Pennsylvania Child Abuse Recognition and Reporting

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Continuing Education Activity

Unfortunately, child abuse and maltreatment is a significant Pennsylvania problem. There is substantial morbidity and mortality associated with child abuse due to a child's inability to protect themselves. Healthcare providers frequently miss child abuse cases. For the diagnosis of child abuse to be made, a high index of suspicion is needed. Pennsylvania has created a legal structure and educational approach to assure health providers are able to identify abuse and neglect in children and know how to engage state agencies in the protection and care of the child. This activity reviews the epidemiology, presentation, diagnosis, and reporting requirements in Pennsylvania of child abuse. It highlights the role of the inter-professional team in its management and prevention.

Objectives:

  • Outline the definitions of child abuse, maltreatment, and neglect, according to Pennsylvania State law.
  • Review the presentation and indicators of a child that has suffered abuse, maltreatment, or neglect.
  • Summarize the situations mandated by Pennsylvania State law in which child abuse, maltreatment, and neglect should be reported.
  • Summarize the situations mandated by Pennsylvania State law in which failure to report child abuse, maltreatment, and neglect could lead to legal retribution.

Introduction

Unfortunately, child abuse and maltreatment is a significant Pennsylvania problem. Substantial morbidity and mortality is associated with child abuse due to a child's inability to protect themselves. Healthcare providers frequently miss a large amount of child abuse cases. For the diagnosis of child abuse to be made, a reasonable cause of suspicion is needed.[1][2][3] Pennsylvania has created a legal structure and educational approach to assure health providers are able to identify abuse and neglect and know how to engage state agencies in the protection and care of the child.

Child Abuse/Neglect In The State Of Pennsylvania

Child abuse and neglect is a significant problem throughout the United States as well as Pennsylvania. Over 3 million children per year are abused or neglected in the U.S., and over 40,000 are the subjects of reports in Pennsylvania. It has been estimated that 1 in 1000 children in Pennsylvania is abused or neglected. The State of Pennsylvania has taken a proactive role by instituting the Pennsylvania Child Protective Services Law (CPS-L) as well as Act 15, Act 115, and General Protective Services Law (GPS-L) with the goal to reduce child abuse, neglect, and trafficking by improving procedures, reporting, and investigation.

Child Protective Services Versus General Protective Services

  • The Pennsylvania Child Welfare System is state-supervised and county-administered
  • Child Protective Services (CPS) and General Protective Services (GPS) are two main functions/services of the county children and youth agencies
  • When a call/referral is made to ChildLine, the trained professionals categorize it a CPS or GPS
  • Cases identified as CPS, require an investigation because the alleged act or failure to act has been identified as one of the 10 categories of abuse per the Child Protective Services Law (CPSL)
  • Cases identified as GPS require an assessment for services and support. In these cases, the act or failure to act is detrimental to a child but do not fall under the 10 categories of child abuse per the CPSL
  • The key distinction between CPS and GPS is that CPS requires an investigation whereas GPS requires an assessment for services and support.

Examples of 10 Categories of CPSL Cases

  • Causing bodily injury to a child through any recent act or failure to act
  • Fabricating, feigning, or intentionally exaggerating or inducing medical symptoms or disease which results in 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 serious 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 t o a child through act 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 neglect of a child
  • Engaging in the following 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 his physical, mental, or emotional health, or morals.
  • Has been placed for care or adoption in violation of law.
  • Has been abandoned by his 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 of the reasonable and lawful commands of his parent, guardian or other custodian and who is ungovernable and found to be in need of 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 jurisdiction of the court, subject to its conditions or placements and who commits an act which is defined as ungovernable in subparagraph (vi).
  • Has been referred under section 6323 of the Juvenile Act (relating to informal adjustment), and who commits an act which is defined as ungovernable in subparagraph (vi).

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 3-days and no underlying pathologic process is discovered. The mother stays with the child, is extremely protective, and engaged in making sure "all stones are overturned" in an attempt to find the cause of the child's condition. The child is set for discharge in the morning and at 4 a.m., 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 tests reveal a dangerously low level. Glucagon is administered and the child recovers quickly. The nurse is suspicious of Munchausen syndrome by proxy. What should the nurse do?

This is an example of potentially inducing medical symptoms with a potentially harmful result. This is a CPS case. The nurse is a mandated reporter who is required to immediately make a report of suspected child abuse as per the Child Protective Services Law via a call to the ChildLine at 1-800-932-0313 (24 hours a day, seven days a week) or electronic mandated reporter system at www.compass.state.pa.us/cwis. Given the gravity of the situation, in this hospital setting, clinicians and social work should also be contacted.

Case Scenario #2

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 was unable to reach the biological mother, the biological father is deceased, and 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 a day and avoid desert due to his grandmother's diabetes. He says he is out of money because he bought dessert every day and spent $30 instead of $20. He says he is "starving". There is no food in the house other than the fruits, vegetables, and frozen meals his mother provided. Which of the following would be an appropriate response of the emergency department health providers?

This is an example of a child that has reasonable parental care and this does not reach CPS standards. This is at best a GPS case. The child should be provided with food and the grandmother contacted. If the grandmother cannot be reached, ChildLine should be contacted and until GPS has evaluated the patient and arranged a safe return to his home environment, the child should not be discharged.

Definitions

"Perpetrator." A person who has committed child abuse as defined in this section. The following shall apply: (1) The term includes only the following:(i) A parent of the child.(ii) A spouse or former spouse of the child's parent.(iii) A paramour or former paramour of the child's parent.(iv) A person 14 years of age or older and responsible for the child's welfare or having direct contact with children as an employee of a child-care services, a school or through a program, activity or service.(v) An individual 14 years of age or older who resides in the same home as the child.(vi) An individual 18 years of age or older who does not reside 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. (vii) An individual 18 years of age or older who engages a child in severe forms of trafficking in persons or sex trafficking, as those terms are defined under section 103 of the Trafficking Victims Protection Act of 2000 (114 Stat. 1466, 22 U.S.C §7102).(2) Only the following may be considered a perpetrator for failing to act, as provided in this section: (i) A parent of the child.(ii) A spouse or former spouse of the child's parent.(iii) A paramour or former paramour of the child's parent.(iv) A person 18 years of age or older and responsible for the child's welfare. (v) A person 18 years of age or older who resides in the same home as the child.

Note: Please note that when we talk about a perpetrator of human trafficking, we must understand that this can be anyone; therefore falling outside of the scope of the traditional definition. As soon as a case is classified as human trafficking, it is considered child abuse and the person alleged to have committed the act is an alleged perpetrator. Inclusion of School Employees

The CPSL allows for school employees to be considered perpetrators under the definition provided for “person responsible for the child’s welfare” or person “having direct contact with children.” § 6303. Definitions:

"School employee." An individual who is employed by a school or who provides a program, activity or service sponsored by a school. The term does not apply to administrative or other support personnel unless the administrative or other support personnel have direct contact with the children.

“Person responsible for the child’s welfare.” A person who provides permanent or temporary care, supervision, mental health diagnosis or treatment, training or control of a child in lieu of parental care, supervision, and control

“Direct contact.” The care, supervision, guidance, or control of children OR routine interaction with children.

Categories of Abuse

The definition of child abuse, via the Child Protective Services Law, starts with “shall mean intentionally, knowingly, or recklessly”

  • Intentionally: Done with the direct purpose of causing the type of harm that resulted
  • Knowingly: Understanding that the harm is “practically certain to result”
  • Recklessly: Conscious disregard for foreseeable risk

The term “child abuse” shall mean 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
  • Causing sexual abuse or exploitation of a child through any act of 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 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 the 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 in a location while a violation of 18 Pa. C.S. §7508.2 (relating to operation of methamphetamine laboratory) is occurring, providing that 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 reasonable 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)
      • *Please note the items in number 8 are also known as “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
    • *Category number 10 was just recently added as of the passing of Act 115 of 2016
  • Bodily Injury: Impairment of physical condition of substantial pain
    • The law considers two parameters: impairment and pain
      • Impairment - If, due to the injury, the child’s ability to function is reduced in any way; either temporarily or permanently
      • 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 other individuals 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
        • The employment, use, persuasion, inducement, enticement or coercion of a child to engage in or assist other individuals to engage in sexually explicit conduct, which includes but is not limited to: Actual or simulated sexual activity for the purpose of producing visual depiction, including photographing, videotaping, computer depicting or filming
          • *This paragraph doe NOT include consensual activities between a child who is 14 years of age or older and another person 14 years of age 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 ad 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 minor).
      • Sexual exploitation as defined in 18 Pa.C.S. § 6320 (relating to sexual exploitation of children).

Case Scenario #3

A 13-year-old female is brought to her pediatrician because of a recent decline in her grades. In the course of 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 step-father next to her mother. The child indicates the step-father has commented that she is a "looker", has "big headlights", and she needs to "fend off the boys at school". The pediatrician attended high school with the step-father and is aware he is not the "brightest bulb" but seems to genuinely care about the child. The child indicates the step-father 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 step-father has always been "very good" to her mother and always kind and considerate to her as well. She does not want to get him into any trouble but feels his comments about her appearance are adding to her anxiety. What should the pediatrician do in this situation?

This probably does not rise to the level of child abuse but it could potentially result in serious mental injury if untreated. The pediatrician should carefully document her evaluation and any decisions she makes. Assuming the mother is open to having the child receive mental health counseling concerning boys, end the child sleeping in the parent's bed, and stopping inappropriate comments from the step-father, this may not rise to the level of a report. However, if the pediatrician was concerned, it is safer to report. In this case, most likely ChildLine would refer the situation to the city children and youth agency and request assessment (GPS) to assist the family and patient in getting appropriate counseling.

Human Trafficking: Federal

  • Human trafficking is a form of child abuse and violation of Federal and State law, that tends to encompass all of the other categories of abuse. This training section on human trafficking consists of sex and labor trafficking as it pertains to children.
  • In the battle against human trafficking, the federal government created legislation known as “The Trafficking Victims and Protection Act of 2000”
  • In 2014, the federal government enhanced legislation through the creation and passing of the “Preventing Sex Trafficking and Strengthening families Act of 2014.
  • In 2015, the federal government also created and passed the “Justice for Victims of Trafficking Act of 2015.

Human Trafficking: State

  • Pennsylvania in turn enacted human trafficking legislation to amend titles 23 (Domestic Relations), 42 (Judiciary and Judicial Procedure), and 18 (Crimes and Offenses). These acts are now known as:
    • Act 94 of 2015
    • Act 105 of 2015
    • Act 115 of 2016

Forms of Trafficking

Sex Trafficking

Sex trafficking in which a commercial sex act is induced by force, fraud, or coercion, or in which the person induced to perform such acts has not attained 18 years of age; or

The recruitment, harboring, transporting, provision, or obtaining of a person for labor of services, through the use of force, fraud or coercion for the purpose of subjection to involuntary servitude, peonage (paying off debt through work); debt bondage (debt slavery, bonded labor or services for a debt or other obligation); or slavery

Labor Trafficking

Labor trafficking is obtained by use of threat or 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 the form of 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;

  • Individual factors (e.g., a child's disability, unmarried mother, maternal smoking, or a parent's depression)
  • Familial factors (e.g., domestic violence at home, more than two siblings at home);
  • Community factors (e.g., lack of recreational facilities); and
  • Societal factors (e.g., poverty).
  • Living in an unrelated adult's home
  • Being a child previously reported to child protective services (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.[4][5][6]

Risk Factors by the Center for Disease Control that Increase Child Abuse and Maltreatment[7][8]

  • Alcoholism and substance abuse
  • Community violence
  • Children younger than 4 years of age
  • 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[7][8]

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

Epidemiology

Each year, millions of children are investigated by Child Protective Services for child abuse and neglect in the United States. Annually, over 3 million children are the subjects of child maltreatment reports. Of those, 20% were found to have evidence of maltreatment.[9] There are over 100,000 referrals for abuse and neglect in Pennsylvania, with nearly half of them confirmed victims. Male and female percentage 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% physically abused, and 5 to 10% sexually abused.[7][8][10]

History and Physical

Diagnosing a patient with child abuse, neglect, or maltreatment is difficult since the victim may be nonverbal, too frightened, or too severely injured to talk. Also, the perpetrator will rarely admit to the injury, and witnesses are uncommon. Clinicians may see children of maltreatment in a range of ways that include:

  • An adult or mandated reporter may bring the child in when they are 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.

Possible abuse should be considered in the evaluation of all injuries of children. A thorough history of present illness is vital to make a correct diagnosis. Essential aspects of the history-taking involve gathering information about the child's behavior before, during, and after the injury. History-taking should include the interview of each caretaker separately and the verbal child, as well. The parent or caretaker should be able to provide their history without interruptions, not to be influenced by the physician'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 of age
  • Burns to genitalia
  • Stocking or glove distributions or patterns
  • The caregiver is unconcerned about the injury.
  • An unexplained delay in seeking care or inconsistencies or discrepancies in the histories provided. 

"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 of age or any bruising in a child less than four months of age). A few injuries that are highly suggestive of abuse include diffuse retinal hemorrhages, posterior rib fractures, and classic metaphyseal lesions [7][8].

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, rope, etc.
  • Injuries that are inconsistent with the child’s age and/or developmental level

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 (i.e., nausea, stomachache, headache, etc.)
  • 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

At-Risk Indicators of Human Trafficking

Youth in:

  • The foster care system

Youth with:

  • 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
  • Homeless or runaway
  • Identify as native or aboriginal

Health Care Provider Mandatory Notification of Substance Exposed Infants

  • 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
    • A 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 for the purpose of assessing a child and the child's family for a plan of safe care and shall not constitute a child abuse report.
        • *Act 54 of 2018

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.
  • 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 their 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.
  • 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.
    • Act 54 of 2018

Pennsylvania Exclusions of Child Abuse

There are exclusions to child abuse – but please note that these exclusions are ONLY for county children and youth professionals working on substantiating reports NOT for consideration of reporters making reports!

If an individual has reasonable suspicion to suspect child abuse – MAKE THE REPORT IMMEDIATELY!

1. Environmental Factors: No child shall be deemed to be physically or mentally abused based on the injuries that result solely from environmental factors, such as inadequate housing, furnishings, income, clothing or medical care, that are beyond the control of the parent responsible for the child’s welfare with whom the child resides. This subsection does not apply to any child-care services as defined in the chapter, 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 service, if appropriate
  • This subsection shall not apply if the failure to provide needed medical or surgical care causes the death of the child
  • This subsection shall not apply to any child-care service as defined under Chapter 63, excluding an adoptive parent

3. Use of force for Supervision, Control, and Safety Purposes: The use of reasonable force on or against a child by the child’s own 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 that are 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 the Parents: Nothing in Chapter 63 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 the 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

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 paragraph, the following shall apply: Acts constitution any of the following crimes against a child shall be subject to the reporting requirements:
    • Rape
    • Involuntary deviate sexual intercourse
    • Sexual assault
    • Aggravated indecent assault
    • Indecent assault
    • Indecent exposure
      • 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 if the person allegedly responsible for the child abuse is a non-perpetrator child

7. Defensive Force: a reasonable force for self-defense or the defense of another individual, consistent with the provisions of 18 Pa. C.S. §505 and §506 shall not be considered child abuse

Evaluation

Any child younger than two years old, for whom there is a concern of physical abuse, 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.[11][12][13][7][8]

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. With the suspicion for any form of child abuse, ChildLine or the county child protective agency needs to be informed. 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 still has the responsibility of being a mandated reporter. It is not the responsibility of the physician to identify the perpetrator but to recognize potential 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 the 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 the 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.[14][15][16][7][8][10]

Pennsylvania Mandated versus Permissive Reporting

Mandated Reporter

  • A person who is required to immediately make a report of suspected child abuse as per the Child Protective Services Law
  • How to Report - Call ChildLine at 1-800-932-0313 (24 hours a day, seven days a week)Use the electronic mandated reporter system at www.compass.state.pa.us/cwis

Permissive Reporter

  • A person who is encouraged to immediately make a report of suspected child abuse
  • How to Report - Call ChildLine at 1-800-932-0313 (24 hours a day, seven days a week)

Persons Who Are Mandated Reporters Of Suspected Child Abuse

The following adults (18 years of age and older) shall make a report of suspected child abuse if they have reasonable cause to suspect such 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, on the basis of 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 host home for children which are subject to supervision and licensure by the Department through the Public Welfare Code

Attorneys As Mandated Reporters

Attorneys 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.

In these cases, attorneys are mandated reporters, required by law, to report.

Privileged Communications

General Rule: 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

Privileged Communications - Clergy

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 member of the clergy 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 is seeking absolution, then it is considered privileged.

Privileged Communications - Attorney

Confidential communication made to an attorney are 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 that the attorney nor the client are required or permitted to disclose confidential discussions between the two parties; unless this privilege is waived by the client

Relating to confidentiality in civil proceedings that the attorney nor the client are required or permitted to disclose confidential discussions between the two parties; unless this privilege is waived by the client.

Basis To Report

Mandated reporters shall make a report of suspected child abuse, if the mandated reporter has reasonable cause to suspect that a child is a victim of child abuse under any of the following circumstances:

  1. The mandated reporter comes into contact with the child in the course of employment, occupation, and practice of a professional through a regularly scheduled program, activity, or service
  2. The mandated reporters are 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
  3. A person makes a specific disclosure to the mandated reporter that an identifiable child is the victim of child abuse
  4. An individual 14 years of age or older makes a specific disclosure to the mandated reporter that the individual has committed child abuse
  • *Nothing under the “Basis to Report” section shall require a child to come before the mandated reporter in order for the mandated reporter to make a report of suspected child abuse

  • *Nothing under the “Basis to Report” section shall require the mandated reporter to identify the person responsible for the child abuse to make a report of suspected child abuse.

  • *It is NOT the mandated reporter’s responsibility to determine if the person who allegedly committed child abuse or harm to a child is a perpetrator

The Reporting Process

  1. Reports are to be made by the person who has a reasonable cause to suspect child abuse
  2. Reports are to be made immediately
  3. Electronic submissions (which can only be made by mandated reporters) through the Child Welfare Portal at www.compass.state.pa.us/cwis or an oral submission to ChildLine at 1-800-932-0313
    • If a mandated reporters makes an oral report through ChildLine, they must also make a written report (“Report of Suspected Child Abuse” CY 47 form) within 48 hours to the Department or county agency assigned to the case. The CY 47 form can be obtained at www.keepkidssafe.pa.gov

The Reporting Process - After the Report Is Made

  1. ChildLine receives the report (either orally or electronically)
  2. ChildLine reviews all of the data and determines which county children and youth agency is should go to
  3. Once a determination is made on the county, ChildLine will immediately transmit the reports they received to the county agency and law enforcement, if appropriate

How is it Determined Where the Data Must be Distributed to?

  • Referral to county agency only (CPS)- If the alleged abuser falls under the definition of perpetrator, as per the CPSL, ChildLine will forward the data to the appropriate county agency for an investigation. This would be classified (at least initially) as a CPS case, as discussed at the beginning of the training
  • Referral to law enforcement officials only - If the alleged abuser is not a perpetrator as per the CPSL, and the behavior includes a violation of law, ChildLine will refer the data to the appropriate law enforcement officials
  • Referral to the county agency and law enforcement officials - If the alleged abuser falls under the definition of the perpetrator as per the CPSL and the behavior reported includes a criminal violation, ChidLine will forward the data to the appropriate county agency and law enforcement officials
  • Referral to the county agency (GPS)- If a report indicates that a child may need other protectives services, ChildLine will refer the report to the proper county agency to assess the needs of the child and provide services, when appropriate. This would be classified (at least initially as a GPS case, as discussed at the beginning of the training

Protections for Reporters

Immunity from Liability

A person, hospital, institution, school, facility, agency or agency employee acting in good faith shall have immunity from the 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
  2. Cooperating or consulting with an investigation 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 as it relates photographs, medical tests and x-rays of the child subject to report (section 6314); relating to taking a child into protective custody (section 6315; relating to admission to private and public hospitals (section 6316); relating to mandatory reporting and postmortem investigation of deaths (section 6317).

Departmental and County Agencies

An official or employee of the Department or county agency who refers a report a suspected child abuse for general protective services to law enforcement authorities or provides services as authorized by Chapter 63 shall have immunity from civil and criminal liability that might otherwise result from the action.

Presumption of Good Faith

For the purposes of any civil or criminal proceeding, the good faith of a mandated reporter as per the CPSL, and of any person required to make a referral to law enforcement officers.

Penalties for Failure to Report

  1. Mandated reporters required to report a case of suspected child abuse or to make a referral to the appropriate authorities commits an offense if the mandated reporter willfully fails to do so:
  2. An offense under Chapter 63 is a felony of the third degree if:
    1. The mandated reporter willfully fails to report
    2. The child abuse constitutes a felony of the first degree or higher; and
    3. The mandated reporter has direct knowledge of the nature of the abuse
  3. An offense not otherwise specified the previous lines, 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, provided that the report was made in a good faith effort to comply with the requirements

Continuing Course of Action

If a person’s willful failure continues while the person knows or has reasonable cause to believe the child is actively being subjected to child abuse, the person commits a misdemeanor of the first degree, except that if the child abuse constitutes a felony of the first degree or higher, the person commits a felony of the third degree.

Multiple Offenses of Failure to Report

A person who commits a second or subsequent offense commits a felony of the third degree, UNLESS the child abuse constitutes a felony of the first degree or higher, the penalty for the second or subsequent offenses is increased to a felony of the second degree.

Statute of Limitations

The statute of limitation for failure to report 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 report was made by a mandated reporter, the Department shall notify the mandated reporter who made the report of suspected child abuse of all of the following within three 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

Penalties for Failure to Report or Refer

  1. If a mandated reporter willfully fails to report suspected child abuse or to make a referral to the appropriate authorities commits an offense.
  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 previously is a misdemeanor of the second degree.

  4. If a mandated reporter makes a report to law enforcement or the appropriate county in lieu of a reporting to ChildLine, this is not an offense under this subsection, as long as the report was made in a good faith effort to comply with the requirements to report.

Differential Diagnosis

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[17]
  • Accidental bruises 
  • Accidental fractures 
  • Accidental burns
  • Accidental head injury 
  • Arteriovenous malformations 
  • Atopic dermatitis[18]
  • Bleeding or hemorrhagic disorder[19][20]
  • Birth trauma[21]
  • Caffey disease[22]
  • Chemical burn[23]
  • Coining[24]
  • Congenital syphilis[25]
  • Contact dermatitis
  • Cupping[24]
  • Erythema multiforme[26]
  • Factitious disorder
  • Hemangioma[27]
  • Henoch-Schönlein purpura[28]
  • Hypervitaminosis A[29]
  • Immune thrombocytopenic purpura[29]
  • Impetigo[30]
  • Inflammatory skin conditions 
  • Insect bites[31]
  • Osteogenesis imperfecta[32]
  • Osteomyelitis[33]
  • Osteopenia
  • Malignancy
  • Meningitis[34]
  • Menkes disease[35]
  • Metabolic disease
  • Mongolian spots[36]
  • Nevi[37]
  • Phytophotodermatitis[38]
  • Rickets [39]
  • Scurvy[40]
  • Sunburn[41]
  • Valsalva induced subconjunctival hemorrhage[42]

Complications

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

Consultations

  • Neurosurgery
  • Ophthalmologist
  • Orthopedic surgeon 
  • Child protective services
  • Social Wok
  • 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 will I be required to report?

  • Contact numbers and details regarding household members, parent/guardian, other persons responsible, alleged perpetrator, alleged abuse, body diagram, safety concerns, actions taken, and additional information.

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

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 have poor performance at school with decreased cognitive function. Clinicians need to have a high index of suspicion for child maltreatment since early identification may be lifesaving. Nurses, doctors, pharmacists, and all other healthcare workers should not hesitate to report child abuse.

When it comes to child abuse, all healthcare workers have a legal, medical, and moral obligation to identify the problem and report it. The majority of child abuse problems present to the Emergency Department; hence nurses and physicians in the ED 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. Even if child abuse is only suspected, the social worker must be informed so that the child can be followed as an outpatient. The law favors the clinician for reporting child abuse, even if it is only a suspicion. On the other hand, failing to report child abuse can have repercussions on the clinician. Unfortunately, despite the best practices, many children continue to suffer from child abuse.[43][44][45][7][8][10] [Level5]

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, signs of child abuse are missed, and thus healthcare workers must be vigilant of abuse in any child who presents with injuries that are out of place. [2][46](Level V). 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 to allow 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. [Level 5]



Contributed by Pennsylvania Department of Human Services
Article Details

Article Author

Munaza Batool Rizvi

Article Author

Gregory Conners

Article Author

Kevin King

Article Author

Richard Lopez

Article Editor:

Joni Rabiner

Updated:

8/1/2021 7:23:50 AM

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