue and of the mandate to report. It is also important that researchers understand how this might be handled with respect to promises of confidentiality in the informed consent, and with respect to the protocol they submit to their IRB.

Legal Background. The Federal Child Abuse Prevention and Treatment Act of 1974 required that each state establish child protective services and develop its own mandated reporting laws. By 1978, state reporting laws were in place. Levine and Levine (1983) document the history of these laws; summaries of these state laws as of 2003 appear in the appendix to this paper. State laws mandate the kinds of situations that must be reported and the kinds of persons who must report. In some states, only helping professionals need report, while in other states, anyone must report. There is considerable state-to-state variability of laws and unpredictability of court decisions. See Kalichman (1999, pp. 14-23) for the definitions of abuse and requirements to report that are excerpted from the reporting statutes of each of the 50 states.

All states require reporting by certain helping professionals such as physicians, psychiatrists, clinical psychologists, counselors, teachers, nurses, and social workers. Some also require reporting by pharmacists and religious healers. In their efforts to locate makers of child pornographic films, Colorado and Illinois require reporting by commercial film developers. Thus, if any of the researchers also happens to be a helping professional or falls into any of the other categories for which reporting is mandated in their state, they would be required to report child abuse according to the criteria established for their state. Anyone who has reasons to suspect child maltreatment must report in the following nine states: Florida, Indiana, Kentucky, Minnesota, Nebraska, New Hampshire, New Jersey, New Mexico, and North Carolina. Obviously, researchers working in these states are operating under a different mandate than those working in the remaining states.

Reporting laws vary with respect to how one learns of the suspected abuse. In some states, a report is required even if the reporting individual learns of it through a third party. Many statutes require reporting when “there is reasonable cause to suspect …” The ambiguity of such wording provides the person reporting with much latitude for deciding what is “reasonable cause” but also leaves open the possibility that abuse learned from a third party must be reported. Hence, investigators must check with their local authorities, such as their institution’s Department of Nursing or Social Work, or the county’s Child Protective Services, to learn how to interpret their State’s law in this matter.

Handling reporting possibilities in the informed consent. Projects should be prepared for the possibility that researchers will come upon reason to suspect child abuse and feel obligated to report it. Projects should discuss this possibility with their IRB. In evaluating a given protocol, the IRB must consider whether there is a chance that the researcher will find reasonable evidence of a reportable situation.

If the IRB believes that a reportable revelation of suspected harm to a child or other vulnerable person might occur, it may require that the informed consent statement include a warning of the limits of confidentiality. A statement adapted from one developed by David Ruja (Gill, 1982) covers most of the reportable issues we will consider in this paper:

What is discussed during our session will be kept confidential except that I am compelled by law to inform an appropriate other person if I hear or believe that your are in danger of hurting yourself or someone else.

For purposes of the present research context, however, Ruja’s statement would be misleading, since the purpose of the research is to report home health hazards, and this reporting should also be explained in the informed consent. 1

The challenge to researchers. The main problem faced by investigators and IRBs is not the state-by-state variability of laws but the lack of clarity about their interpretation. It is not clear whether “reason to believe,” nor do these laws define what exactly what constitutes abuse or reasonable evidence of abuse. This leaves researchers to consider cultural differences and to weigh these against the possibility that the legal bureaucracy may be more harmful to the child than his or her seemingly abusive relatives. The difficulties of defining abuse are many. Estimates of the amount of child abuse vary from 1% to 30% of all children depending on one’s definition (Weis, 1989). How is the act perceived by the child; is it to teach an important lesson (Corbin, 1987), to cure a disease (Gray & Cosgrove, 1985), or is it done unjustly, out of malice? Thus, there is the possibility that reporting will harm both the “victim” and the “perpetrator.”

Note, however, that if the researcher reported, he or she would not be reporting that child abuse had occurred, but only that reasonable evidence was found. It is up to CPS to determine whether there is actually child abuse. Researchers are not mandated reporters; they need not file a report, but simply make a phone call. Their identity is kept confidential, and all statutes provide immunity from a suit when a report made in good faith turns out to be unfounded (Levine, 1982).

What kinds of evidence that might cause a researcher to decide to contact CPS? At the beginning of this section, examples were given of environmental, physical, behavioral and parental clues to abuse that a visiting researcher might observe. Another kind of evidence that might be observed by a researcher in the process of looking for home hazards might be a child who is kept confined to a closet, attic or cellar.

Yet another situation that signals clear-cut ethical responsibility on the part of the researcher is when a child reaches out to the researcher for help concerning an abusive situation. If this occurs, it is presumably because the researcher is seen as a caring and responsible professional who will help. If the researcher ignores a legitimate plea for help, this reduces the likelihood that the person will ever reach outside of the home again for protection against abuse. However, it is possible that a troublesome child who knows how to get an innocent but strict parent into trouble by alleging child abuse may use the researcher to this end. Therefore it is essential that the researcher make as adequate an informal assessment as possible of the likelihood, imminence and magnitude of harm to the child. Although the situation calls for a response, the response should be guided by the details of the situation and carried out with guidance from knowledgeable members of one’s institution. Clinically trained practitioners may know how to interpret verbal or behavioral communications and are able to determine the appropriate action. A phone call to CPS can be made to ask for advice. Indeed, even practicing psychotherapists and other helping professionals indicate that they regularly phone Child Protective Services (CPS) for advice and let CPS decide what should be done. In most states, researchers are not mandated reporters; consequently there is no legal requirement that they report abuse. However, there is an ethical requirement that falls on all adults to protect children. Only mandated reporters have to follow up within 36 hours with a written report to CPS. Anyone else can make a phone call…and that is all. Anyone can report their suspicion of abuse and it is up to CPS to decide whether to investigate.

But, what of the situation in which a respondent relates that another person has abused a child? Should the researcher actively seek and report evidence of abuse and neglect? Should the researcher provide referral information and encourage the individual to phone an appropriate authority and ask for help? In the interests of respecting the autonomy of the respondents, empowering them, and treating them with respect, helping them to phone CPS and report the issue may be the most appropriate response. Moreover, this places responsibility on the person who knows of the abuse first hand.

Tips on preparing the research protocol for one’s IRB. If the protocol recognizes a risk of reportable child abuse, the ambiguity of state laws concerning reporting can lead to extreme IRB decisions such as rejecting the entire protocol or suggesting poor solutions. Even if the IRB has a knowledgeable clinician among its members, that individual may not recognize that the role of the researcher, with respect to reporting suspected child abuse, is far more limited than that of a helping professional. Thus, the protocol should spell out relevant State law, discuss how it pertains to researchers, and clarify what kinds of situations might trigger reporting. 

How is the reporting likely to play out? Specifically, if the researcher feels a moral obligation to report, it is CPS that decides whether child abuse is occurring, not the researcher. In the informed consent, the researcher has stated the duty to report suspected harm to others, but when reporting, the researcher need not inform the household that a report is being made. The researcher should identify him or herself to CPS, knowing that confidentiality will be protected by law and stringent legal sanctions against anyone who breaches this confidentiality. In all probability, CPS has an immense case load and will not investigate this case for a while, hence a visit from a social worker is unlikely to be connected with the researcher or the research project.

 

Elder abuse/neglect

Does the researcher see signs of elder abuse or neglect? In most cases of elder abuse, the perpetrator is a family member, typically an adult child or spouse. The generally accepted definitions of elder abuse include:

  • Physical abuse which is the willful infliction of physical pain or injury, including slapping, bruising, sexually molesting, or restraining.
  • Sexual abuse which is non-consensual sexual contact of any kind.
  • Financial exploitation which is using the resources of an older person without their consent for someone else’s benefit.
  • Neglect which is failure of a caretaker to provide goods or services necessary to avoid physical harm, mental anguish, or mental illness.

Elder abuse is a significant problem. Incidence studies have yielded a wide range of estimates of the percentage of elders who have experienced abuse and the frequency with which it occurs for given individuals. A review of the incidence and nature of elder abuse can be found at http://www.elderabusecenter.org/pdf/research/statistics.pdf. Summarizing briefly from that report:

Two studies asked older participants if they were currently experiencing abuse. Mouton, et al. (1999) reports that 4.3% were currently in an abusive relationship. Harris (1996) reports that 5.8% of older couples had experienced domestic violence in the past year. Lachs, et al (1997) found that 1.6% of elders had been abused, neglected, or exploited over a nine year period. Hudson (1999b) reports that 7.5% of surveyed elders had been abused sometime after turning 65. Hudson and Carlson (1999a) report that 6.2% of adults stated that they had abused an elder.

Three studies estimated the incidence of abuse against elders. Pillemer and Finklehor (1988) estimated 701,000 – 1,093,560 older Americans are victims of abuse each year. Podnieks (1992) estimated 98,000 – 137,000 older Canadians are abused each year. These figures lead to estimates that 32 out of every 1,000 elders in the United States are abused per year and 40 elders per 1,000 in Canada. More recently, the National Center on Elder Abuse commissioned a National Elder Abuse Incidence Study (NEAIS), which estimated approximately 450,000 older people were being abused in 1996 (NEAIS, 1998).

There is the possibility that abused elders will reach out to persons who enter the home and seem like caring persons who might provide needed help. Should this occur, the researcher is morally bound to respond. As in the case of the child who reaches out to the researcher with allegations of abuse, the researcher should make as detailed an assessment of the credibility of the claim and the degree of harm possibly involved, with an awareness that a senile or mentally ill elder may not be providing credible information. That assessment should accompany any reporting to the project directors and to the appropriate elder-abuse agency. The project directors should decide in advance who and how to contact appropriate authorities in their state, as discussed below.

The Administration of Aging (AoA), Department of Health and Human Services, is the only federal agency dedicated to policy development, planning and delivery of supportive services to elders. There are also state elder abuse prevention programs, and federal legislation requires states to develop legislation similar to that for child maltreatment. AoA funds the National Center on Elder Abuse • 1201 15th Street, N.W., Suite 350 • Washington, DC 20005-2842. email: NCEA@nasua.org, phone (202) 898-2586 • Fax: (202) 898-2583 Their web site, http://www.elderabusecenter.org includes a state-by-state listing of toll-free phone numbers for reporting elder abuse. This website also contains much useful information on elder abuse.

What happens when elder abuse is reported? The agency screens calls for potential seriousness, keeping the information confidential. If the agency decides there is a violation of state elder abuse laws, the agency assigns a case worker (in emergencies, usually within 24 hours). If the victim needs crisis intervention, services are available. If no abuse is substantiated, most agencies will work as necessary with other community agencies to obtain any needed social or health services for the elder. The elder has the right to refuse services offered.

Abuse of vulnerable adults

Anyone who has a relative lack of power and autonomy may be subject to abuse. Domestic violence may occur between spouses, or against adults who are physically, emotionally or mentally handicapped. Training in recognition of these problems should be provided to interviewers. The decision to intervene should, however, reside with project directors, and professional consultants. Local social service agencies should be identified and evaluated ahead of time to determine which one(s), if any, might be appropriate to contact when there is credible evidence of abuse of a vulnerable adult. There is no legal mandate to report abuse of vulnerable adults, and researchers are not indemnified against reporting abuse of vulnerable adults that turns out to be unfounded.


1 It is the norm in social and behavioral research that personal information about identified individuals be kept confidential, and that results be reported in aggregated form. Accordingly, the informed consent statement that is developed for the project should state what information would remain confidential and what would be disclosed. Participants should be told the purpose of the research and what information will be reported in general or aggregated form. When identified information will be kept in identified form (e.g., evidence of lead poisoning, or the existence of lead-based paint in a named resident's home) the informed consent should state to whom such information would be disclosed and what would be done in response to that information. The extent of disclosure should be stated; for example, the information might be disclosed to specific city health or housing officials, but these officials might be required to treat the information as confidential that is, not disclosed to others. The project should be mindful of possible abuses of information about identified individuals, and of the need to keep health-related information confidential.