Health Policy$ense

Preventing Child Abuse: Is More Reporting Better?

Evidence says no.

[Editor’s note: Mical Raz, MD, PhD, is a physician and historian of medicine in Penn LDI’s Masters of Science in Health Policy Research program. This blog post reflects her new piece in Pediatrics, which examines the history of mandatory reporting of suspected child abuse and neglect, and questions both its effectiveness and its unintended consequences.]

As the chilling details of the Penn State child sex abuse case came to light, politicians, physicians, and the public alike questioned how egregious abuse could go unreported for so long.

In the aftermath, Pennsylvania adopted extensive new legislation to prevent and detect child abuse. In particular, Pennsylvania now requires child abuse awareness training for any licensed health care professional in the state and significantly expanded the definition of mandatory reporters to include essentially any individual in contact with children.

Increasing reporting seems like a logical approach to improving child safety. It is also ethically and morally compelling. Eradicating the scourge of child abuse requires recognition, and few would argue against reporting a child in danger. But a new study calls into question the effectiveness of expanding mandatory reporting requirements. It  compares outcomes in states with and without universal mandatory reporting (where any adult is considered a mandatory reporter of child abuse and neglect).

The goal of mandatory reporting is to identify children at risk, and intervene to prevent further harm. It is not to create more reports.

This new study found that universal mandatory reporting policies were not correlated with increased identification of children at risk of physical abuse. Rather, universal mandatory reporting policies were associated with increased number of reports by non-professionals, which were less likely to be substantiated, and also associated with a lower number of reports made by some professional groups (which are generally more likely to be substantiated). Taken together, these policies did not achieve their goal of increasing the identification of children at risk of physical abuse.

This adds to the evidence that increased mandatory reporting requirements are not an effective policy to improve detection of children at risk. They have not led to higher rates of substantiated cases – an imperfect yet significant endpoint to examine the effectiveness of policy change. Furthermore, studies suggest that in overburdened systems, substantiation rates decrease.

Policy interventions are messy and often have unintended consequences. In Philadelphia, this is particularly salient with high volumes of reporting, yet no evidence of improved outcomes for children. In fact, the new reporting requirements have inundated the city’s reporting hotline, contributing to excessive waiting times, unanswered calls, spurious calls and unnecessary reports. I’m concerned that this may adversely affect the care of children in imminent risk of serious harm.

The goal of mandatory reporting is to identify children at risk, and intervene to prevent further harm. It is not to create more reports.

Professional vs. public reporting

In the past, physician reports of suspected maltreatment of children have proven in the past to be the most likely to be supported by a subsequent child welfare investigation. More recent studies have continued to find relatively high substantiation rates among reports made by all medical personnel (including medical technicians and assistants). Still, physicians often do not report, and increasing physician reporting is an ongoing challenge.

Studies that surveyed physicians found that non-reporting is often tied to incorrect identification of at-risk children, as well as a lack of trust in the Child Protective Services (CPS) response. Furthermore, individual bias is a huge obstacle – clinicians overreport abuse among minority and low-income populations and underreport whiter and more privileged patients. Therefore, there is no reason to believe that lax legal statutes are a barrier to reporting, or that increasing fines will lead to better identification of children at risk.

Increasing mandatory reporting by the lay public results in an increase in unsubstantiated reports, which could cause harm in a number of ways. Policies designed to actively increase reporting are rarely matched by increased funds or personnel dedicated to children’s care, thus depleting resources that are already scarce, and diverting attention from children at risk of imminent harm.

Furthermore, numerous studies have found that reports of child abuse, and particularly of neglect, disproportionately target low-income families, for whom an investigation is often an emotional and financial hardship. Children suffer when unnecessarily subjected to questioning, physical exams and occasionally temporary removal. Communities suffer when community members, newly designated as mandatory reporters, struggle with the boundaries of their roles and find themselves reporting families, particularly low-income families who are most likely to be accused of neglect, rather than offering assistance. Families may be more reluctant to seek help if they are worried about reporting. Finally, as low-income and African American families are already more likely to be reported to child protective services; increased reporting magnifies these racial biases in child welfare interventions.

Next steps

So what should the engaged physician do to help ensure the safety of our children and communities? Clearly, physicians should continue reporting any concerns of child maltreatment and neglect, while recognizing that most of the reports CPS receives differ greatly from the clinical scenarios pediatricians encounter. Most CPS cases are not the young infant with the traumatic head injury. In fact, in Philadelphia in the past year, the most common reasons for removing children from their home were drug abuse and child behavioral difficulties, rather than physical abuse.

Additionally, as physicians, we are often asked to share our expertise with policymakers. We should question the wisdom of policy interventions that are not supported by evidence and may cause unintended harm.

Finally, as researchers, we can contribute to the body of knowledge on child abuse prevention by examining the effects of mandatory reporting laws with large-scale population studies, and in particular pre-post studies of changes in reporting laws that can provide specific input as to the impact of implement policies. Studies that take into account the experience of children and families as they interact with CPS are also particularly valuable, as behind each report is a family, often struggling with poverty and additional stressors. As we strive to protect children, we should be sure the policies we support are sound.