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.1 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.2
In 1944, the US Supreme Court confirmed the authority of states to intervene in family relationships to protect children.3 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 mandating that suspected physical and/or sexual abuse of minors be reported.
The obligation to report
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.
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.5 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.”6 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.
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.
1. Hanson RK, Pfafflin F, Lutz M, eds. Sexual Abuse in the Catholic Church: Scientific and Legal Perspectives. Vatican City: Libreria EditriceVaticana; 2003:14.
2. Fair Labor Standards Act, 2.9 USC Chapter 8 (June 25, 1938).
3. Prince v Massachusetts, 321 US 158, 165 (1944).
4. Kempe CH, Silverman FN, Steele BF, et al. The battered-child syndrome. JAMA. 1962;181:17-24.
5. US Department of Health and Human Services. Child Welfare Information Gateway. https://www.childwelfare.gov. Accessed June 30, 2014.
6. Wikipedia. Hippocratic Oath. http://en.wikipedia.org/wiki/Hippocratic_Oath. Accessed June 30, 2014.
7. Berlin FS, Malin HM, Dean S. Effects of statutes requiring psychiatrists to report suspected sexual abuse of children. Am J Psychiatry. 1991;148:449-453.
8. Berlin F. Pedophilia: criminal mindset or mental disorder? A conceptual review. Am J Foren Psychiatry. 2011;32:3-25.
9. B4U-ACT. Living in Truth and Dignity. http://www.b4uact.org/science/survey/02.htm. Accessed June 30, 2014.
10. NatCen Social Research. Stop It Now! Evaluation Europe. http://www.stopitnow-evaluation.co.uk/partners/dunkelfeld. Accessed June 30, 2014.
11. Stop It Now! http://www.stopitnow.org. Accessed June 30, 2014.