LEARNING OUTCOME AND OBJECTIVES:  Upon completion of this course, you will have gained the knowledge to identify and report child abuse, child neglect, and trafficking. Specific learning objectives to address potential knowledge gaps include:

• Define terminology related to child abuse.
• Explain the risk and protective factors contributing to child abuse and neglect.
• Recognize physical and behavioral indicators of abuse, neglect, and trafficking.
• Summarize strategies for responding to victims’ disclosures.
• Describe situations in which mandated reporters must report suspected cases of child maltreatment.
• Discuss the consequences for failing to report suspected child abuse.

WHAT IS CHILD ABUSE?

The government has a responsibility to protect children when parents or other persons legally responsible for a child’s care fail to provide proper care and to intervene in cases of child maltreatment. State statutes are divided into criminal and civil categories within each state’s statutory codes. Civil statutes provide guidance for mandated reporters and intervention by child protection agencies. Criminal statutes define which acts are criminal and can lead to arrest and prosecution of an offender.

Child abuse and neglect are significant public health problems which can lead to long-term adverse consequences for a child’s health and well-being. Therefore, healthcare professionals have both a legal and professional responsibility to recognize and report suspected child abuse and maltreatment.

Definitions

The Centers for Disease Control and Prevention (CDC) has developed uniform definitions pertaining to child abuse. However, since different states and government entities vary in their legal definitions of these terms, it is also important for healthcare professionals to know the definitions for child abuse and other related terms in the state(s) in which they live and/or practice.

Generally speaking, child abuse and neglect can be defined as any act or series of acts of commission or omission by a parent, caregiver, or another person in a custodial role (e.g., clergy, coach, teacher) that results in harm, potential for harm, or threat of harm to a child under the age of 18. In more than a dozen states, human trafficking of minors is included in the definition of abuse (CDC, 2021a; CWIG, 2019a). (See also “Types of Abuse” below for more details.)

Types of Abuse

Four commonly recognized categories of abuse and neglect are physical abuse, sexual abuse, emotional abuse, and neglect.

PHYSICAL ABUSE

Physical abuse of a child includes any nonaccidental physical injury of a child that is inflicted by a parent or caretaker. Acts include but are not limited to biting, kicking, hitting, or burning a child under the age of 18. The legal definition of physical abuse also includes actions that pose a substantial risk of physical injury to the child even if no injury is sustained (CDC, 2021a).

SEXUAL ABUSE

Child sexual abuse generally includes any sexual activity by an adult with a minor, since a minor cannot by law consent to any form of sexual activity. Behaviors may include touching, fondling, penetration, or exposing a child to sexual activities. Federally, sexual abuse of a child is defined as the employment, use, persuasion, inducement, enticement, or coercion of any child to engage in, or assist any other person to engage in, any sexually explicit conduct or simulation of such conduct for the purpose of producing a visual depiction of such conduct: or the rape, and in cases of a caretaker or interfamilial relationships, statutory rape, molestation, prostitution of children, or incest with children (CAPTA, 2010; CDC, 2021a).

In 33 states, sexual exploitation of minors is included in the definition of sexual abuse. This form of exploitation includes sex trafficking of children or engaging children in the production of pornography (CWIG, 2019a).

Child sexual abuse does not need to include physical contact between a perpetrator and a child. Some forms of child sexual abuse include:

• Exhibitionism (exposing oneself to a minor)
• Fondling
• Intercourse
• Masturbation in the presence of a minor or forcing a minor to masturbate
• Obscene phone calls, text messages, emails, or digital interaction
• Producing, owning, or sharing pornographic images or movies of children
• Sex of any kind with a minor, including vaginal, oral, or anal sex
• Sex trafficking (see below)
• Any other sexual conduct that is harmful to a child’s mental, emotional, or physical welfare
  (RAINN, 2021)

EMOTIONAL ABUSE

Emotional abuse involves actions that harm the self-esteem or emotional health of a child. Behaviors may involve shaming, rejecting, name-calling, and suppressing love or affection. Emotional abuse may lead to impaired psychological growth and development and involves words, actions, and indifference. This form of abuse may be hard to recognize because there are no visible injuries. Children who are sexually or physically abused may also be emotionally abused.

Emotional abuse may include:

• Verbal abuse
• Constant criticism
• Shaming
• Name-calling
• Excessive demands on a child’s performance (e.g., expectations of high grades in school or becoming “champion” school athletes)
• Not allowing a child to attend school
• Threats
• Rejecting
• Withholding affection
• Isolation
• Negligence
  (Kids Matter, 2021; CDC, 2021a)

HUMAN TRAFFICKING

There are different types of human trafficking, also known as trafficking in persons.

The crime of sex trafficking of children (also referred to as commercial sexual exploitation of children [CSEC]) is a type of child abuse increasingly encountered in the healthcare setting. It is defined in the Trafficking Victims Protection Act (18 USC §1591) as “to recruit, entice, harbor, transport, provide, obtain, or maintain by any means a person, or to benefit financially from such action, knowing or in reckless disregard that the person has not attained the age of 18 years and will be caused to engage in a commercial sex act.”

The term child prostitution is misleading when used in the context of commercial sexual exploitation of children (CSEC). The children who are involved in commercial sex are victims. Traffickers may beat, rape, torture, and use drugs, alcohol, and emotional tactics to gain control over their child victims (US DOJ, 2020; Hornor & Sherfield, 2018).

According to U.S. federal law (22 USC § 7102), labor trafficking is the recruitment, harboring, transportation, provision, or obtaining of a person for labor or services, through the use of force, fraud, or coercion for the purposes of subjection to involuntary servitude, peonage, debt bondage, or slavery. As with sex trafficking, force, fraud, or coercion do not need to exist if the labor trafficking victim is under the age of 18.

Child labor trafficking may include agricultural, domestic service, or factory work where workers provide involuntary labor. Labor trafficking can also occur in beauty services, restaurants, small businesses, or informal settings. Some common situations include peddling and traveling sales crews where young people are moved from town to town selling cheap products such as jewelry or magazines for little or no pay. Other situations include drug dealing in which children are forced to sell drugs. Sometimes labor trafficking may occur when a child is staying with a custodial family member or nonfamily member and is forced to work.

Children are controlled through fear and abuse by their traffickers. It is possible that a child is a victim of labor and sex trafficking simultaneously (NCSSLE, 2021).

Types of Neglect

Neglect is defined as the failure of a parent or other person with responsibility for the child to provide a child with basic physical and emotional needs such as food, clothing, shelter, education, and healthcare to the degree that the child’s health, safety, and well-being are threatened with harm (CWIG, 2019a; CDC, 2021a).

PHYSICAL NEGLECT

Physical neglect is the failure to provide a child with adequate food, shelter, clothing, education, hygiene, medical care, and/or supervision needed for normal growth and development. Leaving a young child or children without supervision by a responsible person is a type of neglect (Childhelp.org, 2021a). Infants and toddlers should never be left alone, even briefly. While older preteens may be responsible and independent enough to be left alone, some older teenagers are too irresponsible or have special needs that limit their ability to be safe if left alone.

EMOTIONAL NEGLECT

Emotional neglect includes parent or other caretaker behaviors that cause or have the potential to cause serious cognitive, affective, or other behavioral health problems. The resulting emotional impairment must be clearly attributable to the unwillingness or inability of the parent or other person legally responsible for the child to exercise a minimum degree of care toward the child.

MEDICAL NEGLECT

Medical neglect is the failure to provide a child with necessary medical or mental health treatment. Some states make provisions for parents who choose not to seek certain forms of medical care for a child due to religious beliefs.

EDUCATIONAL NEGLECT

Educational neglect is the failure to educate a child (e.g., failure to enroll a child in school or preventing a child from attending school) or attend to special education needs (e.g., failure to obtain remedial education services). About half the states, the District of Columbia, American Samoa, Puerto Rico, and the Virgin Islands include failure to educate a child as required by law in their definition of neglect (CWIG, 2019a).

ABANDONMENT

Abandonment is a form of neglect in many states. A child is generally considered to be abandoned when a parent’s whereabouts are unknown, the child has been left alone and suffers serious adverse consequences, or the parent fails to maintain contact with or provide reasonable support for a specified period of time.

COMPARING ABUSE AND NEGLECT

Abuse	Neglect
Parent or other persons legally responsible: Inflict or allow to be inflicted serious injury or substantial risk of physical injury Inflict or allow to be inflicted emotional harm Commit or allow to be committed a sex offense, including sex trafficking or other forms of commercial sex	Parent or other persons legally responsible impair a child’s physical, mental, or emotional condition by: Failing to provide basic needs of food, clothing, shelter, education, or medical care, or education when financially able Failing to provide adequate supervision Engaging in excessive use of drugs or alcohol that interferes in the ability to provide adequate supervision