Care of Victims of Child Maltreatment: The School Nurse’s Role
It is the position of the National Association of School Nurses (NASN) that prevention, early recognition, intervention and treatment of child maltreatment are critical to the physical well-being and academic success of students. Registered professional school nurses (hereinafter referred to as school nurses) serve a vital role in the recognition of early signs of child maltreatment, assessment, identification, intervention, reporting, referral and follow-up of children in need. School nurses are uniquely qualified to participate as members of interdisciplinary teams to collaborate with school personnel, community healthcare professionals, students and families.
The Child Abuse and Prevention and Treatment Act (CAPTA), originally passed in 1974 and amended by the CAPTA Reauthorization Act of 2010, defines child maltreatment as the following:
“Any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation, or an act or failure to act which presents an imminent risk of serious harm” (CAPTA, 2010, p. 6).
A child is defined as a person who has yet to reach the age of 18 years and who is not an emancipated minor. It is important to understand that there are many exceptions and varying definitions made by individual state laws (Child Welfare Information Gateway, n.d.). All 50 states, the District of Columbia, and the U.S. territories have mandatory child maltreatment reporting laws that require certain professionals and institutions to report suspected maltreatment to a Child Protective Services agency (United States Department of Health and Human Services [USDHHS], 2010).
School nurses, teachers, and other school staff are legally required to report suspected child maltreatment (Child Welfare Information Gateway, 2012).
In 2010, Child Protective Services received approximately 3.3 million reports of suspected child maltreatment, and it was estimated that 1560 children died as the result of child maltreatment (CDC, 2012). CAPTA identified the incidence of four types of child abuse:
The psychological and academic impact of child maltreatment can be devastating and create life-long challenges. Children who have been victims of maltreatment exhibit high levels of risk taking and have impaired decision-making skills (Weller & Fisher, 2013). Children who suffered maltreatment were found to have significantly lower cognitive abilities and academic achievement (DeBellis, Wolley, & Hooper, 2013).
The lifetime economic burden of child maltreatment based on the substantiated non-fatal child maltreatment cases and the fatal cases of child maltreatment is estimated to be 124 billion dollars that includes significant costs for health and medical care, productivity losses, child welfare, criminal justice, and special education services (Fang, Brown, Florence, & Mercy, 2012).
School personnel are often the first to become aware that a child may be a victim of maltreatment and is struggling because of adverse events occurring in his or her life. The Adverse Childhood Experiences Study (ACE) identified 17 long-term health issues that were the result of childhood abuse or neglect. These health issues were clustered by the number of adverse experiences a person identified. There is a direct correlation between the number of adverse events experienced by a victim of child maltreatment and the number of long term health issues they experience (CDC, 2010). Child maltreatment increases the childhood risk of diabetes, obesity, grade repetition, and engagement in risk-taking behaviors (USDHHS, 2010). The effect of violence alone on a child increased the risk of appetite problems by 28%, headaches by 57%, sleep problems by 94%, and stomachaches by 174% (Shannon, Bergren, & Matthews, 2010). Childhood maltreatment has been linked to long-term risk for depression (Nanni, Uher, & Danese, 2011), chronic fatigue syndrome (Fuller-Thomsen, Sulman, Grennenstuhl, & Merchant, 2011), higher rates of mental health problems (Burke, Hellman, Scott, Weems, & Carrion, 2011) increased tendencies toward youth violence and intimate partner violence (USDHHS, 2010) and increased risk of psychiatric disorders (Chen et al., 2010). These long-term effects of child maltreatment influence individual health, academic achievement and the healthcare system as a whole (DeBellis et al., 2013).
Early identification and intervention is crucial in promoting recovery and preventing further victimization. Therefore, it is vital that school personnel receive training to recognize the signs of maltreatment and report accordingly. The school nurse is a leader in educating school personnel about recognition of child maltreatment. Signs that indicate child maltreatment may include child reports of maltreatment, sudden behavior changes, lack of medical referral follow-through, learning problems that have no known etiology, child responses that are consistently guarded and/or overly compliant, and child’s avoidance of home or certain individuals. Child maltreatment may present in a variety of ways (Child Welfare Information Gateway, 2013):
Neglect – failure to provide for child’s physical, medical, educational or emotional basic needs, abandonment;
Substance Abuse – prenatal exposure to illicit substances, young children who have access to and/or speak the language of illegal drugs or alcohol, children exposed to the toxic and extremely dangerous process of methamphetamine manufacture.
School nurses are involved in prevention, early identification, reporting, and treatment related to child maltreatment because of their opportunity to interact with children on a daily basis. The role of the school nurse is to report suspicion of abuse; the role of Child Protective Services is to investigate the suspicion. School nurses are accountable and responsible to do the following:
School nurses are uniquely positioned to advance the academic achievement of students by protecting their health and safety. Prevention, early recognition, and treatment of child maltreatment are critical to the physical/emotional well-being of students and, therefore, their academic success. Additionally, school nurses serve as a resource to faculty and staff in the recognition and reporting of child maltreatment.
Burke, N. J., Hellman, J. H., Scott, B.G., Weems, C.F., & Carrion, V.G. (2011). The impact of adverse childhood experiences on an urban pediatric population. Child Abuse & Neglect, 2011, 35(6), 408-13. doi:10.1016/j.chiabu.2011.02.006. Retrieved from http://www.pdfdownload.org/pdf2html/view_online.php?url=http%3A%2F%2Fwww.nutrociencia.com.br%2Fupload_files%2Fartigos_download%2FBurke%2520et%2520al.%2C%25202011.pdf
Centers for Disease Control and Prevention (CDC). (2010). Adverse childhood experiences study (ACE). Retrieved from www.cdc.gov/ace/index.htm
Centers for Disease Control and Prevention (CDC). (2012). Child maltreatment: Facts at a glance. Retrieved from http://www.cdc.gov/violenceprevention/pdf/cm_datasheet2012-a.pdf
Chen, L. P., Murad, M. H., Paras, M.L., Colbenson, K. M., Sattler, A. L.,Goranson, E. N., Elamin, M. B., Seime, R. J., Shinozaki, G., Prokop, L. J., & Zirakzadeh, A. (2010). Sexual abuse and lifetime diagnosis of psychiatric disorders: Systematic review and meta‐analysis. Mayo Clinical Proceedings, 85,618-629. doi:10.4065/mcp.2009.0583
Child Abuse Prevention and Treatment Act (CAPTA) (42 U.S.C.A. 5106g), as amended by the CAPTA Reauthorization Act of 2010. Retrieved from http://www.acf.hhs.gov/programs/cb/laws_policies/cblaws/capta/capta2010.pdf
Child Welfare Information Gateway. (n.d.). Definitions of child abuse and neglect in federal law. Washington, DC: U.S. Department of Health and Human Services, Children’s Bureau. Retrieved from http://www.childwelfare.gov/can/defining/federal.cfm
Child Welfare Information Gateway. (2012). Penalties for failure to report and false reporting of child abuse and neglect. Washington, DC: U.S. Department of Health and Human Services, Children’s Bureau. Retrieved from https://www.childwelfare.gov/systemwide/laws_policies/statutes/report.cfm
Child Welfare Information Gateway. (2013). What is child abuse and neglect? Recognizing the signs and symptoms. Washington, D.C.: U.S. Department of Health and Human Services, Children’s Bureau. Retrieved from https://www.childwelfare.gov/pubs/factsheets/whatiscan.pdf
DeBellis, M.D., Wolley, D.P., & Hooper, S.R. (2013). Neuropsychological findings in pediatric maltreatment relationship of PTSD, dissociative symptoms, and abuse/neglect indices to neurocognitive outcomes. Child Maltreatment, 18(3),171-83. doi: 10.1177/1077559513497420
Fang, X., Brown, D.S., Florence, C.S., & Mercy, J.A. (2012).The economic burden of child maltreatment in the United States and implications for prevention. Child Abuse & Neglect, 36, 156-165. doi:10.1016/j.chiabu.2011.10.006
Fuller-Thomson, E., Sulman, J., Brennenstuhl, S., & Merchant, M. F. (2011). Functional somatic syndromes and childhood physical abuse in women: Data from a representative community-based sample. Journal of Aggression, Maltreatment & Trauma, 20, 445. doi: 10.1080/10926771.2011.566035
Health Resources and Services Administration (HRSA). (2013). Building a medical home for children. Retrieved from http://www.hrsa.gov/healthit/toolbox/childrenstoolbox/buildingmedicalhome/
Nanni, V., Uher, R., & Danese, A. (2011). Childhood maltreatment predicts unfavorable course of illness and treatment outcome in depression: A meta‐analysis. American Journal of Psychiatry, 169(2), 141-51. doi:10.1176/appi.ajp.2011.11020335 . Retrieved from http://ajp.psychiatryonline.org/article.aspx?articleID=483660
Shannon, R.A., Bergren, M.D., & Matthews, A. (2010). Frequent visitors: Somatization in school-age children and implications for school nurses. The Journal of School Nursing, 26, 169-192. doi: 10.1177/1059840509356777
United States Department of Health and Human Services (USDHHS), Administration for Children and Families Administration on Children, Youth and Families Children’s Bureau. (2010). Child maltreatment, 2009. Retrieved from http://archive.acf.hhs.gov/programs/cb/pubs/cm09/cm09.pdf
Weller, J.A., & Fisher, P.A. (2013). Decision-making deficits among maltreated children. Child Maltreatment, 18(3), 184-94. doi: 10.1177/1077559512467846
Acknowledgment of Authors:
Lynnette Ondeck, MEd, BSN, RN, NCSN
Laurie Combe, MN, BSN, RN
Cindy Jo Feeser, BSN, RN, NCSN
Rebecca King, MSN, RN, NCSN
Acknowledgement of 2012 Issue Brief Authors:
Linda Gibbons, MSN, RN, NCSN
Mary Suessmann, MS, BSN, RN
Sharonlee Trefry, MSN, RN, NCSN
Adopted: January 2014
This document replaces the Issue Brief Child Maltreatment (adopted January 2012).
All position statements from the National Association of School Nurses will automatically expire five years after publication unless reaffirmed, revised, or retired at or before that time.