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If our society is to prosper in the future, we must make sure our children have safe, supportive environments where they can grow socially, emotionally and physically. When children are abused or neglected their opportunity for healthy development is undermined by toxic stress that damages the developing architecture of their brains. This damage weakens the foundation that future development is built on and is traumatic and long term, resulting in physical, mental and behavioral problems later in life. Understanding of child maltreatment and its impact has resulted in heightened awareness about the responsibility of adults to respond. When we take the time to respond to suspicions of abuse and neglect, we ensure families get the support they need and children’s basic foundation for future success is solid. A solid foundation will reap many rewards later on as children grow into successful, contributing members of our community.

Physicians and physician assistants have relatively limited access to children. They may see their pediatric patients annually or just a few times a year, usually for no more than 15 minutes. Nonetheless, clinicians can be an important means of identifying potential abuse and neglect . It is important to remember that sometimes a physician is the only professional involved in the life of a young child and may have the opportunity to perform comprehensive evaluations of a child’s health and well-being. Non-pediatric physicians also treat other family members—parents or guardians—who may disclose information about a child’s environment and experiences.

The Impact of Child Maltreatment
In 2005, the Centers for Disease Control and Prevention and insurer Kaiser Permanente released the most comprehensive research to date on the impact of child abuse and neglect. The Adverse Childhood Experiences (ACE) Study, surveyed 17,000 adults about their childhood experiences and compared them with their health histories. The research found that children who suffered severe adversity in childhood—violence, abject poverty, substance abuse in the home, child abuse and neglect—were far more likely to suffer long-term intellectual, behavioral and physical and mental health problems.

Problems now concretely linked to child abuse and neglect include behavioral and achievement problems in school; heart, lung and liver disease; obesity and diabetes; depression, anxiety disorders and increased suicide attempts; increased criminal behaviors, illicit drug use and alcohol abuse; increased risky sexual behavior and unintended pregnancies; and other problems.

What is Child Maltreatment?
North Carolina General Statutes define child abuse as any nonaccidental or substantial risk of injury or pattern of injuries to a child inflicted or allowed to be inflicted by a parent, guardian, caretaker or custodian. Child maltreatment includes:

• Physical Abuse - Any non-accidental physical injury to the child; Can include striking, kicking, burning or biting the child, or any action that results in a physical impairment of the child. Signs of possible physical abuse can include physical injuries that are not likely to have occurred as described; nervousness, hyperactivity, aggressiveness; disruptive and destructive behaviors; unusual wariness of physical contact or fear of a parent or caretaker.


• Sexual Abuse - Any sexual behavior imposed on a juvenile. Sexual abuse can include fondling the genital area, masturbation, oral sex or vaginal or anal penetration by a finger, penis or other object. It also includes exhibitionism, child pornography and suggestive behaviors or comments. Signs of possible sexual abuse can include reversion to behaviors such as bed-wetting, speech loss and thumbsucking; sleep disturbances or nightmares; pain, itching, bruising or bleeding in the genital area; frequent urinary tract infections; or venereal disease established.


• Emotional Abuse - Includes attitudes or behaviors toward a child that create serious emotional or psychological damage. Signs of possible emotional abuse include very low self-esteem; antisocial and destructive behaviors; depressed or suicidal tendencies; or, in some cases, delayed development.


• Neglect - The failure of a parent or other person with responsibility for the child to provide needed food, clothing, shelter, medical care or supervision such that the child's health, safety and well-being are at risk. Signs of possible neglect include consistent hunger, inappropriate dress and poor hygiene; self-destructive behaviors; or unattended medical needs.

Abuse is rarely one isolated incident. Often, there is a pattern of behavior that emerges over a period of time. Children often have difficulty talking about the abuse. This leads to many children “acting out” as a way of expressing their hurt or anger. It is important to remember that even if you see signs, they do not necessarily mean that a child has been abused. The signs will vary according to the type of abuse, its intensity and the developmental age of the child. Some children who are abused display no signs. For this reason, it is important to listen carefully to any child who tells you about an act of maltreatment.

Child maltreatment is not the result of a single cause but of complex interactions between individuals and their environment that influence both development and behavior. Child maltreatment can be examined through a social-ecological model that presents a continuum of risk and protective factors that can either increase resilience or vulnerability to specific behaviors or conditions. Society, community, families and individuals all contribute to the health and well-being of families and children.

Referring a Family to the Department of Social Services
If you suspect child abuse or neglect, you are required by law to refer the family by calling, writing or visiting your county Department of Social Services—Child Protective Services Unit. County contact information can be found at www.dhhs.state.nc.us/dss/local/. You can also call the CARE LINE at 1-800-662-7030 to speak with a counselor who can refer you to the appropriate contact. An intake social worker at the local Child Protective Services Unit will listen to you, ask questions and record all the information provided.

Remember that you do not need to prove that abuse has taken place; you only need reasonable grounds for suspicion. While you may choose to include the parent or caregiver in the referral process, you do not need their permission. You also do not need permission from your workplace; ultimately, you are responsible for making sure the referral has been made. If you make a referral in good faith, you will receive immunity from civil or criminal liability.

North Carolinians also bear an ethical responsibility to make referrals in cases of suspected maltreatment. Child abuse rarely stops without intervention and help. By making a referral, you are helping the family get the services and support that they need to end the cycle of abuse. Abused children carry the trauma associated with abuse throughout their lives. These childhood experiences result in higher risk of poor health outcomes—a risk that is compounded by each additional negative experience.

What Happens After a Referral Has Been Made?
After you have discussed your concerns with a social worker at Child Protective Services, a determination is made as to whether or not the Department of Social Services will complete an assessment.

If intervention is warranted, Child Protective Services may use either an investigative assessment or a family assessment to determine future actions and supports needed for the child and family. The Department of Social Services is required to initiate an assessment within 24 hours for abuse and within 72 hours for neglect.

The assessment may include a visit to the child’s home and school along with interviews of those who are in regular contact with the child. The safety of the child is the top priority at all times.

North Carolina’s Multiple Response System (MRS) is the state’s on-going effort to reform the entire continuum of child welfare services in order to make child welfare more family centered and to keep children safe. MRS begins with the first referral of concerns about a child and his/her family and continues all the way through finding a permanent home for those children who enter foster care. As a reform effort, MRS is not one single program. Rather, MRS is comprised of seven separate strategies delivered to families through a practice model grounded in the use of family-centered practice and system of care principles.

Referred families may have access to counseling, referrals to other agencies and supports, intensive in-home services, as well as help with housing, finances, medical needs and child care. A Child and Family Team will be developed to build a support network for the family. If necessary, emergency foster care services can be established.

Get More Information
Prevent Child Abuse North Carolina has developed a free online self-guided training module that educates viewers in recognizing and responding to suspected child abuse and maltreatment.

In addition, Prevent Child Abuse North Carolina will host a statewide summit on advancing child well-being through prevention of abuse and maltreatment March 4-6, 2013. The meeting will be held at the Raleigh Convention Center. Dr. Vincent Felitti, co-principal investigator for the Adverse Childhood Experiences Study, will open the summit with an inside look into the study and discuss its relevance to the everyday practice of medicine and mental health, as well as its impact on healthcare costs.

Thank you for your commitment to child safety and wellbeing. Your efforts make a difference in lives of countless children.

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Free Online Training sharpens ability to respond when abuse is suspected
Prevent Child Abuse North Carolina offers a free Web-based self-guided training module, Recognizing and Responding to Suspicions of Child Maltreatment. The training provides a comprehensive overview of the signs and symptoms of maltreatment, related North Carolina law and the child protection system.
Access training. You will be asked to register to complete the training