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Child Abuse Recognition and Reporting in Pennsylvania - Act 31 (3 Hours)
Mandated Reporter Training

Online Continuing Education Course

Course Description

PENNSYLVANIA ACT 31 Mandated Training on Child Abuse Recognition and Reporting Requirement. 3-contact-hour training course for INITIAL LICENSE APPLICATION for all mandated reporters. Approved by the PA Department of Human Services, with daily electronic reporting to the Pennsylvania Department of State (DOS).

Course Price: $30.00

Contact Hours: 3

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This course is approved by the Pennsylvania Department of Human Services (PA CE Provider Number CACE000034) and fulfills the requirement for mandated reporters in Pennsylvania for 3 hours of training in recognizing and reporting child abuse.
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Child Abuse Recognition and Reporting in Pennsylvania – Act 31 (3 Hours)
Mandated Reporter Training

LEARNING OUTCOME AND OBJECTIVES:  Upon completion of this course, you will be better prepared to recognize and report child abuse, child maltreatment, and child neglect. Specific learning objectives include:

  • Describe child welfare in Pennsylvania.
  • Differentiate between Child Protective Services and General Protective Services.
  • Define child abuse components, categories, and exclusions.
  • Recognize indicators of child abuse.
  • List provisions and responsibilities for reporting suspected child abuse.
  • Identify the reporting process for suspected child abuse, including protections for reporters and penalties for failure to report.
  • Explain the mandated reporters’ Right-to-Know.

CHILD WELFARE IN PENNSYLVANIA


The goal of the child welfare system in Pennsylvania is to provide for the safety and well-being of children and to protect them from abuse and neglect. Pennsylvania’s child welfare system is supervised by the state and administered by the Children and Youth Agencies of each county. The state’s Department of Human Services (DHS) oversees the child welfare system and provides technical assistance through the Office of Children, Youth, and Families (OCYF).

Two-Track Services

Two tracks of child welfare services exist in Pennsylvania: Child Protective Services (CPS) and General Protective Services (GPS). CPS refers to those referrals to the statewide child abuse hotline, ChildLine, that are registered as suspected child abuse.

CHILDLINE

ChildLine provides information, counseling, and referral services for families and children to ensure safety and well-being of the children of Pennsylvania. The toll-free intake line, 800-932-0313, is available 24 hours a day, seven days a week to receive reports of suspected child abuse (PA Family Support Alliance, 2018b).

To be registered as suspected child abuse, referrals must contain allegations of incidents that meet the definition of child abuse. All other referrals that do not allege suspected child abuse but still present concerns for a child’s safety or well-being are considered GPS.

  • Child protective services are implemented when there is reasonable cause to suspect child abuse and the need for an investigation. Emergency medical services and out-of-home placement are provided when necessary for high-risk situations. CPS is contacted when at least one type of child abuse is suspected: physical, mental, sexual, or neglect. This type of response is often referred to as a traditional response.
  • General protective services are offered when there is concern about something in the home or for nonabuse cases that require support and services to prevent harm to the child. Examples include poor hygiene, inappropriate discipline, inadequate supervision, truancy, and inadequate shelter or clothing. There is no investigation component to this response. GPS protects the welfare and safety of children by offering assistance to parents in fulfilling their parental duties and by helping them to recognize and correct potentially harmful conditions. This type of response may also be called an alternative response.

Providing both CPS and GPS is known as a differential response (DR). DR is a more flexible approach to assisting families in response to reports of suspected child abuse. In cases not deemed to be child abuse, interactions between social workers and parents become less adversarial. Social workers’ presence is perceived as more supportive, as professionals focus on connecting families to needed services. (Task Force, 2012).

CHILD WELFARE INFORMATION SOLUTION

In order to encourage reporting, the reporting process has been streamlined. In January 2015, the Pennsylvania Department of Human Services introduced the Child Welfare Information Solution (CWIS). CWIS is a contemporary case management system that provides immediate electronic sharing of state and county information that is necessary to conduct the child welfare program.

CWIS makes critical statewide child welfare information available from each county. Through this system, county caseworkers have access to needed data to assist them in protecting children from abuse and neglect. DHS can collect reports from county Children and Youth Agencies about both child abuse and children who need general protective services. The creation of this database came about through Act 29 of 2014, an amendment to the Child Protective Services Law (PA DHS, 2015a).

Determining Type of Response

When a referral for possible child abuse is received by a caseworker, social worker, or supervisor, a decision is made as to whether the case will be assigned to GPS or CPS. The person who chooses the type of response varies according to the protocols of each jurisdiction, but the decision is generally made immediately. The choice of the type of response (GPS or CPS) is dependent on the nature of the allegation as well as other factors using criteria that are determined by the agencies (Task Force, 2012).

DIFFERENTIATING BETWEEN CPS AND GPS
Child Protective Services (CPS) General Protective Services (GPS)
Source: Pennsylvania Partnerships for Children, 2012.
For situations that meet the definition of child abuse For situations that can cause harm to children but do not meet the definition of child abuse
  • Similar to a law-enforcement investigation
  • May result in a perpetrator being identified
  • May involve joint investigations with social services, law enforcement, and medical professionals
  • No attempt to identify a perpetrator or determine if abuse occurred
  • Urgent time frame
  • Time frame determined by the level of risk and imminent danger
  • Goal of investigation is to determine if abuse occurred
  • Goal of assessment is to determine family needs to promote child safety and well-being and then provide services
  • Not reassigned to GPS
  • If situation is not determined to meet the definition of child abuse, case is classified as unfounded
  • Can be reassigned to CPS if situation is found to meet the definition of child abuse
  • Investigation must be completed in 30 days
  • Investigation can be extended to 60 days if necessary in order to collaborate with law enforcement
  • County agency personnel must respond immediately if the child was placed in emergency protective custody, or if emergency placement is needed or may be needed but cannot be determined by the report
  • Entire assessment must be completed in 60 days
  • Services are involuntary
  • Services are voluntary
  • Services may be court-ordered if the family refuses services and a child’s safety is in question
  • A perpetrator’s name may be listed in the ChildLine registry if indicated
  • Assessment will not generate the name of a perpetrator to be listed in the ChildLine registry
CASE

Sharon, a sixth-grade math teacher, stops by her friend Janie’s house for coffee. While she is there, Janie’s 5-year-old son, Bobby, who has been diagnosed with autism, runs into the kitchen and for no apparent reason shoves his 2-year-old sister, who falls to the floor. The sister is not injured, but Janie yells at Bobby, picks him up, and throws him across the kitchen, where he slides into a cabinet, hitting the back of his head.

Concerned for his well-being, Sharon examines Bobby and finds that he is uninjured. Even so, Sharon recognizes the importance of taking action for the safety of her friend’s young son. She empathizes with her friend and expresses her concern for the family. She acknowledges how frightening and stressful it must be for Janie to have a child with a serious condition and asks Janie if she could refer Bobby to a program for autistic children that is provided by the school district. Janie tearfully agrees, and Sharon makes a few calls to the school district to gather information about the program.

Sharon, who is a mandated reporter, next makes a report to ChildLine. In her report, Sharon describes Janie’s desire to help her child and her voluntary interest in a referral to services that can help her.

Sharon makes a point to call Janie the next day and frequently thereafter. One month later, Janie tells Sharon that General Protective Services has helped her find a program in which she is learning appropriate new ways of dealing with Bobby’s acting-out behaviors.

WHAT IS CHILD ABUSE?

It is imperative that healthcare professionals and other mandated reporters know how the various categories of child abuse are defined.

Categories of Child Abuse

Child abuse may take many forms. Pennsylvania’s Child Protective Services Law (CPSL) categorizes abuse into the following types:

  • Physical
  • Mental
  • Sexual
  • Neglect
  • Severe forms of trafficking in persons (human trafficking)

Mandated reporters must learn to recognize the indicators for the various forms of child abuse (PFSA, 2018a). (See also “Recognizing Abuse” later in this course.)

DEFINITIONS OF TERMINOLOGY RELATED TO CHILD ABUSE
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 or failure to act
Any act or failure to act committed within two years of the date of the report to the department or county agency
Child
An individual under 18 years of age
Direct contact with children
Care, supervision, guidance, or control of children or routine interaction with 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, or control
Student
An individual enrolled in a public or private school, intermediate unit, or area vocational-technical school who is under 18 years of age
School employee
An individual employed by a school or who provides a program, activity, or service sponsored by a school (does not apply to administrative or other support personnel unless the administrative or other support personnel have direct contact with the children)
Bodily injury
Causing substantial pain or any impairment in physical condition (replaces term serious physical injury, which was deleted by amendment from the statute)
Serious mental injury
A psychological condition, as diagnosed by a physician or licensed psychologist, including the refusal of appropriate treatment, that:
  1. 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
  2. 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:
  1. A repeated, prolonged, or egregious failure to supervise a child in a manner that is appropriate considering the child’s developmental age and abilities
  2. The failure to provide a child with adequate essentials of life, including food, shelter, or medical care
Severe forms of trafficking in persons (human trafficking)
  1. Sex trafficking in which a commercial sex act is induced by force, fraud, or coercion, or in which the person induced to perform such act has not obtained 18 years of age (i.e., sex trafficking does not require there be force, fraud, or coercion if the victim is under 18). Examples include prostitution, pornography, exotic dancing, etc.
  2. Labor trafficking in which labor is obtained by use of threat or serious harm, physical restraint, or abuse of legal process, including the recruitment, harboring, transportation, provision, or obtaining of a person for labor or 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 (a condition compared to that of a slave in respect to exhausting labor or restricted freedom). Examples include being forced to work for little or no pay (frequently in factories or on farms) or domestic servitude (providing child care, cooking, cleaning, yardwork, gardening from 10 to 16 hours per day).

Sources: 23 Pa. C.S. § 6303; U.S. Public Law 106-386 § 103.

Definition of Child Abuse

CPSL, 23 Pa. C.S. § 6303, defines “child abuse” as intentionally, knowingly, or recklessly doing any of the following:

  1. Causing bodily injury to a child through any recent act or failure to act
  2. 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
  3. 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
  4. Causing sexual abuse or exploitation of a child through any act or failure to act (see also “Sexual Abuse or Exploitation” below)
  5. Creating a reasonable likelihood of bodily injury to a child through any recent act or failure to act
  6. Creating a likelihood of sexual abuse or exploitation of a child through any recent act or failure to act
  7. Causing serious physical neglect of a child
  8. Engaging in any of the following recent acts:
    1. Kicking, biting, throwing, burning, stabbing, or cutting a child in a manner that endangers the child
    2. Unreasonably restraining or confining a child, based on consideration of the method, location, or the duration of the restraint or confinement
    3. Forcefully shaking a child under one year of age
    4. Forcefully slapping or otherwise striking a child under one year of age
    5. Interfering with the breathing of a child
    6. Causing a child to be present [when the] operation of methamphetamine laboratory is occurring
    7. 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 sexual offender … has been determined to be a sexually violent predator … has been determined to be a sexually violent delinquent child
  9. Causing the death of the child through any act or failure to act
  10. 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

Definition of Sexual Abuse or Exploitation

CPSL, 23 Pa. C.S. § 6303, further defines “sexual abuse or exploitation” as any of the following:

  1. 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, the following:
    1. Looking at the sexual or other intimate parts of a child or another individual for the purpose of arousing or gratifying sexual desire in any individual
    2. Participating in sexually explicit conversation either in person, by telephone, by computer, or by a computer-aided device for the purpose of sexual stimulation or gratification of any individual
    3. Actual or simulated sexual activity or nudity for the purpose of sexual stimulation or gratification of any individual
    4. Actual or simulated sexual activity for the purpose of producing visual depiction, including photographing, videotaping, computer depicting, or filming (This paragraph does not include consensual activities between a child who is 14 years of age or older and another person who is 14 years of age or older and whose age is within four years of the child’s age.)
  2. Any of the following offenses committed against a child:
    1. Rape (as defined in 18 Pa.C.S. § 3121)
    2. Statutory sexual assault (as defined in 18 Pa.C.S. § 3122.1)
    3. Involuntary deviate sexual intercourse (as defined in 18 Pa.C.S. § 3123)
    4. Sexual assault (as defined in 18 Pa.C.S. § 3124.1)
    5. Institutional sexual assault (as defined in 18 Pa.C.S. § 3124.2)
    6. Aggravated indecent assault (as defined in 18 Pa.C.S. § 3125)
    7. Indecent assault (as defined in 18 Pa.C.S. § 3126)
    8. Indecent exposure (as defined in 18 Pa.C.S. § 3127)
    9. Incest (as defined in 18 Pa.C.S. § 4302)
    10. Prostitution (as defined in 18 Pa.C.S. § 5902)
    11. Sexual abuse (as defined in 18 Pa.C.S. § 6312)
    12. Unlawful contact with a minor (as defined in 18 Pa.C.S. § 6318)
    13. Sexual exploitation (as defined in 18 Pa.C.S. § 6320)

Definition of Perpetrator

A “perpetrator” is a person who has committed child abuse and who is:

  • 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 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 service, a school, or through a program, activity, or service
  • An individual 14 years of age or older who resides in the same home as the child
  • 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
  • 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
    (23 Pa. C.S. § 6304)

In cases involving “failure to act,” perpetrators include only the following:

  • 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 18 years of age or older and responsible for the child’s welfare
  • A person 18 years of age or older who resides in the same home as the child
    (23 Pa. C.S. § 6304)

Current Pennsylvania law expanded the previous definition of perpetrators to include relatives who do not live with the child as well as those engaging a child in trafficking. It also now includes those responsible for the child’s welfare, defined as:

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. The term includes any such person who has direct or regular contact with a child through any program, activity, or service sponsored by a school, for-profit organization, or religious or other not-for-profit organization.

Exclusions

There are two types of exclusions described in the law. “Exclusions to reporting” are instances in which a child may suffer harm but for which a mandated reporter is not required to make a report. “Exclusions to child abuse” (sometimes called “exclusions to substantiating a report”) are instances in which harm to a child must be reported but for which the investigating team may determine that no child abuse has occurred.

EXCLUSIONS TO REPORTING

There are very few situations that do not require a mandated report of suspected child abuse when children are harmed. These include:

  • Confidential communications made to a member of the clergy within the scope of that privilege.
  • Confidential communications made to an attorney under attorney-client privilege and attorney-work product rules, such as a direct confession of child abuse to a family law attorney by a client.

However, the area of privileged communication between any mandated reporter and a client does not apply to situations of suspected child abuse. This includes counselors, school psychologists, and social workers. These persons have an absolute duty to report suspected abuse without exception (23 Pa. C.S. § 6311.1).

EXCLUSIONS TO SUBSTANTIATING A REPORT

Section 6304 of the CPSL explains situations that are considered “exclusions to child abuse.” Such situations must still be reported. At times, however, the CPS investigation may reveal other factors and the report found to be unsubstantiated. That is, the child will not be deemed to be abused.

The following circumstances are exclusions to substantiation of a child abuse report and might result in implementing GPS services rather than CPS services:

  1. Environmental factors, such as inadequate housing, furnishings, income, clothing, or medical care that are beyond the control of the parent or person with whom the child lives
  2. Practice of a bona fide religion that upholds beliefs that are maintained by the child’s parents or relatives with whom the child resides that prevent the child from receiving medical or surgical care. In such cases:
    1. 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.
    2. 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.
    3. The family shall be referred for general protective services, if appropriate.
    4. This subsection shall not apply if the failure to provide needed medical or surgical care causes the death of the child.
    5. This subsection shall not apply to any childcare service as defined in this chapter, excluding an adoptive parent.
  3. Use of force for supervision, control, and safety purposes if the force is incidental, reasonable, or minor physical contact designed to maintain order and control, or if it is necessary to control a disturbance or remove the child from a situation where he or she is at risk for physical injury; to prevent the child from self-harm; for self-defense or to defend another person; or to obtain weapons, dangerous objects, controlled substances, or paraphernalia from the child
  4. Parental rights to use reasonable force for the purposes of supervision, control, or discipline
  5. Participation in events that involve physical contact with a child such as sports, physical education, or recreational activities
  6. Child-on-child contact that results in harm or injury when the child who caused the harm or injury may not be defined as a perpetrator
  7. Defensive force that is reasonable force for self-defense or the defense of another individual that is used for self-protection or for the protection of another person
    (23 Pa.C.S. § 6304; RCPA, 2014)

RISK FACTORS

Health professionals must remain alert for risk factors that may increase the likelihood of child abuse and maltreatment. Risk factors may be either characteristics of a caregiver or of a child and may go undetected.

The Centers for Disease Control and Prevention (CDC) cites the following caregiver risk factors:

  • Parents’ lack of understanding of children’s needs, child development, and parenting skills
  • Parents’ history of child maltreatment in family of origin
  • Substance abuse and/or mental health issues, including depression in the family
  • Parental characteristics such as young age, low education, single parenthood, large number of dependent children, and low income
  • Nonbiological, transient caregivers in the home (e.g., mother’s boyfriend)
  • Parental thoughts and emotions that tend to support or justify maltreatment behaviors
    (CDC, 2017)

The following characteristics of children were determined to be risk factors:

  • Children younger than 4 years of age
  • Special needs that may increase caregiver burden
  • Physical disability
  • Intellectual disability
  • Mental health issues
  • Chronic physical illnesses
    (CDC, 2017)

Additional risk factors include:

  • Social isolation
  • Family disorganization, dissolution, and violence, including intimate partner violence
  • Parenting stress, poor parent-child relationships, and negative interactions
  • Community violence
  • Concentrated neighborhood disadvantage (e.g., high poverty and residential instability, high unemployment rates, and high density of alcohol sales outlets)
  • Poor social connections
    (CDC, 2017)

Risk factors for human trafficking among youth populations include those youth:

  • In the foster care system
  • Who identify as LGBTQI
  • Who are homeless or runaway
  • With disabilities
  • With mental health or substance abuse disorders
  • With a history of sexual abuse
  • With a history of being involved in the welfare system
  • Who identify as native or aboriginal
  • With family dysfunction
  • Who are foreign nationals
  • Who are living on their own
    (AFRJ, 2018)
PARENTAL SUBSTANCE ABUSE AND CHILD ABUSE

Parental substance abuse greatly increases the incidence of child abuse and neglect. A review of research on parental substance abuse and its impact on children showed that:

  • 1 in 5 American children live in homes with parental substance abuse.
  • Children who grow up in homes with prevalent substance abuse are more likely to misuse drugs and alcohol; this leads to multigenerational cycles of addiction.
  • Parents who are struggling with substance use disorders are often unable to meet basic physical, psychological, and emotional needs for their children.
  • Children whose parents use drugs and misuse alcohol are three times more likely to be physically, sexually, or emotionally abused than their peers.
  • Children whose parents use drugs and misuse alcohol are four times more likely to be neglected than their peers.
    (Bergland, 2016)

RECOGNIZING ABUSE

Recognizing Physical Abuse

The category of physical abuse involves any recent act or failure to act by a perpetrator that causes bodily injury to a child. Bodily injury is defined in the CPSL as “impairment of physical condition or substantial pain” (23 Pa.C.S. § 6303).

PHYSICAL INDICATORS OF PHYSICAL ABUSE

Mandatory and permissive reporters need to be alert for physical injuries that are unexplained or inconsistent with a parent’s or other caretaker’s explanation and/or the developmental state of the child.

Bruising

It is important to know both normal and suspicious bruising patterns when assessing children’s injuries. Some red flags for nonaccidental bruising, if observed, should signal suspicion. In particular, the following injuries are worrisome:

  • Bruises in babies who are not yet cruising
  • Bruises on the ears, neck, feet, buttocks, or torso (torso includes chest, back, abdomen, genitalia)
  • Bruises not on the front of the body and/or overlying bone
  • Bruises that are unusually large or numerous
  • Bruises that are clustered or patterned (patterns may include handprints, loop or belt marks, bite marks)
  • Black eyes
  • Bruises around the wrists or ankles (indicating that someone may have tied up the child)
  • Bruises that do not fit with the causal mechanism described
    (Healthy Place, 2016; NSPCC, 2018)
Assessing children's injuries for possible indications of child abuse

Normal and suspicious bruising areas. (Source: Research Foundation of SUNY, 2011.)

Evidence of bruising on child's face indicating possible child abuse

This pattern signals the blow of a hand to the face of a child. (Source: Research Foundation of SUNY, 2011.)

Evidence of arm injuries indicating child abuse

Regular patterns reveal that a looped cord was used to inflict injury on this child. (Source: Research Foundation of SUNY, 2011.)

Lacerations or Abrasions

Typical indications of unexplained lacerations and abrasions that are suspicious include:

  • To mouth, lips, gums, eyes
  • To external genitalia
  • On backs of arms, legs, or torso
  • Human bite marks (these compress the flesh, in contrast to animal bites, which tear the flesh and leave narrower teeth imprints)
    (Healthy Place, 2016; NSPCC, 2018)
Burns

Typical indications of unexplained burns include worrisome:

  • Cigar or cigarette burns, especially on soles, palms, back, or buttocks
  • Immersion burns by scalding water (sock-like, glove-like, doughnut-shaped on buttocks or genitalia; “dunking syndrome”)
  • Patterned like an electric burner, iron, curling iron, or other household appliance
  • Rope burns on arms, legs, neck, or torso
    (Healthy Place, 2016; NSPCC, 2018)
Evidence of arm burn injury, indicating child abuse

A steam iron was used to inflict injury on this child. (Source: Research Foundation of SUNY, 2011.)

Fractures

Typical indications of unexplained fractures include:

  • Fractures to the skull, nose, or facial structure
  • Fractures to the ribs or the leg bones in babies
  • Skeletal trauma with other injuries, such as dislocations
  • Multiple fractures (especially bilateral)
  • Fractures in various stages of healing
  • Swollen or tender limbs
    (Flaherty et al., 2014; NSPCC, 2018)
Head Injuries

Typical indications of unexplained head injuries include:

  • Absence of hair and/or hemorrhaging beneath the scalp due to vigorous hair pulling
  • Subdural hematoma (a hemorrhage beneath the outer covering of the brain, due to severe hitting or shaking)
  • Retinal hemorrhage or detachment, due to shaking
  • Whiplash or pediatric abusive head trauma (see box below)
  • Eye injury
  • Jaw and nasal fractures
  • Tooth or frenulum (of the tongue or lips) injury
    (Healthy Place, 2016; NHAC, 2018)
PEDIATRIC ABUSIVE HEAD TRAUMA

Pediatric abusive head trauma (PAHT) (formerly referred to as shaken baby syndrome) is the third leading cause of head injury in children and the leading cause of serious head injury in the first year of life in the United States (Brown et al., 2016). The CDC defines pediatric abusive head trauma (AHT) as an injury to the skull or intracranial contents of an infant or young child (<5 years of age) due to inflicted blunt impact and/or violent shaking. Simply defined, AHT is child physical abuse that results in injury to the head or brain (Parks et al., 2012).

The clinical presentation of infants or children with AHT can vary. PAHT diagnosis generally includes subdural hematomas, retinal bleeding, fractures, cerebral edema, and rib or long bone fractures (Brown et al., 2016). Other possible findings associated with AHT may include:

  • Lethargy/decreased muscle tone
  • Extreme irritability
  • Decreased appetite, poor feeding, or vomiting for no apparent reason
  • Absence of smiling or vocalization
  • Poor sucking or swallowing
  • Rigidity or posturing
  • Difficulty breathing
  • Seizures
  • Head or forehead appears larger than usual
  • Fontanel (soft spot) bulging
  • Inability to lift head
  • Inability of eyes to focus or track movement; unequal size of pupils
  • Vomiting
  • Apnea
    (Brown et al., 2016; KidsHealth.org, 2018)

Long-term effects of PAHT may be serious and include such issues as blindness, hearing loss, learning difficulties, and impaired intellect (KidsHealth.org, 2018).

BEHAVIORAL INDICATORS OF PHYSICAL ABUSE

Careful assessment of a child’s behavior may also indicate physical abuse, even in the absence of obvious physical injury. Behavioral indicators of physical abuse include the following:

  • Shows fear of going home, fear of parents
  • Apprehensive when other children cry
  • Exhibits aggressive, destructive, or disruptive behavior
  • Exhibits passive, withdrawn, or emotionless behavior
  • Reports injury by parents
  • Displays habit disorders
    • Self-injurious behaviors (e.g., cutting)
    • Psychoneurotic reactions (e.g., obsessions, phobias, compulsiveness, hypochondria)
  • Wears long sleeves or other concealing clothing, even in hot weather, to hide physical injuries
  • Seeks affection from any adult
    (Mayo Clinic, 2015)

Presence of the following parent or other persons legally responsible behaviors may also indicate an abusive relationship:

  • Seems unconcerned about the child
  • Takes an unusual amount of time to obtain medical care for the child
  • Offers inadequate or inappropriate explanation for the child’s injury
  • Offers conflicting explanations for the same injury
  • Misuses alcohol or other drugs
  • Disciplines the child too harshly considering the child’s age or what he or she did wrong
  • Sees the child as bad, evil, etc.
  • Has a history of abuse as a child
  • Attempts to conceal the child’s injury
  • Takes the child to a different doctor or hospital for each injury
  • Shows poor impulse control or lack of emotional control
  • Lacks support network; is isolated from family and friends
  • Has poor self-esteem
  • Uses the child to meet his/her own physical and/or emotional needs
  • Lacks parenting knowledge
  • Lacks interpersonal skills
  • Has unrealistically high standards and expectations for the child
    (Clermont County CPS, 2018)
FACTITIOUS DISORDER IMPOSED ON ANOTHER

Factitious disorder imposed on another (FDIA), formerly known as Munchausen syndrome by proxy (MSP), is a mental illness as well as a form of child abuse. In FDIA, an adult perpetrator (most often the child’s mother) falsifies an illness in the child to gain attention from healthcare professionals, family, friends, and, in some cases, general members of the community. There are not other obvious external rewards such as monetary gain (APA, 2013; Cleveland Clinic, 2014).

It is important to note that the perpetrator, not the child, receives this diagnosis.

Possible warning signs of FDIA in children include:

  • The child has a history of many hospitalizations often accompanied by an unusual set of symptoms.
  • Worsening of the child’s symptoms is usually reported by the perpetrator and is not witnessed by healthcare professionals.
  • The child’s reported condition and symptoms do not agree with results of diagnostic tests.
  • There might be a history of more than one unusual illness or death of children in the family.
  • The child’s condition improves when hospitalized but worsens when the child returns home.
  • Blood in lab samples might not match the child’s blood (e.g., parent “switches” the child’s blood for someone else’s blood).
  • There might be signs of chemicals in the child’s blood, stool, or urine.
    (Cleveland Clinic, 2014)

Recognizing Mental Abuse

The category of mental abuse includes any act or failure to act by a perpetrator that results in serious mental injury. Serious mental injury is defined by the CPSL as a psychological condition diagnosed by a physician or licensed psychologist that:

  • Renders the child chronically and severely anxious, depressed, socially withdrawn, psychotic, or in reasonable fear that his/her safety is threatened
  • Seriously interferes with the child’s ability to accomplish age-appropriate developmental and social tasks
    (23 Pa. C.S. § 6303)

Examples of child indicators of serious mental injury include:

  • Depression
  • Mental or emotional developmental delays
  • Self-injurious behaviors
  • Antisocial behaviors
  • Delinquent behaviors
  • Alcohol or drug abuse
  • Neurotic traits
  • Habit disorders (sucking, nail biting, rocking, etc.)
  • Psychoneurotic reactions (hysteria, obsessive-compulsive behaviors, phobias, hypochondria)
  • Extreme behavior (compliant or passive, aggressive or demanding)
  • Overly adaptive behavior (inappropriately adult, inappropriately infantile)
  • Delays in mental and/or emotional development
  • Suicide attempt

A parent or guardian exhibiting the following indicators may be a perpetrator of mental abuse:

  • Treats children in the family unequally
  • Seems not to care much about the child’s problems
  • Blames or belittles the child
  • Is cold and rejecting
  • Behaves inconsistently toward the child
    (CWIG, 2013)

Recognizing Sexual Abuse

(See also “Definition of Sexual Abuse or Exploitation” earlier in this course.)

Child sexual abuse involves the coercion of a dependent, developmentally immature person to commit a sexual act with someone older. For example, an adult may sexually abuse a child or adolescent, or an older child or adolescent may abuse a younger child. A perpetrator does not have to be an adult in order to sexually abuse a child (RAINN, 2018).

Most perpetrators of child sexual abuse are people who are known to the victim. As many as 93% of children who are sexually abused under the age of 18 know the abuser (RAINN, 2018). Anyone, even a mother, can be a perpetrator, but most are male.

The fact that such abuse is carried out by a family member or friend further increases the child’s reluctance to disclose the abuse, as does shame and guilt plus the fear of not being believed. The child may fear being hurt or even killed for telling the truth and may keep the secret rather than risk the consequences of disclosure. Very young children may not have sufficient language skills or vocabulary to describe what happened (Clermont County CPS, 2018; RAINN, 2018).

Child sexual abuse is found in every race, culture, and class throughout society. Girls are sexually abused more often than boys; however, this may be due to boys’—and later, men’s—tendency not to report their victimization.

There is no particular profile of a child molester or of the typical victim. Even someone highly respected in the community—the parish priest, a teacher, or coach—may be guilty of child sexual abuse.

Negative effects of sexual abuse vary from person to person and range from mild to severe in both the short and long term. Victims may exhibit anxiety, difficulty concentrating, and depression. They may develop eating disorders, self-injury behaviors, substance abuse, or suicide. The effects of childhood sexual abuse often persist into adulthood (Clermont County CPS, 2018; RAINN, 2018).

PHYSICAL INDICATORS OF SEXUAL ABUSE

Physical evidence of sexual abuse may not be present or may be overlooked. Victims of child sexual abuse are seldom injured due to the nature of the acts. Most perpetrators of child sexual abuse go to great lengths to “groom” the children by rewarding them with gifts and attention and try to avoid causing them pain in order to ensure that the relationship will continue.

If physical indicators occur, they may include:

  • Symptoms of sexually transmitted diseases, including oral infections, especially in preteens
  • Difficulty in walking or sitting
  • Torn, stained, or bloody underwear
  • Pain, itching, bruising, or bleeding in the genital or anal area
  • Bruises to the hard or soft palate
  • Pregnancy, especially in early adolescence
  • Painful discharge of urine and/or repeated urinary infections
  • Foreign bodies in the vagina or rectum
  • Painful bowel movements
    (Clermont County CPS, 2018; RAINN, 2018)

BEHAVIORAL INDICATORS OF SEXUAL ABUSE

Children’s behavioral indicators of child sexual abuse include:

  • Unwillingness to change clothes for or participate in physical education activities
  • Withdrawal, fantasy, or regressive behavior, such as returning to bedwetting or thumb-sucking
  • Bizarre, suggestive, or promiscuous sexual behavior or knowledge
  • Verbal disclosure of sexual assault
  • Being commercially sexually exploited (trafficked)
  • Forcing sexual acts on other children
  • Extreme fear of closeness or physical examination
  • Suicide attempts or other self-injurious behaviors
  • Inappropriate sexual behavior
  • Inappropriate sexual knowledge for age
  • Layered or inappropriate clothing
  • Hiding clothing
  • Lack of interest or involvement in activities
    (Clermont County CPS, 2018; RAINN, 2018)

Sexually abusive parents/guardians or other persons legally responsible may exhibit the following behaviors:

  • Very protective or jealous of child
  • Encourages child to engage in prostitution or sexual acts in presence of the caretaker
  • Misuses alcohol or other drugs
  • Is geographically isolated and/or lacking in social and emotional contacts outside the family
  • Has low self-esteem
    (Clermont County CPS, 2018; RAINN, 2018)

Recognizing Trafficking

Victims of trafficking are abused physically, psychologically, and emotionally. The perpetrator/trafficker controls these victims even when they are not physically restrained or confined.

INDICATORS OF SEX TRAFFICKING

Sex trafficking involves a commercial sex act induced by force, fraud, or coercion, or in which the person induced to perform such act has not obtained 18 years of age (i.e., sex trafficking does not require there be force, fraud, or coercion if the victim is under 18). Examples include prostitution, pornography, exotic dancing, etc.

Indicators of child sex trafficking include:

  • Signs of current physical abuse and/or sexually transmitted diseases
  • History of running away or current status as a runaway
  • Inexplicable appearance of expensive gifts, clothing, cell phones, tattoos, or other costly items
  • Presence of an older boyfriend or girlfriend
  • Drug addiction
  • Withdrawal or lack of interest in previous activities
  • Gang involvement
    (PFSA, 2018a)

Victims of sex trafficking often suffer from injuries and other physical and mental health issues such as:

  • Anogenital trauma
  • Bruises, abrasions, lacerations, burns
  • Patterned injuries from belts, ligatures, etc.
  • Head injuries
  • Injuries resulting from being dragged or run over by a car
  • Areas of alopecia due to hair being pulled out
  • Pregnancy and abortion
  • Fractures
  • Sexually transmitted infections
  • Tuberculosis
  • Pelvic inflammatory disease
  • Drug and alcohol addiction or withdrawal symptoms
  • Urinary tract infections
  • Gastrointestinal and respiratory problems
  • Asthma, diabetes, and dental problems that are untreated or not diagnosed
  • Headache and back problems
  • Malnourishment, dehydration
  • Poor hygiene
  • Depression and suicidal thoughts
  • Anxiety, panic attacks, agoraphobia
  • Poor self-esteem, shame, guilt
  • Fear for the safety of family
  • PTSD and memory loss
    (Ark of Hope for Children, 2017)

INDICATORS OF LABOR TRAFFICKING

Labor trafficking involves labor obtained by use of threat or serious harm, physical restraint, or abuse of legal process, including the recruitment, harboring, transportation, provision, or obtaining of a person for labor or 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 (a condition compared to that of a slave in respect to exhausting labor or restricted freedom).

Examples of labor trafficking include agricultural or domestic service workers who are underpaid or not paid at all, physically abusive traveling sales crews that force children to sell legal items (e.g., magazines) or illegal items (e.g., drugs) or to beg, and workers in restaurants and hair and nail salons who are abused, confined, and/or not paid.

Indicators of child labor trafficking include:

  • No freedom to leave or come and go as desired
  • No or very little pay, or payment only through tips
  • Excessive and/or unusual work hours
  • No breaks at work
  • A large debt that cannot be paid off
  • Recruitment through false promises concerning the nature and conditions of the work
  • High security measures in the work and/or living locations
  • Lack of knowledge of whereabouts and/or lost sense of time

It is imperative that all healthcare professionals recognize labor trafficking and report its existence to the appropriate authorities.

Recognizing Physical Neglect

The category of neglect is defined in the CPSL as serious physical neglect by a perpetrator constituting prolonged or repeated lack of supervision or the failure to provide the essentials of life, including adequate medical care, which endangers a child’s life or development or impairs the child’s functioning (23 Pa. C.S. § 6303).

A child may demonstrate indicators of neglect such as:

  • Begging or stealing food
  • Extended stays at school (early arrival or late departure)
  • Constant fatigue, listlessness, or falling asleep in class
  • Alcohol or other substance abuse
  • Delinquency, such as thefts
  • Reports there is no caretaker at home
  • Runaway behavior
  • Habit disorders (sucking, nail biting, rocking, etc.)
  • Conduct disorders (antisocial or destructive behaviors)
  • Neurotic traits (sleep disorders, inhibition of play)
  • Psychoneurotic reactions (hysteria, obsessive-compulsive behaviors, phobias, hypochondria)
  • Extreme behavior (compliant or passive, aggressive or demanding)
  • Overly adaptive behavior (inappropriately adult, inappropriately infantile)
  • Delays in mental and/or emotional development
  • Suicide attempt
    (Clermont County CPS, 2018)
ABANDONMENT OF AN INFANT

Another form of neglect is abandonment of an infant. However Pennsylvania’s Safe Haven law allows parents to relinquish newborns up to 28 days old at any hospital or to a police officer at a police station without the fear of criminal prosecution as long as the baby has not been harmed. The purpose of such laws is to decriminalize leaving unharmed infants anonymously in a safe location in order to save the lives of these unwanted infants.

  • The baby may be given to a hospital staff member without the parent providing any further information. The baby may also be left at a hospital without giving it to anyone, and some hospitals even have a crib or bassinet available for that purpose.
  • If a baby is relinquished to a police station, it must be given to a police officer.
    (PA DHS, 2015c)

Any mandated reporter who learns of abandonment is obligated to fulfill mandated reporter responsibilities (see “Provisions and Responsibilities for Reporting Suspected Child Abuse” later in this course). Failure to report acceptance of newborns is considered to be an offense. A healthcare provider who intentionally or knowingly fails to report the acceptance of a newborn commits a summary offense. A second or subsequent failure to report such acceptance is considered to be a misdemeanor of the third degree [punishable by up to one year of incarceration and no more than $2,500 in fines] (U.S. Legal, 2014).

RECOGNIZING AND RESPONDING TO VICTIMS’ DISCLOSURES

It is difficult for young children to describe abuse and they may only disclose part of what happened initially. It is important not to rush the child and to listen to his or her concerns. If a child discloses abuse, the following actions will help the child:

  • Remain calm and do not allow the child to see any initial response of shock.
  • Thank the child for telling you.
  • Use age-appropriate language and use terms that the child uses to describe anatomical parts.
  • Ask who, what, when, and where so that you will have the information to report to CPS.
  • Ask open-ended questions as opposed to leading questions.
  • Do not make promises that you cannot keep.
  • Explain to the child that he or she may need to repeat this information to someone else.
  • Document what the child tells you using the child’s own words. Use quotations whenever possible.
    (Botash, 2014a; 2014b)

Victimized children may cry out in a variety of nonverbal or indirect ways, for example, a drawing left behind for a teacher, counselor, or trusted relative to see. Some children report vague somatic symptoms to a school nurse, hoping the nurse will guess what happened. To the child, this indirect approach is not betrayal of the abuser and therefore not grounds for punishment.

Some children may come to a trusted teacher or other professional and talk directly and specifically about their situation if that person has established a safe, nurturing environment and a sense of trust. More commonly, however, abused children use other, less direct approaches, such as:

  • Indirect hints. “My brother wouldn’t let me sleep last night.” “My babysitter keeps bothering me.” Appropriate responses would be invitations to say more, such as, “Is it something you are happy about?” and open-ended questions such as, “Can you tell me more?” or “What do you mean?” Gently encourage the child to be more specific. Let the child use his or her own language and do not suggest other words to the child.
  • Disguised disclosure. “What would happen if a girl told someone her mother beat her?” “I know someone who is being touched in a bad way.” An appropriate response would be to encourage the child to state what he or she knows about the “other child.” It is probable that the child will eventually divulge who the abused child really is.
  • Disclosure with strings attached. “I have a problem, but if I tell you about it, you have to promise not to tell anyone else.” Most children know that negative consequences can result if they break the silence about abuse. Appropriate responses would include letting the child know you want to help him or her and telling the child, from the beginning, that there are times when you too may need to get some other special people involved.
FORENSIC INTERVIEWING FOR SEXUAL ASSAULT

Sometimes children and adolescents disclose sexual abuse to a trusted adult or there is cause for the adult to suspect sexual abuse. In those cases, the adult should not question the child further. He or she should instead contact Child Protective Services or, if the child is in imminent danger, the police. These professionals have protocols in place to interview the child by a child interview specialist while police, prosecutors, and caseworkers observe. Such forensic interviewers are trained to communicate in an age- and developmentally appropriate manner. Coordination of services with a child forensic interviewer is essential.

This multidisciplinary interview team approach may be utilized for other types of abuse as well. The expectation of this approach is that it will reduce the impact on the child if there is one interview rather than several by different concerned parties (USDOJ, 2015).

GATHERING FORENSIC EVIDENCE

Whenever there are allegations of suspected child abuse or neglect, the mandated reporter should keep in mind that any records of physical findings may be used as evidence at a trial. Photos, diagrams, and accurate reporting of medical examination findings are invaluable. Photographs and X-rays provide objective visual evidence to substantiate a report of suspected child abuse and are, along with other imaging studies, legally admissible evidence in court proceedings. Photographs are subject to the same guidelines as other medical records. The mandated reporter should take care to use language that is not open to misinterpretation when documenting findings (Pullido, 2012).

Pennsylvania Code § 21.503 maintains that photographs, medical tests, and X-rays of a suspected victim of child abuse may be taken or requested by an RN, LPN, or CRNP if they are clinically indicated. The medical reports of the images and medical tests are to be sent to the county children and youth social service agency at the time the written report is sent or as soon thereafter as possible, up to 48 hours after the electronic report. This information is to be made available to law enforcement officials in the course of the investigation as well (23 Pa.C.S. § 6314 and 6340).

Photographing Evidence

The goal for photographing evidence is to accurately document the findings that serve as a basis for one’s opinion. In Pennsylvania, permission from a parent or guardian is not required prior to taking photographs of suspected child abuse victims (23 Pa. C.S. § 6314).

If photographs will be needed, it is a good idea to inform the child or adolescent and encourage them to participate in the process. Photographs are another form of medical documentation that can provide objective, visual documentation of abuse. There should be a protocol for releasing the photos after a formal request, and a chain of custody may be necessary as well.

Following are practices for taking good forensic photographs:

  • Equipment such as a 35 mm digital camera and/or a colposcope with a camera attached produce images that can easily be transferred.
  • In order to document bruises and other injuries accurately, a photograph of a color wheel is necessary for comparison.
  • The child’s face, body, identification number, and the date should be photographed first. Use good lighting and an uncluttered background.
  • Employ the rule of three: take at least two photos of full body, mid-range, and close-up. Photograph the injury close-up with and without a scale.
  • Photograph clothing if there is transfer evidence such as vegetation, gravel, or dirt.
    (Botash, 2015b)

PROVISIONS AND RESPONSIBILITIES FOR REPORTING SUSPECTED CHILD ABUSE

Who Can or Must Report Child Abuse?

There are two categories of reporters in Pennsylvania: those who must report (mandated) and those who can report (permissive). Mandated reporters have a legal duty to report suspected child abuse and permissive reporters do not. All residents of Pennsylvania are encouraged to report suspected child abuse if they suspect that a child is a victim of abuse or neglect.

Reporters are not expected to validate their suspicions prior to reporting. The basis for making a report should be on one's evaluation of the circumstances, observations, and familiarity with the family or pattern of events (PA Medical Society, 2014).

PA MANDATED REPORTERS

All of the following persons are mandated reporters in Pennsylvania if they are at least 18 years of age, and they must make a report directly to ChildLine or the Child Welfare Information System if they suspect abuse. Mandated reporters include:

  1. A person who is licensed or certified to practice in any health-related field under the jurisdiction of the Department of State
  2. Medical examiner, coroner, or funeral director
  3. Employee of a healthcare facility or provider licensed by the Department of Health who is engaged in the admission, examination, care, or treatment of individuals
  4. School employee
  5. Employee of a childcare service who has direct contact with children in the course of employment
  6. Clergyman, priest, rabbi, minister, Christian Science practitioner, religious healer, or spiritual leader of any regularly established church or other religious organization
  7. 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. Employee of a social services agency who has direct contact with children in the course of employment
  9. Peace officer or law enforcement official
  10. Emergency medical services provider certified by the Department of Health
  11. Employee of a public library who has direct contact with children in the course of employment
  12. 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. 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. 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, community home for individuals with an intellectual disability, or host home for children which are subject to supervision or licensure under the Public Welfare Code
    (23 Pa. C.S. § 6311)

The above list of mandated reporters in Pennsylvania includes youth camp directors, youth athletic coaches, directors and trainers, all Department of Public Health (DPH) employees, and certain employees of the Office of Early Childhood (OEC). School employees formerly reported to their administration and now must report directly to ChildLine.

The reporting requirements affect school employees, staff at child-care and medical facilities, librarians, and volunteers who work in youth sports, church groups, or other organized youth activities.

Concerns about client confidentiality and other issues resulted in limiting the category of attorneys who are mandated to report to those who work for a school, church, or other organization with responsibility for “the care, guidance, control, or supervision of children.”

When Must a Report Be Made?

If any mandated reporter has reason to suspect that a child is or has been abused, they are required to report their suspicions immediately. Mandated reporters only need to have a reasonable cause to suspect abuse and do not need to investigate the facts, identify the person responsible for the child abuse, or determine if the alleged abuser can be legally classified as a perpetrator.

The mandated reporter must make a report if he or she:

  • 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
  • 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
  • Is the recipient of a specific disclosure that an identifiable child is the victim of child abuse
  • Is the recipient of a specific disclosure by an individual 14 years of age or older that the individual has committed child abuse
    (23 Pa. C.S. § 6311)

How Is a Report Made?

The report can be made verbally by calling ChildLine toll free at 800-932-0313, or it may be filed electronically using the Child Welfare Information Solution (CWIS) online at compass.state.pa.us/cwis.

If the immediate report is verbal, it must be followed up with a written report or an electronic report (Form CY-47) within 48 hours. CY-47 forms can be found online at keepkidssafe.pa.gov/forms. (See “Resources” at the end of this course.) If the immediate report is electronic, no additional report is needed.

Permissive reporters can call ChildLine’s toll-free number to make a verbal report of suspected abuse but do not have access to the electronic reporting system (PA DHS, 2015b).

What Is Included in the Report?

When calling ChildLine, and also at the time of submitting an electronic report, the reporter will need the following information, if known:

  • 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
  • Age and sex of each subject of the report
  • Nature and extent of the suspected child abuse, including any evidence of prior abuse to the child or any sibling of the child
  • Name and relationship of each individual responsible for causing the suspected abuse and any evidence of prior abuse by each individual
  • Family composition
  • Source of the report
  • Name, telephone number, and email address of the person making the report
  • Actions taken by the person making the report, including those actions taken under sections 6314 (relating to photographs, medical tests, and X-rays of 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 the department requires by regulation
    (23 Pa. C.S. § 6313b)
REPORTING IMPLICATIONS OF HIPAA

Mandated reporters often express reluctance to report child abuse because they are concerned they may compromise patient privacy under the Health Insurance Portability and Accountability Act (HIPAA) of 1996. HIPAA provisions do not, in fact, affect the responsibilities of mandated reporters as they are defined in the CPSL. The CPSL instructs mandated reporters that the obligation to report overrides laws that protect the confidentiality of privileged communications of healthcare professionals. The CPSL also prevails over mental health regulations (Mental Health Procedures Act), although there are some specific limitations to disclosure for releasing information pertaining to drug and alcohol treatment programs (23 Pa. C.S. § 6311.1, § 5100.38).

What Happens after a Report Is Made?

ChildLine receives the report and determines who is to respond to the report, dependent upon the information reported, such as the identity, if known, of the person who allegedly acted to abuse or harm a child.

ChildLine will immediately transmit oral or electronic reports they receive to the appropriate county agency and/or law enforcement officials.

  • If a person identified falls under the definition of perpetrator, ChildLine will refer the report to the appropriate county agency for an investigation.
  • If the person identified is not a perpetrator and the behavior reported includes a violation of a crime, ChildLine will refer the report to law enforcement officials.
  • If a person identified falls under the definition of perpetrator and the behavior reported includes a criminal violation, ChildLine will refer the report to both the appropriate county agency and law enforcement officials.
  • If a report indicates that a child may be in need of other protective services, ChildLine will refer the report to the proper county agency to assess the needs of the child and provide services, when appropriate.

In cases of a CPS report, the county Children and Youth Agency must begin an investigation within 24 hours. The investigation is thorough and determines whether or not the child was abused and what services are most appropriate for the child. The investigation must be completed within 30 days unless the agency can justify a delay because of the need for further information, such as medical records or interviews of the subjects of the report.

Protections to Reporters

One of the identifiable factors that deter reporting is fear of retaliation. Reporters are assured immunity from civil or criminal liability if they make a report in good faith. They are also safeguarded against discrimination or termination at work and assured confidentiality that the subject(s) of the report will not receive information about who made the report. These protections are in place to encourage reporting and, more importantly, to help protect children.

Penalties for Failure to Report

In 2014, penalties were increased for failure to report suspected child abuse. Penalties for a mandatory reporter who willfully fails to report suspected child abuse include fines of up to $5,000 and incarceration for up to two years for a first offense. The grading of the seriousness of the failure to report is dependent on the grading of the offense committed against the child. In cases of second or subsequent offenses of failure to report, penalties include fines of up to $15,000 and incarceration for up to seven years (PA Medical Society, 2014).

Failure to report may also result in a misdemeanor or felony charge, fines, and incarceration, but it also leads to broader repercussions. But perhaps the most serious consequence of a mandated reporter’s failure to report a case of suspected abuse is leaving a child vulnerable to further harm. Child Welfare cannot act until child abuse is identified and reported—that is, services cannot be offered to the family nor can the child be protected from further suffering.

Mandated Reporters Right-to-Know

Mandated reporters of suspected child abuse who make a report of abuse have the right to limited information about the disposition of the case that was reported. DHS must release this information to the reporter upon request within three business days after the department receives the results of the investigation. The right-to-know policy does not apply to permissive reporters.

The right-to-know rule allows the reporter to receive the following information:

  • The final status of the report following the investigation: whether it was indicated, founded, or unfounded. (“Founded” refers to a judicial adjudication that the child was abused. “Indicated” refers to a county agency or regional staff finding that abuse has occurred. “Unfounded” indicates there is a lack of evidence that the child was abused.)
  • Services provided or arranged by the county agency to protect the child from further child abuse.
    (23 Pa. C.S. § 6311)

CONCLUSION

Child maltreatment, abuse, and neglect negatively impact the health and well-being of society. The fundamental goal for prevention of child maltreatment is to stop child abuse and neglect from occurring at all in order to create healthy children who will in turn become healthy adults.

In Pennsylvania, changes to child abuse laws in recent years have strengthened the state’s ability to protect children from abuse and neglect. More mandated reporters are now obligated to report suspected abuse using a streamlined reporting process. Increased penalties are in place for those who fail to report, alongside additional protections for those who do report.

Reporting suspected child abuse is not only a duty for many professionals throughout Pennsylvania, but it is also an opportunity to help improve the health and well-being of the state’s children and take part in creating a healthier society.

REFERENCES

NOTE: Complete URLs for references retrieved from online sources are provided in the PDF of this course.

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American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental disorders (DSM-5). Arlington, VA: American Psychiatric Association.

Ark of Hope for Children. (2017). Child trafficking statistics. Retrieved from https://arkofhopeforchildren.org

Bergland C. (2016). Harvard study pegs how parental substance abuse impacts kids. Retrieved from https://www.psychologytoday.com

Botash A. (2014a). Child abuse evaluation and treatment for medical providers. History: responding to disclosure of abuse. Retrieved from http://www.ChildAbuseMD.com

Botash A. (2014b). Child abuse evaluation and treatment for medical providers. Documentation: photographic documentation. Retrieved from https://www.ChildAbuseMD.com

Brown J, et al. (2016). Pediatric abusive head trauma: a brief overview. Forensic Scholars Today, 1(4). Retrieved from https://online.csp.edu

Centers for Disease Control and Prevention (CDC). (2017). Child abuse and neglect: risk and protective factors. Retrieved from https://www.cdc.gov

Child Welfare Information Gateway. (CWIG). (2013). What is child abuse and neglect? Recognizing the signs and symptoms. Retrieved from https://www.childwelfare.gov

Clermont County Children’s Protective Services (CPS). (2018). Detecting child abuse and neglect. Retrieved from http://cps.clermontcountyohio.gov

Cleveland Clinic. (2014). Factitious disorder imposed on another (FDIA). Retrieved from https://my.clevelandclinic.org

Healthy Place. (2016). Signs of child physical abuse. Retrieved from https://www.healthyplace.com

KidsHealth.org. (2018). Abusive head trauma. Retrieved from https://kidshealth.org

Mayo Clinic. (2015). Child abuse overview. Retrieved from https://www.mayoclinic.org

National Society for the Prevention of Cruelty to Children (NSPCC). (2018). Physical abuse. Retrieved from https://www.nspcc.org.uk

Nursing Home Abuse Center (NHAC). (2018). Physical abuse: understanding physical abuse of the elderly. Retrieved from https://www.nursinghomeabusecenter.com

Parks SE, Annest JL, Hill HA, Karch DL. (2012). Pediatric abusive head trauma: recommended definitions for public health surveillance and research. Atlanta: Centers for Disease Control and Prevention. Retrieved from http://www.cdc.gov

Pennsylvania Department of Human Services (PA DHS). (2015a). Press release: Department of Human Services launches Child Welfare Information System. Retrieved from http://www.keepkidssafe.pa.gov

Pennsylvania Department of Human Services (PA DHS). (2015b). Mandated reporter frequently asked questions. Retrieved from http://www.keepkidssafe.pa.gov/cs/groups/webcontent/documents/document/c_137646.pdf

Pennsylvania Department of Human Services (PA DHS). (2015c). Fact sheet: Pennsylvania’s safe haven law. Retrieved from http://www.secretsafe.org

Pennsylvania Family Support Alliance (PFSA). (2018a). Changes in the child protective services law (CPSL). Retrieved from http://www.pa-fsa.org

Pennsylvania Family Support Alliance (PFSA). (2018b). What is ChildLine? Retrieved from https://www.pa-fsa.org

Pennsylvania General Assembly. (2018). Consolidated statutes, title 23, chapter 63, child protective services law. Retrieved from http://www.legis.state.pa.us

Pennsylvania Medical Society. (2014). PAMed Consult: signs and symptoms of child abuse. Retrieved from http://www.pamedsoc.org

Pennsylvania Partnerships for Children. (2012). Core components of differential response. Retrieved from https://www.scribd.com

Pullido M. (2012). New York Society for the Prevention of Cruelty to Children professional’s handbook identifying and reporting child abuse and neglect. Retrieved from http://www.nyspcc.org

Rape, Abuse & Incest National Network (RAINN). (2018). Child sexual abuse. Retrieved from https://www.rainn.org

Rehabilitation and Community Providers Association (RCPA). (2014). CPSL information and resources. Child protection legislative amendments definitions only. Retrieved from http://www.paproviders.org

Research Foundation of SUNY/Center for Development of Human Services. (2011). Mandated reporter training: identifying and reporting child abuse and maltreatment/neglect. Buffalo, NY: author. Retrieved from http://www.ocfs.state.ny.us

Task Force on Child Protection (Task Force). (2012). How PA’s approach compares to core components of differential response (DR.). Retrieved from http://www.childprotection.state.pa.us

U. S. Department of Justice (USDOJ). (2015). Child forensic interviewing: best practices. Retrieved from https://www.ojjdp.gov

U.S. Legal, Inc. (2014). Pennsylvania safe haven laws. Retrieved from http://safehavenlaws.uslegal.com

U.S. Public Law 106-386 § 103. (2000). Trafficking Victims Protection Act of 2000. Retrieved from https://www.gpo.gov

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