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 to address potential knowledge gaps include:

• State the goal of the child welfare system in Pennsylvania.
• Differentiate between Child Protective Services and General Protective Services responses to reports of possible abuse or neglect.
• Describe the key components of child abuse and the categories of child abuse as defined by Pennsylvania law.
• Recognize indicators of child abuse and trafficking.
• Summarize the basis and responsibilities for reporting suspected child abuse.
• Describe the process to report child abuse.
• Identify the protections for reporters who act in good faith and penalties for failure to report.

CHILD WELFARE IN PENNSYLVANIA

The Pennsylvania Child Protective Services Law (CPSL) was established in 1975. 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 so that they can grow up and thrive in safe, loving environments. The Commonwealth’s child welfare system exists to protect children and support families. The PA CPSL does not restrict the generally recognized existing rights of parents to use reasonable supervision and control when raising their children.

Recent amendments to the PA CPSL relevant to child abuse recognition and reporting include:

• Act 115 of 2016 (relating to human trafficking)
• Act 54 of 2018 (relating to notification of substance-affected infants by healthcare providers & plan of safe care)
• Act 88 of 2019 (relating to penalties for failure to report or refer)

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). Pennsylvania’s child welfare system is supervised by the state and administered by County children-and-youth agencies (CCYAs) have two main functions: Child Protective Services (CPS) and General Protective Services (GPS).

ChildLine is a free hotline that allows people to report suspected child abuse or neglect. Anyone can call ChildLine to report suspected abuse or general child wellbeing concerns. When a call is received by ChildLine, trained child welfare professionals can assess the concern and make a referral to the best agency to handle the concern, investigate, or provide additional support to the child and/or their family. ChildLine is staffed 24 hours a day, seven days a week. Call 1-800-932-0313 to report suspected abuse or neglect (Commonwealth of PA, 2024b).

Bifurcated System / Two-Track Services

ChildLine professionals determine if the circumstance is to be categorized and investigated as a CPS case or categorized and assessed as a GPS case. When referrals contain allegations of incidents that meet the definition of child abuse, the case is assigned to and investigated by Child Protective Service workers. All other referrals that do not allege suspected child abuse but still present concerns for a child’s safety or well-being are assessed by General Protective Service workers.

• Child protective services are implemented when there is reasonable cause to suspect child abuse. 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.
• 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 aiding parents in fulfilling their parental duties and by helping them to recognize and correct potentially harmful conditions.

DIFFERENTIATING BETWEEN CPS AND GPS REPORTS

Child Protective Services	General Protective Services
(PA DHS, 2024b)
Services and activities provided by DHS and each county agency for child abuse cases	Services and activities provided by each county agency for cases requiring protective services as defined by DHS in regulations
Require an investigation because the alleged act or failure to act meets the PA CPSL’s definition of child abuse.	Require an assessment for services and supports because the alleged act or failure to act may not meet the definition of child abuse but is still detrimental to a child.
Examples of CPS cases: Causing bodily injury to a child through any recent act or failure to act Fabricating, feigning or intentionally exaggerating or inducing a medical symptom or disease which results in a potentially harmful medical evaluation or treatment to the child through any recent act Causing or substantially contributing to serious mental injury to a child through any act or failure to act or a series of such acts or failures to act Causing sexual abuse or exploitation of a child through any act or failure to act Creating a reasonable likelihood of bodily injury to a child through any recent act or failure to act Creating a likelihood of sexual abuse or exploitation of a child through any recent act or failure to act Causing serious physical neglect of a child Engaging in a specific recent “per se” act 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	Examples of GPS cases: Child is without proper parental care or control, subsistence, education as required by law, or other care or control necessary for their physical, mental, or emotional health, or morals Child has been placed for care or adoption in violation of law Child has been abandoned by their parents, guardian, or other custodian Child is without a parent, guardian, or legal custodian Child is habitually and without justification truant from school while subject to compulsory school attendance Child has committed a specific act of habitual disobedience of the reasonable and lawful commands of their parent, guardian, or other custodian and who is ungovernable and found to be in need of care, treatment, or supervision Child is under 10 years of age and has committed a delinquent act Child 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 Child has been referred under section 6323 of the Juvenile Act (relating to informal adjustment) and who commits an act which is defined as ungovernable

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. (See also “Recognizing Abuse” later in this course.)

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 “Definition of 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 a 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

As described in CPSL, 23 Pa. C.S. § 6303 and § 6304:

1. A “perpetrator” is a person who has committed child abuse and who is:
   1. A parent of the child
   2. A spouse or former spouse of the child’s parent
   3. A paramour or former paramour of the child’s parent
   4. 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
   5. An individual 14 years of age or older who resides in the same home as the child
   6. 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
   7. 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
2. In cases involving “failure to act,” perpetrators include only the following:
   1. A parent of the child
   2. A spouse or former spouse of the child’s parent
   3. A paramour or former paramour of the child’s parent
   4. A person 18 years of age or older and responsible for the child’s welfare
   5. A person 18 years of age or older who resides in the same home as the child

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 from 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 only two situations in which persons who fall under the mandated reporter law are excluded from the requirement to report suspected child abuse:

1. Confidential communications made by a communicant to a member of the clergy who is acting in the role of confessor or spiritual counselor, per 42 Pa. C.S. § 5943
2. Confidential communications made to an attorney within the scope of confidentiality as per 42 Pa. C.S. §§ 5916 and 5928. This is related to situations in criminal or civil proceedings in which neither the attorney nor client are required or permitted to disclose the communications unless the client waives the privilege.
   (CWIG, 2019)

It is important to understand that privileged communication between a 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 FROM CHILD ABUSE

Sections 6303 and 6304 of the CPSL explains situations that are considered “exclusions to child abuse.” Most of these 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 by investigators.

Exclusions from child abuse include conduct that causes injury or harm to a child or creates a risk of injury or harm to a child in which there is no evidence that the person acted intentionally, knowingly, or recklessly (i.e., no culpability) when causing the injury or harm to the child or creating a risk of injury or harm to the child.

Exclusions from child abuse also include:

1. 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 or person with whom the child lives.
2. The child has not been provided needed medical or surgical cause 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. 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 exclusion shall not apply if the failure to provide needed medical or surgical care causes the death of the child.
   5. This exclusion shall not apply to any childcare service as defined in this chapter, excluding an adoptive parent.
3. The use of reasonable force on or against a child by the child’s own parent or person responsible for the child’s welfare (see also “rights of parents” below), if any of the following conditions apply:
   1. 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
   2. The use of reasonable force is necessary for the child’s safety and in order to:
      1. To quell a disturbance or remove the child from the scene of a disturbance that threatens physical injury to persons or damage to property
      2. To prevent the child from self-inflicted physical harm
      3. For self-defense or the defense of another individual
      4. 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. Parents’ use of reasonable force on or against their children (i.e., the generally recognized existing “rights of parents”) for the purposes of supervision, control, and discipline of their children. (Such reasonable force shall not constitute child abuse.)
5. Participation in events that involve physical contact, such as a practice or competition in an interscholastic sport, physical education, recreational activity, or extracurricular activity (such contact is not subject to child abuse reporting requirements)
6. Harm or injury to a child that results from the act of another child (child-on-child contact), unless the child who caused the harm or injury is a perpetrator, in which the following shall apply:
   1. Acts constituting any of the following crimes against a child shall be subject to the reporting requirements of the PA CPSL:
      1. Rape as defined in 18 Pa.C.S. § 3121 (relating to rape);
      2. Involuntary deviate sexual intercourse as defined in 18 Pa.C.S. § 3123 (relating to involuntary deviate sexual intercourse);
      3. Sexual assault as defined in 18 Pa.C.S. § 3124.1 (relating to sexual assault);
      4. Aggravated indecent assault as defined in 18 Pa.C.S. § 3125 (relating to aggravated indecent assault);
      5. Indecent assault as defined in 18 Pa.C.S. § 3126 (relating to indecent assault); and
      6. Indecent exposure as defined in 18 Pa.C.S. § 3127 (relating to indecent exposure).
   2. 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.
   3. A law enforcement official who receives a report of suspected child abuse is not required to make a report to DHS if the person allegedly responsible for the child abuse is a non-perpetrator child.
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 and § 6304)

However, nothing in the PA CPSL requires a person who has a reasonable cause to suspect a child is a victim of child abuse to consider these exclusions from child abuse to make a report of suspected child abuse.

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.

Risk Factors for Perpetrating Child Abuse

A caregiver may have certain characteristics that increase the likelihood that they may become a perpetrator of child abuse or neglect. When health professionals observe indicators of possible abuse, they should consider whether the presence of risk factors in a caregiver may signal a need to examine the situation more carefully.

Individual risk factors include:

• Caregivers with drug or alcohol issues
• Caregivers with mental health issues, including depression
• Caregivers who don't understand children's needs or development
• Caregivers who were abused or neglected as children
• Caregivers who are young or single parents or parents with many children
• Caregivers with low education or income
• Caregivers experiencing high levels of parenting stress or economic stress
• Caregivers who use spanking and other forms of corporal punishment for discipline
• Caregivers in the home who are not a biological parent
• Caregivers with attitudes accepting of or justifying violence or aggression

Relationship/family risk factors include:

• Families that have household members in jail or prison
• Families that are isolated from and not connected to other people (extended family, friends, neighbors)
• Families experiencing other types of violence, including relationship violence
• Families with high conflict and negative communication styles

Community risk factors include:

• Communities with high rates of violence and crime
• Communities with high rates of poverty and limited educational and economic opportunities
• Communities with high unemployment rates
• Communities with easy access to drugs and alcohol
• Communities where neighbors don't know or look out for each other
• Communities where there is low community involvement among residents
• Communities with few community activities for young people
• Communities with unstable housing and where residents move frequently
• Communities where families frequently experience food insecurity
  (CDC, 2024a)

Nationally, the most common risk factors reported with child maltreatment are substance abuse and domestic violence (U.S. DHHS, 2024).

Child Risk Factors

While children are not responsible for being abused, certain factors increase their risk for abuse or neglect:

• Children younger than 4 years of age
• Children with special needs that may increase caregiver burden (disabilities, mental health issues, and chronic physical illnesses)
  (CDC, 2024a)

Youth at greater risk for human trafficking include those who have experienced:

• A history of abuse and neglect
• Social disconnection
• Social stigma and exclusions
  (NHTTTAC, n.d.)

(See also “Recognizing Trafficking” later in this course.)

RECOGNIZING ABUSE

There are many possible indicators of child maltreatment or abuse, and these indicators should be viewed together, not in isolation. Similarly, each indicator must be considered in relation to the child’s current age and circumstances and in the context of their physical condition or behavior. These indicators are not all inclusive, and some children may not demonstrate signs or symptoms of abuse or neglect.

Another important aspect to assessing for possible abuse is obtaining an explanation for the presenting concern and whether that explanation is consistent with the observed physical and behavioral indicators. Abuse or maltreatment should never be assumed.

The mandated reporter is encouraged to consider any prior experiences with the child and possible differences between past and present observations.

Any assessment must be objective and free from implicit or explicit bias.

Recognizing Bodily Injury

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 BODILY INJURY

Mandatory and permissive reporters must be alert for physical injuries that are unexplained or inconsistent with the parent or other caretaker’s explanation or the developmental state of the child. However, it is important to remember that indicators of maltreatment or abuse may not always be of a physical nature or visible to view.

Bruising

Bruising is the most common indicator of physical child abuse, and attention to bruises can be an important factor in identifying children who are at risk of physical abuse. It is important to know both normal and suspicious bruising patterns when assessing children’s injuries. Normal bruising usually occurs in the front of the body over bony areas such as the forehead, knees, shins, and elbows.

The TEN-4-FACESp validated clinical screening tool, developed by Dr. Mary Clyde Pierce, can be used to evaluate bruises in children under 4 years of age. The tool guides the clinician to assess bruising associated with three components (regions, infants, patterns) if there is no reasonable explanation for a bruise (Pierce et al., 2021). Children who are under 4 years should not have any bruises in the areas indicated in the chart below, and infants under 4 months should have no bruises anywhere. The size of the bruise is not as important as the location.

Lacerations or Abrasions

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

• On the face, lips, or mouth
• To external genitalia

Burns

Unexplained burns include:

• 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

Fractures

Unexplained fractures may include:

• Fractures to the skull, nose, or facial structure
• Multiple or spiral fractures
• Fractures in various stages of healing
  (SD DSS, 2020)

Head Injuries

Typical indications of unexplained head injuries include:

• Absence of hair 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

Recognizing 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 their safety is threatened
• Seriously interferes with the child’s ability to accomplish age-appropriate developmental and social tasks
  (23 Pa. C.S. § 6303)

Physical indicators in a child of serious mental injury include:

• Frequent nonspecific somatic complaints (stomachache, nausea, headache)
• Enuresis
• Self-harm
• Speech disorders

Behavioral indicators in a child of mental injury include:

• Statements about feeling inadequate
• Fearfulness of trying new things
• Passive behavior, overly compliant
• Poor social relationships with peers
• Exceedingly dependent on adults
• Habits such as thumb-sucking, picking, rocking
• Eating disorders
  (Commonwealth of Pennsylvania, 2024)

A parent or guardian exhibiting the following indicators may be a perpetrator of serious mental injury against a child:

• Making unreasonable demands on the child
• Not considering child’s developmental stage
• Using the child as an issue in marital conflict
• Using the child to satisfy caretaker’s needs
• Objectifying the child (e.g., involving the child in beauty pageants)
• Engaging in acts of domestic violence in front of the child
  (American SPCC, 2021)

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, 2021).

The fact that sexual abuse may be 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 abuse 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, 2021; RAINN, 2021).

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.

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. 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. Anyone, including parents, can be a perpetrator, and most are male.

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, 2021; RAINN, 2021).

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 or repeated urinary infections
• Foreign bodies in the vagina or rectum
• Painful bowel movements
  (Clermont County CPS, 2021; RAINN, 2021; NYS OCFS, n.d.)

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
• Inappropriate, bizarre, suggestive, or promiscuous sexual behavior
• Inappropriate sexual knowledge for age
• Verbal disclosure of sexual assault
• Involvement in commercial sexual exploitation
• Forcing sexual acts on other children
• Extreme fear of closeness or physical examination
• Suicide attempts or other self-injurious behaviors
• Layered or inappropriate clothing
• Hiding clothing
• Lack of interest or involvement in activities
  (Clermont County CPS, 2021; RAINN, 2021; NYS OCFS, n.d.)

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

• Overly protective
• Jealous of child
• Does not allow the child to participate in social activities
• Accuses the child of promiscuity
• Has marital problems
• Authoritarian
• Favoring one child in the family
• Need for control
• History of sexual abuse
  (Clermont County CPS, 2021)

Recognizing Trafficking

The media often portrays trafficking victims as women who are in chains or have a sign written on their hands that says, “Help Me.” However, this is not what most trafficking victims look like. When victims of human trafficking present in healthcare settings, it is uncommon for them to self-disclose that they are victims. They have significant trust issues, and even when asked directly, they are not likely to disclose that they are victims. The exploiter may also accompany victims, and as with victims of domestic violence, that presence will discourage victims from making any disclosures to a clinician.

It is important for healthcare providers to ask about exploitation because up to 88% of adolescent victims of trafficking reported an encounter with a healthcare provider during the time that they were being exploited (Polaris, 2024).

TYPES OF TRAFFICKING

The crime of sex trafficking of children is a type of child abuse increasingly encountered in the healthcare setting. It is defined in the Trafficking Victims Protection Act (18 USC § 1591) as “to recruit, entice, harbor, transport, provide, obtain, or maintain by any means a person, or to benefit financially from such action, knowing or in reckless disregard that the person has not attained the age of 18 years and will be caused to engage in a commercial sex act.”

In 2023, an estimated 1 in 6 of the 28,800 U.S. children who were reported to the National Center for Missing and Exploited Children (NCMEC) as missing were likely trafficked. It is likely that an estimated 19% of the children who ran away from foster care also became involved in sex trafficking in the same year. And NCMEC received 18,400 reports of child sex trafficking in 2023 (NCMEC, 2024).

According to U.S. federal law (22 USC § 7102), labor trafficking is the recruitment, harboring, transportation, provision, or obtaining of a person for labor or services through the use of force, fraud, or coercion for the purposes of subjection to involuntary servitude, peonage, debt bondage, or slavery. As with sex trafficking, force, fraud, or coercion do not need to exist if the labor trafficking victim is under the age of 18.

Child labor trafficking may include agricultural, domestic service, or factory work where workers provide involuntary labor. Labor trafficking can also occur in beauty services, restaurants, small businesses, or informal settings. Some common situations include peddling and traveling sales crews where young people are moved from town to town selling cheap products such as jewelry or magazines for little or no pay. Other situations include drug dealing in which children are forced to sell drugs.

Sometimes labor trafficking may occur when a child is staying with a custodial family member or nonfamily member and is forced to work. Children are controlled through fear and abuse by their traffickers. It is possible that a child is a victim of labor and sex trafficking simultaneously (NCSSLE, 2021).

SIGNS OF TRAFFICKING

Pennsylvania has developed and implemented statewide a tool to screen children for trafficking. The Child Victims of Human Trafficking (CVHT) screening tool has been in use since 2019. It allows child welfare professionals to screen and assess children by identifying the following indicators that a child may be involved with trafficking:

• Current incident or history of previous sex or labor trafficking or acknowledgement of being trafficked
• Being recovered from a runaway episode in a hotel or known area of prostitution
• Report of sex or labor trafficking by parent/guardian, law enforcement, medical or service provider, teacher, child protective services, or juvenile probation officer
• History of running away or getting kicked out four or more times in addition to a history of sexual abuse
• History of running away from another county or state
• Current incident or history of inappropriate sexual behaviors
• Current incident or history of sexually transmitted diseases or pregnancies
• Child not being allowed or unable to speak for themself and being extremely fearful
• Child having no personal items or possessions (including identity documents)
• Child appearing to have material items that they cannot afford (e.g., cell phones, expensive clothing, tablets, etc.)
• Child showing signs of being groomed (i.e., hair done, nails done, new clothing, etc.)
  (PA DHS, 2019)

Other indicators of possible human trafficking in the healthcare setting include:

• Delaying seeking care for an illness
• Malnourishment
• Physical injuries consistent with long-term abuse, such as bruises in various stages of healing or signs of physical or sexual abuse
• Substance use
• Poor hygiene
• Health conditions of vulnerability such as disabilities and mental health issues
• Giving scripted answers/stories
• Minimizing abuse or injuries
• Being anxious
• Not being aware of location, date, or time of day
• Hesitating when answering questions about an injury or illness
• Symptoms related to depression or PTSD
• Presence of a third party who monitors the child’s responses, answers for them, behaves in an aggressive or verbally abusive manner, insists on filling out paperwork, or demands to remain in the room with the child
• Leaving against medical advice or seeming pressured to leave quickly
• Reporting not having a fixed address
  (Polaris, 2024)

Recognizing Serious 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).

Physical indicators of physical neglect include:

• Consistent hunger
• Poor hygiene (skin, teeth, ears, etc.)
• Inappropriate attire for the season
• Failure to thrive (physically or emotionally)
• Positive indication of toxic exposure, especially in newborns, such as drug withdrawal symptoms, tremors, and so forth
• Delayed physical development
• Speech disorders
• Consistent lack of supervision, especially in dangerous activities or for long periods of time
• Unattended physical problems or medical or dental needs
• Chronic truancy
• Abandonment
  (Clermont County CPS, 2021)

A child may demonstrate behavioral 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 shoplifting
• 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 or emotional development
• Suicide attempt
  (Clermont County CPS, 2021)

RECOGNIZING AND RESPONDING TO VICTIMS’ DISCLOSURES

It is difficult for young children to describe abuse. They may only disclose part of what happened, or they may make an indirect disclosure such as, “My stepdad keeps me up at night.” It is important not to rush the child and to listen to their concerns so that the child feels safe and supported. If a child discloses abuse, the following actions by the healthcare professional will help the child:

• Avoid denying what the child discloses
• Provide safety and reassurance
• Listen without making assumptions
• Do not interrogate
• Limit questioning to only four queries:
1. What happened?
2. When did it happen?
3. Where did it happen?
4. Who did it? (How do you know them?)
• Do not make promises
• Document the child’s statements using exact quotes
• Remain nonjudgmental and supportive
• Understand the dynamics of abuse and neglect
• Report suspicions to the authorities
  (Childhelp, 2021)

Interviewing for Sexual Assault

If a child or adolescent discloses sexual abuse to a trusted adult or there is cause for the adult to suspect sexual abuse, the adult should not question the child further. They 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 to minimize trauma and to ensure the use of evidence-based practices to listen more effectively to the child. Forensic interviewers rely on critical thinking, ethical standards, and professional judgment. They must participate in ongoing training and peer review. The American Professional Society on the Abuse of Children published updated practice guidelines for forensic interviewing in 2023 (APSAC Taskforce, 2023).

Management

A physically abused child is screened for emergent needs. Once stability has been established, the child undergoes a history and physical. ChildLine should be informed when there is a suspicion of abuse and the child may need to be seen in an in-patient facility so that lab work and imaging can be done.

A child who has been sexually abused is also evaluated for physical, mental, and psychosocial needs. Baseline testing is performed for sexually transmitted infections (STIs) for children of all ages. Pregnancy and empiric treatment for STIs may also be given to adolescent victims. STI prophylaxis and emergency contraception may be offered if the patient presents within 120 hours. Medication may include a regimen of non-occupational post-exposure prophylaxis (nPEP) if the patient presents within 72 hours. Evaluation at the earliest opportunity can be helpful to examine for anogenital injury and collect forensic evidence (CDC, 2021).

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 also to be made available to law enforcement officials in the course of the investigation (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.

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, 2020).

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 as listed under 23 Pa. C.S. § 6311 has reason to suspect that a child is or has been abused, they are required to report their suspicions immediately by phone to 800-932-0313 or electronically through the Child Welfare Portal. Mandated reporters need only 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 they:

• Come into contact with the child in the course of employment, occupation, and practice of a profession or through a regularly scheduled program, activity, or service
• Are directly responsible for the care, supervision, guidance, or training of the child, or are affiliated with an agency, institution, organization, school, regularly established church or religious organization, or other entity that is directly responsible
• Are the recipient of a specific disclosure that an identifiable child is the victim of child abuse
• Are 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)

It is important to note that under 23 Pa. C.S. § 6311:

• A child is not required to come before the mandated reporter in order for the mandated reporter to make a report of suspected child abuse.
• The mandated reporter is not required to identify the person responsible for the child abuse in order to make a report of suspected child abuse.
• A person who has reasonable cause to suspect a child is a victim of child abuse is not required to consider the exclusions from child abuse in order to make a report of suspected child abuse.

Whenever a mandated reporter who is a member of the staff of a medical or other public or private institution, school, facility, or agency makes a report, they are also required to immediately notify the person in charge of the institution. That person or the designated agent must then facilitate the cooperation of the institution with the investigation of the report.

Mandated reporters who work for agencies/organizations subject to supervision by PA DHS must also be trained on internal policies related to reporting suspected child abuse and are encouraged to receive such training from their employers.

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 https://www.compass.state.pa.us/cwis/public/home.

A confirmation by DHS of the receipt of the report of suspected child abuse submitted electronically shall relieve the person making the report of making an additional oral/verbal or written report of suspected child abuse.

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. However, the failure of a mandated reporter to file form CY-47) shall not relieve the county agency from any duty under the PA CPSL, and the county agency shall proceed as though the mandated reporter complied.

CY-47 forms can be found online at the official website of the Commonwealth of Pennsylvania on the Keep Kids Safe page (report child abuse) found at https://www.pa.gov/en/agencies/dhs/resources/keep-kids-safe/report-child-abuse.html. This page also has useful phone numbers and instructions.

Permissive reporters are concerned individuals who do not fall under the category of mandated reporters. They are encouraged to report suspected child abuse, but they are not required by law to do so. Permissive reporters need only to call ChildLine’s toll-free number to make a verbal report of suspected abuse; they do not need to follow their phone call with a written report (PA DHS, n.d.).

(See also “Resources” at the end of this course.)

What Is Included in the Report?

When calling ChildLine and also at the time of submitting an electronic report, the reporter will be asked to provide the following information, if known. However, it is not required to provide all items in order to report suspected abuse.

1. Names and addresses of the child, the child’s parents, and any other person responsible for the child’s welfare
2. Where the suspected abuse occurred
3. Age and sex of each subject of the report
4. Nature and extent of the suspected child abuse, including any evidence of prior abuse to the child or any sibling of the child
5. Name and relationship of each individual responsible for causing the suspected abuse and any evidence of prior abuse by each individual
6. Family composition
7. Source of the report
8. Name, telephone number, and email address of the person making the report
9. 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)
10. Any other information required by federal law or regulation
11. Any other information that the department requires by regulations
    (23 Pa. C.S. § 6313b)

What Happens After a Report Is Made?

When a county agency or law enforcement receives a referral/report, the county agency or law enforcement official is to notify DHS/ChildLine after ensuring the immediate safety of the child and any other child(ren) in the child’s home.

ChildLine will immediately evaluate and transmit oral or electronic reports they receive to the appropriate county agency 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.

Mandatory Notification of Substance-Affected Infants

Under Pennsylvania law (23 Pa. C.S. § 6386), a healthcare provider involved in the delivery or care of a child under 1 year of age is required to immediately notify the Department of Human Services of the Commonwealth if the provider has determined, based on standards of professional practice, that 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 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 does not constitute a child abuse report.

HEALTHCARE PROVIDERS REQUIRED TO REPORT

Healthcare providers required to submit this notification include licensed hospitals or healthcare facilities or persons who are licensed, certified, or otherwise regulated to provide healthcare services in Pennsylvania, including a physician, podiatrist, optometrist, psychologist, physical therapist, certified nurse practitioner, registered nurse, nurse midwife, physician’s assistant, chiropractor, dentist, pharmacist, or an individual accredited or certified to provide behavioral health services.

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:

• A multidisciplinary team meeting must be held prior to the child’s discharge from the healthcare facility.
• The meeting will inform an assessment of the needs of the child and the child’s parents and immediate caregivers to determine the most appropriate lead agency for developing, implementing, and monitoring a plan of safe care.
• The child’s parents and immediate caregivers must be engaged to identify the need for access to treatment for any substance use disorder or other physical or behavioral health condition that may impact the safety, early childhood development, and well-being of the child.
• Depending upon the needs of the child and parent(s)/caregiver(s), ongoing involvement of the county agency may not be required.

For the purpose of informing the plan of safe care, the multidisciplinary team may include public health agencies, maternal and child health agencies, home visitation programs, substance use disorder prevention and treatment providers, mental health providers, public and private children and youth agencies, early intervention and developmental services, courts, local education agencies, managed care organizations, private insurers, hospitals, and medical providers.

Protections to Reporters

One of the identifiable factors that deters reporting is fear of retaliation. Therefore, as described in the CPSL (23 Pa.C.S. § 6318), a person, hospital, institution, school, facility, agency, or agency employee acting in good faith is considered immune from civil and criminal liability that might otherwise result from any of the following:

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

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

Reporters are also safeguarded against termination or discrimination at work with respect to compensation, hire, tenure, terms, conditions, or privileges of employment, and assured confidentiality that their identity shall be treated as confidential by law enforcement officials.

However, protection from employment discrimination does not apply to an individual making a report of suspected child abuse who is found to be a perpetrator because of the report or to any individual who fails to make a report of suspected child abuse as required under section 6311 (relating to persons required to report suspected child abuse) and is subject to conviction under section 6319 (relating to penalties) for failure to report or to refer (23 Pa.C.S. § 6320).

These protections are in place to encourage reporting and, more importantly, to help protect children.

Penalties for Failure to Report

Act 88 of 2019 (23 Pa. C.S. § 6319) clarified and increased penalties for failure to report child abuse. A mandated reporter who willfully fails to report suspected child abuse or to make a referral to the appropriate authorities commits an offense.

FAILURE TO REPORT OR REFER

The offense is a felony of the third degree if:

• The person or official willfully fails to report
• The child abuse constitutes a felony of the first degree or higher, and
• The person or official has direct knowledge of the nature of the abuse

An offense not otherwise specified previously is a misdemeanor of the second degree.

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

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.

CONTINUING COURSE OF ACTION

Willful failure to report is also a third-degree felony if the mandated reporter continues to fail to report while they know or have reasonable cause to suspect (1) that a child continues to be abused by the same individual or (2) that the same individual continues to have direct contact with children through their job, program, activity, or service. If the child abuse constitutes a felony of the first degree or higher, then continuing willful failure to report is a felony of the second degree.

MULTIPLE OFFENSES

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

STATUTE OF LIMITATIONS

The statute of limitations for failure to report is either the statute of limitations for the crime committed against the minor child or five years, whichever is greater.

Notice to Mandated Reporters

According to the CPSL (23 Pa.C.S. § 6368), DHS shall notify a mandated reporter who made a report of suspected child abuse of all of the following within three (3) business days of DHS’s receipt of the results of the investigation:

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

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.