This document provides an overview and guide for preventing, identifying, reporting, treating, investigating, and prosecuting child abuse and neglect in California. It discusses the different types of child abuse, who is required to report abuse, the reporting process, and the roles and responsibilities of various professionals in addressing abuse. The overall goal is to help protect children from harm.

1. CHILD ABUSE
Prevention Handbook
. . . and intervention guide
Crime and Violence Prevention Center
California Attorney General’s Office

2. Child Abuse
Prevention Handbook
...and intervention guide
Crime and Violence Prevention Center
California Attorney General’s Office

3. April 2006
Revised January 1982, August 1985, March 1993 and January 2000
This Handbook and accompanying Addenda provide general information and current laws to serve
as a practical aid for those who work with children in the field of child abuse prevention and to assist
mandated reporters and others in determining their reporting responsibilities. The Addenda will be
updated every year. Therefore, if there are discrepancies between the Addenda and the Handbook,
please use the information in the Addenda as the most current. Both publications are not intended to
be and should not be considered legal advice. In the event there are questions about laws related to
reporting responsibilities in a specific case, the advice of legal counsel should be sought.
All revisions to the law in this handbook reflect changes through December 2005, unless otherwise noted.

4. Message from the Attorney General
Child abuse and neglect have both human and economic costs. For example, in 2004, the California
Department of Social Services estimated that 378,301 cases of abuse and neglect involving approxi-
mately 713,391 children were referred for investigation. According to an audit conducted in 2002 by
the California Department of Health Services, 140 children died in the state as a result of abuse and
neglect. Prevent Child Abuse-America, one of the nation’s leading child abuse prevention organiza-
tions, estimates the total annual direct and indirect costs of child abuse and neglect is approximately
$94 billion dollars.
New research suggests that children chronically exposed to violence, either through child maltreat-
ment or being raised in homes where domestic violence is present, suffer increased risk of experiencing
depression, post-traumatic stress disorder, greater alcohol and drug abuse and lower academic achieve-
ment.
In California, approximately one in four children are directly exposed to violence as a victim or witness.
Childhood abuse and neglect increases the odds of arrest as a juvenile by 59%, as an adult by 28%
and for a violent crime by 30%.
In California, many communities are involved, and many more are becoming involved, in intervening
in the lives of maltreated children. Child Welfare Services (CWS) recently developed an innovative
approach to address the problems of children and families at the community level. Their vision, “Every
child living in a safe, stable, permanent home, nurtured by healthy families and strong communities,”
serves as a “call to action” for communities to provide the resources necessary to intervene with fami-
lies before they come to the attention of CWS. In the long term, strengthening communities and fami-
lies will go a long way to reducing the number of maltreated children in our state.
The Department of Justice takes a proactive role in the prevention of child abuse and neglect. The
department launched Safe from the Start, a statewide effort designed to reduce children’s exposure to
violence. The Department developed a Megan’s Law CD-Rom and the California Sex Offender Informa-
tion Line. The Department administers the California State Child Death Review Council which contin-
ues to support local child death review teams in their efforts to prevent fatal child abuse and neglect.
The purpose of this handbook is to serve as a guide for those who work with children and who are
mandated to report suspected abuse under the California Child Abuse and Neglect Reporting Act. The
handbook provides an overview of the laws, practices and procedures for the prevention, identification,
reporting, treatment, investigation, and prosecution of child abuse and neglect. It has been updated to
reflect current changes in law and practice. As in the past, we hope that you find its contents helpful.
We cannot view the protection of children as a single person‘s or organization‘s responsibility. Only our
collaborative efforts will ensure a healthier life for the children of California.

5. “There is no greater insight
into the future than recognizing
when we save our children,
we save ourselves.”
Margaret Meade

6. Table of Contents
What is Child Abuse? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
The Extent of the Problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Physical Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Physical Neglect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Sexual Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Exploitation/Child Pornography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Abuse of Children with Disabilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Cultural Differences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
What is Not Child Abuse? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Who are Child Abusers? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
The Nexus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Reporting Child Abuse and Neglect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
The Child Abuse Reporting Act . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Who Reports? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Immunity from Liability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Liability for Failure to Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Purpose of Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Making a Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
What Happens to the Report? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Professional Responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Schools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Child Day Care Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

7. Out-of-Home Child Care Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Medical Community . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Child Welfare (Protective) Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Law Enforcement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Coordinated Investigations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Multidisciplinary Child Death Review Teams . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Legal Community . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Court Appointed Special Advocates (CASA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Probation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Prevention, Intervention and Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
The Role of the Community . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Victims of Crime Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Appendix I: Child Abuse Reporting Forms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Appendix II: Confidentiality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Appendix III: Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
PLEASE NOTE: Addendum I – California Child Abuse and Neglect Reporting Act;
Addendum II – Juvenile Dependency Proceedings; Addendum III – Child Abuse Crimes; and
Addendum IV – Guidelines for Investigation of Child Abuse in Out-of-Home Care Facilities are
a part of this handbook but are located in a separate publication and will be updated on a yearly
basis.

8. What is
Child Abuse?
To many, child abuse is narrowly defined as Certain persons, known as mandated report-
having only physical implications. In reality, ers, are required by law to report any known
child abuse includes: or suspected instance of child abuse. Every-
• Physical abuse; unlawful corporal punish- one else may report child abuse and neglect.
ment or injury. Indicators for suspected child abuse are pre-
sented in this publication to assist mandated
• General and severe neglect. reporters in meeting their responsibilities
• Sexual abuse; sexual assault; exploitation under the Child Abuse and Neglect Reporting
• Willful harming or endangering a child; Act. (See Addendum I for a list of mandated
emotional maltreatment. reporters.)
One of the most important indicators for
Child abuse may involve multiple categories suspecting child abuse is when a child tells
in each family. They include both (overt) acts someone that he or she has been abused.
and omissions. Competent assessments and When a child tells a particular person who is
interventions must consider evaluating mul- an individual required to report child abuse,
tiple categories of abuse. the communication is not privileged. That
individual, by law, must report what the child
The act of inflicting injury or the failure to has related to him or her. An only exception
act so that injury results, is the basis for is when the information is relayed during
making the decision to intervene. A parent “penitential communication.” A clergy mem-
or caretaker may begin by inflicting minor ber who acquires knowledge or reasonable
injuries, then may increasingly cause more suspicion of child abuse during penitential
serious harm over a period of time. There- communication is not required to report
fore, detecting the initial small injuries and abuse or neglect. Penitential communication
intervening with preventive action may save a is the communication, intended to be in
child from future permanent injury or death. confidence, including but not limited to, a
sacramental confession, made to a clergy
Physical injuries, neglect and malnutrition are member who, in the course of the discipline
more readily detectable than the subtle and or practice of his or her church, denomina-
less visible injuries that result from emotional tion, or organization, is authorized or accus-
maltreatment or sexual abuse. However, all tomed to hear those communications, and
categories of abuse endanger or impair a under the discipline, tenets, customs, or
child’s physical and/or emotional health and practices of his or her church, denomination,
development and demand attention. or organization has a duty to keep those
Child Abuse Prevention Handbook

9. communications secret. (Pen. Code, § 11166 including the U.S. Department of Health and
subd. (c) (1)). In addition, and in the recent Human Services, the U.S. Department of Jus-
past, “any custodian of records of a clergy tice and the U.S. Census. According to their
member” were made mandated reporters conservative estimates, approximately $94
and are now required to report child abuse billion is spent each year on direct (those costs
and neglect. Mandated reporters who report associated with the immediate needs of abuse
suspected child abuse cases have immunity, and neglected children) and indirect cost
both civilly and criminally, for making reports. (those costs associated with the long-term
(See “Liability for Failing to Report” page 30.) and/or secondary effects of child abuse and
neglect) for child abuse and neglect.2
The probability that child abuse and neglect
The Extent of the Problem is a leading cause of childhood deaths seems
to be generally accepted. The National Child
In 2003, the National Clearinghouse on Child Abuse and Neglect Data Systems (NCANDS)
Abuse and Neglect reported an estimate of reported that in 2003, there were an estimat-
2.9 millions referrals concerning the welfare ed 1,500 child fatalities related to child abuse
of approximately 5.5 million children were and neglect. More than three-quarters (79%)
made to child protective services agencies of children who were killed were younger
throughout the United States. Of these, than 4 years old. More than one-third of
approximately two-thirds (1.9 million) were child fatalities were attributed to neglect.
accepted for investigation for an assessment. The rate of child abuse and neglect fatalities
More than 60 percent of child victims expe- reported by NCANDS has increased slightly
rienced neglect. Almost 19 percent were over the past several years from 1.84 per
physically abused, 10 percent were sexually 100,000 children to 1.98 in 2002. However,
abused and 5 percent were emotionally mal- experts do not agree whether this represents
treated. Girls were slightly more likely to be an actual increase in child abuse and neglect
victims than boys. Pacific Islanders, Ameri- fatalities, or whether it may be attributed to
can Indian and Alaska Native, and African- improvements in reporting procedures.
American children had the highest rates of
victimization when compared to their national In California, the Department of Health Ser-
population. While the rates of white victims vices estimates that 140 children died as a
of child abuse or neglect were 11.0 per 1,000 result of child abuse and neglect in 2002.
children, the rate for Pacific Islanders was Also in California, the Fatal Child Abuse and
21.4 per 1,000 children, the rate for Ameri- Neglect Surveillance (FCANS) Program was
can Indian or Alaska Natives was 21.3 per introduced to local child death review teams
1,000 children and the rate for African-Ameri- in the fall of 2002. The goal of FCANS is for
cans was 20.4 per 1,000 children.1 all child deaths to be reviewed by local child
death review teams and for the teams to
In addition to the enormous human costs gather relevant data to assist in reducing child
of child abuse and neglect, there are huge abuse fatalities. (See page 54 for information
financial costs. In 2001, Prevent Child Abuse- on child death review teams)
America, a leading child abuse prevention
organization, published data that represented Many researchers and practitioners believe
the first attempt at documenting the nation- child fatalities due to abuse and neglect
wide costs resulting from abuse and neglect. are under reported. State definition of key
Data was drawn from a variety of sources, terms such as “child homicide,” “abuse” and
Child Abuse Prevention Handbook

10. “neglect” vary, therefore, so do the numbers levels of government. Efforts continue to
and types of child fatalities they report. In be made to develop systems that will reflect
addition, some deaths officially labeled acci- more accurately the scope and degree of child
dents, child homicides and/or Sudden Infant abuse and neglect, e.g. FCANS. The number
Death Syndrome (SIDS), might be attributed of suspected child abuse cases reported and
to child abuse and neglect if more compre- investigated in California has steadily risen
hensive investigations were conducted or if over the years as a result of the Child Abuse
there were more consensus in the coding of and Neglect Reporting Act and the increased
abuse on death certificates.3 attention paid to the problem by profession-
als and the public. For example, in 2004, the
When addressing the issue of child maltreat- California Department of Social Services esti-
ment, and especially child fatalities, preven- mated that 378,301 referrals for investigation
tion is a recurring theme. Well-designed and of child abuse and neglect involving 713,391
properly organized child fatality teams appear children were handled by child welfare ser-
to offer hope for defining the underlying vices agencies. Of these, 17 percent were
nature and scope of fatalities due to child for physical abuse, 39 percent for general
abuse and neglect. The child fatality review neglect, 1.5 percent for severe neglect, 8 per-
process helps identify factors that may assist cent for sexual abuse, 4 percent for caretaker
prevention professionals to prevent future absence, 9 percent for emotional abuse, and
deaths. (For more information on the Califor- 1 percent for exploitation and 21 percent for
nia’s child death review process, see page 54) other. (See chart on page 5.)
Although young children are more “at risk” The Department of Justice maintains a Child
of abuse than adolescents, the problem of Abuse Central Index which contains data
adolescent abuse is often underestimated. from child abuse investigations submit-
Unfortunately, child protective services may ted by law enforcement agencies and child
discount adolescents because they are con- welfare services. Between 1999 and 2003,
sidered to be less “at risk” than younger 189,576 child abuse investigation reports
children, and because adolescents are seen as were received by the Department of Justice.
having more options than younger children. Of these, 49 percent involved physical abuse,
Because it is believed that adolescents are 24 percent involved sexual abuse, 27 percent
able to leave the house until the parent/care- involved severe neglect and emotional mal-
taker “calms down,” they can fight back or, treatment. (For further information on the
in some cases, take the abuse with only tem- Child Abuse Central Index, see page 32.)
porary discomfort, they are not considered as
helpless as younger children. However, many
child prostitutes and young people involved in
alcohol and drug abuse are victims of physical
or sexual abuse and neglect at home. Many
“runaways” have similar histories. Thus, ado-
lescents may have more options than younger 1
National Clearinghouse on Child Abuse and Neglect
children, but they are not necessarily positive
Information, Child Maltreatment 2003: Summary of Key
options. Adolescent abuse remains a serious Findings
problem that deserves attention and action. 2
Prevent Child Abuse-America, Total Estimated Costs of Child
Abuse and Neglect in the United States, Statistical Evidence,
2001
The gathering of accurate information and 3
National Clearinghouse on Child Abuse and Neglect:
statistics is recognized as a problem at most Statistics and Interventions, 2002
Child Abuse Prevention Handbook

11. Physical Abuse • Knowledge that a child’s injury is unusual
for a specific age group (any fracture in an
Physical abuse is any non-accidental act that infant).
results in physical injury. Inflicted physical injury
most often represents unreasonably severe cor- • Unexplained injuries (parent, caretaker, or
poral punishment or unjustifiable punishment. child is unable to explain reason for injury;
This usually happens when a person is frus- there are discrepancies in explanation;
trated or angry and strikes, shakes, or throws blame is placed on a third party; explanations
the child. Intentional, deliberate assault, such as are inconsistent with medical diagnosis).
burning, biting, cutting, poking, twisting limbs, • Parent or caretaker delays seeking care
or otherwise torturing a child, is also included in for a child or fails to seek appropriate
this category of child abuse. care.
Indicators of Physical Abuse Behavioral Indicators
These indicators are used to help distinguish Children may exhibit new or concerning
accidental injuries from cases of suspected behaviors for a number of reasons including
physical abuse: child abuse as well as other sources of child-
hood stress such as parental divorce, death
in the family, etc. If a child exhibits drastic
Location and Type of Injury behavioral changes, is excessively aggressive,
Padded areas as the buttocks, back of legs, violent or destructive, is cruel to animals, or
genitalia and cheeks are more concerning becomes visibly depressed or suicidal, a seri-
in that it takes more force to cause bruising. ous mental health evaluation should be done.
Bruises happen when the blood vessels break In addition, it may be an indication that the
under the skin. Thus children who are old child has been abused. If abuse is suspected,
enough to walk often fall and have bruises the mandated reporter must inform Child
over boney surfaces such as the forehead, Protective Services or law enforcement about
knees, shins where blood vessels are break- their concerns.
ing between two hard surfaces (the floor for
example and the underlying bone). However,
simple falls and even disciplinary spanking with Types Of Injuries
an open palm should not be forceful enough
to cause bruising to the buttocks. Protected Damage To Skin and Surface
areas such as ears, neck, and upper lip are Tissue
more concerning because it is difficult to
accidentally bump or fall on these areas. Pat-
terned injuries such as loop marks, slap marks,
Bruises
or grab marks are highly suspicious and in Bruises, also referred to as contusions, result-
some cases indicative of inflicted trauma. ing from abuse are found on multiple surfaces
of the body, particularly the buttocks, back,
genitals, and face. They may appear in a
History
characteristic pattern (outline of hand, paired
The history includes all facts about the child bruises from pinching), or they may clearly
and the injury, including: resemble an impression of an item of jewelry
• Statements by the child that the injury was (a ring), or a disciplinary imprint (a paddle,
caused by abuse. switch, or coat hanger). Linear bruise marks,
Child Abuse Prevention Handbook

12. Number of Children Referred for Investigation in California
1991 - 2004
706,918 715,062 713,391
700,000 690,005 670,426
660,942
600,000 571,214
540,577
500,000
Number of Children
400,000
300,000
200,000
100,000
1991 1993 1995 1996* 1999* 2001 2003 2004
2004 Number and Percentage of Children by Type of Abuse
(Total Number of Children 713,391)
Emotional Abuse Severe Neglect
62,146 (9%) 11,398 (1.5%)
Physical Abuse
124,751 (17%)
Other**
147,496 (21%)
Sexual Abuse
58,926 (8%)
Caretaker Absence/Incapacity
31,225 (4%)
Exploitation
817 (1%)
General Neglect
276,632 (39%)
Source: California Department of Social Services, Statistical Services Branch
* The caseload fall from 1996 to 1999 may be due to transitional issues relating to the
implementation of the Child Welfare Services/Case Management System (CWS/CMS)
** Includes children at risk and at substantial risk of abuse and neglect.

13. strap marks, or loop marks going around a dentists, skilled evidence technicians, or other
curved body surface are almost always evi- experienced individuals. Salivary swabbing
dence of abuse. should be collected, because they may be
used to determine the blood type or even
It is not possible to date bruises. The colors DNA of the biter. In penetrating bite marks,
red, blue, purple or black can occur at any services of the individuals listed above should
time. In addition, bruises of identical age and also be obtained in order to secure accurate
cause on the same person may look different impressions of the bitten area.
and may resolve differently.
If properly collected and analyzed by experi-
In cases where bruises are suspected bite enced forensic dentists, bite mark evidence
marks, investigators should also be prepared can point to the guilt or innocence of a
to seek the expertise of forensic odontolo- perpetrator suspected of involvement in the
gists. physical or sexual abuse of a child.
Abrasions, Lacerations Burns
As with bruising, the multiplicity and location The location of a burn and its characteristics
of the wounds should be considered. For (shape, depth, margins, etc.) may indicate
example, lacerations under the tongue or abuse. It is important to keep in mind that
those of a torn frenulum (the small piece of children instinctively withdraw from pain.
tissue connecting the gum to the lip) could be Burns, without some evidence of withdrawal,
caused by falling with an object in the mouth are highly suspect because a child will usually
or by the use of excessive force during feed- try to escape, which will result in splashes,
ing. Both are suspicious injuries when the vic- uneven burns and sometimes burns on the
tim is an infant who is still unable to stand. hands.
Whipping a child with a belt buckle or belts Scalding a child with hot liquid is the most
or cords that are looped may cause lacera- common abuse burn. Young infants are com-
tions resembling a “C” or “U” shape or other monly scalded by immersion, and older chil-
wounds with distinctive shapes. dren by having liquids thrown or poured on
them.
Bite Marks
Bite marks may be found on any part of a When children are forcibly held in hot water,
child’s body. They may appear to be dough- there are often sharply demarcated burns. If
nut shaped, double horseshoe shaped, or held in water in a “jackknife” position, only
oval in configuration. Individual teeth or the buttocks and genitalia may be burned. If
a blurry area with varying colorations may held down forcibly in a sitting position, the
be observed, depending on the age of the center part of the buttocks (if pressed tightly
bite mark lesion. Time is of the essence in against the tub) is spared from burning, thus
recording bite marks through photography resulting in a “doughnut shaped” burn. If
and/or video taping because some lesions will the extremities are forcibly immersed in hot
become less distinct with time. water, “glove” or “sock” burns to the hands
or feet may result. The burns are often sym-
Photography, employing non-distorting cam- metric and an immersion line is readily evi-
eras, with rulers or scales adjacent to the dent.
lesion, should be accomplished by forensic
Child Abuse Prevention Handbook

14. Abuse may also be suspected when burns are for the child’s state, head injury from possible
pointed or deeper in the middle. This indi- abuse should be considered. The caretaker’s
cates that hot liquid was poured on, or a hot explanation for a fall should be carefully doc-
object (poker, utensil) pressed into the skin. umented as to who was present, the distance
of the fall, the type of surface hit, and time of
Another type of burn characteristic of abuse the injury.
has the shape of a recognizable object evenly
burned into the victim’s skin. These burns The medical evaluation is critical but should
indicate forced contact or “branding” with, not stand-alone. A complete evaluation, even
for example, the grill of an electric heater, the with severe injury, includes a psychosocial
element of an electric stove, or an iron. evaluation of the family, caretakers and home,
which can be completed by hospital social
Cigarette burns are difficult to diagnose, but workers. In general, these evaluations should
when inflicted they are often multiple and are be considered in all cases where child abuse is
usually found on the palms or soles. There suspected.
is a searing effect, perhaps with charring
around the wound. Abusive Head Trauma
Abusive head trauma, (Shaken Baby Syn-
Rope “burns” appear around wrists or ankles drome), describes a constellation of signs
when children are tied to beds or other struc- and symptoms resulting from violent shaking
tures. or shaking and impacting of the head of an
infant. The degree of brain damage depends
Damage To Brain on the amount and duration of the shaking
and the forces involved in the impact of the
Head Injuries head. Signs and symptoms range on a spec-
Head injuries are the most common cause of trum of neurological alterations from minor
child abuse related deaths and an important (irritability, lethargy, tremors, vomiting) to
cause of chronic neurological disabilities. major (seizures, coma, stupor, death). These
neurological changes are due to destruction
Whenever abuse or neglect is suspected, a of the brain cells secondary to trauma, lack of
careful examination of the child’s eyes and oxygen to the brain cells, and swelling of the
nervous system should be performed to look brain. Extensive retinal hemorrhages in one
for signs of intracranial injury. For certain or both eyes are found in the vast majority
groups of suspected victims, a full skeletal of these cases. The classic triad of subdural
trauma series may be necessary as well as tox- hematoma, brain swelling, and retinal hem-
icology. Serious intracranial injury can occur orrhages are accompanied in some, but not
without visible evidence of trauma on the all cases, by bruising of the part of the body
face or scalp. Children with any soft tissue used as a “handle” for shaking. Fractures of
injury to the head should be neurologically the long bones and/or of the ribs may also be
assessed and have an ophthalmological evalu- seen in some cases. Rib fractures or metaphy-
ation to look for retinal hemorrhages. These seal fractures (also called bucket handle or
injuries may cause brain damage or death if corner fractures) are particularly concerning
undetected and untreated. in young children and if seen should prompt
further investigation for a possible shaking
When a child is in an unconscious or unre- event. In many cases, however, there is no
sponsive state and there is no external evi- external evidence of trauma either to the
dence of injury and no adequate explanation head or the body.
Child Abuse Prevention Handbook

15. Approximately 20 percent of cases are fatal in Fractures are most suspicious for inflicted
the first few days after injury. Survivors suffer trauma when there are multiple lesions, they
from handicaps ranging from mild learning are in different stages of healing, and there
disorders and/or behavioral changes, to mod- are unsuspected lesions. Other fractures
erate and severe, such as profound mental that raise suspicion are: metapyhseal frac-
and developmental retardation, paralyses, tures (also known as corner, chip, or bucket
blindness, inability to hear, or a permanent handle fractures) which are at the end of long
vegetative state. bones and may be fractures from excess trac-
tion, jerking, and twisting injuries; multiple
A careful post mortem examination is required rib fractures, especially back rib fractures;
of all infant deaths in California. These exam- and healing or healed fractures without an
inations should always include evaluation for explanation revealed by x-rays. For young
signs of intracranial bleeding, retinal hemor- victims, x-ray bone surveys are important tools
rhages, and points of impact on or within the used to diagnose suspected physical abuse.
body. Evaluations of potentially suspicious Radioisotope bone scans may pick up healing
cases also should include forensic lab study by fractures, subperiosteal hematomas, etc. A
protocol, including toxicology, microscopic tis- pediatric radiologist should be consulted on
sue examination (including the retina), and a all suspicious cases.
full trauma x-ray series.
Damage To Other Internal Organs Physical Neglect
Internal Injuries Neglect is the negligent treatment or mal-
treatment of a child by a parent or caretaker
Blunt blows to the body can cause serious under circumstances indicating harm or
internal injuries to the liver, spleen, pancreas, threatened harm to the child’s health or wel-
kidneys, and other vital organs and occa- fare. The term includes both acts of commis-
sionally can cause shock and result in death. sion and omissions on the part of the respon-
Internal injuries are the second leading cause sible person. The California Child Abuse and
of death for victims of child abuse. Neglect Reporting Act defines two categories
of physical neglect, severe neglect and gen-
Detectable surface evidence of such trauma eral neglect.
is present only about half the time. Physi-
cal indicators of serious internal injuries may Severe neglect means the negligent failure
include distension of the abdomen, blood in of a parent or caretaker to protect the child
the urine, vomiting, and abdominal pain. from severe malnutrition or medically diag-
nosed non-organic failure to thrive. It also
Damage To Skeleton means those situations of neglect where the
parent or caretaker willfully causes or permits
Fractures the person or health of the child to be placed
Any unexplained fracture in an infant or tod- in a situation such that his or her person or
dler is cause for additional inquiry or investi- health is endangered. This includes the inten-
gation. Rib fractures, especially of back ribs, tional failure to provide adequate food, cloth-
are the most common fractures found in ing, shelter, or medical care.
abused children and are caused from either
blunt force (hit) or compression (squeezed). General neglect means the negligent failure
of a parent or caretaker to provide adequate
Child Abuse Prevention Handbook

16. food, clothing, shelter, medical care, or super- tions of harmful substances; a child cared
vision where no physical injury to the child has for by another child); the child is left alone
occurred. in the home, or unsupervised under any
circumstances (left in car, street).
An example of inadequate supervision is when • The conditions in the home are unsanitary
parents leave their children unsupervised dur- (garbage, animal, or human excrement);
ing the hours when the children are out of the home lacks heating or plumbing; there
school. These parents are often unable to are fire hazards or other unsafe home
arrange childcare services to meet their needs. conditions; the sleeping arrangements are
Although these parents may not regard them- cold, dirty, or otherwise inadequate.
selves as “neglecting their children,” leaving
young children without supervision may con- • The nutritional quality of food in the home
stitute general neglect. Children left in these is poor; meals are not prepared; refrigera-
circumstances may also be particularly vulner- tor or cupboards contain spoiled food.
able to accidents, injuries, or crime. Because
these parents don’t see any wrongdoing, this While some of these conditions may exist in
is a very complicated area that is subject to any home environment for a variety of dif-
controversy regarding the age when children ferent reasons, e.g., poverty, welfare reform,
should be left alone, societal and community and limitations on entitlement programs, it is
responsibilities to provide resources, and gov- the extreme or persistent presence of these
ernmental requirements. factors that indicate some degree of neglect.
Disarray and an untidy home do not neces-
Prenatal neglect is maternal substance abuse sarily mean the home is unfit. Extreme condi-
coupled with significant risk factors that indi- tions resulting in an “unfit home” constitute
cate the parent’s inability to provide the child neglect that may justify protective custody
with adequate care. and dependency proceedings under Welfare
and Institutions Code section 300 (see Adden-
dum II), as well as criminal neglect charges.
Indicators of Neglect (See Addendum III.)
Neglect may be suspected if any of the fol-
lowing conditions exist: Psychosocial Failure to Thrive
• The child is lacking adequate medical or Infants or young children who are much
dental care. smaller than would be expected at a par-
• The child is often sleepy or hungry. ticular age can present a difficult diagnostic
problem for physicians. After excluding those
• The child is often dirty, demonstrates infants who are small because they were
poor personal hygiene, or is inadequately small at birth, there remains a large group of
dressed for weather conditions. infants with low weights and perhaps short
• The child is depressed, withdrawn or apa- lengths and small head circumferences. Some
thetic; exhibits antisocial or destructive of these children are small because of a fail-
behavior, shows exaggerated fearfulness; ure to meet their nutritional needs and/or
or suffers from substance abuse, or speech, failure to meet their emotional needs. These
eating, or habit disorders (biting, rocking, children may also demonstrate delayed devel-
whining). opment and abnormal behavior. Some of
• There is evidence of poor supervision the small children, however, do have hidden
(repeated falls down stairs; repeated inges- medical problems. Hospitalization may be
Child Abuse Prevention Handbook

17. required to screen for significant medical ill- may be present, in varying degrees, fol-lowing
ness and, more important, to see if the child chronic and severe emotional abuse, especially
responds to adequate nutrition and a nurtur- when there is little or no nurturing.
ing environment with a rapid weight gain and
more appropriate behavior. Evaluation is more This is especially true for neonates, infants
than weighting and measuring a baby. Chil- and toddlers. These children may become
dren who suffer neglect may also receive spo- chronically withdrawn and anxious and lose
radic disconnected medial care and are likely basic social and language skills necessary for
only to be examined in emergency rooms. intimate relationships. They may become
They may have no ongoing measurement of developmentally delayed, socially limited, and,
development except as noted by caretakers. in some cases, antisocial or chronically unable
Growth charts compare the child to other to protect themselves from others.
children noting percentile size in head, body
length and weight. Feeding failure for what- Verbal assault (belittling, screaming, threats,
ever reason will generally damage weight first, blaming, sarcasm), unpredictable responses,
length second, and head circumference third, continual negative moods, constant family
so it may be helpful to observe the caretaker’s discord, and chronically communicating con-
feeding habits. In fact, the best environment flicting messages are examples of ways parents
to observe this is in the home. Pediatric exper- may subject their children to emotional abuse.
tise is vital to access such changes but growth
charts should be kept on all infants and tod- Emotional abuse and neglect are also com-
dlers who may be suffering neglect. Failure to ponents of other abuse and neglect. Sexual
document physical growth and other markers abuse and physical abuse may be the official
of child development may prevent an accurate category for a report but emotional damage
diagnosis and make it impossible to protect a also exists. Emotional abuse/neglect may
child or provide useful intervention. damage children of all ages but may be criti-
cal with infants and toddlers leaving them
If left untreated, the physical and/or emotional with permanent developmental deficits.
health of the child may be endangered, and
emotional disorders, school problems, retar- Behavioral Indicators of Children
dation, and other problems may result.
Emotional abuse may be suspected if the child:
• Is withdrawn, depressed and apathetic.
Emotional Maltreatment • Is clingy and forms indiscriminate attachments.
• “Acts out” and is considered a behavior
Emotional Abuse problem (e.g. bullies others, chronically
uses profanity).
Just as physical injuries can scar and incapaci-
tate a child, emotional maltreatment can crip- • Exhibits exaggerated fearfulness.
ple and handicap a child emotionally, behav- • Is overly rigid in conforming to instructions
iorally and intellectually. Self-esteem can be of teachers, doctors, and other adults.
damaged. Severe psychological disorders have
• Suffers from sleep, speech, or eating disor-
been traced to excessively distorted parental
ders.
attitudes and actions. One of the hallmarks
of emotional abuse is the absence of positive • Displays other signs of emotional turmoil
interaction (e.g. praising) from parent to their (repetitive, rhythmic movements; rocking,
child. Emotional and behavioral problems whining, picking at scabs).
10 Child Abuse Prevention Handbook

18. • Suffers from enuresis (bed wetting) and Suspected cases of emotional abuse that con-
fecal soiling. stitute willful cruelty or unjustifiable punish-
• Pays inordinate attention to details, or ment of a child are required to be reported
exhibits little or no verbal or physical com- by mandated reporters. This means a report
munication with others. must be made of any situation where any
person willfully causes or permits any child
• Unwittingly makes comments such as, to suffer, or inflicts on any child, unjustifiable
“Mommy/Daddy always tells me I’m bad.” mental suffering. (Pen. Code, § 11165.3.)
However, mandated reporters may also report
The behavior patterns mentioned may, of any degree of mental suffering. While these
course, be due to other causes, but the suspi- cases may not always be prosecuted, report-
cion of abuse should not be dismissed. ing provides the opportunity for intervention
and/or therapy with the family.
Behavioral Indicators of Parents/
Caretakers Emotional Deprivation
A child may become emotionally distressed
Emotional deprivation has been defined as
when:
“. . . the deprivation suffered by children
• Parents or caretakers place demands on when their parents do not provide the nor-
the child that are based on unreasonable mal experiences producing feelings of being
or impossible expectations or without loved, wanted, secure, and worthy.”
consideration of the child’s developmental
capacity. Caretakers might also provide cause for evalu-
• The child is used as a “battle ground” for ation and possible reporting of a neonate at
marital conflicts. risk. Withholding affection with touch, smiles
and sound may be more damaging than ver-
• The child is used to satisfy the parent’s/
bal and even physical assault. Children may
caretaker’s own ego needs and the child is
provoke assault if necessary to gain nega-
neither old enough nor mature enough to
tive interaction rather than suffer the pain of
understand.
being ignored. This may damage children of
• The child victim is “objectified” by the all ages but is critical for infants and young
perpetrator, the child is referred to as “it” toddlers. Intervention may include consid-
(“it” cried, “it” died). eration of caretaker depression, substance
• The child is a witness to domestic violence. abuse, parenting deficits, and lack of social or
financial support for the caretaker. Consid-
eration should be made for evaluation of the
Emotional abuse can be seen as proving a
caretaker for these issues as well as possible
self-fulfilling prophecy. If a child is degraded
domestic violence.
enough, the child will begin to live up to the
image communicated by the abusing parent
or caretaker. Behavioral Indicators of Emotional
Deprivation
Emotional abuse cases can be extremely diffi- Emotional deprivation may be suspected if the
cult to prove, and cumulative documentation child:
by witnesses is imperative. Such cases should • Refuses to eat adequate amounts of food
be referred to treatment as soon as possible. and is therefore very frail.
Child Abuse Prevention Handbook 11

19. • Is unable to perform normal learned func- Sexual abuse encompasses a broad spectrum
tions for a given age (walking, talking); of behavior, and it may consist of many acts
exhibits developmental delays, par- over a long period of time (chronic molesta-
ticularly with verbal and nonverbal social tion) or a single incident. It may progress
skills. from less intimate types of sexual activity to
• Displays antisocial behavior (aggression, active body contact and later to some form
behavioral disruption, bullying others) of penetration. Victims range in age from
or obvious “delinquent” behavior (drug younger than one year through adolescence.
abuse, vandalism); conversely, is abnor- Specifically, sexual assault includes: rape,
mally unresponsive, sad, or withdrawn. rape in concert, incest, sodomy, oral copula-
tion, penetration of genital or anal opening
• Constantly “seeks out” by a foreign object, and child
and “pesters” other molestation. It also includes
adults, such as teachers lewd or lascivious conduct with
or neighbors, for atten- a child under the age of 14
tion and affection. years, which may apply to any
• Displays exaggerated lewd touching if done with the
fears. intent of arousing or gratifying
• Apathy, withdrawal the sexual desires of either the
and lack of response to person involved or the child;
human interaction. lewd or lascivious conduct with
a child 14 or 15 years of age by
a person at least 10 years older
When parents ignore their than the child; and unlawful
children, whether because sexual intercourse with a minor
of drug or alcohol use, under 16 years of age by a per-
psychiatric disturbances, son over the age of 21 years.
personal problems, outside Sexual exploitation includes
activities, or other preoccupying situations, conduct or activities related to pornography
serious consequences can occur. However, depicting minors, and promoting prostitution
reporting these situations is not mandated by minors. (See Addendum III for a detailed
unless they constitute a form of legally defined review of these crimes.)
abuse or neglect. Emotional neglect may be
seen as a lesser form of child abuse/neglect. It The nature of sexual abuse, the guilt and
may not be reportable or may be assessed out shame of the child victim, and the possible
with no intervention. It is, however, a central involvement of parents, stepparents, friends,
issue for much of what damages children. or other persons in a child caretaker role,
These children may return with more severe make it extremely difficult for children to
damage and are therefore worthy of voluntary come forward to report sexual abuse. Yet,
intervention and follow-up. despite these problems, reports of sexual
abuse made to child protective agencies
continue to increase. This increase is usually
Sexual Abuse attributed to the passage of the Child Abuse
and Neglect Reporting Act and the public’s
As defined in the Child Abuse and Neglect increased concern for child victims.
Reporting Act, sexual abuse is a sexual assault
on, or the sexual exploitation of, a minor.
12 Child Abuse Prevention Handbook

20. Sometimes a child who does seek help is • A child’s injury/disease (vaginal trauma,
accused of making up stories, because many sexually transmitted disease) is unusual for
people cannot believe that the apparently the specific age group.
well-adjusted person involved could be capa- • A young girl is pregnant or has a sexu-
ble of sexual abuse. If the matter does come ally transmitted disease. Pregnancy of a
to the attention of authorities, the child may minor does not, in and of itself, constitute
give in to pressure from parents or caretakers the basis of reasonable suspicion of sexual
and deny that any sexual abuse has occurred. abuse and should not be reported. (Pen.
Even if protective attention is gained, the Code, § 11166, subd.(a).) However, other
child may feel guilty about “turning in” the information such as statements by the
abuser or breaking up the family and, con- minor, indication of coercion, or significant
sequently, withdraw the complaint. This age disparity between the minors may lead
process leads many to be skeptical of a child’s to a reasonable suspicion of sexual abuse
complaint of sexual abuse, and leaves him or that must be reported.
her feeling helpless and guilty for causing so
much trouble.
Behavioral Indicators
The sad reality of sexual abuse is that without
third party reporting, the child often remains Sexual Behaviors of Children
trapped in secrecy by shame, fear, and the It is natural for children to have curiosity
threats of the abuser. about their bodies, and therefore it may be
difficult to tease out whether a child is act-
ing sexually due to normal age appropriate
Indicators of Sexual Abuse curiosity or if it is in response to sexual abuse.
Sexual abuse of a child may surface through a The following list of behaviors are indicators
broad range of physical, behavioral and social of sexual abuse and deserve further evalu-
symptoms. Some of theses indicators, taken ation with a mental health provider and/or
separately, may not be symptomatic of sexual pediatric expert.
abuse. They are listed below as a guide, and • Detailed and age inappropriate under-
should be examined in the context of other standing of sexual behavior (especially by
behavior(s) or situational factors.4 younger children).
• Inappropriate, unusual, or aggressive sexu-
History al behavior with peers or toys.
• A child reports sexual activities to a friend, • Compulsive indiscreet masturbation to the
classmate, teacher, friend’s mother, or exclusion of normal childhood activities.
other trusted adult. The disclosure may
be direct or indirect (“I know someone...”; • “Excessive” curiosity about sexual matters
“What would you do if...?”; “I heard or genitalia (self and others).
something about somebody.”) It is not • Any coercion, force, pain in putting some-
uncommon for the disclosure by children thing in genitals of self or other child.
experiencing chronic or acute sexual abuse
to be delayed.
• Child wears torn, stained, or bloody under-
4
clothing. State Office of Criminal Justice Planning Publication
(now known as the Governor’s Office of Emergency
Services), Medical Protocol for Examination of Sexual
Assault and Child Sexual Abuse Victims, 2001
Child Abuse Prevention Handbook 13

21. This list is only meant as a very brief guideline. Incestuous/Intrafamilial Abuse
Any time a mandated reporter has a “suspi- Sexual abuse of children within the family is
cion” of child abuse, whether the indicator is the most hidden form of child abuse. In spite
mentioned in this handbook or not, they must of its taboo and the difficulty of detection,
report it to the proper authority. some researchers believe this abuse may be
even more common than physical abuse.
Behavioral Indicators in Older
Children and Adolescents Incest means sexual activity between certain
close relatives (e.g., parents and children, siblings,
As discussed previously, children may exhibit new
grandparents and grandchildren); intrafamilial
or concerning behaviors for a number of differ-
abuse means sexual activity between persons in a
ent reasons including child abuse as well as other
family setting (e.g., stepparents, boyfriends).
sources of childhood stress such as divorce, etc.
Any child who exhibits drastic behavioral chang-
In most reported cases, the father or another
es, runs away from home, becomes aggressive,
man acting as the parent is the initiator. In
depressed or exhibits delinquent behavior, has
some cases, the mother or another woman
frequent school absences, or has a sudden drop
is the offending adult. Although girls are the
in school performance, becomes fearful of home
most frequent victims, boys are also victims,
life, becomes withdrawn, abuses alcohol or
much more often than previously believed.
drugs, becomes suicidal, deserves our attention.
The embarrassment and shame deter girls and
If sexual abuse is suspected, it should be reported
boys alike from reporting the abuse.
to child protective services or law enforcement.
The initial sexual abuse may occur at any age,
Physical Symptoms
from infancy through adolescence. Sexual abuse
If a child has physical symptoms such as geni- may be followed by guilt provoking demands for
tal discharge or infection, a sexually transmit- secrecy and/or threats of terrible harm or conse-
ted disease, physical trauma or irritations to quences if the secret is revealed. The child may
the anal/genital area (pain, itching, swelling, then fear disgrace, hatred, or blame for breaking
bruising, bleeding, lacerations, or abrasions), up the family if the secret is revealed.
they should be evaluated by a trained medical
professional as well as possible involvement of Regardless of how gentle or forceful, or how
child protective services and law enforcement. trivial or coincidental the first approach
may have been, sexual coercion tends to be
How to Get Help repeated and to escalate over a period of
As discussed later in this handbook, most years. The child may eventually accept the
counties have a team of nurse practitioners blame for tempting and provoking the abuser.
and/or doctors who are trained specialist in
the evaluation and diagnosis of sexual abuse. The mother, who would usually be expected
These teams are usually available 24 hours to protect the child, may purposely try to
a day to evaluate acute (less than 72 hours) stay isolated from a problem of sexual abuse.
sexual abuse cases, and are associated with Sometimes she is distant and uncommunica-
the local emergency room. Some hospitals tive, or so disapproving of sexual matters that
also have child abuse experts who are able to the child is afraid to speak up. Sometimes
answer questions during the day. she is extremely insecure and the potential
loss of her husband or partner, and the eco-
nomic security he provides, is so threatening
14 Child Abuse Prevention Handbook

22. that she cannot allow herself to believe or
even to suspect that her child is or could be
Exploitation/Child
at risk. She may have been a victim herself of Pornography
child abuse and may not trust her judgment
or her right to challenge the male authority. Internet Exploitation
Some mothers actually know their children
Children have always been vulnerable to
are sexually abused, but for whatever reason,
victimization, but with the wide use of the
they “look the other way.”
computer, a whole new danger threatens
children; with so many children online, today’s
Until the victim is old enough to realize that
predators can easily find and exploit them. By
incest and intrafamilial abuse are not common
the end of the year 2005, 77 million children
occurrences, and/or the victim is strong enough
were online and that number is only growing.
to obtain help outside the family, there is no
escape unless the abuse is reported.
Unfortunately, criminals are also using mod-
Extrafamilial Sexual Abuse ern technology. Today, with so many children
online, the Internet provides predators a new
Children who are abused by someone out- arena (cyberspace) to target children for crimi-
side their family typically know their molester. nal acts. Because of its anonymity, rapid trans-
They meet them at school, youth programs, mission, and unsupervised nature, the Internet
churches, in their neighborhood, or at other rec- has become the venue of choice for predators
reational activities. People who molest children who transmit and receive child pornography.
fall into all age categories, including pre-teens
and the elderly. Although there are several clas- Today, the virtual playground of cyberspace
sifications of child molesters, a pedophile pres- affords these child sexual predators the opportu-
ents the greatest danger to children because a nity to engage children in anonymous exchanges
pedophile’s main sexual interest is a child. that often lead to personal questions designed to
assess whether the child can be lured into sexual
Pedophiles tend to be well liked by children conversation and sexual contact. The nature of
and may choose work in professions or vol- Internet crimes presents new challenges for law
unteer organizations that allow them easy enforcement with regard to the collection of
access to children and where they can devel- evidence, and apprehending offenders. The fol-
op the trust and respect of children and their lowing are just a few statistics that highlight the
parents. They sometimes believe sex with severity of the problem:
children is appropriate and even beneficial.
Children may be lured into sexual relation- • One in 5 youths have received a sexual
ships with love, rewards, promises, and gifts. approach or solicitation over the internet;
• One in 17 youth was threatened or
Most cases of extrafamilial sexual abuse harassed in the past year;
involve a perpetrator known to the child. • Only a fraction of all episodes was report-
However, cases of abuse by strangers do ed to authorities such as the police, an
occur. Typically, in these cases the stranger internet services provider, or a hotline;
will entice the child (“Will you help me find
my puppy?”), convince the child that his or • In households with home internet access,
her parent requested the stranger to pick up only 1/3 of parents said they had filtering
the child, or simply abduct the child. or blocking software on their computers.
Child Abuse Prevention Handbook 15

23. Regardless of law enforcement’s ability to • Tell your children to never give out their
detect and arrest child sexual predators using address.
the Internet, the most effective protection
against child victimization is an involved and The National Center for Missing and Exploited
educated parent. The following is a set of Children’s (NCMEC) Cyber Tipline serves as a
guidelines recommended for parents regard- national resource for tips and leads regarding
ing their children’s use of the Internet: the sexual exploitation of children. NCMEC
• Help children to understand why it is is a national clearinghouse for information
important that they do not give out per- on cases of abducted, runaway, and sexually
sonal information, even if their new e-mail exploited youth. NCMEC does not investi-
pal seems to be real friendly, or a “cool” gate such cases, but receives leads and dis-
web site offers them a free gift for the seminates them to various investigative law
information. enforcement agencies. In the effort to assist
• Let your children know they can come to law enforcement, NCMEC offers technical
you if they are receiving messages that assistance, information dissemination, and
make them feel uncomfortable. Tell them advice. NCMEC can be reached through the
that in such an event, they should save the Internet at www.missingkids.com or by calling
messages for you to read and handle in an their toll free hotline at 1-800-843-5678.
appropriate manner.
The Missing Children’s Program of the Office
• Set up guidelines that deal specifically of Juvenile Justice and Delinquency Program
with meeting people on the Internet. Talk (OJJDP) initiated its Internet Crimes Against
to your children about what to do if their Children (ICAC) task force program where
new Internet “friend” asks to see them in state and local law enforcement agencies
person, or wants your children to send pic- can acquire the skills, equipment and person-
tures of themselves. nel resources to respond effectively to ICAC
• Teach your children about “netiquette” offenses. To learn more, please visit their web-
(etiquette on the Internet), so that they site at: ojjdp.cjrs.org/programs/index.html.
will not accidentally offend anyone, but
will still protect themselves. NOTE: All mandated reporters are required
• Keep the computer in a high traffic part to report suspected sexual exploitation. (For
of the house such as the living room. You further details on these laws, see Addendum
can then easily monitor your children’s III.)
activities without making them feel as if
you are watching over their shoulders all
the time. Abuse of Children with
• Find web sites you think your children will
enjoy and “bookmark” them. This
Disabilities
will help direct your children away from Children with disabilities represent approxi-
using search engines, where they might mately 15% of the child population. The first
find inappropriate sites. national study conducted on the incidence of
abuse of children with disabilities found that
• Most importantly, spend time with your they are abused at approximately twice the
children talking about their experiences rate of those in the general population.6
online. Give them a chance to show you A more recent and comprehensive study
what they have learned or the things they published in 2001, conducted at Boys Town
like.5
16 Child Abuse Prevention Handbook

24. University by Dr. Patricia Sullivan, found that same, but in some cases, children with disabil-
the increased rate was 3.5 times that of ities may easily bruise or fracture themselves,
children, in general.7 Yet, most profession- so care must be taken to understand the
als estimate that the rates are much higher, disability when assessing whether abuse has
somewhere between 4 to10 times the rate.8 occurred. Communication issues are critical.
Children are frequently able to communicate
Children may acquire serious and chronic dis- the abuse, but they are often disbelieved due
abilities through abuse, and then become to prejudice against or misunderstanding of
more vulnerable. An estimated 25 percent individuals with disabilities. Use of assisted
of children with developmental disabilities communication skills may be required, or the
acquired the disability as a direct result of use of an interpreter may be necessary when
abuse.9 “Developmental Disability” is a legal conducting an interview.
term defined in the Welfare and Institutions
code that established a network of Regional Children with physical disabilities as well
Centers throughout California to provide for as those with psychiatric, sensory (hearing,
the needs of children and adults with “devel- vision), and communication (non verbal, lan-
opmental disabilities.” The main theme of guage processing impairments) disabilities,
“developmental disability” is that the disabil- have all been victims of abuse. Although
ity is of such significance that it interrupts the statistics indicate that physical assault is most
normal developmental process of the child. frequently reported, sexual abuse is recog-
This category of disability represents about nized as grossly under reported. Incest and
5% of all children with disabilities. Child abuse perpetrated within the family mirrors
Abuse Neglect Disability Outreach is the that which occurs in the general population.
only agency that provides wrap-around ser- Emotional and verbal maltreatment is also a
vices to children with other disabilities. serious problem among this population.
Children with developmental disabilities (those In most cases to date, the perpetrators are
that impair the developmental process, such male, with the victims nearly equally divided
as mental retardation, autism, cerebral palsy
and other physical disabilities) receive services
from a wide array of professionals, and thus,
are vulnerable to a much higher number of 5
Daniel Armagh, A Safety Net for the Internet: Protecting
trusted individuals who may abuse them. In Our Children, American Prosecutor’s Research Institute’s
National Center for Prosecution of Child Abuse.
this population, 99 percent of the perpetra- 6
Westat Report: National Incidence Study on Abuse of
tors are known to and trusted by the child Children with Disabilities, U.S. Department of Health and
and family.10 In many cases, when the per- Human Services, 1991.
7
In Focus: The Risk and Prevention of Maltreatment of
petrator is an approved service provider, the Children with Disabilities, National Clearinghouse on Child
abuse is not reported. However, when discov- Abuse and Neglect Information, 2001.
8
ered, the perpetrator is fired and frequently 9
James Garbarino, Special Children, Special Risks, 1989.
N. J. Baladerian, Ph.D., unpublished research paper, 1991,
moves to new employment or a volunteer
prepared for Centers for Disease Control Conference on
position and continues the abuse. Prevention of Disabilities, Washington, D.C. Compiles all
studies available in literature search on abuse of children
Emotional and behavioral signs of abuse in with disabilities and disability caused by abuse and neglect.
(A Nation’s Shame: Fatal Child Abuse and Neglect in the
children with disabilities may differ from those United States, A Report of the U.S. Advisory Board on Child
exhibited by children without disabilities due Abuse and Neglect, April 1995.)
10
to differences caused by the disability. For Seattle Rape Relief, Special Education Curriculum on Sexual
Exploitation, Seattle, WA; Developmental Disabilities Project,
example, physical signs of abuse are the 1979.
Child Abuse Prevention Handbook 17

25. between boys and girls. No single category of address issues of abuse as these relate to chil-
persons is identified as perpetrators. Howev- dren with disabilities.
er, transporters (bus drivers) do appear to rep-
resent a high proportion of those convicted. Cultural Differences
Some reports indicate that child abuse report- Our ideas concerning the parenting of chil-
ing soars at ages five to six, when many chil- dren may contrast greatly with other cultures.
dren enter school and come into contact with Cultural differences may become evident in
mandated reporters. Children with disabilities various aspects of child rearing. Cultural defi-
frequently stay within the school system until nitions of child abuse and neglect are wide
age 22; however, after 18, their abuse would and varied. Therefore, the professional must
be reported to Adult Protective Services. be aware of the discrepancies between our
culture and others when assessing children
Most children with disabilities receive spe- they suspect of being abused. There are
cial educational services, either on a regu- times when the professional needs to make
lar school campus or a separate school. decisions regarding whether to report child
Although they are mandated reporters, many abuse, educate the parents, or simply accept
special education teachers believe that “no the practice as “different” and not harm-
one would abuse a child with a disability” ful. The law does give the professional some
and blind themselves to signs of abuse, and guidance in this area. According to Welfare
do not report what they observe. They may and Institutions Code section 16509, “Cul-
attribute physical signs or behavioral changes tural and religious child rearing practices and
to the disability, rather than recognize these beliefs which differ from the general com-
as potential signs of abuse. Further, because munity standards shall not in themselves cre-
some disabilities result in behaviors of aggres- ate a need for child welfare services unless
sion (toward self or others) there are increas- the practice presents a specific danger to the
ing reports that teachers and teacher aides physical or emotional safety of the child.”
abuse children in the school system through Therefore, when a professional believes that
the misuses of restraint procedures. a practice falls within the definitions of child
abuse, it must be reported. If a mandated
Information about abuse of children with dis- reporter is unsure about a particular cultural
abilities is not familiar to many in the lay or practice, it is recommended they contact their
professional communities, which may leave local child protective services agency and dis-
these children more vulnerable to abuse. The cuss their concerns. Since cultural practices
signs of abuse they display may be ignored or are so diverse, mandated reporters are strong-
mistakenly attributed to the disability. Cases ly encouraged to receive cultural diversity
are less likely to be reported, thoroughly training to better understand these practices.
investigated, and prosecuted. Lack of serious
attention to the needs of disabled children
throughout the child abuse response system
is unique when compared to any other group
of child victims, and must be addressed. In
recent years, more attention to this popula-
tion has emerged with training programs for
those who respond to child abuse calls, and
modifications of training programs for man-
dated reporters are currently underway to
18 Child Abuse Prevention Handbook

26. What is Not
Child Abuse?
Mandated reporters often have questions 16509.1 are not considered child neglect.
about situations that may or may not be child Not receiving specific medical treatment for
abuse. Listed below are situations or circum- religious reasons (Pen. Code § 11165.2 (b)
stances that are not considered child abuse is further codified in Welfare Institutions
for purposes of the Child Abuse and Neglect Code 16509, which states, “…religious child
Reporting Act: rearing practices and beliefs which differ
from the general community standards shall
• Children fighting. Injuries caused by
not in themselves create a need for child
children fighting by mutual consent. (Pen.
welfare services unless the practice presents
Code, § 11165.6.)
a specific danger to the physical or emotional
• Reasonable force. Injuries caused by safety of the child.”
reasonable and necessary force used by a
• Voluntary sexual activity between
peace officer acting within the scope of
children under the age of 14. Voluntary
his or her employment. (Pen. Code,
sexual conduct between children who are
§ 11165.6.) Injuries caused by reasonable
both under the age of 14 years and who
and necessary force used by public school
are of similar age and sophistication is not
personnel to stop a disturbance that is
a crime and need not be reported under
threatening physical injury to someone or
the Child Abuse and Neglect Reporting
damage to property, for purposes of self-
Act. (People ex rel. Eichenberger v. Stock-
defense, or to obtain possession of weap-
ton Pregnancy Control Medical Clinic, Inc.
ons or other dangerous objects within the
(1988) 203 Cal.App.3d 225; Planned Par-
control of a child. (Pen. Code, § 11165.4)
enthood Affiliates v. Van de Kamp (1986)
• Corporal punishment. Spanking is not 181 Cal.App.3d 245.)
considered child abuse, however, when
• Pregnancy. Pregnancy of a minor, does
“any person willfully inflicts upon any child
not, in and of itself, constitute the basis of a
any cruel or inhuman corporal punishment
reasonable suspicion of sexual abuse. (Pen.
or injury resulting in a traumatic condi-
Code, § 11166, subd. (1).) Pregnancy may
tion,” it is considered “unlawful corporal
be cause for a report if the pregnancy was
punishment” and must be reported. (Pen.
conceived by a female under age 16 and a
Code § 11165.4)
male over 21. Similar consideration should
• Medical treatment. An informed and be made for other evidence of sexual activ-
appropriate medical decision (Pen. Code § ity including sexually transmitted diseases
11165.2 (b) and treatment by spiritual means including Gonorrhea, Chlamydia, Genital
as provided by Welfare Institutions Code Herpes, genital warts and HIV.
Child Abuse Prevention Handbook 19

27. • Past abuse of a child who is an adult at and is only determined after completing an
the time of disclosure. There is no duty autopsy, a death scene investigation, and a
to report child abuse unless the victim is a review of the case history of both the baby
child, meaning a person under the age of and the family.11 SIDS is not contagious,
18 years. (Pen. Code, § 11165.) Accord- and is not caused by immunizations, suf-
ingly, past abuse of a child who is an adult focation, or by child abuse or neglect.
at the time of disclosure or discovery of the
abuse need not be reported. However, if a Researchers and clinicians have discovered
mandated reporter has a “reasonable sus- that although SIDS cannot be predicated or
picion” due to the conversation with this prevented, there are things parents and care-
adult that someone under the age of 18 givers can do to lower an infant’s risk of SIDS.
has been abused or is in danger of being The Back-to-Sleep campaign, a national pub-
abused, it must be reported. lic health educational effort, which began in
• Maternal substance abuse and positive 1994, recommends that all babies be placed
toxicology screen at birth. A positive on their backs to sleep, unless otherwise
toxicology screen at the time an infant is instructed by a physician. Infant care prac-
delivered is not, in and of itself, a sufficient tices that should be followed by parents to
basis for reporting child abuse or neglect. reduce their baby’s risk for SIDS include the
However, any indication of maternal sub- following:
stance abuse shall lead to an assessment • Always place your baby on his/her back to
of the needs of the mother and child pur- sleep, even for naps.
suant to Health and Safety Code section
123605. If other factors are present that • Never allow smoking around your baby.
indicate a risk to the child, a report must • Place your baby on a firm, flat surface to
be made, but a report based on risk to sleep.
a child that relates solely to the parent’s • Remove all soft things such as loose bed-
inability to provide the child with regular ding, pillows, and stuffed toys from the
care due to the parent’s substance abuse sleep area.
shall be made only to county welfare
departments and not to law enforcement • Never place your baby on a sofa, water-
agencies. (Pen. Code, § 11165.13.) bed, soft chair, pillow, or beanbag.
• Sudden Infant Death Syndrome (SIDS). • Take special precautions when your baby is
SIDS is the sudden death of an infant in bed with you.
under one year of age which remains • Make sure your baby doesn’t get too hot.
unexplained after a thorough case inves- • Keep your baby’s face and head uncovered
tigation including performance of a com- during sleep.
plete autopsy, examination of the death
scene, and review of the clinical history • Share this information with everyone who
(Willinger, et al., 1991). It is the major cares for your baby.
cause of death infants from one month to
one year of age, with most death occur-
ring between two and four months. SIDS
occurs quickly and quietly in seemingly
healthy infants, usually during sleep and
happens in all social, economic, and ethnic
groups. It is a recognized cause of death 11
What is SIDS. US Department of Health and Human
Services, Maternal and Child Health Bureau, 2004.
20 Child Abuse Prevention Handbook

28. Who are Child
Abusers?
Child abuse occurs in all cultural, ethnic, Early identification, reporting, and interven-
occupational, and socioeconomic groups. tion are essential and vital to protect the child
Although many people assume that parents because people who abuse typically repeat
are the only culprits, children can become the abuse and increase its frequency.
victims of abuse by persons in non-parental
relationships, such as siblings, family friends, Over the years, studies have shown that a
neighbors, acquaintances, or strangers. variety of factors are associated with child
Those who abuse children may also be trusted abuse. Many of these factors apply to and
to care for our children, such as teachers, characterize the general population (such as
childcare providers, or foster parents. They stress, social isolation, transiency, and other
may be male or female; they may be adults, factors discussed in this section). Child abuse
adolescents, or children. is seldom the result of any single factor.
Rather, a combination of circumstances and
According to recent statistics, more than 80 personality types may precipitate an act of
percent of perpetrators were parents. Other abuse. The existence of one or more of the
relatives accounted for 7 percent and unmar- following factors could trigger abusive acts: a
ried partners of parents accounted for 3 per- predisposition toward maltreatment (perhaps
cent. The remaining percent includes persons as a result of having been abused, neglected,
with other relationships, e.g., camp coun- or witnessing domestic violence); emotional
selors, school employees, or unknown rela- stress, such as marital or employment prob-
tionships to the child. Female perpetrators, lems; substance abuse; a lack of constructive
mostly mothers, are typically younger than outlets for tension, anger, or aggression; or
male perpetrators, mostly fathers. Women poor impulse control.
also comprised a larger percentage than
men, 58 percent compared to 42 percent.12 Many people cannot understand how a par-
As previously reported, child abuse fatalities ent can abuse or neglect a child. Frequently,
have increased over the past several years. In abusive parents or caretakers themselves
2002, one or both parents were involved in
79 percent of child abuse and neglect fatali-
ties. Of the other 21 percent of fatalities, 16 12
National Clearinghouse on Child Abuse and Neglect
percent were the result of maltreatment by Information, Child Maltreatment: Summary of Key Findings,
non-parent caretakers, and 5 percent were 2003.
from unknown person or persons.13 13
National Clearinghouse on Child Abuse and Neglect, Child
Abuse and Neglect Fatalities: Statistics and Interventions,
2004.
Child Abuse Prevention Handbook 21