(Personal )family member brings up read flags for CSA--what to do?

[futureapppsy2]

---

Members don't see this ad.

An extended family member recently asked my thoughts on their young (4 y/o) child that suddenly started experiencing some really intense challenging behaviors, and there were so many red flags for CSA there (sudden intense fear around toileting, sudden, intense desire to cover up all parts of their body at all times, incredibly intense anxiety and rage, sudden onset of night terrors, sudden fear of being without their parents, all corresponding somewhat closely to starting at a new child care facility). The family member seems convinced its definitely PANDAS/PANS, and I talked to them about the importance of getting a really thorough, high quality evaluation to figure out what is going on and help keep the child safe, but they pretty much dismissed it and were focused on how they can get PANDAS testing. Is there anything else that I can/should do here, either from a liability perspective (they're in a different state, and I've never actually met the child) or from a just encouraging them to make sure they get the right assessment/treatment?

 

[Bartelby]

I don't think there's any big liability risk.

If it were my family member I would share my concerns honestly, along with why I think that way even though I can't be sure about anything. And if it were my kid, even if I couldn't know if anything occurred I would pull them from that daycare and see how they do in a different environment.

Sorry to hear you're dealing with this, sounds like a really tough situation.

 

[Celexa]

I'm sorry you are dealing with this. I doubt there is any liability in giving "I think you should seek out the appropriate professional" advice to a family member. At least in terms of medical liability. In terms of any role as a mandated reporter... I do not feel expert enough to weigh in.

4 is very young and it's hard to find childhood psychiatrists in general in a lot of places. Perhaps you could help by locating a specific clinic, ideally one that specializes in mental health evaluations in very young children, and provide your family member with a specific number to call?

 

[Crayola227]

I think with mandatory reporting basically any reasonable suspicion can be reported. I know I would in this situation no matter what the situation with the family member or the state.

This isn't a joke (not that you think it is). This is very serious and the odds are good this child is really suffering, and if it's abuse and no one who had an inkling did anything...

I get CPS is not the end all be all of solving problems, but it's a start and at least you would be doing the bare minimum here to protect the child.

We ALL have this obligation to children regardless of relationships or the law. The law just makes explicit and binding this obligation humans have anyway, for folks in the best position to recognize and most likely to come across the signs. Mandatory reporting I don't see as saying "you have to report." Because we all have the obligation. It spells out the consequences in our case if we fail to. Perhaps you have no liability here. It doesn't really change the moral obligation.

For reasons, it can't all be left up to parents. Frequently they can't be impartial.

Availability of good child psych I kind of see a little bit beside the point.

Obviously the ideal thing is if you can get the parents to acknowledge this as a possibility and act on it, but what if you can't and they don't?

The darkest place to go as well, is that the child is being abused by someone besides someone at the child care center. I would worry how that might be playing into a focus on a medical diagnosis to explain these symptoms.

It also might be incidental the new childcare. It could be another relative, a church person, family friend, house worker, anyone really.

They say the symptoms are new, but who really knows the timeline and what was noticed and what wasn't. This could have been going on for years, and it could go on for many years more.

Sometimes all it takes the speaking up of ONE person to bust an entire ring of children being horribly abused for years. For all you know other children are having the same experiences and those parents think it's vaccine autism. One data point can blow these things wide open.

It's up to you what more you do with the parents. I think there is a moral obligation to do whatever it takes to be sure that this is addressed as thoroughly as possible at the highest levels.

The only person who might be betrayed here is the child.

Too many children have been abused only to find out later there was someone who knew something and never said anything to the right people.

 

[Bartelby]

I think with mandatory reporting basically any reasonable suspicion can be reported.

That's a good point. If there is enough to reach that reasonable suspicion threshold then technically you could face civil or criminal liability for not reporting (though specifics will probably vary by state). Mandated reporting applies if we have reasonable suspicion of child abuse in any context, not just in a professional context.

 

[calvnandhobbs68]

I agree I don't think there's really any liability risk here. If you're concerned about mandated reporting, it's highly unlikely any mandated reporting statues apply in this situation but you can always check the laws in the state the child is in. I totally agree with you that I would also be suspicious and discussing possible trauma with the caregivers in this case but with the information you have above it'd be a stretch to call it "suspected" child abuse which is what many statutes refer to. It gets even more vague when you're in different states, especially if you aren't licensed in that state and so the mandated reporting laws of that state typically don't apply to you.

In most states anyone CAN make a report but isn't mandated to make a report, so you certainly could make a report either way. I don't think this would be a frivolous report but I'll be honest that CPS may not take this very seriously since you've never actually evaluated the child/family/situation yourself and you don't really have any firsthand information about the situation and you may totally kill any relationship you have with this family (and then possibly opportunity to help convince them get a real eval) if you contact CPS now based on just this info alone.

I'm sorry this is definitely a tough situation. I also agree I'd tell the parents straight up my thought process (which wouldn't typically be PANDAS anyway based on the info provided....) and even point them to resources that state the same thing. For instance:

Mental Health Services - Child Advocacy Center

Child abuse and neglect have been identified, among other criteria, as adverse childhood experiences (ACEs). A landmark study by the Centers for Disease Control and Kaiser Permanente (Adverse Childhood Experiences Study (ACEs) revealed that, left unchecked, a high number of ACEs can have a...

childadvocacycenter.org

I do think it'd be difficult to even find a child psychiatrist who would see a 4yo. I tend to screen out kids that young because typically people are coming to me wanting meds when what these kids really need >90% of the time is consistent therapy and seeing me actually becomes counterproductive because it starts disincentivizing people from seeking out a child therapist. Finding someone who specializes in play therapy (and doesn't buy into the whole PANS/PANDAS thing here....) would probably be the best bet in this age. If they're open to the possibility of evaluating for possible trauma, children's advocacy centers can often help point them in the direction of therapists they refer to internally or externally.

 

[calvnandhobbs68]

That's a good point. If there is enough to reach that reasonable suspicion threshold then technically you could face civil or criminal liability for not reporting (though specifics will probably vary by state). Mandated reporting applies if we have reasonable suspicion of child abuse in any context, not just in a professional context.

So this actually does vary significantly by state. Some states only apply if you come into contact with the child during the course of your professional activities or if you get a disclosure of specific abuse from a third party. Some states are very broad and literally require EVERYONE to report. Either way, anyone CAN report in most states, this doesn't preclude OP from reporting it's just a matter of mandated reporting or not.

For instance, here is Ohio's:
A report is required when a mandated person is acting in an official or professional capacity and knows or suspects that a child under age 18 or a person under age 21 with a developmental disability or physical impairment has suffered or faces a threat of suffering any physical or mental wound, injury, disability, or condition of a nature that reasonably indicates abuse or neglect of the child.


vs here is Oklahoma's
Mandatory reporters include the following:
All persons
School employees
Physicians, surgeons, or other health-care professionals, including doctors of medicine, licensed osteopathic physicians, residents, and interns, or midwives
Commercial film and photographic print processors or computer technicians

A report is required when any of the following apply:
Any person has reason to believe that a child under age 18 is a victim of abuse or neglect.
A physician, surgeon, other health-care professional (including doctors of medicine, licensed osteopathic physicians, residents, and interns), or midwife is involved in the prenatal care of expectant mothers or the delivery or care of infants and an infant tests positive for alcohol or a controlled dangerous substance or is diagnosed with neonatal abstinence syndrome or fetal alcohol spectrum disorder.

 

[Crayola227]

It's probably worth looking into how CPS works in that state as well. Where I am, anyone can make a call about anything, and as long as they aren't acting maliciously in the making of the report... CPS is obligated to take the report and then they have to do something with it. Could just be record the information, could be open an investigation. I believe that you can be kept anonymous from any party involved unless it goes to court. You don't even need to know who the child is - suspecting they exist and may be in danger is enough. A scenario I was in was seeing a drug addict in the ED who confided they were homeless and their child who was not in the ED, was with the people they were staying with. It was lost on the other physicians involved that despite it being vague, there were too many unknowns and this type of situation poses many, many risks to a child. It was reported.

But this was all in my state as I explained how it is.

I agree approaches that are most likely to have the parents be allies are best where possible.

If it were possible to make an anonymous report on the childcare facility that would be one option that might help shed light on that may not put scrutiny directly on the relatives. Of course if it isn't the facility then it might not do much good, especially if there isn't more info than that.

People are often concerned about consequences to parties such as these based on whispers. 🤷‍♀️

Eta: I should have said, the person who filed's name is kept confidential by CPS, as in, not given to the various parties being investigated, unless it goes to court. And also that what I describe is my understanding in my state and my state alone. I shared this to illustrate that it can vary by state, and in my particular state, there is basically no reason from the perspective of a reporter "getting in trouble" unless they are acting maliciously or they failed to report.

 

[Crayola227]

All good points raised by everyone here.

I will say, as far as reasonable suspicion goes, what the OP said is written literally like a USMLE question. Big changes in the life of a young child can cause some of the issues we saw listed. Words are kind escaping me here. It's kind of like a high WBC count and leukemia. You have your must rule out worst case dx. The fact it reads like a board question is what has me really concerned and feeling like it meets the level of reasonable suspicion.

 

[calvnandhobbs68]

The anonymous part is also variable by state but many states do not allow you to report anonymously due to the all too familiar scenarios of disgruntled family members calling CPS or divorced parents repeatedly calling CPS on each other. That shouldn’t preclude you from reporting, they’d probably know who it was anyway. This is also why I always tell people that I’m contacting CPS and the reasons I’m doing so.

You can’t make a report on a facility generally. You have to have some information about a specific victim even if it’s fairly vague to give CPS some idea of who to contact next. Every form I’ve ever filled out or telephone call I’ve made in multiple states CPS systems have wanted as much info on a specific individual as possible.

 

[Stagg737]

I believe that you can be kept anonymous from any party involved unless it goes to court. You don't even need to know who the child is - suspecting they exist and may be in danger is enough.

Will just point out that both of these can vary significantly. In my state one can technically make an anonymous report, but the threshold for reporting is very low ("A report must be made by a mandated reporter if there is reason to suspect that a child has been harmed as a result of physical, mental, emotional or sexual abuse.") and if you report anonymously you are not protected in any way if someone accuses you of not reporting. Reports are supposed to be confidential unless it goes to court though. So they've basically set up a system where it's dumb to file anonymously.

Where I'm at a child's name or location is required for a report to be actionable. Ie, the state won't take any action if there isn't either a specific child identified or their location of residence isn't known per a SW I worked with who previously worked for CPS here.

 

[Crayola227]

The anonymous part is also variable by state but many states do not allow you to report anonymously due to the all too familiar scenarios of disgruntled family members calling CPS or divorced parents repeatedly calling CPS on each other. That shouldn’t preclude you from reporting, they’d probably know who it was anyway. This is also why I always tell people that I’m contacting CPS and the reasons I’m doing so.

You can’t make a report on a facility generally. You have to have some information about a specific victim even if it’s fairly vague to give CPS some idea of who to contact next. Every form I’ve ever filled out or telephone call I’ve made in multiple states CPS systems have wanted as much info on a specific individual as possible.

Sorry, I should have said, the people being reported are not told who filed the report in my state. CPS and law enforcement will know, precisely for the reasons you state.

 

[Crayola227]

Will just point out that both of these can vary significantly. In my state one can technically make an anonymous report, but the threshold for reporting is very low ("A report must be made by a mandated reporter if there is reason to suspect that a child has been harmed as a result of physical, mental, emotional or sexual abuse.") and if you report anonymously you are not protected in any way if someone accuses you of not reporting. Reports are supposed to be confidential unless it goes to court though. So they've basically set up a system where it's dumb to file anonymously.

Where I'm at a child's name or location is required for a report to be actionable. Ie, the state won't take any action if there isn't either a specific child identified or their location of residence isn't known per a SW I worked with who previously worked for CPS here.

It might be dumb to report anonymously for the purposes of avoiding liability for not reporting, and if anonymous complaints are given different weight or otherwise negatively impacts the effectiveness of an investigation. But I wouldn't say it's dumb to file anonymously if otherwise a report that should be made would not otherwise be made.

I can't speak for every situation. But much of the time with sex crimes and law enforcement, it becomes about what if any data is in the system. Reports, even vague, can pile up and with other data points can sometimes make a difference. Or not.

I couldn't sleep if I was seriously laying in my bed wondering if a child was being sexually abused or not and I didn't absolve my soul by making a report. I'd rather be laughed at by the SW or CPS or cop then know I didn't act at all. I mean in instances where you're seriously wondering.

Too often people say something isn't worth reporting because they don't think it will do anything. But that kind of misses how these kinds of criminals often get caught. But I probably watch and read too many true crime things.

 

[AcronymAllergy]

This is tough, I'm sure. RE: liability, as has been said, potentially not much of an issue but can be very state specific. If you're a member of any professional societies/state psych associations, they'll often have a free ethics consultation available. I'd make use of it here. I don't know if this crosses a threshold for reasonable suspicion; I can see arguments both ways. I would feel a pull to report if I weren't comfortable discussing it directly with the parents, but I'd 100% want to have an impartial ethics consultation to fall back on as support for such.

I can also see the concern about talking directly with the parents given their response thus far. If they were more open and you had a good relationship with them, I'd have a frank discussion about my concerns (e.g., "listen, I don't want to scare you, but here's what I'm worried about"), which might jar them out of their myopic focus on PANDAS. On the flip side, in a highly cynical world, there's the potential that you talk with them and they lash out (not just personally, but professionally) against you.

 

[Ceke2002]

As someone who has experienced CSA I think I would have appreciated knowing someone was in my corner. My own family chose to deal with stuff behind closed doors when the abuse was discovered; it wasn't exactly helpful to my long term mental health. Keep encouraging the family member to have a proper assessment done, and report your own concerns to the relevant body if you can. If CSA is occurring then this child needs proper care and support.