Child Abuse and Neglect Red Flags for Mandated Reporters Providing Online Services

Mandated reporters are professionals that, as part of their professional duties, are expected to report suspected child, dependent adult, or elder abuse and neglect. For therapists, especially those working with children, it’s an aspect of our job that we are acutely aware of. Reporting suspected child abuse and neglect have become more difficult for clinicians, as their usual ways of assessing are not accessible during a time of social distancing and online therapy. Red flags are warning signs to look out for that potential child abuse and neglect are occurring within a client’s home. This does not mean it IS occurring, but it does mean therapists use sound clinical judgement and consult with supervisors/colleagues.

As someone who has been doing online therapy with children and families for years, I’ve had to make child abuse reports. Often its because the abuse happened in front of me. Guardians forget that they are on camera and that I can see what they are doing. When you’re in your home, comfortable, you’re going to act like you would at home. This is the easiest way to suspect abuse as I saw it with my own eyes.

But when working with children and families online, it’s best to understand the red flags for potential child abuse. It won’t always happen on camera (including sexual abuse or neglect).

First, most of the signs for potential abuse will come from interactions with the caregiver. As it’s hard to obtain privacy similar to in-office, there will be increased interactions between guardian and therapist. Use these interactions to obtain critical information when assessing for potential child abuse and neglect.

Take note of these red flags for child abuse from the caregiver:

• Shows little concern for youth's schooling or engagement in treatment.

• Not accessible for follow-up and communication.

• Does not follow up on referrals for mental or medical care.

• Minimal ability to recognize physical or emotional distress in the youth. The youth is upset, crying, or screaming, and the guardian does not respond.

• Excessively blames problems in the household on the youth and complains to teachers/providers that not enough is being done to stop their disruptive behavior. Minimal acknowledgment or refusal to make any connections over how the pandemic and disruption to routine has caused trauma.

• Uses belittling language in front of the youth when speaking to providers, such as calling them "useless," "worthless," or "evil”.

• Showing unnecessary and over-the-top attention to the youth and speaks of getting jealous over other family members giving the youth attention. Unnecessary attention may include requesting the youth do sessions on their lap (and doesn't match developmental need) or in their bedroom when youth has other private space options.

• Demands an inappropriate level of physical or academic performance that isn't age or developmentally appropriate.

• Severely limits the youth's contact with friends, family, and teachers or providers. Session times or class times are shortened unnecessarily.

• Physically disciplining the youth on camera (with or without an object). Providers are expected to ask the youth about pain level (requesting the guardian not be present if possible) and request to see the area to look for signs of marks left on the body.

Reminder that these signs can also be signs of trauma, depression, or anxiety that the caregiver is experiencing. As the pandemic continues to bring about uncertainty, caregivers are facing unprecedented amounts of stress and mental unwellness. Therefore assessment may include need for additional services and resources (such as childcare, budgeting for finances, etc.).

In every training I provide to clinicians on teletherapy with children and families, I always emphasize the importance of using a larger monitor. All the research points out that a larger monitor helps prevent fatigue because it is easier to discern changes in expression. What I have also found, personally, is that it also makes it easier to detect bruising discoloration or facial expressions of pain. I would highly recommend all my online clinicians to start using larger monitors when providing therapy.

Larger monitor or not, we must always look for signs of potential abuse during our interactions with youth. Attempt to make as private a session as possible. Teach youth to type out their answers in the chat feature if you sense that someone is in the room with them, or is coaching them on what to say to you. Be keyed-in to patterns of behavior. You’ll notice when your youth have changed in ways that don’t seem to match their current developmental level and level in treatment.

Take note these different interactions with youth that are potential red flags for abuse:

• Signs in behavior changes, including aggression, anger, hostility, hyperactivity, or shyness.

• Signs of regression, including encopresis, enuresis, or loss of previously acquired developmental skills.

• Signs of weight loss in the face (sunken cheeks, sunken eyes, seeing collarbone easily, etc.). Inquire about how much the youth weighs or if they have lost weight. Ask what their diet is. Ask them if they are hiding food or keeping food in special places. Ask them if their room has a smell or ask the guardian if they have noticed a smell (looking for signs of hoarding).

• Wearing the same outfit daily. Ask how long and how often they have been wearing the same outfit. Even at home and finding more ways to be relaxed, youth should still at least change their clothes fairly regularly (learn what is normal for the family and if anything has changed behavior-wise). On the opposite spectrum, look for signs of the youth changing their clothes often. Ask how many showers they take.

• Excessive scratching of their arms or legs. These are potential signs of healing wounds.

• Signs of difficulty using the mouse, keyboard, or fine tools (like pencil and pens). Inquire if they are in pain when using these items.

• Include movement exercises in session and see if the youth has difficulty with certain movements (stretching their arms all the way up or twisting their back and body) that shouldn't be a problem. This may be an indicator of pain.

• Unexplained injuries or injuries that don't match the explanation, such as bruises, fractures, or burns. Look for these on their arms, shoulders, and/or legs (which may be visible during movement exercises).

• Looking at pornography during the session, or requesting to undress or show explicit sexual acts on screen.

• Reporting a desire to run away, self-harm, or die by suicide.

If you do find yourself in a situation where you must make a mandated report, here are a few tips to help you:

• Always document any suspicions you have and report them to your agency and supervisor. Work as a team to decide what you need to do.

• Become familiar with your local and professional policies & procedures. Bookmark those links so you can reference them right away, even in session if needed.

• Bookmark the contact information for your local child protective services website. This way you have the paperwork you need to fill out accessible, and the phone number to contact in order to make the report.

  • Remember that some of these reports ask for information about other youth in the household, including ages and birthdates. Having it pulled up on your screen will make it easier for you to obtain as much information as possible.

• Have your supervisor’s number at the ready, so that you can call them. Note that with teletherapy, you can even invite your supervisor into the digital session to help you assess, or help you speak to the guardian about why a mandated report might need to be made.

Presence of one or some of these red flags does not immediately mean child abuse or neglect is occurring. As clinicians, we are trained to use a whole host of information we gain from our cases to determine if a report should be made. That being said, you don’t have to have proof. Mandated reporters simply need suspicion of abuse to make a report. If you have reasonable suspicion that child abuse is occurring, then you can report. It is the job of your local child protective services to investigate and make a determination. Look for patterns, ask questions, and review your notes.

Additionally, we must continue to be aware of our own biases and systemic racism. Statistically, mandated reporters have been found to suspect child abuse and neglect happening in BIPOC (Black, Indigenous People of Color) families more then that of Caucasian/white families. Numerous studies have also found that reports of child abuse and neglect disproportionately target those of low-income families, for whom undergoing an entire investigation is often both an emotional and financial hardship. Children should not have to undergo unnecessary questioning, physical exams, and even temporary removal, as these experiences alone are traumatic. Be mindful of your own biases. Learn about the systemic racism that puts undue harm onto BIPOC families. Consult with supervisors, colleagues, and take additional cultural humility training. In the end, use strong clinical judgment and consult when making mandated reporting determinations.

Intervention and prevention will be some of the strongest ways to address potential child abuse and neglect. Remember that the pandemic has put trauma and stress on families who were currently struggling, and new stress and traumas to families who weren’t. The pandemic continues to change normal routines for youth, so some of the red flags of abuse (such as regression or thoughts of self-harm) could be a sign of mental unwellness brought on by the pandemic. Your client and their family may need additional support, such as parenting classes, tutoring, or meal assistance. They may need to learn new coping skills and ways to address undesirable behavior, as the pandemic has brought about trauma responses in youth. Noticing the signs of strain for a family and providing the appropriate level of response and care, will help prevent them from developing abuse patterns.

I’ve made a digital version of the list above for download to use as a reference guide. This should help you learn and remember some of the red flags.

What have you noticed in your practice (without giving away confidential information)? Are there red flags I’m missing that I should add?

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