Continuing Education Activity

Healthcare providers in Pennsylvania must adhere to the Pennsylvania Child Protective Services Law (CPSL), 23 Pa.C.S. Chapter 63 (relating to child protective services) when recognizing and reporting suspected child abuse. The CPSL was established in 1975 to protect children from abuse, allow the opportunity for healthy growth and development, and preserve and stabilize the family whenever possible. This activity outlines the categories and common indicators of child abuse, as well as the requirements and procedures for reporting suspected child abuse.

Objectives:

• Understand the categories of child abuse outlined in the CPSL, including common indicators for suspected child abuse.

• Understand a healthcare provider's role in recognizing and reporting suspected child abuse.

• Understand the requirements for reporting suspected child abuse, as outlined in the CPSL.

• Understand the legal penalties for a mandated reporter who willfully fails to report suspected child abuse.

Introduction

Healthcare providers in Pennsylvania are mandated reporters of suspected child abuse; if a mandated reporter has reasonable cause to suspect a child was or is a victim of child abuse, the mandated reporter must immediately make a report of suspected child abuse in accordance with the Pennsylvania Child Protective Services Law (CPSL), 23 Pa.C.S. Chapter 63 (relating to child protective services). This not only requires an understanding of the categories and common indicators of child abuse but also the roles and responsibilities for reporting suspected child abuse.

Child Abuse/Neglect In The State Of Pennsylvania

In the US, over 3 million children per year are abused or neglected. In Pennsylvania, over 40,000 are the subjects of reports, and approximately 1 in 1000 children are abused or neglected.[1]

The Pennsylvania child welfare system is state-supervised and county-administered. The two main functions of the county children-and-youth agencies are Child Protective Services (CPS) and General Protective Services (GPS).

Child Protective Services Versus General Protective Services

CPS are services and activities provided by the department and each county agency for child abuse cases. Cases identified as “CPS” require an investigation because the alleged act or failure to act meets the PA CPSL’s definition of child abuse. The PA CPSL’s definition of child abuse recognizes 10 separate categories of child abuse.GPS are services and activities each county agency provides for cases requiring protective services as defined by PA DHS in regulations. Cases identified as “GPS” require an assessment for services and supports. In these cases, the alleged act or failure to act does not meet the definition of child abuse but is still detrimental to a child. The primary purpose of GPS is to protect the rights and welfare of children so that they have an opportunity for healthy growth and development.

Examples of 10 Categories of CPS Cases

• Causing bodily injury to a child through any recent act or failure to act
• Fabricating, feigning, or intentionally exaggerating or inducing a medical symptom or disease that results in a potentially harmful medical evaluation or treatment to the child through any recent act
• Causing or substantially contributing to serious mental injury to a child through any act or failure to act or a series of such acts or failures to act
• Causing sexual abuse or exploitation of a child through any act or failure to act
• Creating a reasonable likelihood of bodily injury to a child through any recent act or failure to act
• Creating a likelihood of sexual abuse or exploitation of a child through any recent act or failure to act
• Causing serious physical neglect of a child
• Engaging in specific recent "per se" acts
• Causing the death of the child through any act or failure to act
• Engaging a child in a severe form of trafficking in persons or sex trafficking, as those terms are defined under section 103 of the Trafficking Victims Protection Act of 2000

Examples of GPS Cases—Services to prevent the potential for harm to a child who meets one of the following conditions:

• Is without proper parental care or control, subsistence, education as required by law, or other care or control necessary for their physical, mental, or emotional health or morals.
• Has been placed for care or adoption in violation of law.
• Has been abandoned by their parents, guardian, or other custodian.
• Is without a parent, guardian, or legal custodian.
• Is habitually and without justification truant from school while subject to compulsory school attendance.
• Has committed a specific act of habitual disobedience to the reasonable and lawful commands of their parent, guardian, or other custodian, and who is ungovernable and found to need care, treatment, or supervision.
• Is under 10 years of age and has committed a delinquent act.
• Has been formerly adjudicated dependent under section 6341 of the Juvenile Act (relating to adjudication) and is under the court's jurisdiction, subject to its conditions or placements and who commits an act defined as ungovernable.
• Has been referred under section 6323 of the Juvenile Act (relating to informal adjustment), and who commits an act that is defined as ungovernable.

Definitions

The 3 components of child abuse include the following:

1. A child: An individual under 18 years old.
2. Act(s) or failure(s) to act; Recent act; or Recent act or failure to act- Act: Something that is done to harm or cause potential harm to a child- Failure to act: Something that is NOT done to prevent harm or potential harm to a child- Recent act: Any act committed within two (2) years of the date of the report to the department or county agency- Recent act or failure to act: Any act or failure to act committed within two (2) years of the date of the report to the department or county agency
3. Intentionally, Knowingly, or Recklessly- Intentionally: Done with the direct purpose of causing the type of harm that resulted- Knowingly: Awareness that harm is practically certain to result- Recklessly: Conscious disregard of substantial and unjustifiable risk

Perpetrator: A person who has committed child abuse. The term includes only the following:

• Parent of the child
• Spouse or former spouse of the child's parent
• Person 14 years or older and responsible for the child's welfare or having direct contact with the child as an employee of a childcare service, school or school program, activity, or service.
• Individual 14 years or older who live in the same house as the child
• Individual 18 years or older who does not live in the same home as the child but is related within the third degree of consanguinity or affinity by birth or adoption to the child
• Individual 18 years or older who engages a child in severe forms of trafficking in persons or sex trafficking as defined in section 103 of the Victims Protection Act of 2000

      Only the following may be considered a perpetrator for failing to act:

• A parent of the child.
• A spouse or former spouse of the child's parent.
• A paramour or former paramour of the child's parent.
• A person aged 18 years or older and responsible for the child's welfare.
• A person aged 18 years or older who resides in the same home as the child.

Categories of Child Abuse

The PA CPSL defines "child abuse" as intentionally, knowingly, or recklessly doing any of the following:

• Causing bodily injury to a child through any recent act or failure to act
• Fabricating, feigning, or intentionally exaggerating or inducing a medical symptom or disease which results in a potentially harmful medical evaluation or treatment to the child through any recent act (This is also known as Munchausen By Proxy)
• Causing or substantially contributing to serious mental injury through any act or failure to act or a series of such acts or failures to act
• Causing sexual abuse or exploitation of a child through any act or failure to act
• Creating a reasonable likelihood of bodily injury to a child through any recent act or failure to act
• Creating a likelihood of sexual abuse or exploitation of a child through any recent act or failure to act
• Causing serious physical neglect of a child
• Engaging in any of the following recent "per se" acts
  • Kicking, biting, throwing, burning, stabbing, or cutting a child in a manner that endangers the child
  • Unreasonably restraining or confining a child, based on consideration of the method, location, or duration of the restraint or confinement
  • Forcefully shaking a child under one year of age
  • Forcefully slapping or otherwise striking a child under one year of age
  • Interfering with the breathing of a child
  • Causing a child to be present at a location while a violation of 18 Pa.C.S. § 7508.2 (relating to the operation of a methamphetamine laboratory) is occurring, provided the violation is being investigated by law enforcement
  • Leaving a child unsupervised with an individual, other than the child’s parent, who the actor knows or reasonably should have known:
    • Is required to register as a Tier II or Tier III sexual offender under 42 Pa. C.S. Ch. 97 Subch. H (relating to registration of sexual offenders), where the victim of the sexual offense was under 18 years of age when the crime was committed
    • Has been determined to be a sexually violent predator under 42 Pa. C.S. §9799.24 (relating to assessments) or any of its predecessors
    • Has been determined to be a sexually violent delinquent child as defined in 42 Pa.C.S. § 9799.12 (relating to definitions)
    • Has been determined to be a sexually violent predator under 42 Pa.C.S. § 9799.58 (relating to  assessments) or has to register for life under 42 Pa.C.S. § 9799.55(b) (relating to registration) 
• Causing the death of the child through any act or failure to act
• Engaging a child in a severe form of trafficking in persons or sex trafficking, as those terms are defined under section 103 of the Trafficking Victims Protection Act of 2000

• Bodily Injury: Impairment of physical condition or substantial pain 
  • The law considers two parameters: impairment and pain.
    • Impairment - If, due to the injury, the child’s ability to function is reduced temporarily or permanently in any way
    • Substantial pain - If the child experiences what a reasonable person believes to be substantial pain

• Serious Mental Injury: A psychological condition, as diagnosed by a physician or licensed psychologist, including the refusal of appropriate treatment, that
  • Renders a child chronically and severely anxious, agitated, depressed, socially withdrawn, psychotic, or in reasonable fear that the child’s life or safety is threatened or;
  • Seriously interferes with a child’s ability to accomplish age-appropriate developmental and social tasks

• Serious Physical Neglect: Any of the following when committed by a perpetrator that endangers a child’s life or health, threatens a child’s well-being, causes bodily injury, or impairs a child’s health, development, or functioning:
  • A repeated, prolonged, or egregious failure to supervise a child in a manner that is appropriate considering the child’s developmental age and abilities
  • The failure to provide a child with adequate essentials of life, including food, shelter, or medical care

• Sexual Abuse and Exploitation: Any of the following:
  • The employment, use, persuasion, inducement, enticement, or coercion of a child to engage in or assist another individual to engage in sexually explicit conduct, which includes but is not limited to:
    • Looking at sexual or other intimate parts of a child or another individual for the purpose of arousing or gratifying sexual desire in any individual
    • Participating in sexually explicit conversation either in person, by telephone, by computer, or by computer-aided device for the purpose of sexual stimulation or gratification of any individual
    • Actual or simulated sexual activity or nudity for the purpose of sexual stimulation or gratification of any individual
    • Actual or simulated sexual activity for the purpose of producing visual depiction, including photographing, videotaping, computer depicting or filming
  • *The above bullets do NOT include consensual activities between a child who is 14 years or older and another person 14 years or older and whose age is within four years of the child’s age.
  • Any of the following offenses committed against a child:
    • Rape as defined in 18 Pa.C.S. § 3121 (relating to rape)
    • Statutory sexual assault as defined in 18 Pa.C.S. §3122.1 (relating to statutory sexual assault)
    • Involuntary deviate sexual intercourse as defined in 18 Pa. C.S. §3123 (relating to involuntary deviate sexual intercourse)
    • Sexual assault as defined in 18 Pa. C.S. §3124.1 (relating to sexual assault)
    • Institutional sexual assault as defined in 18 Pa. C.S. §3124.2 (relating to institutional sexual assault)
    • Aggravated indecent assault as defined in 18 Pa. C.S. § 3125 (relating to aggravated indecent assault
    • Indecent assault as defined in 18 Pa.C.S. § 3126 (relating to indecent assault).
    • Indecent exposure as defined in 18 Pa.C.S. § 3127 (relating to indecent exposure).
    • Incest as defined in 18 Pa.C.S. § 4302 (relating to incest).
    • Prostitution as defined in 18 Pa.C.S. § 5902 (relating to prostitution and related offenses).
    • Sexual abuse as defined in 18 Pa.C.S. § 6312 (relating to sexual abuse of children).
    • Unlawful contact with a minor as defined in 18 Pa.C.S. § 6318 (relating to unlawful contact with a minor).
    • Sexual exploitation as defined in 18 Pa.C.S. § 6320 (relating to sexual exploitation of children).

Severe Forms of Trafficking in Persons

The recruitment, harboring, transportation, provision, or obtaining of a person for labor or services through the use of force, fraud, or coercion for subjection to involuntary servitude, peonage, debt bondage, or slavery

• Peonage: Paying off debt through work
• Debt bondage: Debt slavery, bonded labor, or services for a debt or other obligation
• Slavery: A condition compared to that of a slave with respect to exhausting labor or restricted freedom

2. Sex trafficking in which a commercial sex act induced by force, fraud, or coercion or in which the individual induced to perform such act has not attained 18 years of age

• Sex trafficking: The recruitment, harboring, transportation, provision, obtaining, patronizing, or soliciting of a person for the purpose of a commercial sex act.
• Commercial sex act: Any sex act on account of which anything of value is given to or received by any person.

Labor Trafficking

Labor trafficking is labor obtained through threat of serious harm, physical restraint, or abuse of legal process.

• Examples:
  • Being forced to work for little or no pay (frequently in factories or farms)
  • Domestic Servitude – providing services within a household from 10-16 hours per day (frequently in child care, cooking, cleaning, yard work, gardening, etc.)

Etiology

All races, ethnicities, and socioeconomic groups are affected by child abuse, with boys and adolescents more commonly affected. Infants tend to have increased morbidity and mortality with physical abuse. Multiple factors increase a child's risk of abuse. These risks include the following:

• Individual factors (eg, a child's disability, unmarried mother, maternal smoking, or a parent's depression)
• Familial factors (eg, domestic violence at home, more than two siblings at home);
• Community factors (eg, lack of recreational facilities); and
• Societal factors (eg, poverty).
• Living in an unrelated adult's home
• Being a child previously reported to CPS.

There are also “protective factors” that decrease the risk of child maltreatment, including family support and parental concern. Preventive factors include parental education regarding child development and parenting, social support, and parental resilience.[2][3][4]

Risk Factors by the Center for Disease Control that Increase Child Abuse and Maltreatment[5][6]

• Alcoholism and substance abuse
• Community violence
• Children younger than 4 years
• Family disorganization, dissolution, and violence
• Family history of child abuse and maltreatment
• Intellectual disability
• Lack of understanding of development and needs
• Limited education
• A large number of dependent children
• Low income
• Mental health issues
• Parenting stress
• Parental emotions that tend to justify maltreatment
• Physical disability or illness
• Poor parenting skills
• Social isolation
• Single parenthood
• Transient caregivers
• Young age
• Unemployment rates

Potential Long-Term Sequela of Child Abuse[5][6]

• Health and mental health conditions
• Low life potential
• Premature death
• Substance abuse

Epidemiology

Each year, millions of children are investigated by CPS for child abuse and neglect in the United States. Annually, more than 3 million children are the subjects of child maltreatment reports. Of those, 20% were found to have evidence of maltreatment.[7] Annually, there are more than 100,000 referrals for abuse and neglect in Pennsylvania, with nearly half of them confirmed victims. Male and female percentages of victims are similar. Children younger than 3 are at the highest risk. African Americans and Native Americans have the highest rate of abuse and neglect. Of those abused, approximately 75% are neglected, 15 to 20% are physically abused, and 5 to 10% are sexually abused.[5][6][8]

History and Physical

Identifying a victim of child abuse, neglect, or maltreatment can be difficult, such as (1) when the child is nonverbal or too frightened or too severely injured to speak, (2) if the alleged perpetrator denies responsibility, and/or (3) if there were any witnesses. Clinicians may encounter victims of child abuse or maltreatment in many ways, including:

• An adult or mandated reporter may bring the child in when concerned about abuse.
• A child or adolescent may come in disclosing the abuse.
• A perpetrator may be concerned that the abuse is severe and bring in the patient for medical care.
• A child may present for care unrelated to the abuse, and the abuse may be found incidentally.

TEN 4 is a useful mnemonic device used to recall which bruising locations are of concern in cases involving physical abuse: Torso, Ear, Neck, and 4 (less than four years old or any bruising in a child less than four months old). A few injuries that are highly suggestive of abuse include diffuse retinal hemorrhages, posterior rib fractures, and classic metaphyseal lesions. [5][6]

The State of Pennsylvania has developed the following list of indicators to assist clinicians in identifying potential victims.

Indicators Of Bodily Injury

Physical

• Unexplained injuries
• Unbelievable or inconsistent explanations of injuries
• Multiple bruises in various stages of healing
• Bruises located on the face, ears, neck, buttocks, back, chest, thighs, back of legs, and genitalia
• Bruises that resemble objects, such as a hand, fist, belt buckle, and rope.
• Injuries that are inconsistent with the child’s age and/or developmental level
• Burns

Behavioral

• Fear of going home
• Extreme apprehensiveness/vigilance
• Pronounced aggression or passivity
• Flinches easily or avoids being touched
• Play includes abusive talk or behavior
• Unable to recall how injuries occurred, or account of injuries is inconsistent with the nature of the injuries
• Fear of parent or caregiver

Indicators of Sexual Abuse or Exploitation

Physical

• Sleep disturbances
• Bedwetting
• Pain or irritation in genital/anal area
• Difficulty walking or sitting
• Difficulty urinating
• Pregnancy
• Positive testing for sexually transmitted diseases
• Excessive or injurious masturbation

Behavioral

• Sexually promiscuous
• Developmental age-inappropriate sexual play and/or drawings
• Cruelty to others
• Cruelty to animals
• Firesetting
• Anxious
• Withdrawn

Indicators of Serious Mental Injury

Physical

• Frequent psychosomatic complaints (ie, nausea, stomachache, headache)
• Bedwetting
• Self-harm
• Speech Disorders

Behavioral

• Expressing feelings of inadequacy
• Fearful of trying new things
• Overly compliant
• Poor peer relationships
• Excessive dependence on adults
• Habit disorders (sucking, rocking, etc.)
• Eating disorders

Indicators of Serious Physical Neglect

Physical

• Lack of adequate medical and dental care
• Often hungry
• Lack of shelter
• Child's weight significantly lower than what is normal for their age/gender
• Developmental delays
• Persistent (untreated) conditions (eg, head lice, diaper rash)
• Exposure to hazards (eg, illegal drugs, rodent/insect infestation, mold)
• Dirty clothing, inappropriate for the weather, or doesn't fit.

Behavioral

• Not registered in school
• Inadequate or inappropriate supervision
• Poor impulse control
• Frequently fatigued
• Parentified behaviors

Youth More Commonly At-Risk of Human Trafficking

• Youth in the foster care system
• Youth with any of the following:
  • Disabilities
  • Mental health and/or substance abuse disorders
  • History of sexual abuse
  • History of being involved in the welfare system
  • Family dysfunction
• Youth who identify as LGBTQ
• Youth who are homeless or runaway
• Youth who identify as native or aboriginal

Human Trafficking Victim Identification/Warning Signs

• A youth verified to be under the age of 18 and is in any way involved in the sex industry or has a prior arrest for prostitution or related charges.
• Has an explicit sexual online profile
• Excessive frequenting of Internet chat rooms or classified sites
• Depicts elements of sexual exploitation in drawing, poetry, or other modes of creative expression
• Frequent or multiple sexually transmitted diseases or pregnancies
• Lying about or not being aware of their true age
• Having no knowledge of personal data, such as but not limited to age, name, and/or date of birth
• Having no identification
• Wearing sexually provocative clothing
• Wearing new clothes of any style, getting hair and/or nails done with no financial means
• Secrecy about whereabouts
• having late nights or unusual hours
• Having a tattoo that they are reluctant to explain
• Being in a controlling or dominating relationship
• Not having control of own finances
• Exhibit hypervigilance or paranoid behaviors
• Express interest in or in relationships with adults or much older adults

Healthcare Provider Mandatory Notification of Substance-Exposed Infants (Act 54 of 2018)

• A health care provider shall immediately give notice or cause notice to be given to the department if the provider is involved in the delivery or care of a child under one year of age and the health care provider has determined, based on standards of professional practice, the child was born affected by:
  • substance use or withdrawal symptoms resulting from prenatal drug exposure, or
  • fetal alcohol spectrum disorder.
• Notification to the department can be made to ChildLine electronically through the Child Welfare Portal or at 1-800-932-0313
• This notification is to assess a child and the child's family for a plan of safe care and shall not constitute a child abuse report.

A healthcare provider is a licensed hospital or healthcare facility or person who is licensed, certified, or otherwise regulated to provide healthcare services under the laws of this Commonwealth, including a physician, podiatrist, optometrist, psychologist, physical therapist, certified nurse practitioner, registered nurse, nurse midwife, physician's assistant, chiropractor, dentist, pharmacist, or an individual accredited or certified to provide behavioral health services.

After the Health Care Provider’s Notification of  Substance Exposed Infants: Plan of Safe Care

• After notification of a child born affected by substance use or withdrawal symptoms resulting from prenatal drug exposure or a fetal alcohol spectrum disorder and prior to the child's discharge from the health care facility:
• A multidisciplinary team meeting must be held to assess the needs of the child and the child’s parents and immediate caregivers.
• A multidisciplinary team, for the purpose of informing the Plan of Safe Care, may include:
  • Public health agencies
  • Maternal and child health agencies
  • Home visitation programs;
  • Substance use disorder prevention and treatment providers
  • Mental health providers
  • Public and private children and youth agencies
  • Early intervention and developmental services
  • Courts
  • Local education agencies
  • Managed care organizations and private insurers
  • Hospitals and medical providers.
• The most appropriate lead agency for developing, implementing, and monitoring a Plan of Safe Care must be determined.
• The child's parents and immediate caregivers must be engaged to identify the need for access to treatment for any substance use disorder or other physical or behavioral health condition that may impact the safety, early childhood development, and well-being of the child.
• The ongoing involvement of the county agency (CCYA), after taking into consideration the individual needs of the child and the child's parents and immediate caregivers, may not be required.

Exclusions to Child Abuse

Nothing in the PA CPSL requires a person who has reasonable cause to suspect a child is a victim of child abuse to consider the exclusions from child abuse before making a report of suspected child abuse. Exclusions from child abuse are considered/determined by DHS or the investigating agency after receipt of a referral/report.

1. Environmental Factors: No child shall be deemed to be physically or mentally abused based on injuries that result solely from environmental factors, such as inadequate housing, furnishings, income, clothing, and medical care, that are beyond the control of the parent or person responsible for the child’s welfare with whom the child resides. This exclusion does not apply to any childcare service under the CPSL, excluding an adoptive parent.

2. Practice of Religious Beliefs: If, upon investigation, the county agency determines that a child has not been provided needed medical or surgical care because of sincerely held religious beliefs of the child’s parents or relative within the third degree of consanguinity and with whom the child resides, which beliefs are consistent with those of a bona fide religion, the child shall not be deemed to be physically or mentally abused. In such cases, the following shall apply:

• The county agency shall closely monitor the child and the child’s family and shall seek court-ordered medical intervention when the lack of medical or surgical care threatens the child’s life or long-term health.
• All correspondence with a subject of the report and the records of the department and the county agency shall not reference child abuse and shall acknowledge the religious basis for the child’s condition.
• The family shall be referred for general protective services if appropriate.
• This exclusion shall not apply if the failure to provide needed medical or surgical care causes the death of the child.
• This exclusion shall not apply to any child-care service as defined under the CPSL, excluding an adoptive parent.

3. Use of force for Supervision, Control, and Safety Purposes: Subject to the "Rights of Parents" exclusion, the use of reasonable force on or against a child by the child’s parent or person responsible for the child’s welfare shall not be considered child abuse if any of the following conditions apply:

• The use of reasonable force constitutes incidental, minor, or reasonable physical contact with the child or other actions designed to maintain order and control.
• The use of reasonable force is necessary
  • to quell a disturbance or remove the child from the scene of a disturbance that threatens physical injury to persons or damage to property,
  • to prevent the child from self-inflicted physical harm,
  • for self-defense or the defense of another individual, or
  • to obtain possession of weapons or other dangerous objects or controlled substances or paraphernalia that are on the child or within the control of the child.

4. Rights of Parents: Nothing in the CPSL shall be construed to restrict the generally recognized existing rights of parents to use reasonable force on or against their children for the purposes of supervision, control, and discipline of their children. Such reasonable force shall not constitute child abuse

5. Participation in Events that Involve Physical Contact with a Child: An individual participating in a practice or competition in an interscholastic sport, physical education, a recreational activity or extracurricular activity that involves physical contact with a child does not, in itself, constitute contact that is subject to the reporting requirements under the CPSL.

6. Child-on-Child Contact:

• Harm or injury to a child that results from the act of another child shall not constitute child abuse unless the child who caused the harm or injury is a perpetrator.
• Notwithstanding the above bullet point, the following shall apply: Acts constituting any of the following Title 18 crimes against a child shall be subject to the reporting requirements under the CPSL:
  • Rape as defined in 18 Pa.C.S. § 3121
  • Involuntary deviate sexual intercourse as defined in 18 Pa.C.S. § 3123
  • Sexual assault as defined in 18 Pa.C.S. § 3124.1
  • Aggravated indecent assault as defined in 18 Pa.C.S. § 3125
  • Indecent assault as defined in 18 Pa.C.S. § 3126
  • Indecent exposure as defined in 18 Pa.C.S. § 3127

• No child shall be deemed to be a perpetrator of child abuse based solely on physical or mental injuries caused to another child in the course of a dispute, fight, or scuffle entered into by mutual consent.• A law enforcement official who receives a report of suspected child abuse is not required to make a report to the department under section 6334(a) (relating to disposition of complaints received), if the person allegedly responsible for the child abuse is a nonperpetrator child.

7. Defensive Force: Reasonable force for self-defense or the defense of another individual, consistent with the provisions of 18 Pa.C.S. §§ 505 (relating to use of force in self-protection) and 506 (relating to use of force for the protection of other persons), shall not be considered child abuse.

Reporting Suspected Child AbuseAny person may make an oral (1-800-932-0313) or written report of suspected child abuse, which may be submitted electronically, or cause a report of suspected child abuse to be made to DHS, county agency, or law enforcement, if that person has reasonable cause to suspect that a child is a victim of child abuse.Mandated Reporters

The following adults (aged 18 years and older) are required to make a report of suspected child abuse, subject to subsection (b) (relating to basis to report), if the person has reasonable cause to suspect that a child is a victim of child abuse.

1. A person licensed or certified to practice in any health-related field under the jurisdiction of the Department of State
2. A medical examiner, coroner, or funeral director
3. An employee of a health care facility or provider licensed by the Department of Health, who is engaged in the admission, examination, care, or treatment of individuals
4. A school employee
5. An employee of a child-care service who has direct contact with children in the course of employment
6. A clergyman, priest, rabbi, minister, Christian Science practitioner, religious healer, or spiritual leader of any regularly established church or other religious organization
7. An individual, paid or unpaid, who, based on the individual’s role as an integral part of a regularly scheduled program, activity, or service, is a person responsible for the child’s welfare or has direct contact with children
8. An employee of a social service agency who had direct contact with children in the course of employment
9. A peace officer or law enforcement official
10. An emergency medical services provider certified by the Department of Health
11. An employee of a public library who has direct contact with children in the course of employment
12. An individual supervised or managed by a person listed under paragraphs (1), (2), (3), (4), (5), (6), (7), (8), (9), (10), (11), and (13), who has direct contact with children in the course of employment.
13. An independent contractor
14. An attorney affiliated with an agency, institution, organization, or other entity, including a school or regularly established religious organization that is responsible for the care, supervision, guidance, or control of children
15. A foster parent
16. An adult family member who is a person responsible for the child’s welfare and provides services to a child in a family living home, a community home for individuals with an intellectual disability, or a host home for children that are subject to supervision and licensure by the Department through the Public Welfare Code

A mandated reporter enumerated in section 6311(a) of the PA CPSL shall make a report of suspected child abuse in accordance with section 6313 (relating to reporting procedure) if the mandated reporter has reasonable cause to suspect that a child is a victim of child abuse under any of the following circumstances:

• The mandated reporter comes into contact with the child in the course of employment, occupation, and practice of a profession or through a regularly scheduled program, activity, or service.
• The mandated reporter is directly responsible for the care, supervision, guidance, or training of the child or is affiliated with an agency, institution, organization, school, regularly established church or religious organization, or other entity that is directly responsible for the care, supervision, guidance, or training of the child.
• A person makes a specific disclosure to the mandated reporter that an identifiable child is the victim of child abuse.
• An individual 14 years of age or older makes a specific disclosure to the mandated reporter that the individual has committed child abuse.

Nothing in section 6311 of the PA CPSL requires a child to come before the mandated reporter to make a report of suspected child abuse.Nothing in section 6311 of the PA CPSL requires the mandated reporter to identify the person responsible for the child abuse to make a report of suspected child abuse.Whenever a person is required to report under section 6311(b) of the PA CPSL in the capacity as a member of the staff of a medical or other public or private institution, school, facility, or agency, that person shall report immediately in accordance with section 6313 (relating to reporting procedure) and shall immediately thereafter notify the person in charge of the institution, school, facility, or agency or the designated agent of the person in charge.

• Upon notification, the person in charge or the designated agent, if any, shall facilitate the cooperation of the institution, school, facility, or agency with the investigation of the report.
• Any intimidation, retaliation, or obstruction in the investigation of the report is subject to the provisions of 18 Pa.C.S. § 4958 (relating to intimidation, retaliation, or obstruction in child abuse cases).
• The PA CPSL does not require more than one report from any such institution, school, facility, or agency.

Confidential Communications

General Rule: Subject to "Confidential Communications," privileged communications between a mandated reporter and a patient or client of the mandated reporter shall NOT:

1. Apply to a situation involving child abuse
2. Relieve the mandated reporter of the duty to make a report of suspected child abuse

Confidential Communications - Clergy

Confidential communications made to a member of the clergy are protected. Please note the following:

Pennsylvania courts have interpreted our clergy-communicant privilege as applying only to confidential communications between a communicant and a clergy member in his or her role as confessor or spiritual counselor. See, e.g., Hutchison v. Luddy, 414 Pa.Super. 138, 146, 606 A.2d 905, 908 (1992); Commonwealth v. Patterson, 392 Pa.Super. 331, 572 A.2d 1258 (1990); Fahlfeder v. Commonwealth, Pennsylvania Board of Probation and Parole, 80 Pa.Cmwlth. 86, 470 A.2d 1130 (1984). In summary, if the communication is in confidence and the person seeks absolution, it is considered privileged.

Confidential Communications - Attorney

Confidential communication to an attorney is protected under Pennsylvania law SO LONG AS they are within the scope of confidentiality as per 42 Pa.C.S. §§5916 and 5928.

Relating to confidentiality in criminal proceedings, neither the attorney nor the client is required or permitted to disclose confidential discussions between the 2 parties unless the client waives this privilege.

Relating to confidentiality in civil proceedings, neither the attorney nor the client is required or permitted to disclose confidential discussions between the 2 parties unless the client waives this privilege.

The Reporting Process

A mandated reporter must immediately make an oral report of suspected child abuse to DHS via the Statewide toll-free telephone number (1-800-932-0313) or a written report via the self-service Child Welfare Portal (http://www.compass.state.pa.us/cwis).A mandated reporter making an oral report of suspected child abuse to the department via the Statewide toll-free telephone number under section 6332 (relating to the establishment of a statewide toll-free telephone number) shall also make a written report, which may be submitted electronically, within 48 hours to DHS or county agency assigned to the case in a manner and format prescribed by DHS.The failure of the mandated reporter to file the written report described in the paragraph immediately above shall not relieve the county agency from any duty under the PA CPSL, and the county agency shall proceed as though the mandated reporter complied.Mandated reporters are required to identify themselves and their contact information when making a report of suspected child abuse. This provides documentation that the report was made but is also helpful so that the children-and-youth caseworker can contact the mandated reporter if clarification on the situation or additional information is needed.

Contents of ReportA written report of suspected child abuse, which may be submitted electronically, shall include the following information if known:

• The names and addresses of the child, the child's parents, and any other person responsible for the child's welfare
• Where the suspected abuse occurred
• The age and sex of each subject of the report
• The nature and extent of the suspected child abuse, including any evidence of prior abuse to the child or any sibling of the child
• The name and relationship of each individual responsible for causing the suspected abuse and any evidence of prior abuse by each individual
• Family composition
• The source of the report
• The name, telephone number, and email address of the person making the report
• The actions taken by the person making the report, including those actions taken under section 6314 (relating to photographs, medical tests, and x-rays of a child subject to report), 6315 (relating to taking a child into protective custody), 6316 (relating to admission to private and public hospitals) or 6317 (relating to mandatory reporting and postmortem investigation of deaths)
• Any other information required by Federal law or regulation
• Any other information that DHS requires by regulation

Protections for Reporters

Immunity from Liability

A person, hospital, institution, school, facility, agency, or agency employee acting in good faith shall have immunity from civil and criminal liability that might otherwise result from any of the following:

1. Making a report of suspected child abuse or making a referral for general protective services, regardless of whether the report is required to be made under the CPSL.
2. Cooperating or consulting with an investigation under the CPSL including providing information to a child fatality or near-fatality review team.
3. Testifying in a proceeding arising out of an instance of suspected child abuse or general protective services
4. Engaging in any action authorized under 23 Pa.C.S. § 6314 (relating to photographs, medical tests, and x-rays of child subject to report), § 6315 (relating to taking child into protective custody), § 6316 (relating to admission to private and public hospitals), or § 6317 (relating to mandatory reporting and postmortem investigation of deaths).

Departmental and County Agency Immunity

An official or Department or county agency employee who refers a report of suspected child abuse for general protective services to law enforcement authorities or provides services as authorized by the CPSL shall have immunity from civil and criminal liability that might otherwise result from the action.

Protecting IdentityExcept for reports under section 6340(a)(9) and (10) of the PA CPSL and in response to a law enforcement official investigating allegations of false reports under 18 Pa.C.S. § 4906.1 (relating to false reports of child abuse), the release of data by DHS, county, institution, school, facility, or agency or designated agent of the person in charge that would identify the person who made a report of suspected child abuse or who cooperated in a subsequent investigation is prohibited.

Law enforcement officials shall treat all reporting sources as confidential informants.

Presumption of Good Faith

For the purpose of any civil or criminal proceeding, the good faith of a person required to report suspected child abuse and of any person required to make a referral to law enforcement officers under the PA CPSL shall be presumed.

Protection from Employment DiscriminationBasis for relief – A person may commence an action for appropriate relief if all of the following apply:

• The person is required to report suspected child abuse or encouraged to report suspected child abuse.
• The person acted in good faith in making or causing the report of suspected child abuse to be made.
• As a result of making the report of suspected child abuse, the person is discharged from employment or is discriminated against concerning compensation, hire, tenure, terms, conditions, or privileges of employment.

This does not apply to an individual making a report of suspected child abuse who is found to be a perpetrator because of the report or to any individual who fails to make a report of suspected child abuse as required and is subject to conviction for failure to report or to refer.

Penalties for Failure to Report

1. A person or official required by the PA CPSL to report a case of suspected child abuse or to make a referral to the appropriate authorities commit an offense if the person or official willfully fails to do so:
2. The offense is a felony of the third degree if:
   1. The person or official willfully fails to report
   2. The child abuse constitutes a felony of the first degree or higher, and
   3. The person or official has direct knowledge of the nature of the abuse.
3. An offense not otherwise specified above is a misdemeanor of the second degree.
4. A report of suspected child abuse to law enforcement or the appropriate county agency by a mandated reporter, made in lieu of a report to the Department (ChildLine or the Child Welfare Portal), shall not constitute an offense under section 6319(a) of the CPSL, provided that the report was made in a good faith effort to comply with the requirements of the CPSL.

Continuing Course of Action

If a person’s willful failure to report an individual suspected of child abuse continues while the person knows or has reasonable cause to suspect the child is actively being subjected to child abuse by the same individual, or while the person knows or has reasonable cause to suspect that the same individual continues to have direct contact with children through the individual's employment, program, activity, or service, the person commits a felony of the third degree, except that, if the child abuse constitutes a felony of the first degree or higher, the person commits a felony of the second degree.

Multiple Offenses of Failure to Report

A person who, at the time of sentencing for an offense under section 6319 of the CPSL, has been convicted of a prior offense under this section commits a felony of the third degree, except if the child abuse constitutes a felony of the first degree or higher, the penalty for the second or subsequent offenses is a felony of the second degree.

Statute of Limitations

The statute of limitation for an offense under section 6319 of the CPSL (described above) shall be either the statute of limitations for the crime committed against the minor child or five years, whichever is greater.

Mandated Reporters Right to Know

If a mandated reporter made a report, the Department shall notify the mandated reporter who made the report of suspected child abuse of all of the following within 3 business days of the Department’s receipt of the results of the investigation:

1. Whether the child abuse report was founded, indicated, or unfounded
2. Any services provided, arranged for, or to be provided by the county agency to protect the child

Evaluation

Any child younger than two years old, for whom there is a concern of physical abuse/bodily injury, should have a skeletal survey as part of the evaluation. Additionally, any sibling younger than two years of age of an abused child should also have a skeletal survey. A skeletal survey consists of 21 dedicated views, as recommended by the American College of Radiology. The views include anteroposterior (AP) and lateral aspects of the skull; lateral spine; AP, right posterior oblique, left posterior oblique of chest/rib technique; AP pelvis; AP of each femur; AP of each leg; AP of each humerus; AP of each forearm; posterior and anterior views of each hand; AP (dorsoventral) of each foot. If the findings are abnormal or equivocal, a follow-up survey is indicated in 2 weeks to visualize healing patterns.

Laboratory evaluation may be performed to rule out other diseases as causes of the injuries. These can including bone (calcium, magnesium, phosphate, alkaline phosphatase), hematology (CBC), coagulation (PT, PTT, INR), metabolic (glucose, BUN, creatinine, albumin, protein), liver (AST, ALT), pancreatic (amylase and lipase), and bleeding diathesis (von Willebrand antigen, von Willebrand activity, Factor VIII, Factor IX, and platelet function assays).

One should consider that the most common differential diagnosis of non-accidental injury is an accidental injury.[9][10][11][5][6]

Treatment / Management

Initial management of an abused child involves stabilization, including assessing the patient's airway, breathing, and circulation. Once sure that the patient is stable, a complete history and physical examination are necessary. A mandated reporter who has reasonable cause to suspect a child is a victim of child abuse must immediately make a report of suspected child abuse to ChildLine immediately. If there is a child abuse specialist at the pediatric center, their involvement would be optimal. If the patient is seen in an outpatient setting, there may be a need to transfer the patient to a hospital for laboratory and radiologic evaluation and the appropriate continuation of care. Even if a child was transferred to another physician or facility, the physician first involved with the patient care is still responsible for being a mandated reporter. Nothing under section 6311 of the PA CPSL (relating to persons required to report suspected child abuse) requires a mandated reporter to identify the person responsible for the child abuse to make a report of suspected child abuse. The physician should continue to advocate for the child, ensuring that the patient receives the appropriate follow-up services.

Victims of sexual abuse should have their physical, mental, and psychosocial needs addressed. Baseline sexually transmitted infection (STI) and pregnancy testing should be performed, as well as empiric treatment for HIV, gonorrhea, chlamydia, trichomonas, and bacterial vaginosis infection for adolescent victims. This management is possible if the patients present within 72 hours of the incident to receive appropriate care and emergency contraception if desired. Prepubertal patients are not provided with prophylactic treatment due to the low incidence of STIs in this age group. Urgent evaluation (optimally in less than 72 hours) can prove extremely beneficial for patients needing prophylactic treatment, patients with anogenital injury, for collection of forensic evidence, for patients needing urgent child protection, and in those having suicidal ideation or any other form of symptom and/or injury requiring urgent medical care.[12][13][14][5][6][8]

Differential Diagnosis

Suspected child abuse should be considered in the evaluation of all injuries of children. A thorough history of the present illness is vital to make a correct diagnosis. Essential aspects of collecting the history involve gathering information about the child's behavior before, during, and after the injury. The parent or caretaker should be able to provide the history without interruptions and not be influenced by the provider's questions or interpretations. Pediatric abuse should be considered in each of the following:

• A non-ambulatory infant with any injury
• Injury in a nonverbal child
• Injury inconsistent with the child's physical abilities
• A statement of harm from the verbal child
• Mechanism of injury not plausible; multiple injuries, particularly at varying ages
• Bruises on the torso, ear, or neck in a child younger than 4 years
• Burns to genitalia
• Stocking or glove distributions or patterns
• Caregiver is unconcerned about the injury
• An unexplained delay in seeking care or inconsistencies or discrepancies in the histories provided

The differential diagnosis depends on age, injury type, and signs and symptoms. The differential diagnosis of injury usually differentiates between accidental and inflicted trauma. An astute healthcare provider must carefully consider organic disease processes or accidental injury versus deliberately inflicted trauma.

• Accidental asphyxia[15]
• Accidental bruises 
• Accidental fractures 
• Accidental burns
• Accidental head injury 
• Arteriovenous malformations 
• Atopic dermatitis[16]
• Bleeding or hemorrhagic disorder[17][18]
• Birth trauma[19]
• Caffey disease[20]
• Chemical burn[21]
• Coining[22]
• Congenital syphilis[23]
• Contact dermatitis
• Cupping[22]
• Erythema multiforme[24]
• Factitious disorder
• Hemangioma[25]
• Henoch-Schönlein purpura[26]
• Hypervitaminosis A[27]
• Immune thrombocytopenic purpura[27]
• Impetigo[28]
• Inflammatory skin conditions 
• Insect bites[29]
• Osteogenesis imperfecta[30]
• Osteomyelitis[31]
• Osteopenia
• Malignancy
• Meningitis[32]
• Menkes disease[33]
• Metabolic disease
• Mongolian spots[34]
• Nevi[35]
• Phytophotodermatitis[36]
• Rickets [37]
• Scurvy[38]
• Sunburn[39]
• Valsalva induced subconjunctival hemorrhage[40]

Complications

Complications often observed in child abuse cases are as follows:

• Fractures
• Burns
• Disfigurement
• Emotional trauma
• Seizures
• Mental retardation
• PTSD

Consultations

Consultations may include the following:

• Neurosurgery
• Ophthalmologist
• Orthopedic surgeon 
• Child protective services
• Social Work
• Psychiatrist

Pearls and Other Issues

How do I access the Child Welfare Portal?

• Go to https://www.compass.state.pa.us/cwis/public/home/
• Create an individual account and follow the instructions

Once I am in the Child Welfare Portal, how do I report?

• Go to "my Abuse Referrals Page," where you can create a new referral, view previous referrals, and edit or delete previously saved referrals not yet submitted.

What information should I include in a report of suspected child abuse?

Contents of report. A written report of suspected child abuse, which may be submitted electronically, shall include the following information if known:

• The names and addresses of the child, the child's parents, and any other person responsible for the child's welfare
• Where the suspected abuse occurred
• The age and sex of each subject of the report
• The nature and extent of the suspected child abuse, including any evidence of prior abuse to the child or any sibling of the child
• The name and relationship of each individual responsible for causing the suspected abuse and any evidence of prior abuse by each individual
• Family composition
• The source of the report
• The name, telephone number, and e-mail address of the person making the report
• The actions taken by the person making the report, including those actions taken under section 6314 (relating to photographs, medical tests, and x-rays of a child subject to report), 6315 (relating to taking a child into protective custody), 6316 (relating to admission to private and public hospitals) or 6317 (relating to mandatory reporting and postmortem investigation of deaths)
• Any other information required by Federal law or regulation
• Any other information that DHS requires by regulation

 *Please see the video clip of the signup procedure for the details provided.

Case Scenario #1

A 4-year-old child is admitted to the hospital for a third episode of hypoglycemia and lethargy. Prior workup has been unable to determine an organic cause. The child is observed in the hospital for three days, and no underlying pathologic process is discovered. The mother stays with the child, is extremely protective, and engages in making sure "all stones are overturned" to find the cause of the child's condition. The child is set for discharge in the morning at 4 am. While making rounds, the nurse finds the mother wide awake standing at the bedside. During her examination, the child has a seizure. A bedside rapid blood sugar test reveals a dangerously low level. Glucagon is administered, and the child recovers quickly. What should the nurse do?

In this case, there is reasonable cause to suspect child abuse, specifically "fabricating, feigning, or intentionally exaggerating or inducing medical symptoms or disease which results in potentially harmful medical evaluation or treatment to a child through any recent act," as well as a basis to report. A nurse is a mandated reporter of suspected child abuse and is therefore required to make a report of suspected child abuse to Childline via phone at 1-800-932-0313 (24 hours a day, 7 days a week) or electronically via the Child Welfare Portal at www.compass.state.pa.us/cwis, if there is reasonable cause to suspect that a child is a victim of child abuse, and they come into contact with the child in the course of employment, occupation, and practice of a profession or through a regularly scheduled program, activity, or service, or they are directly responsible for the care, supervision, guidance or training of the child, or are affiliated with an agency, institution, organization, school, regularly established church or religious organization or other entity that is directly responsible for the care, supervision, guidance or training of the child. Given the gravity of the situation, clinicians and social workers should also be contacted in this hospital setting.

Case Scenario #2

A 13-year-old girl is brought to her pediatrician because of a recent decline in her grades. During a private interview, she admits she has "problems with boys at school" and "bad dreams about boys always staring at her." The child privately admits she regularly gets up in the middle of the night and sleeps with the biological mother on her side of the bed, with her stepfather next to her mother. The child indicates the stepfather has commented that she is a "looker," has "big headlights," and needs to "fend off the boys at school." The pediatrician attended high school with the stepfather and knows he is not the "brightest bulb" but seems to care about the child genuinely. The child indicates the stepfather wears pajamas, has never touched her, and always knocks before entering the bathroom or her room. She says she is very anxious about attending school and is afraid to speak with her mother about her school problems. She says her stepfather has always been "very good" to her mother and is always kind and considerate to her as well. She does not want to get him into trouble but feels his comments about her appearance add to her anxiety. What should the pediatrician do in this situation?

Given the totality of the circumstances, there may not be reasonable cause to suspect child abuse; however, there remain numerous concerns, such as the child's problems at school, nightmares, child co-sleeping at the age of 13, and the stepfather's inappropriate comments to the child. General concerns for a child's safety, health, and well-being may be reported to ChildLine for assessment of services and support. The PA CPSL prescribes that a person, hospital, institution, school, facility, agency, or agency employee acting in good faith shall have immunity from civil and criminal liability that might otherwise result from making a report of suspected child abuse or making a referral for general protective services, regardless of whether the report is required to be made under the PA CPSL. 

Case Scenario #3

A 16-year-old child presents to the emergency department due to acting out at school. Shortly after arrival, the child asks for a sandwich. The school could not reach the biological mother, and the biological father is deceased. The child indicates his mother is on a honeymoon on a boat somewhere in the Cayman Islands. He is currently being taken care of by his grandmother, who is at work as a dietician, but she will be home shortly. The mother left him with $200 ten days ago and told him to buy local fast food for both of them for dinner. He admits he was told not to spend more than $20 daily and avoid dessert due to his grandmother's diabetes. He says he is out of money because he bought dessert daily and spent $30 instead of $20. He says he is "starving." There is no food in the house besides the fruits, vegetables, and frozen meals his mother provided. Which of the following would be an appropriate response of the emergency department health providers?

The child should be given food, and the grandmother should be contacted. Additionally, while there may not be reasonable cause to suspect child abuse, the PA CPSL prescribes that a person, hospital, institution, school, facility, agency, or agency employee acting in good faith shall have immunity from civil and criminal liability that might otherwise result from making a report of suspected child abuse or making a referral for general protective services, regardless of whether the report is required to be made under the PA CPSL. General concerns for a child's safety, health, and well-being may be reported to ChildLine for assessment of services and support.

Enhancing Healthcare Team Outcomes

Child abuse is a public health problem that leads to lifelong health consequences, both physically and psychologically. Physically, those who undergo abusive head trauma may have neurologic deficits, developmental delays, cerebral palsy, and other forms of disability. Psychologically, child abuse patients tend to have higher rates of depression, conduct disorder, and substance abuse. Academically, these children may perform poorly at school and have decreased cognitive function. 

All healthcare providers have a legal, medical, and moral obligation to report suspected abuse. Most child abuse cases present to the emergency department; hence, nurses and physicians in the emergency department are often the first to notice the problem. The key is to be aware of the problem; allowing abused children to return to their parents usually leads to more violence and sometimes even death. The social worker must be informed of suspected child abuse so that the child can be followed as an outpatient. 

Evidence-Based Outcomes

Child abuse is a serious problem in many countries. While there is an acute awareness of the problem, many children fail to be referred or reported and consequently continue to suffer abuse, sometimes even death. In a busy emergency room, healthcare workers must be vigilant of abuse in any child who presents with injuries that are inconsistent or unexplainable.[41][42] Studies have shown that the incidence of morbidity and mortality can be decreased through prevention and treatment. The goal is to prevent abuse and neglect, allowing a healthy childhood that will result in healthy adults. Society, community, and individual health providers must work together to provide a safe environment for children. Reporting suspected child abuse is an obligation of all health professionals as it is an opportunity to improve a child's health, safety, and well-being.