Separation of children from their parents is one possible traumatizing consequence of a mandated report, which is not to be taken lightly. This commentary on a case considers how racism and poverty should influence clinicians’ construal of their duties as mandatory reporters of abuse and offers recommendations about how to respond in similarly difficult cases.
Case
AB, age 1 year, is accompanied to a visit with pediatrician, Dr K. AB’s grandmother apologizes for missing prior scheduled appointments and explains that she and her daughter both work many hours beyond full-time. Dr K asks about AB’s caregiver when they’re at work. AB’s grandmother pauses and explains that neighbors “check in on” AB during the day. Dr K, recording AB’s below-normal weight, certainly feels there’s enough evidence to suspect that AB is neglected, although AB’s lack of regular adult supervision and insufficient caloric intake are due to poverty, not to insufficient parental impulse or love.
Dr K hesitates, therefore, to “suspect” neglect. Dr K learned that one result of a recent mandatory report to the state’s child welfare agency led to a 3-year-old patient’s removal from a home in which the parents live in poverty. When that child returned to Dr K for an annual visit, the child was in a third foster care home, could not sustain eye contact with Dr K, would not engage in any kind of play Dr K tried to initiate, and was still underweight.
Dr K worries, “Neglect is obvious, so, yes, I suspect it. This means I’m mandated by federal law to report this to the state. But, ethically, that hasn’t helped some of my patients before and might do more harm than good for AB.” Dr K doesn’t speak with anyone else and wonders what to do.
Commentary
Federal law requires that all 50 states have procedures for mandatory reporting by certain individuals when they suspect child abuse and neglect. This case illustrates a common dilemma in child welfare for mandatory reporters and caregivers who seek help for children with profound vulnerabilities. Dr K clearly recognizes what constitutes neglect from a medical perspective (ie, the child is underweight and alone for a good portion of the day). However, after asking the grandmother one question about childcare arrangements, Dr K did not ask additional questions to better understand what was happening in the life of the family or to evaluate what the improper weight may be due to—for example, the child’s having a medical condition or not being fed properly or regularly, or something else. We do not know whether differences of language or culture or racial dynamics affected the ability of the grandmother and Dr K to communicate effectively and truly understand one another. Regardless, Dr K is justified in being concerned by the mere fact of a 1-year-old child being left alone for long periods of time. Whether Dr K took the extra step of considering the cause of AB’s neglect—specifically, whether it is attributable to intentionally inadequate caretaking or perhaps to financial hardship, lack of access to childcare, unstable housing, or food insecurity—is not stated in the case. In short, Dr K was left with many unknowns about what could be contributing to his concerns about the health and well-being of the child, but he seems worried that help is needed.
For mandatory reporters, especially medical doctors who are trained to examine the totality of a patient’s well-being, the dilemma is whether to make a diagnosis of neglect or child maltreatment generally and report the family to a child abuse hotline or to dig deeper into the circumstances of the family’s life to learn more about the root causes of the warning signs. A deeper dive might result in recognizing the problem as poverty or hardship and lead to efforts to connect the family to concrete support as opposed to labeling the problem as child maltreatment.
The next section outlines the grounds for this assertion and places Dr K’s dilemma within the larger context of a system that is doing harm. We then explain ethical concerns stemming from definitions of neglect and mandatory reporting. Finally, we discuss distinguishing between hardship and neglect and describe an ethical approach to child welfare.