Version 1.0 is a set of recommendations designed to promote consistent terminology and data collection related to child maltreatment. This document was developed through an extensive consultation process. It is published by the National Center for Injury Prevention and Control (NCIPC), part of Centers for Disease Control and Prevention (CDC).# INTRODUCTION The Problem of Child Maltreatment
Child maltreatment is a considerable social and public health problem in the United States. In 2004, data collected from Child Protective Services (CPS) determined approximately 900,000 children in the United States were victims of child maltreatment and about 1,500 children died because of abuse or neglect (US DHHS, 2006). Unfortunately, these numbers likely underestimate the number of children affected by maltreatment due to underreporting and focus on a single data source.
Research into the consequences of child maltreatment has identified various acute and severe negative outcomes such as death, injury, and traumatic brain injury. Research has also uncovered many deleterious long-term developmental outcomes: academic problems, anxiety, conduct disorder, childhood aggression, delinquency, depression, increased risk for suicide, high-risk sexual behavior, interpersonal problems, poor physical health, posttraumatic stress disorder, risky health behaviors, substance abuse, and youth violence (e.g., Bolger, Patterson, and Kupersmidt 1998;Cerezo and Frias 1994;Felitti et al. 1998;Kang et al. 1999;Mannarino and Cohen 1996;Widom 1999). Along with the legal and medical consequences, these substantial short-and long-term sequelae make prevention, early identification, and intervention a necessity.

# The Need for Consistent Definitions and Data Elements
Calculation of child victimization rates for maltreatment depends on how the definition of maltreatment is operationalized. To date, the multiple sectors addressing this issue (CPS, legal and medical communities, public health officials, researchers, practitioners, and advocates) often use their own definitions, thus limiting communication across disciplines and hampering efforts to identify, assess, track, treat, and prevent child abuse and neglect effectively. In addition, victimization rates are often based on reports from a single source, for example, vital statistics or CPS (e.g., National Child Abuse and Neglect Data System ). The most recent NCANDS estimate is 11.9 per 1,000 children, or 872,000 victims per year in 2004 (US DHHS, 2006). However, the Third National Incidence Study, with its more inclusive ascertainment methods (e.g., multiple sources), suggests CPS may investigate fewer than half the actual number of maltreatment cases (Sedlak and Broadhurst 1996).
Estimates for child fatalities due to maltreatment vary to an even greater extent depending on the methodologies, definitions, and sources used (Crume et al. 2002;Herman-Giddens et al. 1999;McClain, Sacks, Frohlke, and Ewigman 1993). On the one hand, death certificate data from 2002 suggest rates as low as 0.28 per 100,000 children 0 to 17 years of age (N = 204) (CDC Wonder website: . cdc.gov/). On the other hand, the NCANDS Child Maltreatment 2004 report estimates 2.0 per 100,000 children 0 to 17 years of age (N ~ 1,500). Fatality rates vary inversely by age as well, with the rate for infants varying by source from 2.4 per 100,000 for vital statistics to 17.5 per 100,000 for CPS sources. This lack of consistent information about the number of children affected by maltreatment limits the ability of the public health community to respond to the problem in several ways. First, it limits ability to gauge the magnitude of child maltreatment in relation to other public health problems. Second, it limits ability to identify those groups at highest risk who might benefit from focused intervention or increased services. Finally, it limits ability to monitor changes in the incidence and prevalence of child maltreatment over time. In turn, this limits the ability to monitor the effectiveness of child maltreatment prevention and intervention activities (Saltzman et al. 1999).

# The Public Health Approach to Child Maltreatment
The mission of the Centers for Disease Control and Prevention (CDC) is to promote health and quality of life by preventing and controlling disease, injury, and disability. Child maltreatment can result in direct physical, behavioral, social, and emotional harm and disability and is a risk factor for a range of other health risk factors that contribute to acute and chronic health problems. For example, research has shown that individuals who experienced multiple forms of child maltreatment early in life are more likely to engage in health risk behaviors such as smoking and heavy alcohol use. These health risk behaviors have been linked to poor health outcomes such as respiratory illness, liver damage, and cancer later in life (Edwards 2004). The ultimate goal of CDC's child maltreatment prevention activities is to prevent child maltreatment before it occurs. To do this, CDC uses the public health model in which surveillance is the first step.
Surveillance is defined as the ongoing, systematic collection, analysis, and interpretation of outcomespecific data for use in the planning, implementation, and evaluation of public health practice (Thacker and Berkelman 1988). Public health based child maltreatment surveillance systems rely on a variety of unique data sources, for example, hospital in-patient records, emergency department records, police and homicide reports, child death review findings, and medical examiner and coroner reports. These surveillance systems also use traditional CPS data that have been used by databases such as NCANDS and the Adoption and Foster Care Analysis Reporting System (AFCARS).
Although the research and legal communities have attempted to develop consistent and uniform definitions of child abuse and neglect, none of these definitions is adequate for use in public health surveillance. Research definitions such as the Maltreatment Coding Scheme for Abuse Allegations (MCS) Cicchetti 1991, 1993) and the "harm" and "endangerment" standards from the National Incidence Study (NIS) rely on interview data from a variety of sources that are not available to state and local health departments. Also, legal definitions vary from state to state, making comparisons across states and the collection of national data difficult. Users of this document are strongly encouraged to familiarize themselves with the child abuse and neglect laws in their state when designing surveillance systems because the differences may affect the language used to find cases and interpret data.
Because no public health based definitions for child maltreatment exist, public health officials continue to use terms related to child maltreatment in different ways and use different terms to describe the same acts. Not surprising, these inconsistencies have contributed to varied conclusions about the incidence and prevalence of child abuse and neglect.

# CDC Development of Uniform Definitions and Recommended Data Elements
In 1999, CDC published Version 1.0 of Intimate Partner Violence Surveillance: Uniform Definitions and Recommended Data Elements (Saltzman et al. 1999;revised 2002). That document was intended to guide data collection for public health surveillance of intimate partner violence. In 2002, CDC published Version 1.0 of Sexual Violence Surveillance: Uniform Definitions and Recommended Data Elements (Basile and Saltzman 2002). It covered sexual violence committed by all perpetrators and was intended for surveillance of sexual violence against both adult and child victims.
This document is the third in the series of Uniform Definitions and Recommended Data Elements. We used a process and format similar to that of the other two documents and focused on all types of child maltreatment, including sexual abuse. To maintain consistency and ease of use, we have drawn heavily from the sexual violence definitions in our definitions of sexual abuse. However, the definition of sexual abuse in this document covers only sexual violence against children that occurs in the context of a caregiver relationship.

# Development Process
Professionals in child maltreatment research, prevention, and surveillance from settings including universities, state health departments, hospitals, contract research firms, and federal agencies served as panelists for this project. The panelists first met in March 2003. At this meeting, panelists were charged with generating initial drafts of operational definitions of child maltreatment overall and the individual types of child maltreatment. The results of this meeting were compiled and refined and sent to the panelists for feedback in December 2003. Expanded and revised documents were presented to the panel in June 2004 and November 2004. The final draft of the document was sent to the panelists and other child maltreatment experts for review in May 2005.

# Purpose
This document defines child maltreatment, presents associated terms, and recommends data elements for voluntary use by individuals and organizations in the public health community. It is designed to aid state and local health department staff in the collection of public health surveillance data on child maltreatment. This document is not intended to be a set of mandates; rather, it is intended to promote and improve consistency of child maltreatment surveillance for public health practices.
The recommended data elements are designed to help people collect information of value for public health surveillance of child maltreatment and to serve as a technical reference for the collection of surveillance data. Developers of surveillance systems may choose to include as many or as few of the recommended data elements as they deem feasible. If the recommended data elements can be uniformly recorded and the data made available to numerous users, information about the characteristics and risk factors for child maltreatment will become more comparable and problems such as data incompatibility and the high cost of collecting, linking, and using data can be substantially reduced. The data elements in this document may be most useful for systematic, on-going collection, analysis, and interpretation of data already available from sources such as emergency departments, police departments, or CPS records. These data are typically collected for other agency-related purposes, but can later be extracted and used for surveillance.
Other approaches to surveillance exist that can be potentially viable options for measuring the incidence and prevalence of child maltreatment. Surveys, for example, involve systematic data collection from a representative sample of the population of interest for analysis and interpretation. Survey data are collected directly from individuals such as parents, caregivers, and children. Although the definitions and data elements contained in this document apply to some surveys, they were not designed specifically for use in surveys and discussion of these definitions and elements in this context is beyond the scope of the current document.

# Content and Scope
This document contains definitions and data elements that can be used to create instruments for surveillance. Users should be aware that its contents neither represent instruments for surveillance nor provide clinical information for identifying child maltreatment. The document is divided into two major sections:
- Uniform Definitions (for child maltreatment) - Recommended Data Elements for Child Maltreatment Surveillance In the first section, we provide a conceptual definition of child maltreatment and associated terms. In the second section, we provide recommended data elements for surveillance. The recommended data elements are divided into basic data elements and expanded data elements. The basic data elements represent fundamental information that should be collected in a child maltreatment surveillance system. Although not mandatory, these data elements should be relatively easy to collect. Some basic data elements may not be available or may be inappropriate to collect from certain data sources. If users of a surveillance system are unable to collect some basic data elements, the system is by no means inadequate. If resources allow, collection of the expanded data elements-which includes the basic data elements-will yield additional beneficial information. This information will provide richer dataset that includes contextual variables which may be more difficult to collect than the basic data elements.
An example of information that may be difficult to obtain is Injury Characteristics. Depending on the data sources used, the linkage across different data systems, and the completeness of available records, data for this element can be difficult or time-consuming to collect. Although not included in the list of basic data elements, we do not imply that injury characteristics are unimportant; rather, we acknowledge that these data are difficult to capture in a surveillance system.
Although we recommend definitions and data elements for use in child maltreatment surveillance systems, this document does not specify a database structure for the elements, preferring to leave the decision and choice of software to the database designer. However, the elements in this document can be used either in a flat file format, where one child record links to each incident, or in a relational database format, where multiple incident records may be linked to each child record. Examples of these database types can be found in existing data systems: death certificate data is stored in a flat file format, whereas both the FBI's National Incident Based Reporting System and the CDC's National Violent Death Reporting System use relational databases.
The flat file format is easier to implement and analyze. However, if a file in this format is set up with one record for each incident, it will be necessary to link multiple incidents for the same child in some fashion. A flat format also requires that the designer include enough fields to handle the most complicated incidents (e.g., those with multiple caregivers) or else force the user to choose among several caregivers for the one or two to be recorded. Either way, a flat file format will require relabeling the repeated variables (e.g., caregiver1 and caregiver2).
On the other hand, the relational database format can accommodate multiple records linked to a single record, whether those are multiple caregivers in one incident or multiple incidents for one child. A relational database tends to require more programming assistance to implement. Each surveillance system should use the format that best matches the available technical resources. For the most part, data from two systems that share the same data elements but use different database structures should be comparable. This document's order of presentation for various types of child maltreatment does not imply a hierarchy of risk or harm to the child; all abuse and neglect can have serious negative consequences for the victims.

# Caveats to the Use of this Document
- As with all research on children, ethical and safety issues are paramount. No data should be collected or stored in a way that would jeopardize a child's safety. Those interested in developing a surveillance system for child maltreatment must be particularly conscious of the need to preserve confidentiality. The issue of confidentiality must also be balanced with the need for data linkage across multiple data sources, perhaps through mechanisms such as encryption designed to preserve confidentiality and individual anonymity.
- Recognize that the parent and child behaviors and child outcomes which can be markers for child maltreatment are diverse and can result from other stressors or trauma. For example, infants and toddlers who present subdural hemotoma in emergency rooms could have suffered the injury from a fall or as a result of being unintentionally struck on the head-not as a consequence of shaken baby syndrome. Users should rely on multiple sources for data and consider available contextual information to determine whether a behavior or injury is, in fact, an indicator of child maltreatment.
- Because identification and documentation of child maltreatment is not standard across the many sources that collect data on abuse and neglect, data from multiple sources may be needed to better estimate the number of children who experience maltreatment. However, use of multiple data sources can present logistical and economic challenges. Data collection from multiple data sources can be costly, and these data will need to be linked once collected. As such, developers of surveillance systems may want to explore the viability of various approaches to determine the most efficacious and cost-effective method of child maltreatment surveillance. The recommendations in this document provide suggested means for organizing information whether it comes from a single source or a variety of sources.
- The definitions in this document include discrete types of violence: physical abuse, sexual abuse, psychological abuse, and neglect (Failure to Provide and Failure to Supervise). We recommend that users of the document take several approaches to assess the incidence and prevalence of child maltreatment when designing their surveillance system.
- First, research has demonstrated that experiencing maltreatment of any type can have deleterious consequences on development (Bolger, Patterson, and Kupersmidt 1998;Cerezo and Frias 1994;Felitti et al. 1998;Kang et al. 1999;Mannarino and Cohen 1996;Widom 1999). For this reason, we recommend that surveillance systems be designed to capture whether a child has experienced any maltreatment-regardless of the type experienced. o Second, research on child maltreatment has demonstrated that the various types of maltreatment often co-occur (Cicchetti and Barnett 1991;Clausen and Crittenden 1991;Higgins and McCabe 2000;Lewis, Mallouh, and Webb 1989;McGee and Wolfe 1991;Straus and Gelles 1986). As such, we recommend that the incidence of each type of maltreatment be documented separately to gauge its magnitude relative to other types of maltreatment.
- Many issues covered in this document fall into a grey area where it is difficult to delineate or encompass every possibility. Surveillance allows for error and interpretation by the individuals involved and does not strive for the same precision as research.

# Next Steps
As users of this document apply these definitions and data elements, we hope that most acts of child maltreatment will be captured. This document serves as a starting point, and revisions may become necessary as the definitions and data elements are used.

# UNIFORM DEFINITIONS

# CHILD MALTREATMENT AND ASSOCIATED TERMS

# Child Maltreatment
Any act or series of acts of commission 1 or omission by a parent 2 or other caregiver that results in harm, potential for harm, or threat of harm to a child 3 .

# Acts of Commission (Child Abuse 4 )
Words or overt actions that cause harm, potential harm, or threat of harm to a child. Acts of commission are deliberate and intentional; however, harm to a child may or may not be the intended consequence. Intentionality only applies to the caregivers' acts-not the consequences of those acts. For example, a caregiver may intend to hit a child as punishment (i.e., hitting the child is not accidental or unintentional) but not intend to cause the child to have a concussion. The following types of maltreatment involve acts of commission:
- Physical abuse - Sexual abuse - Psychological abuse

# Acts of Omission (Child Neglect)
The failure to provide for a child's basic physical, emotional, or educational needs or to protect a child from harm or potential harm 5 . Like acts of commission, harm to a child may or may not be the intended consequence.The following types of maltreatment involve acts of omission: 1 Words in boldface type will be defined. 2 The term "parent" includes custodial and noncustodial parents. 3 The terms "maltreatment" and "abuse" are often used interchangeably in the literature. However, in this document, "maltreatment" is a general term that includes both abuse and neglect; "abuse" refers explicitly to acts of commission. 4 In this document, the term "abuse" includes single acts and repeated, ongoing acts. 5 Adapted from Administration for Children and Families (ACF), What is Child Maltreatment?
Caregiver A caregiver 6 is a person, or people, who at the time of the maltreatment is in a permanent (primary caregiver) or temporary (substitute caregiver) custodial role. In a custodial role, the person is responsible for care and control of the child and for the child's overall health and welfare.
- Primary caregivers must live with the child at least part of the time and can include, but are not limited to, a relative or biological, adoptive, step-, or foster parent(s); a legal guardian(s); or their intimate partner 7 .
- Substitute caregivers may or may not reside with the child and can include clergy, coaches, teachers, relatives, babysitters, residential facility staff, or others who are not the child's primary caregiver(s).

# Harm
Any acute disruption caused by the threatened or actual acts of commission or omission to a child's physical or emotional health (ISPCAN 2003). Disruptions can affect the child's physical, cognitive, or emotional development.
Threat of harm occurs when a parent or caregiver expresses an intention or gives signs or warnings through the use of words, gestures, or weapons to communicate the likelihood of inflicting harm to the child. Threat of harm can be explicit or implicit. Explicit threats would include such acts as pointing a gun at the child or raising a hand as if to strike the child. Implicit threats would include such acts as kicking holes in walls or breaking down doors.
Disruption of physical health includes, but is not exclusive to, physical injuries, avoidable illnesses, and inadequate nutrition.
- Physical injuries are physical harm, including death, occurring to the body from exposure to thermal, mechanical, electrical, or chemical energy interacting with the body in amounts or rates that exceed the threshold of physiological tolerance, or from the absence of such essentials as oxygen or heat (Holder et al. 2001 (Saltzman, Fanslow et al. 1999).
Disruption of emotional health can include anxiety problems, disruption of social functioning, impaired relationships, depression and depressive symptoms, eating disorders, posttraumatic stress (including posttraumatic stress disorder ), externalizing behaviors (e.g., aggression), lack of education, school failure, delinquency, or substance abuse.
Harm can be immediate (e.g., broken bones) or delayed (e.g., depression, PTSD).

# Child
Any individual from birth through 17 years of age 8 at the time of maltreatment.
For the purposes of this document, maltreatment of an adult (age 18 or older) is not considered child maltreatment regardless of the emotional or intellectual age of the person.
For the purposes of this document the following are irrelevant to determining whether child maltreatment has occurred:
- Caregiver's intent to harm the child.
- Caregiver's legal liability for the maltreatment. - Caregiver's economic means.
- Caregiver's religious or cultural norms.

# DEFINITIONS OF ACTS OF COMMISSION (CHILD ABUSE)
For the purposes of this document, an incident of child maltreatment is defined as an event documented by CPS, law enforcement, the medical system, or other reporting source (e.g.,school) in which child maltreatment is alleged or confirmed 9 .

# Physical Abuse
Physical abuse is defined as the intentional use of physical force against a child that results in, or has the potential to result in, physical injury.
Physical abuse includes physical acts ranging from those which do not leave a physical mark on the child to physical acts which cause permanent disability, disfigurement, or death (Barnett, Manly, and Cicchetti 1993). Physical abuse can result from discipline or physical punishment (ACF 2002).
Physical acts can include hitting, kicking, punching, beating, stabbing, biting, pushing, shoving, throwing, pulling, dragging, dropping, shaking, strangling/choking, smothering, burning, scalding, and poisoning.

# Exceptions
Physical injuries to the anal or genital area or surrounding areas (e.g., anal or genital bruising or tearing; internal injuries resulting from penetration by a penis, hand, finger, or other object) that occur during attempted or completed sexual abuse, or other physical injuries that result from attempted or completed sexual abuse (e.g., bruises due to restraint, hitting, pushing) are considered sexual abuse and do not constitute physical abuse.

# Sexual Abuse
Any completed or attempted (non-completed) sexual act, sexual contact with, or exploitation (i.e., noncontact sexual interaction) of a child by a caregiver.

# Sexual Act
Sexual acts include contact involving penetration, however slight, between the mouth, penis, vulva, or anus of the child and another individual. Sexual acts also include penetration, however slight, of the anal or genital opening by a hand, finger, or other object (Basile and Saltzman 2002). Genital on genital contact includes:

# Noncontact Sexual Abuse
Noncontact sexual abuse does not include physical contact of a sexual nature between the caregiver and the child.
Noncontact sexual abuse can include the following:
1. Acts which expose a child to sexual activity (e.g., pornography; voyeurism of the child by an adult; intentional exposure of a child to exhibitionism); 2. Filming 10 of a child in a sexual manner (e.g., depiction, either photographic or cinematic, of a child in a sexual act); 3. Sexual harassment of a child (e.g., quid pro quo; creating a hostile environment because of comments or attention of a sexual nature by a caregiver to a child); 4. Prostitution of a child (e.g., employing, using, persuading, inducing, enticing, encouraging, allowing, or permitting a child to engage in or assist any other person to engage in, prostitution 11 , or sexual trafficking. Sexual trafficking is defined as the act of transporting children across international borders through deception for forced sexual activity such as prostitution or sexual slavery (Miller and Jayasundara 2001).

# Psychological Abuse
Intentional caregiver behavior (i.e., act of commission) that conveys to a child that he/she is worthless, flawed, unloved, unwanted, endangered, or valued only in meeting another's needs 12 . Psychological abuse can be continual (e.g., chronic and pervasive) or episodic (e.g., triggered by a specific context or situation: caregiver substance use/abuse) (Kairys and Johnson 2002).
Psychologically abusive behaviors may include blaming, belittling, degrading, intimidating, terrorizing, isolating, restraining, confining, corrupting, exploiting, spurning, or otherwise behaving in a manner that is harmful, potentially harmful, or insensitive to the child's developmental needs, or can potentially damage the child psychologically or emotionally (Barnett, Manly, and Cicchetti 1991;McGee and Wolfe 1991a, b).

# Terrorizing
Terrorizing includes caregiver behavior that is life-threatening; makes a child feel unsafe (e.g., situations that are likely to physically hurt, kill, or abandon the child) (Myers et al. 2002); sets unrealistic expectations of the child with threat of loss, harm, or danger if expectations are not met; and threatens or perpetrates violence against a child or a child's loved ones or objects (including toys, pets, or other possessions) (Kairys and Johnson 2002). For example, placing a child in unpredictable or chaotic circumstances would be considered terrorizing as would be placing a child in a situation reasonably considered dangerous by either the child or another adult.

# Isolating
Psychological isolation occurs when a caregiver forbids, prevents, or minimizes a child's contact with others.

# DEFINITIONS OF ACTS OF OMISSION (CHILD NEGLECT)
Failure to Provide (Barnett, Manly, and Cicchetti 1993) Failure by a caregiver to meet a child's basic physical, emotional, medical/dental, or educational needs-or combination thereof. Failure to provide includes the following:

# Physical Neglect
Caregiver fails to provide adequate nutrition, hygiene, or shelter; or, caregiver fails to provide clothing that is adequately clean, appropriate size, or adequate for the weather. Several examples follow (Barnett, Manly, and Cicchetti 1993):
- Nutrition: A 9-year-old child makes dinner several times per week because the caregiver(s) are sleeping, away, or otherwise unavailable; a child misses or is denied meals on numerous occasions over time; a child is diagnosed as being severely malnourished.
- Hygiene: Child is dirty, smells bad, or has unwashed hair. Child's living situation is unsanitary; dirty dishes and spoiled food are left on the kitchen table and counter.
- Shelter: Living arrangements for the child and family are unstable for two weeks or more; the residence is infested with roaches or vermin; residence in unheated or inadequately heated because caregivers have failed to ensure heat available.
- Clothing: The child always wears clothing that is too small; the child is not given a warm coat and gloves when the weather is cold.

# Emotional Neglect
Caregiver ignores the child, or denies emotional responsiveness or adequate access to mental health care (e.g., caregiver does not respond to infant cries or older child's attempt to interact) (Barnett, Manly, and Cicchetti 1993).

# Medical/Dental Neglect
Caregiver fails to provide adequate access to medical, vision, or dental care for the child. Examples include the following:
- Caregiver does not administer prescribed medications;
- Caregiver refuses to take the child for needed medical attention or seek timely medical attention (Barnett, Manly, and Cicchetti 1993).

# Educational Neglect
Caregiver fails to provide access to adequate education. Examples include:
- Caregiver allows child to miss 25 or more school days in one academic year without excuse;
- Caregiver does not enroll the child in school; caregiver encourages a child (under 16 years of age) to drop out of school (Barnett, Manly, and Cicchetti 1993).

# Failure to Supervise
Failure by the caregiver to ensure a child's safety within and outside the home given the child's emotional and developmental needs (Barnett, Manly, and Cicchetti 1993).

# Inadequate Supervision
Failure by the caregiver to ensure that the child engages in safe activities and uses appropriate safety devices; to ensure that the child is not exposed to unnecessary hazards; or to ensure appropriate supervision by an adequate substitute caregiver (Barnett, Manly, and Cicchetti 1993).
Inadequate supervision (sometimes called "supervisional neglect ") includes occasions when a caregiver knowingly fails to protect a child from maltreatment perpetrated by a substitute caregiver. Under such conditions, the primary caregiver's behavior would be considered neglectful only if the maltreatment was recognized and allowed to occur. Regardless of the primary caregiver's knowledge of the maltreatment, the substitute caregiver's behavior would be considered maltreatment.

# Exposure to Violent Environments
Caregiver intentionally 13 fails to take available measures to protect the child from pervasive violence within the home, neighborhood, or community (Kairys and Johnson 2002). For example, a caregiver who sells illicit drugs out of the child's home exposes the child to a violent environment; or, a school bus driver (temporary caregiver) who allows a student to be routinely victimized by another student while riding the bus without taking steps to intervene (e.g., notifying school administrators) also exposes a child to a violent environment.
Exposure of a child to violence between caregivers in the home may also qualify as exposure to a violent environment, particularly if the caregivers do not take available measures to protect the child from exposure. But, in instances where the caregiver is being victimized by a partner, and alternatives to protect the child are not available, or the caregiver is unaware of alternatives, the caregiver is not maltreating the child.

# CO-OCCURRENCE OF MULTIPLE TYPES OF ABUSE AND NEGLECT 14
Multiple forms of maltreatment often coexist, as described in these examples:
- Police find a 20-month-old child with bruises on extremities, cigarette burns to the forehead and upper chest, and signs of dehydration. The child was at home with the male caregiver who was high on opium. In this instance, physical abuse, failure to provide (adequate nutrition), failure to protect (caregiver is under the influence of drugs and unable to care for the child), and psychological abuse have occurred.
- Paramedics find a two-and-a-half-year-old child. The undressed child was walking outside in the winter and had belt-patterned bruises on the legs and trunk. The child also had ethyl alcohol in his blood system. In this example, physical abuse, failure to provide (adequate clothing), and failure to protect (unaccompanied child) have occurred.
- Upon reading a school report card, the caregiver/parent slaps the child's face, withholds food, and berates the child's ability until "better marks" are produced. In this scenario, physical abuse, failure to provide, and psychological abuse have occurred.

# INTRODUCTION
Each section describes the recommended data elements that can be included in a surveillance system designed to collect information on child maltreatment. The order in which the data elements are presented is not intended to suggest a hierarchy; users may select data elements that best fit their surveillance needs.
Depending on the applicability of the information, some or all of the following categories of information are listed for each data element:
- Description or definition of the data element;
- Uses/data element type describes how the data element should be used and whether it is a basic or expanded data element;
- Discussion of relevant conceptual or operational issues;
- Allow for multiple responses indicates when it is appropriate to include all applicable answers or response options;
- Field values/coding instructions indicate how to enter data in the field and what each represents;
- Data standards or guidelines used to define the data elements and its field values;
- Other references consulted in developing the data elements.

# BASIC AND EXPANDED DATA ELEMENTS FOR CHILD MALTREATMENT SURVEILLANCE

# Discussion
The data elements in this section relate directly to information about the index child.
Creators of surveillance systems should be mindful of confidentiality and safety issues as they develop and use their system. No data should be collected or stored that could potentially jeopardize a child's safety. When developing a surveillance system for child maltreatment, the issue of confidentiality must be balanced with the need for data linkage across multiple data sets. Data elements containing identifying information may be stripped once data from all records related to the child have been identified and entered into the surveillance system.

# *Expanded data element
Case ID 1.01

# Description/Definition
A required, unique identification code used by the agency compiling child maltreatment surveillance data.

# Uses/Data Element Type
Ensures that entered or accessed records correspond with the proper child. It also facilitates data linkage for administrative and research purposes.
Data element type: Basic.

# Discussion
Case ID may be assigned by the agency compiling child maltreatment (CM) surveillance data, or it may be an identifier previously assigned by the contributing data source. Case ID can be identical to the identifier created to allow linkage across multiple sources.
Because identification and documentation of CM is not standard across the many sources that may collect data on abuse and neglect, data from multiple sources may be needed to better estimate the number of children who experience maltreatment. As such, developers of surveillance systems may want to explore the viability of a variety of approaches to child maltreatment surveillance. One method is to include data from multiple sources (e.g. The mechanics of how to set up a database that accommodates data from multiple sources are not discussed in this document. Users should refer to other sources for information on how to set up a database.

# Allow for Multiple Responses
No.

# Field Values/Coding Instructions
For recommended field values and coding instructions, please refer to Data Standards or Guidelines listed below.

# Data Standards or Guidelines
Health Level 7, Version 3.0 (HL7 2003); www.HL7.org
Child's Name 1.02

# Description/Definition
Child's first, middle, and last name.

# Uses/Data Element Type
Allows for linking data on a particular child across records, thus reducing the chance of duplicate records on the same child.
Can be used with 1.03 Alternate Name for Child to ensure that records related to the child are correctly linked to the child.
Data element type: Basic.

# Discussion
The practice of including names in public health surveillance systems is not uncommon. Most state-level surveillance systems for infectious diseases include names, as do surveillance systems such as the National Violent Death Reporting System. Additionally, inclusion of the index child's name(s) in a surveillance system to track child maltreatment allows for a unique identifier that can facilitate data linkage across sources.
These data are not intended for tracking victims or offenders. Protection of individuals' privacy is paramount; to protect child victim privacy and confidentiality, access to this data element must be limited to authorized personnel.

# Allow for Multiple Responses
No.

# Field Values/Coding Instructions
Record child's name as follows: I f the child's name does not conform to the coding instructions above, please refer to the Data Standards or Guidelines listed below.
Alternate Name for Child 1.03

# Description/Definition
Other first, middle, and last name by which child is known.

# Uses/Data Element Type
Allows for linking data on a particular child across records, thus reducing the chance of duplicate records on the same child.
Can be used with 1.02 Child's Name to ensure that records related to the child are correctly linked to the child.
Data element type: Basic.

# Discussion
The practice of including names in public health surveillance systems is not uncommon. Most state-level surveillance systems for infectious diseases include names, as do surveillance systems such as the National Violent Death Reporting System. Additionally, inclusion of the index child's name(s) in a surveillance system to track child maltreatment allows for a unique identifier that can facilitate data linkage across sources.
These data are not intended for tracking victims or offenders. Protection of individuals' privacy is paramount; to protect child victim privacy and confidentiality, access to this data element must be limited to authorized personnel.

# Allow for Multiple Responses
No.

# Discussion
Because developmental changes occur rapidly in the first three years of life, record the child's age in months for ages 3 years (36 months) and younger . Age in months allows for greater precision and a better understanding of the child's physical, cognitive, and emotional abilities at the time of the incident of maltreatment.
If the child's exact age is not available, an estimated age can be used.

# Allow for Multiple Responses
No.

# Field Values/Coding Instructions
Record age in months and round to the nearest month. For example, a child who is 2 years and 3 months would be coded as 27 months of age. If the child is 2 years, 3 months, and 15 or fewer days, the age would be coded as 27 months. On the other hand, if the child is 2 years, 3 months, and 16 or more days, the age would be coded as 28 months.

# Data Standards or Guidelines
Common Data Elements Implementation Guide, Version 2.4 (CDC 2000); www.cdc.gov/data/index.htm
Age (in Years) of Child Older Than 3 years 1.06

# Description/Definition
Age of child, if the child is older than 3 years, at the time of the incident on which data are being collected.

# Uses/Data Element Type
Can be used if child's date of birth (see 1.04) is not available or is in question.
Data element type: Expanded.

# Discussion
If the child's exact age is not available, an estimated age can be used.

# Allow for Multiple Responses
No.

# Field Values/Coding Instructions
Record age in years. If fractional ages (e.g., 7.5 years or 7 12 years) are provided, round to the nearest year. For example, a child who is 7.5 years of age would be coded as 8 years.

# Data Standards or Guidelines
Common Data Elements Implementation Guide, Version 2.4 (CDC 2000); www.cdc.gov/data/index.htm
Sex of Child 1.07

# Description/Definition
Sex of child.

# Uses/Data Element Type
Standard demographic and identifying information.
Data element type: Basic.

# Allow for Multiple Responses
No. Data element type: Basic.

# Field Values/Coding Instructions

# Discussion
The categories below represent a social-political construct designed for collecting data on the race and ethnicity of broad population groups in the United States. For more than 20 years, the Federal government has promoted the use of a common language to ensure uniformity and comparability of data on race and ethnicity. Development of the data standards stemmed in large measure from new responsibilities to enforce civil rights laws. Data were needed to monitor equal access in housing, education, employment, and other areas for populations that historically had experienced discrimination and differential treatment because of their race or ethnicity. The standards are used not only in the decennial census (which provides data for the "denominator" for many measures), but also in household surveys, on administrative forms (e.g., school registration and mortgage-lending applications), and in medical and other research.
Race is a concept used to differentiate population groups largely by physical characteristics transmitted by descent. This concept lacks clear scientific definition, as racial categories are neither precise nor mutually exclusive. The common use of race in the United States draws upon differences not only in physical attributes, but also in ancestry and geographic origins.  (OMB 1997) was developed to meet Federal legislative and program requirements, and these standards are used widely in the public and private sectors. The directive provides five basic racial categories but states that collection of race data need not be limited to these categories. However, additional reporting that uses more detail must be organized in such a way that the additional categories can be aggregated into the five basic groups. Although the directive does not specify a method for determining an individual's race, OMB prefers self-identification to identification by an observer whenever possible. The directive states that persons of multiple racial origins should be coded using multiple categories, not a multiracial category.

# Allow for Multiple Responses
Yes. If the agency providing the data to the child maltreatment surveillance system uses multiple racial categories, the child maltreatment surveillance system also allows for multiple racial categories to be coded. Uses/Data Element Type Provides information on preexisting disabilities or health conditions that the child may have which are not likely to have resulted from abuse or neglect. Differentiates between conditions existing before the onset of maltreatment, comorbid conditions, and conditions resulting from maltreatment.

# Field Values/Coding Instructions
Data element type: Expanded.

# Discussion
Access to data on preexisting disabilities or health conditions will allow for more accurate prevalence rates of risk factors for maltreatment and for specific points of intervention.
Children with physical, behavioral, health, and cognitive disabilities are at higher risk for maltreatment than children without such conditions Knutson 1998, 2000). These children comprise more than one third of the maltreated children between birth and 18 years of age.

# Allow for Multiple Responses
Yes.

# Field Values/Coding Instructions

# Discussion
As defined previously, an incident of child maltreatment is an event documented by CPS, law enforcement, the medical system, or other reporting sources (e.g., school) where child maltreatment is alleged or confirmed.

# Date of Incident 2.01

# Description/Definition
Date of the current incident of child maltreatment.

# Uses/Data Element Type
Provides information on when the incident occurred.
Date of Incident can be used with data element 1.04 Birth Date of Child to calculate the child's age at the time of the current incident.
If date of incident is not available, 2.02 Date of Report to Child Protective Services can be used instead.
Data element type: Basic.

# Discussion
If the incident of maltreatment exceeded one day, code the date that the incident ended. If the date of the incident is unknown, use the date of record (report).

# Allow for Multiple Responses
No.

# Field Values/Coding Instructions
For recommended field values and coding instructions, please refer to Data Standards and Guidelines listed below.

# Data Standards or Guidelines E1384-96 (ASTM 1996)
Health Level 7, Version 3.0 (HL7 2003); www.HL7.org
Date of Report to Child Protective Services (CPS) 2.02

# Description/Definition
Date on which the current incident of child maltreatment was reported to CPS.

# Uses/Data Element Type
Provides information on when the incident came to the attention of CPS.
If the actual date of incident is not available, Date of Report to Child Protective Services can be used as a proxy for data element 2.01 Date of Incident.
Data element type: Basic.

# Discussion
If the date of incident is unknown, use the date of record (report).

# Allow for Multiple Responses
No.

# Field Values/Coding Instructions
For recommended field values and coding instructions, please refer to Data Standards and Guidelines listed below.

# Data Standards or Guidelines E1384-96 (ASTM 1996).
Health Level 7, Version 3.0 (HL7 2003); www.HL7.org
Location where Maltreatment Occurred 2.03

# Description/Definition
Where did the maltreatment occur?

# Uses/Data Element Type
Describes the context in which the maltreatment took place.
Can be used with 2.04.03 Type of Residence to determine the specific type of location or residence if the response below is "Child's residence".
Data element type: Expanded.

# Discussion
Child maltreatment does not always occur in the child's home. The location(s) where child maltreatment occurs is beneficial for designing effective prevention programs.

# Allow for Multiple Responses
Yes.

# Field Values/Coding Instructions

# Uses/Data Element Type
Provides the location at which the index child resides at least most of the time.
Can be used with 2.04.02 Child's Second Address at Time of Incident to determine where the child was living at the time of the incident of maltreatment.
Data element type: Basic.

# Discussion
When child custody is shared due to parental divorce or legal separation, a child can have more than one official address. The first address should be the one where the index child was staying at the time of the incident. The other address, where the child spends some or most of the time, may be entered in 2.04.02 Child's Second Address at Time of Incident.

# Allow for Multiple Responses
No.

# Field Values/Coding Instructions
For recommended field values and coding instructions, please refer to Data Standards and Guidelines listed below.

# Data Standards or Guidelines
Health Level 7, Version 3.0 (HL7 2003); www.HL7.org
Child's Second Address at Time of Incident 2.04.02

# Description/Definition
Address of the index child's second official residence at time of incident.

# Uses/Data Element Type
Provides the second location at which the index child resides when not at the first address (see 2.04.01 Child's First Address at Time of Incident).
Can be used with 2.04.01 Child's First Address at Time of Incident to determine where the child was living at the time of the incident of maltreatment.
Data element type: Basic.

# Discussion
In cases where custody of a child is shared due to parental divorce or legal separation, a child can have more than one official address. The other address at which the child spends some or most of the time may be entered in 2.04.01 Child's First Address at Time of Incident.

# Data Type (and Field Length)
XAD -extended address ( 106)

# Allow for Multiple Responses
No.

# Field Values/Coding Instructions
For recommended field values and coding instructions, please refer to Data Standards and Guidelines listed below.

# Data Standards or Guidelines
Health Level 7, Version 3.0 (HL7 2003); www.HL7.org
Type of Residence 2.04.03

# Description/Definition
Type of residence or living arrangement in which the index child resides at the time of the incident.

# Uses/Data Element Type
Provides information on the context and environment in which the child lives at the time of the incident.
Data element type: Expanded.

# Discussion
If the index child has more than one address, as indicated by data in 2. 04

# Uses/Data Element Type
The length of time the child has lived at the current address can provide information on the stability of the child's living situation.
Data element type: Expanded.

# Discussion
See discussion under 2.04.04 Time in First Residence.

# Allow for Multiple Responses
No.

# Field Values/Coding Instructions
Record time in residence in number of months, rounded to the nearest month.
Physical Abuse

# Discussion
Physical abuse is the intentional use of physical force against a child that results in or has the potential to result in physical injury. Physical abuse includes physical acts ranging from those which do not leave a physical mark on the child to those which cause permanent disability, disfigurement, or death.
Physical abuse can result from discipline or physical punishment and is coded regardless of the caregiver's intent to harm or injure the child.
The following are considered sexual abuse and should be coded accordingly:
- Physical injuries to the anal, genital, or surrounding areas that occur during attempted or completed sexual abuse (e.g., anal or genital bruising or tear; internal injuries resulting from penetration by a penis, hand, finger, or other object) - Other physical injuries that result from attempted or completed sexual abuse (e.g., bruises due to restraint, hitting, or pushing)
Notation of Physical Abuse 2.04.06

# Description/Definition
Is physical abuse noted in any record of this incident of maltreatment?

# Uses/Data Element Type
Used to describe whether the child experienced physical abuse.
Data element type: Basic.

# Discussion
Noted physical abuse includes any mention of the term "physical abuse" or "child physical abuse" or intentionally inflicted injury of the child by a caregiver in the child's record. Noted physical abuse also includes suspected abuse or an indication that an abuse-related referral was made (e.g., to CPS).
If the record has a notation that physical abuse is suspected, code physical abuse as noted in that record. Other terms that can be used include but are not limited to "substantiated," "indicated," "reason to suspect," "suspected," "reported," "documented," "founded," "supported," "credible evidence exists," "suspected-confirmation unknown," or "suspected-confirmed."
Do not note physical abuse if the record indicated that the abuse was "unsubstantiated," "unsubstantiated due to intentionally false report," "ruled out," or "suspected-ruled out" (NCANDS 2004;DePanfilis and Salus 2003).

# Allow for Multiple Responses
No.

# Field Values/Coding Instructions
Code Description
No, physical abuse is not noted in any record of this incident of maltreatment. 02Yes, physical abuse is noted in one or more records of this incident of maltreatment. 99It is unknown if physical abuse occurred in this incident of maltreatment.
Abusive Head Trauma/Shaken Baby Syndrome 2.04.07

# Description/Definition
Describes a constellation of injuries related to violently shaking an infant or toddler and can include impact to the head if the infant is subsequently thrown down onto a crib or other surface.

# Uses/Data Element Type
Can be used to determine whether the child is a victim of Shaken Baby Syndrome (SBS)/Abusive Head Trauma (AHT).
Data element type: Basic.

# Discussion
SBS/AHT is defined as the violent shaking of an infant or child with sufficient vigor to produce whiplash forces which can result in subdural and retinal bleeding, seizures, paralysis, and death. SBS commonly occurs in the context of an inconsistent or inappropriate history given by the caregiver and can be accompanied by other injuries such as posterior rib fractures and retinal hemorrhages.
SBS/AHT is commonly observed in children under 1 year of age, but it has been documented in children as old as 3 to 4 years of age.

# Allow for Multiple Responses
No.

# Field Values/Coding Instructions

# Description/Definition
Archival data sources from which child maltreatment surveillance information is abstracted.

# Uses/Data Element Type
Identifies the data source(s) documenting physical abuse in the current incident of maltreatment.
Data element type: Basic.

# Allow for Multiple Responses
Yes. Repetition is allowed to identify all sources containing data on physical abuse in the current incident. Sexual acts comprise acts in which contact involves penetration, however slight, between the caregiver and the child. A caregiver can also force or coerce a child to commit a sexual act on another individual (either adult or child).

# Field Values/Coding Instructions
Abusive sexual contact includes acts in which penetration is not attempted, but intentional touching occurs either directly or through the clothing of the genitalia, anus, groin, breast, inner thigh, or buttocks. Sexual contact can be performed by the caregiver on the child, by the child on the caregiver, or by the child on another adult or child through force or coercion by the caregiver. Sexual contact does not include touching required for normal care or attention to day-to-day needs of the child.
Noncontact sexual abuse does not require physical contact of a sexual nature between the caregiver and the child. However, it does include acts which expose a child to sexual activity such as filming of a child in a sexual manner, sexual harassment of a child, or prostitution of a child.
Notation of Sexual Abuse 2.04.09

# Description/Definition
Is sexual abuse noted in any record of this incident of maltreatment?
Uses/Data Element Type Describes whether the child experienced sexual abuse.
Data element type: Basic.

# Discussion
Noted sexual abuse includes any mention of the term "sexual abuse," "child sexual abuse," or similar variation in the child's record. Noted sexual abuse also includes suspected abuse or an indication that an abuse-related referral was made (e.g., to CPS). If a notation in the record states that sexual abuse is suspected, code sexual abuse as documented in that record. Other terms that can be used include, but are not limited to, "substantiated," "indicated," "reason to suspect," "suspected," "reported," "documented," "founded," "supported," "credible evidence exists," "suspected-confirmation unknown," or "suspected-confirmed."
Sexual abuse would not be noted if the record indicated that the sexual abuse was "unsubstantiated," "unsubstantiated due to intentionally false report," "ruled out," or "suspected-ruled out" (NCANDS 2004;DePanfilis and Salus 2003).

# Allow for Multiple Responses
No.

# Field Values/Coding Instructions
Code Description
No, sexual abuse is not noted in any record of this incident of maltreatment. 02Yes, sexual abuse is noted in one or more records of this incident of maltreatment. 99It is unknown if sexual abuse occurred in this incident of maltreatment.
Data Source(s) Documenting Sexual Abuse 2.04.10

# Description/Definition
Archival data sources from which child maltreatment surveillance information is abstracted.

# Uses/Data Element Type
Identifies the data source(s) documenting sexual abuse in the current incident of maltreatment.
Data element type: Basic.

# Allow for Multiple Responses
Yes. Repetition is allowed to identify all sources containing data on sexual abuse in the current incident.

# Field Values/Coding Instructions

# Discussion
Sexual acts include penetration, however slight, between the mouth, penis, vulva, or anus of the child and the adult. Sexual acts can also include penetration, however slight, of the anal or genital opening by a hand, finger, or other object.
Sexual acts can be performed by the caregiver on the child or by the child on the caregiver. A caregiver can also force or coerce a child to commit a sexual act on another individual (either child or adult).
Penetration Status 2.04.11

# Description/Definition
Describes whether the sexual abuse involved penetration or attempted penetration of either the child or the adult.

# Uses/Data Element Type
If used with 2.04.12 Object Used for Sexual Act(s) and 2.04.13 Part of the Body Affected by Sexual Act(s) information can be gathered regarding the process by which the abusive sexual contact occurred.
Data element type: Expanded.

# Discussion
Penetration is defined as sexual contact involving penetration, however slight, of the mouth, penis, vulva, or anus. Penetration status is either all or nothing. That is, even slight penetration should be included as "penetration."
No penetration includes intentional touching, either directly or through the clothing.

# Allow for Multiple Responses
No. Object Used for Sexual Act(s) 2.04.12

# Field Values/Coding Instructions

# Description/Definition
Describes the object used for penetration or attempted penetration.

# Uses/Data Element Type
If used with 2. 04.11 Penetration Status and 2.04.13 Part of the Body Affected by Sexual Act(s) information can be gathered regarding the process by which the abusive sexual contact occurred.
Data element type: Expanded.

# Allow for Multiple Responses
Yes. Part of the Body Affected by Sexual Act(s) 2.04.13

# Field Values/Coding Instructions

# Description/Definition
Describes the body part penetrated or attempted to be penetrated during the sexual act and whether the penetration was done by the adult or child.

# Uses/Data Element Type
If used with 2.04.11 Penetration Status and 2.04.12 Object Used for Sexual Act(s) information can be gathered regarding the process by which the abusive sexual contact occurred.
Data element type: Expanded.

# Allow for Multiple Responses
Yes. Sexually Transmitted Disease Diagnosed 2.04.14

# Field Values/Coding Instructions

# Description/Definition
Whether a sexually transmitted disease (STD) was found in the context of the current incident of sexual abuse.
Uses/Data Element Type Documents sexually transmitted disease infection related to the current incident of sexual abuse. Identification of the STD can precede or follow the discovery of sexual abuse.
Data element type: Expanded.

# Discussion
STDs in children, particularly ages 0 to 9 years, are a signal that sexual abuse may be occurring.
With older children and teenagers who could be sexually active, it is important to differentiate between STDs resulting from sexual abuse and STDs resulting from other sexual behavior.
In addition, if the incident of sexual abuse was within 3 to 6 months of the date of record, possible STD infection can be unknown or undetectable.

# Allow for Multiple Responses
No.

# Field Values/Coding Instructions

# Uses/Data Element Type
Indicates whether the index child experienced abusive sexual contact in this incident of maltreatment.
Data element type: Expanded.

# Discussion
Abusive sexual contact includes intentional touching, either directly or through the clothing, that does not involve penetration.
Abusive sexual contact can be performed by the caregiver on the child or by the child on the caregiver. A caregiver can also force or coerce a child to engage in sexual contact with another individual (child or adult).

# Allow for Multiple Responses
No.

# Field Values/Coding Instructions
Code Description
No, abusive sexual contact did not occur in this incident of maltreatment. 02Yes, abusive sexual contact occurred in this incident of maltreatment. 99It is unknown/not documented whether abusive sexual contact occurred.

# Other References Basile and Saltzman 2002
Object Used for Abusive Sexual Contact 2.04.16

# Description/Definition
Describes the object used for sexual contact.

# Uses/Data Element Type
If used with 2. 04.11 Penetration Status and 2.04.17 Part of the Body Affected by Abusive Sexual Contact information can be gathered regarding the process by which the abusive sexual contact occurred.
Data element type: Expanded.

# Allow for Multiple Responses
Yes.

# Field Values/Coding Instructions

# Uses/Data Element Type
Indicates whether the index child experienced noncontact sexual abuse in this incident of maltreatment.
Data element type: Expanded.

# Discussion
Noncontact sexual abuse includes acts such as:
- Voyeurism of the child by an adult;
- Intentional exposure of a child to exhibitionism;
- Exposure to pornography;
- Photograph(s) of a child in a sexual manner or act;
- Filming of a child engaged in a sexual manner or act;
- Sexual harassment of a child;
- Sexual trafficking of a child;
- Employing, using, persuading, inducing, enticing, encouraging, allowing, or permitting a child to engage in or assist any other person to engage in prostitution.
Noncontact sexual abuse does not include physical contact of a sexual nature between the caregiver and the child.

# Allow for Multiple Responses
No.

# Field Values/Coding Instructions
Code Description
No, noncontact sexual abuse did not occur in this incident of maltreatment. 02Yes, noncontact sexual abuse occurred in this incident of maltreatment (specify). 99
It is unknown/not documented whether noncontact sexual abuse occurred.
Method of Noncontact Sexual Abuse 2.04.19

# Description/Definition
Describes the method by which noncontact sexual abuse occurred.

# Uses/Data Element Type
Describes the process(es) by which the child experienced noncontact sexual abuse.
Data element type: Expanded.

# Discussion
Noncontact sexual abuse includes acts such as:
- Voyeurism of the child by an adult;
- Intentional exposure of a child to exhibitionism;
- Exposure to pornography;
- Photograph(s) of a child in a sexual manner or act;
- Filming of a child engaged in a sexual manner or act;
- Sexual harassment of a child;
- Sexual trafficking of a child;
- Employing, using, persuading, inducing, enticing, encouraging, allowing, or permitting a child to engage in or assist any other person to engage in prostitution.

# Allow for Multiple Responses
Yes.

# Field Values/Coding Instructions

# Discussion
It can be argued that all forms of child maltreatment include psychological abuse because all forms of child maltreatment have emotional consequences for the child. However, specific caregiver behaviors that involve trauma to the child caused by acts, threats of acts, or coercive tactics such as those listed below constitute a form of child maltreatment that is unique. This list is not exhaustive.
Psychological/emotional maltreatment can include but is not limited tothe following: - Behaving in a manner that is harmful, potentially harmful, or insensitive to the child's developmental needs; - Behaving in a manner that can potentially damage the child psychologically or emotionally.
Because psychological abuse is often difficult to detect and is unlikely to be picked up by data systems used in traditional public health surveillance, the number of children who experience psychological abuse will likely exceed those counted in traditional surveillance.

# Notation of Psychological Abuse

# Description/Definition
Is psychological abuse noted in any record of this incident of maltreatment?
Uses/Data Element Type Describes whether the child experienced psychological abuse.
Data element type: Basic.

# Discussion
Noted psychological abuse includes any mention of the terms "psychological abuse," "emotional abuse," "psychological maltreatment," or similar variation in the child's record. Noted psychological abuse also includes suspected abuse. If there is a notation in the record that psychological abuse is suspected, then code psychological abuse as documented in that record. Other terms that can be used include but are not limited to "substantiated," "indicated," "reason to suspect," "suspected," "reported," "documented," "founded," "supported," "credible evidence exists," "suspected-confirmation unknown," or "suspectedconfirmed."
Psychological abuse would not be noted if the record indicated that the psychological abuse was "unsubstantiated," "unsubstantiated due to intentionally false report," "ruled out," or "suspectedruled out" (NCANDS 2004;DePanfilis and Salus 2003).

# Allow for Multiple Responses
No.

# Field Values/Coding Instructions
Code Description
No, psychological abuse is not noted in any record of this incident of maltreatment. 02Yes, psychological abuse is noted in one or more records of this incident of maltreatment. 99It is unknown whether psychological abuse occurred in this incident of maltreatment.
Data Source(s) Documenting Psychological Abuse 2.04.21

# Description/Definition
Archival data sources from which child maltreatment surveillance information is abstracted.

# Uses/Data Element Type
Identifies the data source(s) documenting psychological abuse in the current incident of maltreatment.
Data element type: Basic.

# Allow for Multiple Responses
Yes. Repetition is allowed to identify all sources containing data on psychological abuse in the current incident. Method of Psychological Abuse 2.04.22

# Field Values/Coding Instructions

# Description/Definition
Describes the process by which psychological abuse occurred.

# Uses/Data Element Type
Describes the process(es) by which the child was psychologically abused.
Data element type: Expanded.

# Discussion
Psychologically abusive behaviors can include blaming, belittling, degrading, intimidating, terrorizing, isolating, restraining, confining, corrupting, exploiting, spurning or behaving in a manner that is harmful, potentially harmful, or insensitive to the child's developmental needs or may potentially damage the child psychologically or emotionally. (Barnett, Manly, and Cicchetti 1993;McGee and Wolfe 1991a, b) Terrorizing includes caregiver behavior that is life-threatening or makes a child feel unsafe (e.g., situations in which a child is likely to be hurt, killed, or abandoned) (Myers et al. 2002); sets unrealistic expectations of the child with threat of loss, harm, or danger if not met; and threatens or perpetrates violence against a child or a child's loved ones or objects (toys, pets, other possessions) (Kairys and Johnson 2002). For example, placing a child in unpredictable or chaotic circumstances would be considered terrorizing as would be placing a child in a situation that would reasonably be considered dangerous by the child or another adult.
Isolating (psychological) occurs when a caregiver forbids, prevents, or minimizes a child's contact with others.

# Allow for Multiple Responses
Yes.

# Field Values/Coding Instructions

# Discussion
Neglect encompasses a multitude of caregiver behaviors that can be divided into two types:
1. Failure to provide or meet the basic physical, emotional, or educational needs of the child. Failure to provide includes physical, emotional, medical/dental, and educational neglect;
2. Failure to supervise or ensure a child's safety within and outside the residence, given the emotional and developmental needs of the child. Failure to supervise includes inadequate supervision and exposure of the child to violent environments.
Although neglect comprises most maltreatment cases (DHHS 2003), neglect is less likely than physical or sexual abuse to be captured by data systems used in traditional public health surveillance. For example, emergency departments and hospitals are likely to see only the most egregious cases of medical, dental, or supervisional neglect. Few, if any, cases of physical, emotional, or educational neglect are seen. Consequently, physicians may fail to recognize and document cases of neglect. For this reason, traditional surveillance systems may undercount cases of neglect.
Failure to provide 2.04.23 Notation of failure to provide 2.04.24 Data source(s) documenting failure to provide 2.04.25 Mitigating circumstances for failure to provide*

# Discussion
Neglect-failure to provide includes the following types of neglect:
- Physical neglect: Caregiver fails to provide adequate nutrition, hygiene, shelter, or clothing that is adequately clean, appropriate size, or adequate for the weather.
Examples (Barnett, Manly, and Cicchetti 1993):
Nutrition: A 9-year-old makes dinner several times per week because the caregiver(s) are away, sleeping, or otherwise unavailable; a child misses or is denied meals on a number of occasions over time; a child is diagnosed as being severely malnourished.
Hygiene: Child is dirty, smells bad, or has unwashed hair. Child's living situation is unsanitary; dirty dishes and spoiled food are left on the kitchen table and counter.
Shelter: Child and family are without stable living arrangements for two weeks or more; child's residence is infested with roaches or vermin; residence is unheated because caregiver(s) failed to ensure availability of adequate heating.
Clothing: Child always wears clothing that is too small; child is not given a warm coat and gloves when the weather is cold.
- Emotional neglect: Caregiver ignores or denies emotional responsiveness to the child or provides inadequate access to mental health care for the child. Example: Caregiver does not respond to infant cries or older child's attempts to initiate interaction (Barnett, Manly, and Cicchetti 1993).
- Medical/dental neglect: Caregiver fails to provide adequate access to medical, vision, or dental care. Example: The caregiver does not administer prescribed medications. The caregiver refuses to take the child for needed medical attention (Barnett, Manly, and Cicchetti 1993).
- Educational neglect: Caregiver fails to provide access to adequate education. Examples: Caregiver allows child to miss 25 or more school days in one academic year without excuse; caregiver does not enroll the child in school; caregiver encourages a child (under 16 years of age) to drop out of school (Barnett, Manly, and Cicchetti 1993).
*Expanded data element Notation of Failure to Provide 2.04.23

# Description/Definition
Is failure to provide on the part of the caregiver noted in any record of this incident of maltreatment?
Uses/Data Element Type Describes whether the caregiver failed to provide for the child's basic needs.
Data element type: Basic.

# Discussion
Noted neglect-failure to provide includes any mention of the term "neglect," "denial," or "withholding" of basic necessities or "failure to provide." Examples of failure to provide are found in 2.04.34 Mechanism of Harm/Injury. Noted neglect-failure to provide also includes suspected neglect. If there is a notation in the record that "neglect-failure to provide" is suspected, then code neglect as documented in that record. Other terms that can be used include but are not limited to "substantiated," "indicated," "reason to suspect," "suspected," "reported," "documented," "founded," "supported," "credible evidence exists," "suspected-confirmation unknown," or "suspectedconfirmed."
Failure to provide would not be noted if the record indicated that the failure to provide was "unsubstantiated," "unsubstantiated due to intentionally false report," "ruled out," or "suspectedruled out" (NCANDS 2004;DePanfilis and Salus 2003).

# Allow for Multiple Responses
No.

# Field Values/Coding Instructions
Code Description
No, failure to provide is not noted in any record of this incident of maltreatment. 02Yes, failure to provide is noted in one or more records of this incident of maltreatment. 99It is unknown if failure to provide occurred in this incident of maltreatment.

# Discussion
Neglect-failure to supervise includes the following:
- Inadequate supervision. Failure by the caregiver to ensure that the child engages in safe activities, uses appropriate safety devices, is not exposed to unnecessary hazards, or is supervised by an adequate substitute caregiver.
Inadequate supervision includes occasions when a caregiver knowingly fails to protect the child from maltreatment perpetrated by a substitute caregiver. When this occurs, the primary caregiver's behavior would be considered neglectful only if the maltreatment was recognized and allowed to occur or recur.
- Exposure to violent environments. Failure by the caregiver to take available measures to protect the child from violence within the residence, neighborhood, or community. Uses/Data Element Type Describes whether the child experienced a lack of supervision by the caregiver.
Data element type: Basic.

# Discussion
Noted neglect-failure to supervise includes any mention of the term "neglect" or "failure to supervise" in addition to terms listed in 2.04.29 Method of Harm/Injury Related to Failure to Supervise. Noted neglect-failure to supervise also includes suspected neglect. If the record notes that neglect-failure to supervise is suspected, code as neglect. Other terms that can be used include but are not limited to "substantiated," "indicated," "reason to suspect," "suspected," "reported," "documented," "founded," "supported," "credible evidence exists," "suspected-confirmation unknown," or "suspected-confirmed."
Failure to supervise would not be noted if the record indicated that the failure to supervise was "unsubstantiated," "unsubstantiated due to intentionally false report," "ruled out," or "suspectedruled out" (NCANDS 2004;DePanfilis and Salus 2003).

# Allow for Multiple Responses
No.

# Field Values/Coding Instructions
Code Description
No, failure to supervise is not noted in any record of this incident of maltreatment. 02Yes, failure to supervise is noted in one or more records of this incident of maltreatment. 99It is unknown if failure to supervise occurred in this incident of maltreatment.
Harm Resulting from Failure to Supervise 2.04.28

# Description/Definition
Describes whether the child was harmed because of the caregiver's failure to supervise.

# Uses/Data Element Type
When used with data element 3.13 Factors Affecting Caregiver at Time of Incident, it is possible to examine the reason(s) the child was unsupervised and whether this lack of supervision resulted in harm or injury.
Data element type: Expanded.

# Discussion
An example of a child inadequately supervised with no harm or injury resulting would be a toddler who is left alone to play in an unfenced yard for several hours.
An example of a child inadequately supervised with harm but no injury resulting would be a toddler who wanders away at a park and is located later by the park rangers who transport the child to safety. The child is traumatized, but uninjured, by the experience.

# Allow for Multiple Responses
No.

# Field Values/Coding Instructions

# Description/Definition
Describes the process by which the caregiver failed to supervise the child.

# Uses/Data Element Type
Determines the processes by which the caregiver failed to supervise the child.
Can be used with section 3.13 Factors Affecting Caregiver at Time of Incident to determine specific caregiver factors that may have contributed to failure to ensure the safety of the child.
Data element type: Expanded.

# Allow for Multiple Responses
Yes.  Cicchetti 1991, 1993.

# Field Values/Coding Instructions
Child Fatality Related to Maltreatment Incident 2.04.30

# Description/Definition
Did the child die as a result of the incident of maltreatment?
Uses/Data Element Type Provides information about child mortality due to child maltreatment.
Data element type: Basic.

# Discussion
No time frame for death is specified for this data element. Include a death if the original incident/ injury qualifies as maltreatment based on the case definition outlined in this document and the medical examiner/coroner or death certificate classify the subsequent death as due to the incident.

# Allow for Multiple Responses
No.

# Field Values/Coding Instructions

# Description/Definition
Was the child under the influence of alcohol or drugs at the time of the current incident of maltreatment?
Uses/Data Element Type Provides information about the child's behavior and susceptibility to influence at the time of the incident.
Data element type: Expanded.

# Discussion
Alcohol and drug use by a child is a risk factor for child maltreatment, particularly sexual abuse (Martino, Collins, and Ellickson 2004). Additionally, adults who abuse children have been known to give children drugs or alcohol.
Drugs prescribed for the child and over-the-counter medications used as directed should not be included unless given to the child in excess.

# Allow for Multiple Responses
No.

# Field Values/Coding Instructions

# Code Description
Injury Characteristics 2.04.33

# Description/Definition
Characteristics that may prompt suspicion of child maltreatment by health care providers or others responsible for the care of children.

# Uses/Data Element Type
Provides indicators that maltreatment may have, or did, occur.
Data element type: Expanded.

# Allow for Multiple Responses
Yes.

# Field Values/Coding Instructions

# Description/Definition
Describes the mechanism by which the maltreatment occurred.

# Uses/Data Element Type
Describes the mechanism(s) by which the child was harmed or injured.
Data element type: Expanded.

# Allow for Multiple Responses
Yes.

# Field Values/Coding Instructions

# Description/Definition
Existence and location of external physical injury to child resulting from maltreatment.

# Uses/Data Element Type
Describes external physical injuries resulting from maltreatment sustained by the child.
May be used with data elements 2.04.  Failure to Supervise to provide information on injuries related to different types of abuse.
Can provide information on the severity of the injury sustained by the child.
Data element type: Expanded.

# Discussion
To develop prevention strategies and advance the recognition of physical child maltreatment, it recommended that is the description of the injury include, when possible, whether the injury was inflicted by the caregiver or resulted from the caregiver's failure to protect or supervise the child.

# Allow for Multiple Responses
Yes.

# Field Values/Coding Instructions

# Description/Definition
Were ICD 9/10 codes for child abuse or neglect assigned to the case?
Uses/Data Element Type Provides information on the ICD 9/10 codes assigned to the case. Codes can be used for descriptive purposes and as a potential measure of the application of these codes. Application of these codes can be compared to reports of child maltreatment and to other sources and thus may be used to determine the extent of under-ascertainment of child maltreatment if these codes are used as the sole source of maltreatment data.
Data element type: Expanded.

# Discussion
Use of ICD 9/10 codes varies by hospital and region. As such, physicians may or may not use the ICD 9/10 codes for child maltreatment.
The ICD 9 code for general child maltreatment is 995.5X Child maltreatment syndrome.
The ICD 9 code for child abuse is E967 Child battering and other maltreatment, which includes:
- E967.0 Child battering and other maltreatment by parent - E967.1 Child battering and other maltreatment by other specified person - E967.2 Child battering and other maltreatment by unspecified person
The ICD 9 code for child neglect is E968.4 Assault by other and unspecified means-criminal neglect ("Abandonment of child, infant, or other helpless person with intent to injure or kill" WHO 1991, p.1045).
Additional ICD 9 codes for Homicide and injury purposely inflicted by other persons are commonly used for cases of maltreatment in which the victim fits the age criteria for a child and the perpetrator is designated as a caregiver. For the purpose of the document, incident is defined as any contact with CPS, law enforcement, the medical system, or other reporting sources where child maltreatment is alleged or confirmed Information for some data elements in this section may not be available for non-primary caregivers; therefore, developers of the surveillance system will need to decide how missing data should be handled.
Prior CPS Involvement with Family/Household 4.03

# Description/Definition
Describes prior contact between CPS and the index child's family or household.

# Uses/Data Element Type
Provides information on whether the index child's family or household is known to CPS.
Data element type: Expanded.

# Discussion
Prior CPS involvement with the family is a known risk factor for subsequent CPS involvement.
Exercise caution when using this data element as a risk factor for maltreatment in the light of potential biases found in reports to CPS. Some researchers have found racial, cultural, and socioeconomic disparities among children and families who are reported to CPS relative to those who are not (Cohen, DeVos, and Newberger 1997;Minnesota DHS 2002;Roberts 2002;Tsang 2001), whereas other researchers have not found these disparities (Sedlak and Broadhurst 1996). Nevertheless, knowing whether prior contact has occurred between the family and CPS is useful.

# Allow for Multiple Responses
No.

# Field Values/Coding Instructions