Most mental health consultants will be asked at some point to help assess parenting competence and medical neglect. In the hospital setting, the source of these referrals may be a child abuse protection team that consults with the pediatric team on all cases of suspected abuse or neglect. Preferred practice dictates that the patient and family have been told of the consultation and its purposes. The consultant should explicitly state to the family that the information and findings obtained in this assessment are not confidential or privileged and must be communicated to the pediatric team. If the parents refuse appropriate assessment, the refusal itself may constitute neglect.

As in the assessment of violence, the consultant needs to clarify the expectations underlying the request. Rarely is a professional certain that abuse has occurred, and allegations of sexual molestation and cases of Munchausen by proxy (see Chapter 12, "Munchausen by Proxy") can be particularly difficult to prove. The consultant must be clear that although he or she can provide a psychiatric assessment that includes parental psychopathology and a sense of the parent-child relationship, he or she is not a detective able to determine who abused or neglected whom. Table 4-2 summarizes parental qualities that should be assessed in the determination of parental capacity because they are particularly relevant to the treatment of physically ill children and adolescents.

In most jurisdictions, health care providers are mandated reporters of child abuse or neglect and should take this responsibility seriously. Symptoms that may be suggestive but not diagnostic of abuse might require further exploration and eventual reporting with state agencies in the absence of clear evidence. The legal standard for reporting to state child protection services is reasonable belief, not knowledge. The potential risks and benefits of filing a report should be explored, and the ultimate goal must be the best interest of the child. The medical team may decide that filing a report without much evidence to support allegations could lead to a ruptured treatment alliance, which would be detrimental to the child's health. Such decisions must be carefully explored, because the desire to preserve the treatment alliance may be driven by a reluctance to be confrontational with the family, contribute to the persistent deterioration of the child's health, and ultimately lead to harm.

Occasionally, the reluctance to report suspicions of abuse or neglect may stem from concerns about the lack of effective response from state agencies. Filing a report, however, can serve multiple purposes. First, filing the report could be a symbolic act that may serve as a check or deterrent to the parent's behaviors. Second, the filed report creates a paper trail of evidence indicating that care providers at some point had concerns about parental capacity. (Even if unsubstantiated, a series of reports could eventually help build a case for subsequent protective action.) Third, in the unfortunate event of a bad outcome as a result of parental abuse or negligence, evidence of reports filed by clinicians may place the legal burden

Table 4-2. Assessment of parental capacity

Parental strengths

Parental deficits

Cognitive understanding of child's physical, medical, and emotional needs

Adequate organizational skills and ability to supervise child's treatment


Access to extended family and social support Capacity for emotional warmth and nurturance

Cognitive limitations or mental retardation that interferes with understanding of child's physical or medical needs

Inadequate financial resources to support child's physical and emotional needs

Inability to enforce discipline or set limits appropriately


Alcohol or substance abuse

History of abuse or neglect

Source. Adapted from Barnum R: "Parenting Assessment in Cases of Neglect and Abuse," in Principles and Practice of Child and Adolescent Forensic Psychiatry. Edited by Schetky DH, Benedek EP. Washington, DC, American Psychiatric Publishing, 2002, pp. 81-96. Copyright 2002, American Psychiatric Publishing. Used with permission.

of responsibility on state protective agencies for not taking appropriate action.

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