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Continuing Education for Health Professionals

IA: Child Abuse, A Guide for Mandatory Reporters

Module 5

What Is Child Abuse Under Iowa Law?

The Department of Human Services has the legal authority to conduct an assessment of child abuse when it is alleged that:

  • The victim is a child.
  • The child is subjected to one or more of the ten categories of child abuse defined in Iowa Code section 232.68:
    • Physical abuse
    • Mental injury
    • Sexual abuse
    • Denial of critical care
    • Child prostitution
    • Sexual trafficking
    • Presence of illegal drugs
    • Manufacturing or possession of a dangerous substance
    • Bestiality in the presence of a minor
    • Allows access by a registered sex offender
    • Allows access to obscene material
    • Recruitment, harboring, transportation, provision, obtaining, patronizing, or soliciting of a child for the purpose of commercial sexual activity
  • The abuse is the result of the acts or omissions of the person responsible for the care of the child.

Child

A child is defined in Iowa Code section 232.68 as any person under the age of 18 years.

The victim of child abuse is a person under the age of 18 who has suffered one or more of the categories of child abuse as defined in Iowa law listed above.

Caretaker

A perpetrator of child abuse must be a person responsible for the care of a child. A person responsible for the care of a child is defined in Iowa Code section 232.68 as:

  • Parent, guardian, or foster parent
  • A relative or any other person with whom the child resides and who assumes care or supervision of the child, without reference to the length of time or continuity of such residence
  • An employee or agent of any public or private facility providing care for a child, including an institution, hospital, health care facility, group home, mental health center, residential treatment center, shelter care facility, detention center, or child care facility
  • Any person providing care for a child, but with whom the child does not reside, without reference to the duration of the care

A person who assumes responsibility for the care or supervision of the child may assume such responsibility through verbal or written agreement, or implicitly through the willing assumption of the caretaking role.

Perpetrators of child abuse come from all walks of life, races, religions, and nationalities. They come from all professions and represent all levels of intelligence and standards of living. There is no single social stratum free from incidents of child abuse.

Abusive parents may show disregard for the child’s own needs, limited abilities, and feelings. Many abusive parents believe that children exist to satisfy parental needs and that the child’s needs are unimportant. Children who don’t satisfy the parent’s needs may become victims of child abuse.

Sexual abusers may have deviant personality traits and behaviors that can result in sexual contact with a child. Sexual abuse perpetrators sometimes use threats, bribery, coercion, or force to engage a child in sexual activity. They violate the trust that a child inherently places in them for care and protection, and exploit the power and authority of their position as a trusted caretaker in order to misuse a child sexually. Often the child is threatened or warned “not to tell,” creating a conspiracy of silence about the abuse.

Educators as Caretakers

Normally teachers are not considered caretakers in the teaching and supervising of children. If there is an accusation of child abuse (physical abuse, sexual abuse, or child prostitution) by an employee in the school district, every school district will have policies and procedures in place that they will follow.

Iowa Code section 280.17 requires that

[t]he board of directors of a school district and the authorities in charge of a nonpublic school shall prescribe procedures, in accordance with the guidelines contained in the model policy developed by the department of education in consultation with the department of human services, and adopted by the department of education pursuant to chapter 17A , for the handling of reports of child abuse, as defined in section 232.68, subsection 2, paragraph “a” , subparagraph (1), (3), or (5), alleged to have been committed by an employee or agent of the public or nonpublic school.

The jurisdiction established by Iowa Administrative Code 281–102.3 is that “To constitute a violation of these rules, acts of the school employee must be alleged to have occurred on school grounds, on school time, on a school-sponsored activity, or in a school-related context.”

There are times when an educator may be in the role of a caretaker and outside the jurisdiction of the school. For example, a teacher could be considered a caretaker if the teacher is responsible for supervising a child on an overnight trip.

The Department of Human Services will review reports of child abuse alleged to have been committed by an employee or agent of a public or nonpublic school to determine if a joint assessment with school investigative personnel is appropriate. Where jurisdiction is unclear or there are other extenuating circumstances, DHS may initiate an assessment.

Children as Caretakers

Children are sometimes caretakers for other children and may be responsible for abusing a child in their care. Children may be in a caretaker role, for example, as a babysitter. An adult caretaker may be considered responsible if they delegated care responsibilities to an inappropriate minor caregiver.

A mandatory reporter who suspects that abuse has occurred when one child is caring for another is required by law to make a child abuse report; DHS will then determine if any action should be taken.

Physical Abuse

Physical abuse is defined as any non-accidental physical injury, or injury that is at variance with the history given of it, suffered by a child as the result of the acts or omissions of a person responsible for the care of the child.

Common indicators could include unusual or unexplained burns, bruises, or fractures. Health services personnel should be especially alert to cases of child abuse where inconsistent histories are presented. Inconsistent histories can take the form of an explanation that does not fit the degree or type of injury to the child, or where the story or explanation of the injury changes over time.

Some indicators of child abuse are not visible on the child’s body. Many times there are no physical indicators of abuse. A child’s behavior can change as a result of abuse. Health services personnel need to be alert to possible behavioral indicators of abuse and if they believe those to be present they are required to make a report. Behavioral indicators include behaviors such as:

  • Extreme aggression
  • Withdrawal
  • Seductive behaviors
  • Being uncomfortable with physical contact or closeness

Mental Injury

Mental injury is defined as any mental injury to a child’s intellectual or psychological capacity as evidenced by an observable and substantial impairment in the child’s ability to function within the child’s normal range of performance and behavior as the result of the acts or omissions of a person responsible for the care of the child, if the impairment is diagnosed and confirmed by a licensed physician or qualified mental health professional as defined in Iowa Code section 622.10.

Examples of mental injury may include:

  • Ignoring the child and failing to provide necessary stimulation, responsiveness, and validation of the child’s worth in normal family routine
  • Rejecting the child’s value, needs, and request for adult validation and nurturance
  • Isolating the child from the family and community; denying the child normal human contact
  • Terrorizing the child with continual verbal assaults, creating a climate of fear, hostility, and anxiety, thus preventing the child from gaining feelings of safety and security
  • Corrupting the child by encouraging and reinforcing destructive, antisocial behavior until the child is so impaired in socio-emotional development that interaction in normal social environments is not possible
  • Verbally assaulting the child with constant, excessive name-calling, harsh threats, and sarcastic put downs that continually “beat down” the child’s self-esteem with humiliation
  • Over-pressuring the child with subtle but consistent pressure to grow up fast and to achieve too early in the areas of academics, physical or motor skills, or social interaction, which leaves the child feeling that he or she is never quite good enough

Sexual Abuse

Sexual abuse is defined as the commission of a sexual offense with or to a child, pursuant to Iowa Code Chapter 709, Iowa Code section 726.2, or Iowa Code section 728.12, subsection 1, as a result of the acts or omissions of the person responsible for the care of the child.

Notwithstanding Iowa Code section 702.5, the commission of a sexual offense under this paragraph includes any sexual offense referred to in this paragraph with or to a person under the age of 18 years.

There are several subcategories of sexual abuse:

  • First-degree sexual abuse
  • Second-degree sexual abuse
  • Third-degree sexual abuse
  • Lascivious acts with a child
  • Indecent exposure
  • Assault with intent to commit sexual abuse
  • Indecent contact with a child
  • Lascivious conduct with a minor
  • Incest
  • Sexual exploitation by a counselor, therapist, or school employee
  • Sexual exploitation of a minor
  • Sexual misconduct with offenders and juveniles
  • Invasion of privacy (nudity)

Behavioral indicators of sexual abuse could include things such as excessive knowledge of sexual matters beyond normal developmental age, or seductiveness. Physical indicators of sexual abuse could include things such as bruised or bleeding genitalia, venereal disease, or even pregnancy.

Sexual Trafficking

Human trafficking is a modern-day form of slavery, and is a felony under Iowa law. Oftentimes, victims pay to be illegally transported into the United States only to find themselves in the servitude of traffickers. Traffickers force many victims into prostitution, involuntary labor, and other forms of enslavement to repay debts, which are often “entry fees” into the United States (Iowa DOJ, 2018).

According to the U.S. Department of Health and Human Services, after drug dealing, human trafficking is tied with arms dealing as the second-largest criminal industry in the world, generating about $32 billion each year. Many human trafficking victims are children. According to a study of U.S. Department of Justice human trafficking task force cases, 83 percent of sex trafficking victims identified in the United States were U.S. citizens. The average age that U.S. citizens are first used for commercial sex is 12–14 (Iowa DOJ, 2018).

Any child under the age of 18 who is manipulated or forced to engage in sex acts for money (or for anything of value) is a victim of sex trafficking. Severe forms of human trafficking include sex trafficking in which a commercial sex act* is induced by force, fraud, or coercion, or in which the person induced to perform such act has not attained 18 years of age.

*Commercial sex act: any sex act in which anything of value is given to or received by any person.

When a child under 18 years of age is recruited, enticed, harbored, transported, provided, obtained, patronized, solicited, or maintained to perform a commercial sex act, proving force, fraud, or coercion is not necessary for the offense to be prosecuted as human trafficking. There are no exceptions to this rule: no cultural or socioeconomic rationalizations alter the fact that children who are exploited in prostitution are trafficking victims (USDOS, 2017).

The use of children in commercial sex is prohibited under U.S. law and by statute in most countries. Sex trafficking has devastating effects on children, causing long-lasting physical and psychological trauma, disease (including HIV/AIDS), drug addiction, unwanted pregnancy, malnutrition, social ostracism, and even death (USDOS, 2017).

Recognizing warning signs and key indicators for human trafficking of young people is the first step in identifying victims. Healthcare providers must be aware of these warning signs in boys and girls under that age of 18:

  • Has an explicitly sexual online profile.
  • Depicts sexual exploitation in drawing, poetry, or other modes of creative expression
  • Presents with frequent or multiple sexually transmitted diseases or pregnancies.
  • Lies about or unaware of his or her true age.
  • Has no knowledge of personal data, such as date of birth.
  • Wears sexually provocative clothing, has new clothes, gets hair and nails done with no financial means.
  • Expresses secrecy about whereabouts.
  • Is in a controlling or dominating relationship.
  • Exhibits hyper-vigilance or paranoid behaviors.
  • Expresses interest in or is in relationships with adults or much older men or women.

Denial of Critical Care

Denial of critical care is defined as the failure on the part of a person responsible for the care of a child to provide for the adequate food, shelter, clothing, medical or mental health treatment, supervision, or other care necessary for the child’s health and welfare when financially able to do so or when offered financial or other reasonable means to do so.

 

Did You Know. . .

What most people think of as an issue of neglect is covered under the child abuse category of “denial of critical care.”

 

A parent or guardian legitimately practicing religious beliefs who does not provide specified medical treatment for a child for that reason alone shall not be considered to be abusing the child. However, this does not preclude a court from ordering that medical service be provided to the child where the child’s health requires it.

Denial of critical care includes the following eight sub-categories:

  1. Failure to provide adequate food and nutrition to such an extent that there is danger of the child suffering injury or death
  2. Failure to provide adequate shelter to such an extent that there is danger of the child suffering injury or death
  3. Failure to provide adequate clothing to such an extent that there is danger of the child suffering injury or death
  4. Failure to provide adequate health care to such an extent that there is danger of the child suffering serious injury or death
  5. Failure to provide the mental health care necessary to adequately treat an observable and substantial impairment in the child’s ability to function
  6. Gross failure to meet the emotional needs of the child necessary for normal development evidenced by the presence of an observable and substantial impairment in the child’s ability to function within the normal range of performance and behavior
  7. Failure to provide proper supervision of a child which a reasonable and prudent person would exercise under similar facts and circumstances, to such an extent that the failure resulted in direct harm or created a risk of harm to the child or there is danger of the child suffering injury or death.

     

    This definition includes cruel and undue confinement of a child and the dangerous operation of a motor vehicle when the person responsible for the care of the child is driving recklessly or driving while intoxicated with the child in the vehicle.

     

    This subcategory also includes:

     

    • Illegal drug usage by the caretaker of a child. When you make an allegation of denial of critical care because a child lacks proper supervision due to illegal drug usage by a caretaker you may be asked questions to help DHS determine the type of drug and the degree of risk to the child. Some illegal drugs may have a greater impact on the supervision abilities of the caretaker than others. For example, methamphetamine usage by a child’s caretaker has inherent risks to the child given the known effects of methamphetamines. DHS will consider the known effect of the drug named and other information to assess risk to the child’s safety. You may be asked about the child’s access to the drugs and about the caretaker’s use of drugs, being under the influence of drugs while supervising or transporting child, dealing drugs, possession of weapons, etc.
    • Children home alone. DHS receives many inquiries each year regarding when a child can be left home alone safely. Iowa law does not define an age that is appropriate for a child to be left alone. Each situation is unique. Examples of questions to help determine whether there are safety concerns for the child include:

       

      • Does the child have any physical disabilities?
      • Could the child get out of the house in an emergency?
      • Does the child have a phone and know how to use it?
      • Does the child know how to reach the caretaker?
      • How long will the child be left home alone?
      • Is the child afraid to be left home alone?
      • Does the child know how to respond to an emergency such as fire or injury?
    • Lice and truancy. Head lice and truancy are often reported as child abuse allegations. However, the endangerment does not generally rise to the level that must be present to constitute a child abuse allegation. If other conditions are present or the situation poses a risk to the child’s health and welfare, it should be reported as child abuse. Even if the report is rejected for assessment, other services may be offered to the child and family.
  8. Failure to respond to the infant’s life-threatening conditions by failing to provide treatment which in the treating physician’s judgment will be most likely to be effective in ameliorating or correcting all conditions. This subcategory or the denial of critical care abuse type is also known as “withholding of medically indicated treatment.” The type of treatments included are appropriate nutrition, hydration, and medication. The term does not include the failure to provide treatment other than appropriate nutrition, hydration, and medication to an infant when, in the treating physician’s medical judgment, any of the following circumstances apply:

     

    • The infant is chronically and irreversibly comatose. The provision of treatment would merely prolong dying, not be effective in ameliorating or correcting all of the infant’s life-threatening conditions, or otherwise be futile in terms of the survival of the infant. The provision of the treatment would be virtually futile in terms of the survival of the infant and the treatment itself under the circumstances would be inhumane.

Child Prostitution

Child prostitution is defined as the acts or omissions of a person responsible for the care of a child which allow, permit, or encourage the child to engage in acts prohibited pursuant to Iowa Code section 725.1. Notwithstanding Iowa Code section 702.5, acts or omissions under this paragraph include an act or omission referred to in this paragraph with or to a person under the age of 18 years.

 

Did You Know. . .

Prostitution is defined as a person who sells or offers for sale the person’s services as a partner in a sex act, or who purchases or offers to purchase such services.

 

Presence of Illegal Drugs

Presence of illegal drugs is defined as occurring when an illegal drug is present in a child’s body as a direct and foreseeable consequence of the acts or omissions of the person responsible for the care of the child.

Iowa Code section 232.77, subsection 2 states:

If a health practitioner discovers in a child physical or behavioral symptoms of the effects of exposure to cocaine, heroin, amphetamine, methamphetamine, or other illegal drugs, or combinations or derivatives thereof, which were not prescribed by a health practitioner, or if the health practitioner has determined through examination of the natural mother of the child that the child was exposed in utero, the health practitioner may perform or cause to be performed a medically relevant test, as defined in section 232.73, on the child. The practitioner shall report any positive results of such a test on the child to the department. The department shall begin an assessment pursuant to section 232.71B upon receipt of such a report. A positive test result obtained prior to the birth of a child shall not be used for the criminal prosecution of a parent for acts and omissions resulting in intrauterine exposure of the child to an illegal drug.

Illegal drugs are defined as cocaine, heroin, amphetamine, methamphetamine, other illegal drugs (including marijuana), or combinations or derivatives of illegal drugs that were not prescribed by a health practitioner.

The Comprehensive Addiction and Recovery Act of 2016 (CARA)

As of July 1, 2017, healthcare providers involved in the delivery or care of an infant affected by any substance abuse or withdrawal symptoms resulting from prenatal drug exposure or Fetal Alcohol Spectrum Disorder will be required to notify the department via the Child Abuse Hotline at 1800 362-2178. Prior to this, only infants born positive for an illegal substance in the child’s body were required to be reported.

This change in Iowa law is the result of new federal legislation. Public Law 114-198, the Comprehensive Addiction and Recovery Act of 2016 (CARA) was passed on July 22, 2016. The intent of this legislation is to address the problem of opioid addiction and to assist states in handling infants born with a substance abuse disorder.

The Iowa Department of Human Services has implemented policies and procedures to address the needs of these infants and their families. When a Child in Need of Assistance assessment is initiated, the DHS worker will consult with the healthcare provider to confirm that the infant is affected by substance abuse, withdrawal symptoms, or Fetal Alcohol Spectrum Disorder. Once confirmed, a Safe Plan of Care will be developed. The healthcare provider will be asked to review the plan and agree that the concerns and needs of the child and family have been identified and addressed.

 

If DHS is notified by a health practitioner that an infant is substance-affected and additional information is provided that constitutes a child abuse allegation, the department shall commence a Child Abuse Assessment rather than a Child in Need of Assistance assessment. A Safe Plan of Care will be developed as previously indicated.

Examples of situations that may result in a determination of this type of abuse:

  • An infant is born with illegal drugs present in the infant’s system as determined by a medical test. The illegal drugs were present in the infant’s body due to the illegal drug usage by the mother before the baby’s birth.
  • A 3-year-old child tests positive for illegal drugs due to exposure to the illegal drugs when the child’s caretakers used illegal drugs in the child’s home.

Dangerous Substances

Manufacturing or possession of a dangerous substance is defined in Iowa Code section 232.2, subsection 6, paragraph p, as occurring when the person responsible for the care of a child: unlawfully manufactures a dangerous substance in the presence of a child, knowingly allows such manufacture by another person in the presence of a child, or in the presence of a child possesses a product containing ephedrine, its salts, optical isomers, salts of optical isomers, or pseudoephedrine, its salts, optical isomers, salts of optical isomers, with the intent to use the product as a precursor or an intermediary to a dangerous substance.

For the purposes of this definition, in the presence of a child means the manufacture or possession occurred:

  • In the physical presence of a child, or
  • In a child’s home, on the premises, or in a motor vehicle located on the premises, or
  • Under other circumstances in which a reasonably prudent person would know that the manufacture or possession may be seen, smelled, or heard by a child.

Iowa Code section 232.2, subsection 6, paragraph p, defines dangerous substance as:

  • Amphetamine, its salts, isomers, or salts of its isomers
  • Methamphetamine, its salts, isomers, or salts of its isomers
  • A chemical or combination of chemicals that poses a reasonable risk of causing an explosion, fire, or other danger to the life or health of people who are in the vicinity while the chemical or combination of chemicals is used or is intended to be used in any of the following:
    • The process of manufacturing an illegal or controlled substance
    • As a precursor in the manufacturing of an illegal or controlled substance
    • As an intermediary in the manufacturing of an illegal or controlled substance

Note: DHS must report this type of allegation to law enforcement, as this is a criminal act.

Bestiality in the Presence of a Minor

Bestiality in the presence of a minor is defined as the commission of a sex act with an animal in the presence of a minor, as defined in Iowa Code section 717C.1, by a person who resides in a home with a child, as the result of the acts or omissions of a person responsible for the care of the child. DHS must report this type of allegation to law enforcement, as this is a criminal act.

Allows Access by a Registered Sex Offender

It is child abuse if a caretaker knowingly allows unsupervised access to a child by a registered sex offender or allows a registered sex offender to have custody or control of a child up to age 14 or a child up to age 18 if the child has a mental or physical disability. The exceptions are if the registered sex offender is the caretaker’s spouse or is a minor child of the caretaker. DHS must report this type of allegation to law enforcement, as this is a criminal act under child endangerment.

Allows Access to Obscene Material

This type of abuse is defined as a caretaker knowingly allowing a child access to obscene material, exhibiting obscene material to a child, or disseminating obscene material to a child, as defined in Iowa Code Section 728.1.

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