Child Abuse Notes

Introduction to Documentation and Reporting in Therapy

• Importance of Documentation

  • Therapists should always have a notebook or a note head for documentation of facts shared by clients.

Fundamental Questions During Client Interaction

• What to Observe

  • Notice the client's reactions when asked questions or sharing information.

  • Document observable facts, reactions, and emotional responses.

• Inquiry into Physical Sensations

  • Example: Therapist asked a client, Aretha, about her bodily sensations when feeling nervous or scared.

  • Aretha struggled to differentiate between feelings of fear and physical pain.

Managing Information in Reports

• Importance of Having Sufficient Data

  • Therapists often get into trouble thinking they need all information before making a report.

  • Key point: Use the facts available at the moment to make a report.

• Effective Communication with Caregivers

  • When contacting a caregiver, convey what was disclosed and their responses accurately.

  • Document direct quotes from caregivers, e.g., “Aretha's always lying” concludes with discussing family dynamics regarding Aretha's two moms.

Writing Clinical Recommendations

• Preparing Recommendations

  • Therapists should provide recommendations based on clinical observations.

  • Example recommendation: Suggesting ongoing therapy to help Aretha address emotional regulation and feelings of guilt.

• Observations from Caregivers

  • Document specific observations made about the caregiver over time and interactions, using facts without making judgment calls.

• Example: Recommend parenting education classes if observed patterns indicate a need.

Reporting to Authorities

• Making Reports to County Agencies

  • Importance of prompt reporting after a disclosure or suspicion.

  • Reports should be written within 24 to 48 hours and sent electronically or via fax.

  • Understand that response times from Children and Family Services can vary.

  • Emergency responses in 2 hours, or up to 48 hours for non-urgent cases.

• The Reporting Process

  • After a report is made, an intake worker assesses it for urgency.

  • The report is given to an emergency response worker for initial investigation.

  • This may include interviewing the child and contacting caregivers.

Response to Initial Reports

• Investigative Steps

  • If necessary, law enforcement may get involved, especially in cases of sexual abuse or physical abuse.

  • Children may be taken to healthcare facilities for forensic examinations if injuries are suspected.

  • Priority is to stabilize health and safety before further investigations.

• Case Handling by Emergency Response Workers

  • Emergency workers may continue to manage the case or refer it to other dependency workers.

  • Reporting party is usually not kept updated on ongoing investigations.

  • Possible outcomes of reports include:

  • Substantiated: Evidence found.

  • Unsubstantiated: Lack of evidence for claims.

  • Indicated: Some evidence exists but not enough for full substantiation.

Understanding Forensic Exams

• Protocol for Child Examining

  • Forensic exams follow significant disclosures of abuse.

  • Children cannot consent to this without parental encouragement, but older children may contest parental decisions.

  • Description of a forensic exam: involves detailed evidence collection through swabs and photographs, akin to a rape kit for adults.

• The Process During an Exam

  • Short interviews are conducted with children to avoid suggesting details, protecting the integrity of the information they provide.

  • Following an exam, forensic interviews may occur in controlled environments, guided by specialized interviewers.

  • The necessity of minimal questioning arises from research showing children's memory and articulation differ from adults.

  • Throughout the process, maintaining a clean and non-coercive investigative environment is critical to preserve the child's experience and trust.

Real-Life Applications and Challenges

• Engagement with Children Post-Disclosure

  • Discuss with children about what to expect from investigations is crucial but complex due to varying police department policies.

  • Transparency is essential: explain to the child what can be shared while acknowledging uncertainties about the investigation workflow.

• Navigating the Complexities of Reporting

  • Encourage therapists not to fixate on the outcomes of investigations since they have no control over them.

  • Focus should remain on making thorough and accurate reports and continuing therapeutic support for the client.