Fred S. Berlin, MD, PhD

Health professionals must familiarize themselves with relevant reporting statutes and arm themselves with knowledge about what constitutes neglect or abuse. In 1944, the US Supreme Court confirmed the authority of states to intervene in family relationships to protect children.

In 1961, physical child abuse was recognized by the medical profession as the “battered child syndrome,” which was characterized by severe physical injury, and even the death of a child.4 Subsequently, during the 1960s, a number of states began adopting laws 

 that suspected physical and/or sexual abuse of minors be reported.

Some jurisdictions mandate the reporting of suspected maltreatment or abuse of various vulnerable populations besides children (eg, the elderly, developmentally disabled persons, the severely disabled). Jurisdictions may require a telephone call or a written statement within 24 to 36 hours of finding out about a reportable event. Maintaining documentation that a suspected incident has been reported is important.

Mandatory Reporting of Suspected Child Abuse

1. Prince v Massachusetts, 321 US 158, 165 (1944).

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When did the US Supreme Court confirm the authority of states to intervene in family relationships to protect children? Find out in this quiz.

Mini Quiz: Obligation to Report Abuse

Child abuse has been documented worldwide for centuries. As early as ad 135, a Christian bishop named Polycarp (later canonized as a saint) had written about it.

 In the US, it had not been until 1938 that President Franklin D. Roosevelt signed into law the Fair Labor Standards Act that statutorily put a stop to the abuse and misuse of children in the workplace.

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 confirmed the authority of states to intervene in family relationships to protect children.

 In 1961, physical child abuse was recognized by the medical profession as the “battered child syndrome,” which was characterized by severe physical injury, and even the death of a child.

 Subsequently, during the 1960s, a number of states began adopting laws mandating that suspected physical and/or sexual abuse of minors be reported.

Today, all psychiatrists must familiarize themselves with relevant reporting statutes and be knowledgeable about what constitutes neglect or abuse. Some jurisdictions mandate the reporting of suspected maltreatment or abuse of various vulnerable populations besides children (eg, the elderly, the mentally retarded, the severely disabled). Jurisdictions may require a telephone call or a written statement within 24 to 36 hours of finding out about a reportable event. Maintaining documentation that a suspected incident has been reported is important.

If a psychiatrist is in doubt as to whether a specific incident is reportable, documented consultation with a professional colleague can be useful. In addition, guidance can usually be obtained from relevant reporting agencies without first disclosing a patient’s identity. Failure to make a required report can result in professional sanctions (eg, suspension or loss of one’s medical license and/or privileges). On the other hand, psychiatrists are ordinarily granted protection against civil suits when making a good-faith report.

Today, all psychiatrists must familiarize themselves with relevant reporting statutes and be knowledgeable about what constitutes neglect or abuse.

Many psychiatric inpatient facilities and outpatient clinics make in-house legal counsel available to provide guidance regarding such matters, and often specific individuals (such as a social worker) are assigned the task of notifying the appropriate authorities. Psychiatrists in private practice ordinarily need to make such required notifications on their own. The US Department of Health and Human Services provides online state-by-state guidelines that explain when and how to report.

 If required to testify in court (which is rare), psychiatrists should answer questions honestly, within the parameters required by their state’s statutes. Local branches of the American Psychiatric Association may be able to provide guidance regarding possible concerns.

Privileged communications vs mandatory reporting

One version of the Hippocratic Oath states, “All that may come to my knowledge in the exercise of my profession . . . which ought not to be spread abroad, I will keep secret.”

 Ordinarily, psychiatrists are mandated to maintain strict confidentiality regarding information divulged by patients, and the patient is granted the statutorily assured “privilege” that that will be so. Many psychiatrists feel uncomfortable about obtaining information that may be used for purposes other than to help their patients. Thus, some instruct their patients not to divulge reportable incriminating information (which may, in turn, compromise treatment).

In one anonymous unpublished survey, a number of psychiatrists expressed reticence about mandated reports. It is likely that most responders had been concerned that making such a report might compromise effective psychiatric care. Nevertheless, if it can be shown that mandatory reporting protects children, it becomes difficult to make an ethical argument against doing so. However, under certain circumstances, mandated reporting may inadvertently work against the best interests of children.

In many jurisdictions, psychiatrists have a “duty to warn,” or a “duty to protect” if they have received information suggesting that a patient may constitute an imminent risk to others. That said, the mandated reporting of suspected child abuse still stands in marked contrast to other sorts of mandates. For example, in most states, psychiatrists are not mandated to report patient self-disclosures about the commission of past murders, rapes, spousal abuse, tax evasion, drug distribution, or the possession and/or distribution of child pornography (and are ordinarily statutorily prohibited from doing so). Given that there is no mandate to report patients who have obtained and/or exchanged child pornography over the Internet, some individuals who have been compulsively doing so have sought treatment. They likely would not have done so had mandatory reporting been required. Self-disclosures about having used a minor to produce child pornography are reportable.

There are 3 circumstances under which mandatory reporting may be required:

• If a psychiatrist interviews a child and suspects abuse

• If a psychiatrist suspects such abuse based on information obtained from a concerned third party (eg, the child’s mother)

• If a psychiatrist suspects abuse (or has reason to believe that it has occurred) on the basis of the self-disclosures of an adult patient

Ordinarily, it would only be when suspicion is based on the self-disclosures of an adult patient that a conflict of interest could exist between the patient’s desire to maintain confidentiality and the psychiatrist’s obligation to make a mandated report.

Occasionally, there can also be instances in which a report might be required over the objections of a child or adolescent patient. Although victimized, some youngsters may not want a family member to be removed from the home, or for that individual to be incarcerated. Some youngsters may fear having a parent’s name on a sex offender registry, thereby causing additional unwanted difficulties for the entire family. Nevertheless, most psychiatrists likely appreciate the importance of making a report based on a child’s self-disclosures: that child may need further treatment; other children may be at risk; the alleged perpetrator may need to be stopped, and perhaps also sanctioned and treated.

Psychiatrists must also comply with statutes regarding the mandatory reporting of self-disclosures made by adult patients. However, it is important that future public policy be informed by research data that have looked at the intended and the unintended consequences of such statutes.

Unintended consequences of mandatory reporting

In Maryland, the first statute mandating psychiatrists to report suspected child abuse was enacted in 1964.

 It required reporting suspicions based on findings from an examination or interview of a child. Twenty-four years later, that statute was modified to also require reporting suspicions based on self-disclosures made by adult patients during therapy. One year later, in 1989, psychiatrists were additionally mandated to report suspicions based on the self-disclosures of adult patients made at the time of an initial psychiatric intake assessment.

The mandated reporting of suspected child abuse still stands in marked contrast to other sorts of mandates.

Historically, The Johns Hopkins Sexual Disorders Clinic, located in Maryland, had kept track of all adults who had self-referred for treatment. It had also kept track of all self-disclosures made during therapy about committed acts that had possibly been abusive. Before the statutory mandate of 1989, 73 men (previously unknown to law enforcement) over a 10-year period sought treatment in relationship to activities involving possible child sexual abuse. Those 73 men had made various sorts of disclosures. For example, one man acknowledged having touched a child on the upper thigh and privately feeling sexually excited. On the basis of such information, clinicians had been able to initiate an early intervention plan designed to prevent further problems.

After the statutory change, patients had to be told about the new reporting mandate via an “informed consent” process. Since then, the number of self-referrals by persons willing to self-incriminate to get treatment for a sexual disorder at Johns Hopkins has dropped to nearly zero. Self-incriminating, possibly reportable disclosures during therapy have also dropped to a similarly low level. Although self-disclosures in the past had sometimes not allowed as thorough an investigation of the situation in question as one might have desired, at least something positive could be done. In the absence of such self-disclosures, this is rarely possible.

In many jurisdictions, mandatory reporting requires that self-disclosures made by adult patients about their own abuse as a child be reported-even over the objections of the adult patient in question. This additional, unintended consequence of mandatory reporting can cause significant distress and damage to the psychiatrist-patient relationship.

Does mandatory reporting deter seeking treatment?

Pedophilia is a psychiatric disorder in which, through no fault of one’s own, an individual’s sexual desires are directed, either in whole or in part, toward prepubescent children.

 The B4U-ACT organization conducted an anonymous Internet survey designed to obtain information from persons who feel such desires.

 There were 193 respondents aged 15 to 70 years from various countries. Findings from the survey indicate that more than 66% of persons who had experienced enduring attractions to much younger children had been aware of such feelings before age 18. Just over a quarter (26%) had considered suicide at some point, and 41% of those who had considered it, had considered it before age 18. Clearly this is a population in need of mental health care-40% of the respondents expressed an interest in receiving it. However, many had also expressed the fear that were they to seek it, they would be reported, even if they had never actually committed an act of child sexual abuse.

Three respondents said: “Parents will disown you, teachers will report you, friends will abandon you. . . . People in my situation can’t discuss this without serious risk of persecution, and/or harassment.” “I’m a 15-year-old male . . . I’m not attracted to anyone my age or older any more. I’m only attracted to prepubescent girls. I feel like there is no hope for me, and sometimes I feel like killing myself. . . . I think about seeing a psychologist and everything, but I can’t talk to anyone at this time because my parents would find out and get the wrong idea, and people will judge me and think I really want to hurt little kids.” “I want to have sex with children all the time, but I know I cannot and will not because it will ruin that child’s life, and it will do the same to mine. I look at pictures all the time. That helps me deal with my desires without actually going out and having sex with a young child.”

Most of the respondents had not sought treatment, but they provided a number of reasons why they had desired treatment: 79% had wanted help figuring out how to live in society, given their attractions to children; 76% had wanted help learning how to deal with society’s negative responses; and 29% had wanted help learning to control their sexual feelings. To the extent that fears about mandated reporting may be deterring such individuals from seeking help, both they and society may be worse off.

The survey participants also provided a number of explanations about why they had not sought treatment: 85% felt that their feelings would be misunderstood; 54% expressed concern that they would be treated with disrespect; and 57% feared that their feelings (let alone their behaviors) would not be treated confidentially (ie, they feared being reported).

Mandatory reporting (as well as the “duty to protect”) has done a great deal of good. Mandatory reporting has helped identify and obtain treatment for many child victims. In most instances, when a report is made on the basis of information obtained from a child or a concerned third party, psychiatrists are not placed into a potentially adversarial position with their patients. Psychiatrists cannot report what they do not know, and if reporting self-disclosures about possible abuse enacted by adult patients continues to be mandated, generally such self-disclosures will simply not be made. Mandatory reporting may deter individuals who can pose a risk to children from seeking psychiatric help. Such help is not only beneficial to the adult in question, but when successful, can also assist in preventing future acts of child abuse.

In spite of the existence of sex offender registries, more than 95% of documented sexual abuse in any given year is perpetrated by individuals with no history of a prior sexual offense conviction. In recognition of that fact, public service announcements in Germany encourage persons who may be sexually attracted to children to seek treatment.

 The project has a good deal of public support, and there is no mandate to report.

In the US, such public service announcements are rare. However, the organization Stop It Now! has begun to make these types of announcements.

 Individuals who respond by calling their telephone helpline sometimes cannot be referred for psychiatric care without being reported, which means that care will likely not be forthcoming. Most attorneys (defense attorneys in most states are not mandated to report) would advise their clients not to self-incriminate in order to obtain needed treatment, especially in circumstances in which reporting is required. It is hoped that in the future, consideration can be given to modifying mandates so that these crucial issues can be addressed.

Dr Berlin is Associate Professor and Director of the Sexual Behavior Consultation Unit in the department of psychiatry and behavioral sciences at The Johns Hopkins University School of Medicine in Baltimore. He reports no conflicts on interest concerning the subject matter of this article.

Sexual Abuse in the Catholic Church: Scientific and Legal Perspectives.

 Vatican City: Libreria EditriceVaticana; 2003:14.

 Fair Labor Standards Act, 2.9 USC Chapter 8 (June 25, 1938).

 Kempe CH, Silverman FN, Steele BF, et al. The battered-child syndrome. 

 US Department of Health and Human Services. Child Welfare Information Gateway. 

http://en.wikipedia.org/wiki/Hippocratic_Oath

 Berlin FS, Malin HM, Dean S. Effects of statutes requiring psychiatrists to report suspected sexual abuse of children. 

 Berlin F. Pedophilia: criminal mindset or mental disorder? A conceptual review. 

http://www.b4uact.org/science/survey/02.htm

 NatCen Social Research. Stop It Now! Evaluation Europe. 

http://www.stopitnow-evaluation.co.uk/partners/dunkelfeld

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All psychiatrists must familiarize themselves with relevant reporting statutes and be knowledgeable about what constitutes neglect or abuse.