Child Abuse | Copyright © 2008 CEUFast.com

Course Contents

	Purpose/Goals    Objectives    Physical Abuse    Neglect    Sexual Abuse    Psychological Abuse    Withholding of Medical Treatment    Prenatal Exposure to Drugs    Shaken Baby Syndrome    Munchausen's Syndrome by Proxy    Factors Influencing Child Abuse        Child characteristics (NCANDS, 2008)        Family characteristics (Sedlak, 1996)        Abuser Characteristics    Impact of Abuse on Children    Reporting Child Abuse    Summary    Child Abuse Reporting Contact Information    References    Click any section in the index above to browse to the corresponding course section

Purpose/Goals

The purpose of this course is to assist healthcare professionals in identifying and responding to child abuse.

Objectives

After completing this course, the learner will be able to meet the following six objectives:

The Administration for Children and Families in their 17th annual report of data reported that the rate and number of children who were victims of child abuse or neglect is lower for FY 2006 than it was five years ago (US DHHS, 2008). During 2002, children were abused or neglected at a rate of 12.3 per thousand children in the population resulting in an estimated 910,000 victims; for 2006, the rate was 12.1, resulting in an estimated 905,000 victims.
Key findings in this report include the following (US DHHS, 2008):

	The rate and number of all children who received an investigation or assessment increased since 2002.
	For 2002, the rate was 43.8 children per thousand in the population, resulting in an estimated 3,240,000 children who received an investigation or assessment; for 2006, the rate was 47.8 resulting in an estimated 3,573,000 children.
	Nationally, 64.2 % of child victims experienced neglect, 16.0 % were physically abused, 8.8 % were sexually abused, and 6.6 % were emotionally or psychologically maltreated. Rates of victimization by maltreatment type have fluctuated only slightly during the past several years.

Each State provides its own definitions of child abuse and neglect within the civil and criminal context. Civil laws, or statutes, describe the circumstances and conditions that obligate mandated reporters to report known or suspected cases of abuse. They also provide definitions necessary for juvenile/family courts to take custody of a child alleged to have been maltreated. Criminal statutes define the forms of maltreatment that are criminally punishable (NCANDS, 2008). All states require healthcare personnel, school personnel, daycare providers and law enforcement personnel to report child abuse. Failure to do so is a crime.
Child abuse and neglect is, at a minimum:

	Any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation.
	An act or failure to act that presents an imminent risk of serious harm.

The National Child Abuse and Neglect Data System (NCANDS) reported an estimated 1,530 child fatalities in 2006 (NCANDA, 2008). This translates to a rate of 2.04 children per 100,000 children in the general population. NCANDS defines child fatality as the death of a child caused by an injury resulting from abuse or neglect, or where abuse or neglect was a contributing factor (NCANDA, 2008). The rate of child abuse and neglect fatalities reported by NCANDS has varied slightly during the last several years beginning with a rate of 1.96 per 100,000 in 2001, increasing to 1.98 in 2002, 2.00 in 2003, 2.03 in 2004, decreasing back to 1.96 in 2005, and increasing to 2.04 in 2006. It is likely that the slight increase in fatalities reported by NCANDS from 2001 to 2006 is due to improved reporting by some of the states (NCANDA, 2008).

Physical Abuse

Physical abuse is the use of physical force that may result in bodily injury, physical pain, or impairment. Physical abuse may include acts of violence like striking, hitting, beating, pushing, shoving, shaking, slapping, kicking, pinching, and burning. This abuse may not have been intended to hurt the child; but an injury may have resulted from over- discipline or physical punishment (National Clearinghouse, 2003).
Signs and symptoms of physical abuse may be:

	Bruises, black eyes, welts, lacerations or rope marks
	Bone fractures, broken bones or skull fractures
	Open wounds, cuts, punctures or untreated injuries in various stages of healing
	Sprains, dislocations or internal injuries/bleeding
	Physical signs of being subjected to punishment or signs of being restrained
	A sudden change in behavior
	A child's report of physical abuse

Neglect

Neglect is the failure to provide for the child's basic needs. 43% of identified neglect cases were physical neglect, which includes unsafe housing, not being fed nutritionally adequate meals, inadequate clothing, and grossly inadequate hygiene. 37% of identified neglect cases were inadequate supervision of children and 21% were failure or delay in providing health care. Assessing child neglect requires consideration of cultural values and standards of care and recognition that poverty may contribute to the failure to provide the necessities of life (National Clearinghouse, 2003).

The Study of National Incidence and Prevalence of Child Abuse use the following standardized categories and definitions of child neglect: (National Clearinghouse, 2003).

	Refusal of Health Care
	Delay in Health Care
	Abandonment
	Expulsion
	Other Custody Issues
	Other Physical Neglect
	Inadequate Supervision
	Inadequate Nurturance/Affection
	Chronic/Extreme Abuse or Domestic Violence
	Permitted Drug/Alcohol Abuse
	Permitted Other Maladaptive Behavior
	Refusal of Psychological Care
	Delay in Psychological Care
	Other Emotional Neglect
	Permitted Chronic Truancy
	Failure to Enroll/Other Truancy
	Inattention to Special Education Need

Sexual Abuse

Sexual abuse is (National Clearinghouse, 2003):

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.

This may include fondling a child's genitals, intercourse, incest, rape, sodomy, exhibitionism, voyeurism, exposure to pornography, or commercial exploitation through prostitution or pornographic material. Consensual sexual contact with a child is statutory rape. The age of consent for sexual contact is defined by each state. Signs and symptoms of sexual abuse include:

	Bruises around the breasts or genital area
	Unexplained venereal disease or genital infections
	Unexplained vaginal or anal bleeding
	Torn, stained, or bloody underclothing
	A torn or scarred hymen
	Frequent urinary tract infections
	Sexual acting out,
	A child's report of sexually assault or rape
	Bruising or petechiae of the hard and soft palate or lacerations of the frenulum that can result from forced oral penetration (Lahoti, 2001).

Psychological Abuse

Psychological/emotional abuse includes acts or omissions by the parents or caregivers. This can cause serious behavioral, cognitive, emotional, or mental disorders. Psychological abuse is almost always present when other forms of abuse are identified (National Clearinghouse, 2003). This can include constant verbal abuse, harassment, belittling, humiliation, isolation from friends and family and intimidation. Signs and symptoms of psychological abuse include:

	Being emotionally upset or agitated
	Being extremely withdrawn and non communicative or non responsive
	Unusual behavior, like sucking, biting or rocking
	Aggression, depression, eating disturbances and regression
	A child's report of being verbally or emotionally mistreated

Withholding of Medical Treatment

Withholding of medically indicated treatment is (National Clearinghouse, 2003):

The failure to respond to the infant's life threatening conditions by providing treatment (including appropriate nutrition, hydration, and medication) that in the treating physician's or physicians' reasonable medical judgment, will be most likely to be effective in ameliorating or correcting all such conditions. But, the term does not include the failure to provide treatment (other than appropriate nutrition, hydration, and medication) to an infant when, in the treating physician's or physicians' reasonable medical judgment:

	The infant is chronically and irreversibly comatose
	The provision of such treatment would merely prolong dying; not be effective in ameliorating or correcting all of the infant's life-threatening conditions; or otherwise be futile in terms of the survival of the infant
	The provision of such treatment would be virtually futile in terms of the survival of the infant and the treatment itself under such circumstances would be inhumane.

This is a major concern with severely disabled newborns. Food and water must always be provided regardless of the extent of disabilities, and quality of life cannot be a criterion for deciding appropriate medical treatment.

Federal regulations require Child Protective Services programs to actively investigate reported cases of withholding of medical treatment. Hospitals are required to observe the provisions of the law and to post notices of the law in newborn nurseries.

Prenatal Exposure to Drugs

Pregnant women who abuse alcohol have exposed their fetuses to the serious mental and physical disabilities known as fetal alcohol syndrome. An estimated 73% of pregnant women have used alcohol sometime during their pregnancy. The incidence of fetal alcohol syndrome is 1.9 births per 1,000. Prenatal exposure to cocaine and other drugs also results in negative developmental disorders (National Clearinghouse, 2003).

Shaken Baby Syndrome

When a baby is vigorously shaken, the head moves back and forth. A baby's head and neck are susceptible to head trauma because the muscles are not fully developed and the brain tissue is exceptionally fragile. Shaken Baby Syndrome occurs most frequently in infants younger than six months old, but it can occur up to age three (National Shaken Baby, 2008). The sudden whiplash motion causes the injury to the baby. That motion can cause bleeding inside the head and increased pressure on the brain, causing the brain to pull apart. Often, there are no obvious outward signs. Shaken Baby Syndrome is one of the leading forms of fatal child abuse. Head trauma, is the leading cause of disability due to abuse of infants (National Shaken Baby, 2008). Shaken baby syndrome is often misdiagnosed and under diagnosed (Hopper, 1999).

Munchausen's Syndrome by Proxy

Munchausen's syndrome by proxy (MSBP) is when a parent commits physical abuse while trying to intentionally fabricating illnesses in their children. The existing research is based on a small number of cases and needs to be expanded. However, the research suggests that victims of MSBP experience significant psychological and psychiatric symptomatology in both childhood and adulthood. Most cases of MSBP are believed go undetected, so the actual incidence of this type of abuse is unknown. Because of the sometimes extreme abuse inflicted by parents with MSBP (e.g., broken bones, poisoning), their children are at great risk for serious physical and psychiatric morbidity (Kaplan, 1999).

Factors Influencing Child Abuse

The incidence of child maltreatment varies as a function of family income, family structure, family size, and the metropolitan status of the county. As circumstances deteriorate, maltreatment becomes more prevalent and more severe (Sedlak, 1996).

Child characteristics (NCANDS, 2008):

	The highest victimization rates were for the 0-3 age group, 13.9 per 1,000
	Victimization rates by race/ethnicity ranged from 4.4 per 1,000 for Asian/Pacific Islander to 25.2 per 1,000 for African-American victims
	43% % of the fatalities were younger than 1 year of age, and 86% were younger than 6 years of age
	38% of the fatalities were associated with neglect
	Girls were sexually abused more often than boys
	Boys had a greater risk of serious injury and emotional neglect than girls
	Children are vulnerable to sexual abuse from age three on
	Older children have greater opportunities for escape, and are more able to defend themselves and/or retaliate
	Pre-maturity, difficult temperament and mentally handicapped children have been associated with parents that are less responsive and less attentive to their needs (National Clearinghouse, 2003)
	Physical abuse peaks in the 4-8 year old age range. Psychological abuse peaks in the 6-8 year old range and remains at a similar level through adolescence (Kaplan, 1999)

Unless otherwise noted, the statistics noted below are taken from Child Maltreatment 2006 and refer to the Federal fiscal year (FY) 2006 (U.S. Department of Health and Human Services, 2008).

(Child Maltreatment 2006 and refer to the Federal fiscal year (FY) 2006(U.S. Department of Health and Human Services, 2008).

Research indicates that young children, ages 3 and younger, are the most frequent victims of child fatalities. NCANDS data for 2006 demonstrated that children younger than 1 year accounted for 44.2 % of fatalities, while children younger than 4 years accounted for more than three-quarters (78.0 %) of fatalities. These children are the most vulnerable for many reasons, including their small size, dependency, and inability to defend themselves. Fatal child abuse may be due to acute or chronic abuse. Repeated abuse over a period of time (e.g., battered child syndrome) is a chronic situation and an acute abuse may involve a single, impulsive incident (e.g., drowning, suffocating, or shaking a baby). In cases of fatal neglect, the child's death results from a caregiver's failure to act. The neglect may be chronic (e.g., extended malnourishment) or acute (e.g., an infant or child who drowns after being left unsupervised in the bathtub).
In 2006, 41.1% of child maltreatment fatalities were associated with neglect alone. Physical abuse alone was cited in almost one-quarter (22.4%) of reported fatalities. Another 31.4% of fatalities were the result of multiple maltreatment types. In 2006, one or both parents were responsible for 75.9% of child abuse or neglect fatalities. 14.7% of fatalities were the result of maltreatment by non-parent caretakers, and the remaining 9.5% represents unknown or missing information.

Family characteristics (Sedlak, 1996)

	Children of single parents have a 77% greater risk of being harmed by physical abuse; an 87% greater risk of being harmed by physical neglect; and an 80% greater risk of suffering serious injury or harm from abuse or neglect.
	Children in the largest families were physically neglected at nearly three times the rate of those who came from single-child families.
	Children from families with annual incomes below $15,000 as compared to children from families with annual incomes above $30,000 per year were over 22 times more likely to experience some form of maltreatment.
	Children from the lowest income families were 18 times more likely to be sexually abused, almost 56 times more likely to be educationally neglected, and over 22 times more likely to be seriously injured from maltreatment.
	The estimated rate of neglect among families with four or more children was almost double the rate among families with three or fewer children (National Clearinghouse, 2003).

Abuser Characteristics

The ability to provide adequate care for a child depends partly on the parent's emotional maturity, coping skills, knowledge about children, mental capacity, and parenting skills. Alcohol or drug abuse is often present in cases of child neglect (National Clearinghouse, 2003).

NCANDS (2008) found the following conclusions about perpetrators, when the perpetrator was known:

	62% of perpetrators were female.
	87% of all victims were maltreated by at least one parent.
	The most common pattern of was a child victimized by a female parent acting alone.
	Neglect and physical abuse were more frequently perpetrated by a female parent.
	Sexual abuse was more frequently perpetrated by a male parent.

The following are five characteristics of neglectful mothers (National Clearinghouse, 2008):

	Impulse-ridden
	Apathetic
	Suffering from reactive depression
	Mentally retarded
	Psychotic

High-risk parents may be identified using the following indicators (National Clearinghouse, 2008):

	Poverty
	Mental retardation
	Drug abuse
	Lack of social support
	History of being maltreated
	Observing parent¬ and infant interactions for indicators of poor bonding
	Standard risk assessment instruments.

Impact of Abuse on Children

Physical abuse or neglect is associated with a large number of interpersonal, cognitive, emotional, behavioral, and substance abuse problems. There is also an associated increase in psychiatric disorders and increased mental health services utilization. There is an association between physical abuse and the risk for suicidal behavior, particularly in adolescents. Aggressive and delinquent behaviors are frequently correlated with physical abuse (Kaplan, 1999).

Psychological maltreatment may have a stronger relationship to long-term psychological functioning than other forms of maltreatment. Psychological abuse is a stronger predictor than physical maltreatment of a wide array of problems, including internalizing and externalizing behaviors, social impairment, low self-esteem, suicidal behavior, as well as current and previous psychiatric diagnoses and hospitalizations.

A history of physical abuse increased a subject's odds of attempting suicide by almost 5 times, while a history of psychological abuse increased the odds of a suicide attempt by more than 12 times. Perceived emotional rejection by parents has been associated with poor adolescent and young adult outcomes in substance abuse and delinquency (Kaplan, 1999).

Abused children may have impaired cognitive abilities, poor academic achievement and deficits in both receptive and expressive language. Abused adolescents report deficits in the social functioning, like impaired styles of interpersonal attachment, engaging in more aggression in their peer relationships, and exhibiting more abusive or coercive behaviors in dating relationships. Abuse victims are at increased risk for a variety of child and adolescent psychiatric diagnoses, including depressive disorders, anxiety disorders, conduct disorder, oppositional defiant disorder, attention-deficit/hyperactivity disorder and substance abuse (Kaplan, 1999).

Reporting Child Abuse

Each State has specific agencies to receive and investigate reports of suspected child abuse and neglect. Usually, this is done by child protective services (CPS), within a Department of Social Services, Department of Human Resources, or Division of Family and Children Services. A list of that contact information is at the end of this course.

In some States, police departments also may receive reports of child abuse or neglect. If you don't know whom to call, you can call Childhelp USA, National Child Abuse Hotline at 1-800-4-A-CHILD (1-800-422-4453; TDD 1-800-2-A-CHILD). This Hotline is available 24 hours, 7 days a week. They can tell you where to file your report and can help you make the report. State Toll-Free Child Abuse

Child abuse victims come into frequent contact with health professionals, but physicians often only treat their injuries. Because there is a lack of training on what to look for and how to ask about abuse, health professionals often fail to identify victims. Opportunities for intervention are missed and victims continue to suffer the adverse health consequences of physical and emotional abuse (Nudelman, 1999).

Early intervention with parents identified as high risk for neglect, using home health visitation, has proven to be an effective prevention strategy. Home visitors can initiate contact with the mothers during their pregnancy or at the time of their delivery in the hospital, and should provide follow up in-home visits for up to 2 years (National Clearinghouse, 2008).

Healthcare professionals are often the first to observe abuse and neglect, and their observations are often crucial in substantiating that abuse has occurred. They can help by:

	Reporting suspected cases of child abuse to Children's Protective Services
	Documenting abuse in the medical record
	Safeguarding evidence
	Providing medical advice, referrals, and safety planning
	Showing empathy and compassion
	Identifying the somatic signs and symptoms of abuse
	Evaluating the plausibility of explanations given for common injuries and conditions
	Providing expert testimony
	Assessing cognitive status and health factors that affect it
	Treating injuries or health problems that result from abuse
	Performing abuse screenings
	Encouraging clinics, hospitals, health maintenance organizations, or other medical providers to develop or adopt protocols for screening and responding to abuse
	Provide referrals to legal and social services
	Learning more about child abuse

Screening questions should always be asked in a private room, away from the batterer and preceded by assurances of strict confidentiality. Health care providers should also be trained to find ways to separate the patient from their parent if the latter demands to accompany the patient into the examining room (Nudelman, 1999).

Summary

Child fatalities due to abuse and neglect are a serious problem in the United States. Fatalities disproportionately affect young children and most often are caused by one or both of the child's parents. Child fatality review teams have been created to accurately count, respond to, and prevent child abuse and neglect fatalities, as well as other preventable deaths.

Prevention is one way of helping to prevent abuse, neglect and untimely deaths from occurring. The child fatality review process helps identify risk factors that may assist prevention professionals. These prevention teams are demonstrating effectiveness in translating review findings into action by partnering with child welfare and other child health and safety groups. In some States, review team annual reports have led to State legislation, policy changes, or prevention programs (National Center for Child Death Review, 2007).

In 2003, the Office on Child Abuse and Neglect, within the Children's Bureau, Administration for Children and Families, U.S. Department of Health and Human Services, launched a Child Abuse Prevention Initiative to raise awareness of the issue in a much more visible and comprehensive way than ever before. Today, “The Prevention Initiative” is an opportunity to work together in communities across the country to support parents and promote safe children and healthy families. Increasingly, this effort focuses on promoting protective factors that enhance the capacity of parents, caregivers, and communities to protect, nurture, and promote the healthy development of children. Healthcare professionals working in emergency rooms and clinics need to take the initiative to report child abuse findings to the proper authorities in a timely manner before deaths occur to our nation's innocents.

Child Abuse Reporting Contact Information

Reporting Numbers Resource List is from Child Welfare Information Gateway. Information Updated on September 29, 2008.
State toll-free numbers for specific agencies designated to receive and investigate reports of suspected child abuse and neglect.

Alabama Local (toll): (334) 242-9500;
http://www.dhr.state.al.us/page.asp?pageid=304

Alaska Toll-Free: (800) 478-4444;
http://www.hss.state.ak.us/ocs/default.htm

Arizona Toll-Free: (888) SOS-CHILD (888-767-2445)
https://www.azdes.gov/dcyf/cps/reporting.asp

Arkansas Toll-Free: (800) 482-5964
http://www.state.ar.us/dhs/chilnfam/child_protective_services.htm

California
http://www.dss.cahwnet.gov/cdssweb/PG20.htm
Click on the website above for information on reporting or call Childhelp® (800-422-4453) for assistance.

Colorado Local (toll): (303) 866-5932
http://www.cdhs.state.co.us/childwelfare/FAQ.htm

Connecticut TDD: (800) 624-5518 Toll-Free: (800) 842-2288
http://www.state.ct.us/dcf/HOTLINE.htm

Delaware Toll-Free: (800) 292-9582
http://www.state.de.us/kids/

District of Columbia Local (toll): (202) 671-SAFE (202-671-7233)
http://cfsa.dc.gov/cfsa/cwp/view.asp?a=3&q=520663&cfsaNav=|31319|

Florida Toll-Free: (800) 96-ABUSE (800-962-2873)
http://www.dcf.state.fl.us/abuse/

Georgia
http://dfcs.dhr.georgia.gov/portal/site
Click on the website above for information on reporting or call Childhelp® (800-422-4453) for assistance.

Hawaii Local (toll): (808) 832-5300
http://www.hawaii.gov/dhs/protection/social_services/child_welfare/

Idaho Toll-Free: (800) 926-2588
http://www.healthandwelfare.idaho.gov/site/3333/default.aspx

Illinois Toll-Free: (800) 252-2873 Local (toll): (217) 524-2606
http://www.state.il.us/dcfs/child/index.shtml

Indiana Toll-Free: (800) 800-5556
http://www.in.gov/dcs/protection/dfcchi.html

Iowa Toll-Free: (800) 362-2178
http://www.dhs.state.ia.us/dhs2005/dhs_homepage/children_family/abuse_reporting/child_abuse.html

Kansas Toll-Free: (800) 922-5330
http://www.srskansas.org/services/child_protective_services.htm

Kentucky Toll-Free: (800) 752-6200
http://chfs.ky.gov/dcbs/dpp/childsafety.htm

Louisiana
http://www.dss.state.la.us/departments/ocs/Reporting_Child_Abuse-Neglect.html
Click on the website above for information on reporting or call Childhelp® (800-422-4453) for assistance.

Maine TTY: (800) 963-9490 Toll-Free: (800) 452-1999
http://www.maine.gov/dhhs/bcfs/abusereporting.htm

Maryland
http://www.dhr.state.md.us/cps/report.htm
Click on the website above for information on reporting or call Childhelp® (800-422-4453) for assistance.

Massachusetts Toll-Free: (800) 792-5200
http://mass.gov/?pageID=eohhs2terminal&L=5&L0=Home&L1=Consumer&L2=Family+Services&L3=Violence%2c+Abuse+or+Neglect&L4=Child+Abuse+and+Neglect&sid=Eeohhs2&b=terminalcontent&f=dss_c_can_reporting&csid=Eeohhs2

Michigan
http://www.michigan.gov/dhs/0,1607,7-124-5452_7119_7193-15252--,00.html
Click on the website above for information on reporting or call Childhelp® (800-422-4453) for assistance.

Minnesota
http://www.dhs.state.mn.us/main/
Click on the website above for information on reporting or call Childhelp® (800-422-4453) for assistance.

Mississippi Toll-Free: (800) 222-8000 Local (toll): (601) 359-4991
http://www.mdhs.state.ms.us/fcs_prot.html

Missouri Toll-Free: (800) 392-3738 Local (toll): (573) 751-3448
http://www.dss.mo.gov/cd/rptcan.htm

Montana Toll-Free: (866) 820-5437
http://www.dphhs.mt.gov/cfsd/index.shtml

Nebraska Toll-Free: (800) 652-1999
http://www.hhs.state.ne.us/cha/chaindex.htm

Nevada Toll-Free: (800) 992-5757
http://dcfs.state.nv.us/DCFS_ReportSuspectedChildAbuse.htm

New Hampshire Toll-Free: (800) 894-5533 Local (toll): (603) 271-6556
http://www.dhhs.state.nh.us/DHHS/BCP/default.htm

New Jersey TDD: (800) 835-5510 TTY: (800) 835-5510 Toll-Free: (877) 652-2873
http://www.state.nj.us/dcf/abuse/how/

New Mexico Toll-Free: (800) 797-3260 Local (toll): (505) 841-6100
http://www.cyfd.org/report.htm

New York TDD: (800) 369-2437 Toll-Free: (800) 342-3720 Local (toll): (518) 474-8740
http://www.ocfs.state.ny.us/main/cps/

North Carolina
http://www.dhhs.state.nc.us/dss/cps/index.htm
Click on the website above for information on reporting or call Childhelp® (800-422-4453) for assistance.

North Dakota
http://www.nd.gov/dhs/services/childfamily/cps/#reporting
Click on the website above for information on reporting or call Childhelp® (800-422-4453) for assistance.

Ohio
http://jfs.ohio.gov/county/cntydir.stm
Contact the county Public Children Services Agency using the list above or call Childhelp® (800-422-4453) for assistance.

Oklahoma Toll-Free: (800) 522-3511
http://www.okdhs.org/programsandservices/cps/default.htm

Oregon
http://www.oregon.gov/DHS/children/abuse/cps/report.shtml
Click on the website above for information on reporting or call Childhelp® (800-422-4453) for assistance.

Pennsylvania Toll-Free: (800) 932-0313
http://www.dpw.state.pa.us/ServicesPrograms/ChildWelfare/003671030.htm

Puerto Rico Toll-Free: (800) 981-8333 Local (toll): (787) 749-1333 Spanish Information on Website: http://www.gobierno.pr/GPRPortal/StandAlone/AgencyInformation.aspx?Filter=177

Rhode Island Toll-Free: (800) RI-CHILD (800-742-4453)
http://www.dcyf.ri.gov/child_welfare/index.php

South Carolina Local (toll): (803) 898-7318
http://www.state.sc.us/dss/cps/index.html

South Dakota
http://dss.sd.gov/cps/protective/reporting.asp
Click on the website above for information on reporting or call Childhelp® (800-422-4453) for assistance.

Tennessee Toll-Free: (877) 237-0004
http://state.tn.us/youth/childsafety.htm

Texas Toll-Free: (800) 252-5400
https://www.dfps.state.tx.us/Child_Protection/About_Child_Protective_Services/reportChildAbuse.asp

Utah Toll-Free: (800) 678-9399
http://www.hsdcfs.utah.gov

Vermont After hours: (800) 649-5285
http://www.dcf.state.vt.us/fsd/reporting_child_abuse

Virginia Toll-Free: (800) 552-7096 Local (toll): (804) 786-8536
http://www.dss.virginia.gov/family/cps/index.html

Washington TTY: (800) 624-6186 Toll-Free: (866) END-HARM (866-363-4276) After hours: (800) 562-5624
http://www1.dshs.wa.gov/ca/safety/abuseReport.asp?2

West Virginia Toll-Free: (800) 352-6513
http://www.wvdhhr.org/bcf/children_adult/cps/report.asp

Wisconsin
http://dcf.wisconsin.gov/children/CPS/cpswimap.HTM
Click on the website above for information on reporting or call Childhelp® (800-422-4453) for assistance.

Wyoming
http://dfsweb.state.wy.us/menu.htm
Click on the website above for information on reporting or call Childhelp® (800-422-4453) for assistance.

If a number is out of service you can call:
Child Abuse Hotline 1-800-4-A-CHILD (1-800-422-4453)

Adolescent Crisis Intervention & Counseling Nineline
1-800-999-9999 an internet resource site 2008:
http://www.childwelfare.gov/pubs/reslist/rl_dsp.cfm?rs_id=21&rate_chno=19-00044.

References

Child Welfare Information Gateway Resource (2008).
http://www.childwelfare.gov/index.cfm. Retrieved on 09/2008.

Hopper, J. (1999) Child Abuse: Statistics, Research and Resources. Manisses, 04/1999.

Kaplan, S., (1999). Adolescent Abuse and Neglect Research: A Review of the Past 10 Years. Part I: Physical and Emotional Abuse and Neglect.

Journal of the American Academy of Child and Adolescent Psychiatry. 10/1999.

Lahoti, S. (2001). Evaluating the Child for Sexual Abuse, American Family Physician, 03/1/2001.

National Child Abuse and Neglect Reporting System (NCANDS), (2008), www.calib.com/nccanch/pubs/factsheets/canstats.cfm. Retrieved on 09/2008.

National Children's Advocacy Center. (2008). http://www.nationalcac.org/ Retrieved on 09/2008

National Clearinghouse on Child Abuse and Neglect (2008). Information at www.calib.com/nccanch, Retrieved on 09/2008.

National Shaken Baby Syndrome Campaign. (2008). Babies are fragile. Please don't shake a child. National Exchange Club Foundation, www.preventchildabuse.com, Retrieved on 09/2008.

Nudelman, J., et al. (1999). Building Bridges Between Domestic Violence Advocates and Health Care Providers. National Resource Center on Domestic Violence www.vaw.umn.edu/library/dv/. Retrieved on 09/2008.

Sedlak, A., et.al. (1996). Executive Summary of the Third National Incidence Study of Child Abuse and Neglect. U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families and National Center on Child Abuse and Neglect. Westat, Inc

U.S. Department of Health & Human Services (2008) Recognizing Child Abuse and Neglect: Signs and Symptoms: http://www.childwelfare.gov/pubs/factsheets/signs.cfm Retrieved on 09/2008.

U.S. Department of Health & Human Services (2008). Statistics and Research. Retrieved on 9/200 at http://www.acf.hhs.gov/programs/cb/stats_research/index.htm#can.