Child Abuse Recognition and Reporting in Pennsylvania (3 CH)
Mandated Reporter Training
COURSE PRICE: $30.00
CONTACT HOURS: 3
This course (WIME00001) is approved by the Pennsylvania Department of Human Services. PA CE Provider Number CACE000034. Program Number CAPR000033.
Wild Iris Medical Education, Inc. is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.
Course Availability: Expires November 1, 2018. You must score 70% or better on the test and complete the course evaluation to earn a certificate of completion for this CE activity. Wild Iris Medical Education, Inc., provides educational activities that are free from bias. The information provided in this course is to be used for educational purposes only. It is not intended as a substitute for professional healthcare. Medical Disclaimer Legal Disclaimer Disclosures
This course is approved by the Pennsylvania Department of Human Services (PA CE Provider Number CACE000034) and fulfills the requirement for nurses and other mandated reporters in Pennsylvania for 3 hours of training in recognizing and reporting child abuse. Need only 2 CH for this topic?
We report course completions electronically to the Pennsylvania Department of State (DOS) every 24 hours.
Child Abuse Recognition and Reporting in Pennsylvania (3 CH)
Mandated Reporter Training
Copyright © 2015 Wild Iris Medical Education, Inc. All Rights Reserved.
COURSE OBJECTIVE: The purpose of this course is to enable mandatory reporters in Pennsylvania to identify and report child abuse, child maltreatment, and child neglect.
Upon completion of this course, you will be able to:
- 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.
TABLE OF CONTENTS
The government has a responsibility to protect children when parents fail to provide proper care and to intervene in cases of child maltreatment. Likewise, healthcare professionals have a responsibility to recognize and report suspected child abuse and maltreatment.
Parents have the primary responsibility for their children and the legal right to raise them as they see fit. This right falls under the 14th Amendment of the United States Constitution, which states “no state [shall] deprive any person of life, liberty, or property without due process of law.” The Supreme Court states that “liberty” as referred to in the amendment denotes not merely freedom from bodily restraint but also the right of the individual to establish a home and bring up children (USDHHS, 2014).
Although the Constitution upholds the rights of parents, initially there were no laws to protect children. The first organization established with the purpose of protecting children from abuse and neglect was a nongovernmental agency; in 1874, the Society for the Prevention of Cruelty to Children was established in New York. A federal Children’s Bureau was not founded until 1912, demonstrating that Congress officially acknowledged the government’s obligation to protect children from maltreatment.
The Child Abuse Prevention and Treatment Act (CAPTA) of 1974 was signed into law many years later and was the first legislative effort of the federal government to improve the response to child abuse and neglect. Pennsylvania followed soon thereafter by enacting the first Child Protective Services Law (CPSL) in the state in 1975.
In 1996, the Office on Child Abuse and Neglect (OCAN) was created to provide national leadership for child abuse and neglect policy and programs. In the year 2000, the Child Abuse Prevention and Enforcement Act (P.L. 106–77) was enacted. This legislation authorized law enforcement to enforce child abuse and neglect laws, promote child abuse prevention programs, and develop a system to track suspected offenders.
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 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. 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 involving 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 and are not required to substantiate abuse.
CHILD WELFARE INFORMATION SOLUTION
In order to encourage reporting, the reporting process has been streamlined. In January 2015, the Pennsylvania Department of Human Services (DHS) 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. County caseworkers have access to needed data through this system that assists them to protect 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.
Source: PA DHS, 2015a.
Determining Type of Response
When a referral for possible child abuse is received by a caseworker, social worker, or a 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 (Child Welfare Information Gateway, 2014).
|Child Protective Services (CPS)||General Protective Services (GPS)|
|Source: Pennsylvania Partnerships for Children, 2012.|
Sharon, a sixth-grade math teacher, stops by her friend Janie’s house for coffee on the way to work. 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 rages at Bobby, picks him up, and throws him across the kitchen, where he slides into a cabinet, hitting the back of his head.
Sharon takes off her coat and examines Bobby. He too is okay, but Sharon recognizes the importance of taking action for the safety of her friend’s young son. Sharon first sits down with Bobby on her lap to talk to Janie. 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, and one month later, Janie tells Sharon that General Protective Services has helped her find a program in which she has learned appropriate new ways of dealing with Bobby’s acting-out behaviors. Bobby has also been enrolled in the school district’s program for autistic children and is doing much better.
WHAT IS CHILD ABUSE?
Pennsylvania enacted numerous changes related to child abuse on December 31, 2014. The purpose of these changes is to:
- Strengthen the state’s ability to better protect children from abuse and neglect by amending the definitions of child abuse and perpetrator
- Streamline and clarify the mandatory child abuse reporting processes
- Increase penalties for failure to report suspected child abuse and protect persons who report child abuse
- Promote the use of multi-disciplinary investigative teams (MDITs) to investigate child abuse related crimes
- Support the use of information technology to increase efficiency and tracking of child abuse data
(Keep Kids Safe PA, 2015)
Categories of Child Abuse
Child abuse may take many forms. Pennsylvania’s CPSL categorizes abuse into the following types:
Mandated reporters need to learn to recognize the indicators for the various forms of child abuse (PA DPW, 2015). (For a detailed discussion on recognizing these categories of abuse, see “Recognizing Abuse” later in this course.)
- 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.
- 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.
- 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. (This term replaces “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:
- Renders a child chronically and severely anxious, agitated, depressed, socially withdrawn, psychotic or in reasonable fear that the child’s life or safety is threatened; or
- Seriously interferes with a child’s ability to accomplish age-appropriate developmental and social tasks.
- Serious physical neglect
- Any of the following when committed by a perpetrator that endangers a child’s life or health, threatens a child’s well-being, causes bodily injury, or impairs a child’s health, development, or functioning:
- A repeated, prolonged or egregious failure to supervise a child in a manner that is appropriate considering the child’s developmental age and abilities.
- The failure to provide a child with adequate essentials of life, including food, shelter or medical care
Source: 23 Pa. C.S. ¨ 6303.
CPSL, 23 Pa. C.S. § 6303, defines “child abuse” as intentionally, knowingly, or recklessly doing any of the following:
- Causing bodily injury to a child through any recent act or failure to act
- Fabricating, feigning, or intentionally exaggerating or inducing a medical symptom or disease which results in a potentially harmful medical evaluation or treatment to the child through any recent act
- 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 (see also “Sexual Abuse or Exploitation” below)
- Creating a reasonable likelihood of bodily injury to a child through any recent act or failure to act
- Creating a likelihood of sexual abuse or exploitation of a child through any recent act or failure to act
- Causing serious physical neglect of a child
- Engaging in any of the following recent acts:
- Kicking, biting, throwing, burning, stabbing, or cutting a child in a manner that endangers the child
- Unreasonably restraining or confining a child, based on consideration of the method, location, or the duration of the restraint or confinement
- Forcefully shaking a child under one year of age
- Forcefully slapping or otherwise striking a child under one year of age
- Interfering with the breathing of a child
- Causing a child to be present [when the] operation of methamphetamine laboratory is occurring
- 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
- Causing the death of the child through any act or failure to act
SEXUAL ABUSE OR EXPLOITATION
CPSL, 23 Pa. C.S. § 6303, further defines sexual abuse or exploitation as any of the following:
- The employment, use, persuasion, inducement, enticement or coercion of a child to engage in or assist another individual to engage in sexually explicit conduct, which includes, but is not limited to, the following:
- 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.
- 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.
- Actual or simulated sexual activity or nudity for the purpose of sexual stimulation or gratification of any individual.
- Actual or simulated sexual activity for the purpose of producing visual depiction, including photographing, videotaping, computer depicting or filming. (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.)
- Any of the following offenses committed against a child:
- Rape (as defined in 18 Pa.C.S. § 3121)
- Statutory sexual assault (as defined in 18 Pa.C.S. § 3122.1)
- Involuntary deviate sexual intercourse (as defined in 18 Pa.C.S. § 3123)
- Sexual assault (as defined in 18 Pa.C.S. § 3124.1)
- Institutional sexual assault (as defined in 18 Pa.C.S. § 3124.2)
- Aggravated indecent assault (as defined in 18 Pa.C.S. § 3125)
- Indecent assault (as defined in 18 Pa.C.S. § 3126)
- Indecent exposure (as defined in 18 Pa.C.S. § 3127)
- Incest (as defined in 18 Pa.C.S. § 4302)
- Prostitution (as defined in 18 Pa.C.S. § 5902)
- Sexual abuse (as defined in 18 Pa.C.S. § 6312)
- Unlawful contact with a minor (as defined in 18 Pa.C.S. § 6318)
- Sexual exploitation (as defined in 18 Pa.C.S. § 6320)
CHANGES TO THE LAW
- Current law reflects a lower threshold for physical abuse. The previous definition of child abuse set the threshold as “serious physical injury,” which meant causing severe pain or significantly impairing the child’s physical functioning. The current definition requires only “bodily injury.” For instance, a child’s buttocks are submersed in hot water after soiling his or her underpants, causing burns and blisters.
- The law now recognizes abuse such as Munchausen Syndrome by Proxy (discussed later in this course) under the provision for “fabricating, feigning, or intentionally exaggerating or inducing a medical symptom or disease.”
- The previous law limited mental abuse to “direct causes” of serious mental injury, whereas the law now includes acts that “substantially contribute” to mental injury of a child even if they do not directly cause the child to become anxious, depressed, fearful, or exhibit other types of mental injury.
- There were two changes to the definition of sexual abuse in the new law:
- A child under the age of 13 may not consent to sexual intercourse regardless of the offender’s age, nor can a child under the age of 16 consent when the offender is more than four years older than the child and is not married to the child.
- Sexual abuse does not include consensual activities between a child who is 13 to 15 years of age or older and another person who is 13 years of age or older and whose age is within four years of the child’s age.
- Current law deems “intentionally, knowingly, or recklessly engaging in conduct that might cause bodily injury” to constitute child abuse, regardless of whether an injury results.
- Current law expands the definition of serious physical neglect to include behavior that impacts the child’s health or development and that only has to occur once. The previous law required that the neglect had to be prolonged or repeated behavior.
- The list of types of conduct that constitute abuse was broadened to include acts such as keeping a child at an illegal methamphetamine lab or leaving a child with a nonparent who is a registered sex offender.
- Current law allows for school employees to be considered perpetrators under the definition provided for “person responsible for the child’s welfare.” Previously, only incidents of sexual abuse or exploitation and serious bodily injury by a school employee were considered child abuse, and there was a separate reporting and investigation process in place for other types of abuse.
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
(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 don’t live with the child. 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.
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 the child abuse to a family law attorney by a client.
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:
- 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.
- 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:
- The county agency shall closely monitor the child and the child’s family and shall seek court-ordered medical intervention when the lack of medical or surgical care threatens the child’s life or long-term health.
- All correspondence with a subject of the report and the records of the department and the county agency shall not reference child abuse and shall acknowledge the religious basis for the child’s condition.
- The family shall be referred for general protective services, if appropriate.
- This subsection shall not apply if the failure to provide needed medical or surgical care causes the death of the child.
- This subsection shall not apply to any child-care service as defined in this chapter, excluding an adoptive parent.
- 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.
- Parental rights to use reasonable force for the purposes of supervision, control, or discipline.
- Participation in events that involve physical contact with a child such as sports, physical education, or recreational activities.
- 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.
- 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)
PREVALENCE AND RISK FACTORS
Nationally, an estimated 3,188,000 children received a CPS response in 2013, and the estimated number of child victims in 2013 was 679,000, or 9.1 victims per 1,000 children. It is estimated that 1,520 children nationally died as a result of abuse and neglect in that year. Investigations have determined that:
- 79% were victims of neglect
- 18% suffered physical abuse
- 9% suffered sexual abuse
- 8.7% suffered psychological abuse
- 10% were victims of other forms of maltreatment such as abandonment, threats of harm, or parental drug abuse
Pennsylvania’s child abuse statistics in 2013 did not conform to the national numbers:
- Only 1.2 out of every 1,000 children in Pennsylvania were reported as being victims of suspected abuse versus 9.1 of 1,000 nationally.
- In Pennsylvania, only 6.8% of the child victims suffered from neglect, as compared to 79% nationally.
- Nationally, 18% of the child victims suffered physical abuse and in Pennsylvania that number was 30%.
- 67.6% of child victims in Pennsylvania were sexually abused, while only 9% suffered sexual abuse nationally.
(PA DPW, 2015)
The youngest children are the most vulnerable to maltreatment. In 2013, states reported that:
- The victimization rate was highest for children younger than 1 year (23.1 per 1,000 children in the population of the same age).
- More than one-quarter of victims were younger than 3 years.
- Twenty percent of victims were ages 3–5 years.
- The percentages of child victims were similar for both boys and girls.
There appears to be a racial disparity in the incidence of child fatalities. African American children had the highest fatality rate within their group, with a recorded number of 4.52 deaths per 100,000 children. This is approximately three times higher than the rates of white (1.53 per 100,000) or Hispanic (1.44 per 100,000) child fatalities (USDHHS, 2015a).
Health professionals need to be alert for risk factors that may increase the likelihood of child abuse and maltreatment. Risk factors may be either characteristics of a caregiver or a child and may go undetected.
The 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 male partner)
- Parental thoughts and emotions that tend to support or justify maltreatment behaviors
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
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 outlets
- Poor social connections
Presence of these factors signals the need for the professional to examine the situation more closely, carefully, and methodically. These factors seldom appear in isolation but rather in clusters.
PARENTAL SUBSTANCE ABUSE AND CHILD ABUSE
Parental substance abuse greatly increases the incidence of child abuse and neglect.
- Children are three times more likely to be abused and four times more likely to be neglected when they live with parents who abuse drugs and alcohol than children who reside in families where there is no substance abuse.
- Substance abuse is present in 40% to 80% of families in which children are victims of abuse and neglect.
- Children of parents who are substance abusers are likely to remain in foster care longer and return to foster care after being reunited than children of parents who are not.
- Children of parents who abuse drugs and alcohol are at risk for high rates of alcoholism and other substance abuse.
- Youth who abuse substances have increased problems at school, pregnancy, and the criminal justice system.
- More than 8 million children live with parents who are substance abusers.
Source: NCCAFV, 2015.
Many children suffer multiple types of abuse, which increases their risk of serious health consequences as adults. The Adverse Childhood Experience (ACE) study, published in 2009, investigated the association between childhood maltreatment and later-life health and well-being.
The findings suggest that certain negative experiences in childhood are major risk factors for illness, poor quality of life, and death later in life. The more adverse childhood experiences that were experienced by an individual, the greater the risk of developing alcoholism, chronic obstructive pulmonary disease (COPD), depression, illicit drug use, intimate partner violence, sexually transmitted infections, criminality, and smoking.
Source: CDC, 2014.
Protective Factors to Reduce Child Maltreatment
Protective factors safeguard children from being abused or neglected. There is scientific evidence to support that a supportive family environment and social networks have a protective effect. Several other potential protective factors have been identified. Ongoing research is exploring whether the following factors can buffer children from maltreatment:
- Nurturing parenting skills
- Stable family relationships
- Household rules and child monitoring
- Parental employment
- Adequate housing
- Access to healthcare and social services
- Caring adults outside the family who can serve as role models or mentors
- Communities that support parents and take responsibility for preventing abuse
The CDC reports that evidenced-based programs can abate child maltreatment. Some examples of programs that have proven to prevent child abuse are government sponsored child-parent centers, nurse family visits in the home, skill building through parent-child interaction therapy, and parent screening in the pediatric primary care setting (CDC, 2015a).
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 the parent or other caretaker’s explanation and/or the developmental state of the child.
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)
- Bruises that do not fit with the causal mechanism described
(Ward et al., 2013)
Normal and suspicious bruising areas. (Source: Research Foundation of SUNY, 2006.)
This pattern signals the blow of a hand to the face of a child. (Source: NYS OCFS, 2006.)
Regular patterns reveal that a looped cord was used to inflict injury on this child. (Source: NYS OCFS, 2006.)
Susan, the school nurse, was doing routine height and weight measurements for the fifth grade. She valued the opportunity to spend a little time alone with each child. Tommy, small for his age and withdrawn, was in Susan’s office for evaluation. He was new this year to the school district, and his records indicated he was already frequently absent. Susan observed that Tommy was dressed in jeans and a long-sleeved, hooded jacket even though it was 80 degrees out. He also had a black eye as well as a bruise on his opposite cheek. She asked him if he would remove his jacket before stepping on the scale, and when he did so, she noticed four round bruises on the outside of his upper right arm and one round bruise on the inside of his upper right arm. Susan asked Tommy how he had hurt himself, and he said he ran into a door.
Susan believed that the injuries were more consistent with physical abuse and reported her suspicions to CPS. Tommy was interviewed by a social worker, and it was determined that Tommy had been battered by his stepfather. The injury to his eye was the result of being punched. The injury to the right side of his face was sustained when his stepfather struck him as he tried to flee. He incurred the bruises to his right arm when the stepfather grabbed him from behind, causing a patterned injury of four fingers and a thumb.
Tommy’s stepfather was arrested and incarcerated. He pleaded no contest to the charges. Tommy and his mother were referred to counseling.
Lacerations or Abrasions
Typical indications of unexplained lacerations and abrasions 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)
Typical indications of 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
A steam iron was used to inflict injury on this child. (Source: NYS OCFS, 2006.)
Typical indications of unexplained fractures include:
- Fractures to the skull, nose, or facial structure
- Skeletal trauma with other injuries, such as dislocations
- Multiple fractures
- Fractures in various stages of healing
- Swollen or tender limbs
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
PEDIATRIC ABUSIVE HEAD TRAUMA
Abusive head injury is the most common cause of death as the result of child physical abuse. In 2009, the American Academy of Pediatrics (AAP) recommended using the term abusive head trauma (AHT) in place of shaken baby syndrome. Although the policy statement continued to recognize shaking as a potential cause of serious neurologic injury, the use of abusive head trauma includes all mechanisms of inflicted head injury, such as battering and other forms of trauma.
The CDC defines pediatric 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, 2012).
The clinical presentation of infants or children with AHT can vary, and nonaccidental injury should be considered in all children with neurologic signs and symptoms, especially if no other injuries are observed. Subdural and retinal hemorrhages are the most common findings (Narang, 2014).
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
- 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
Source: Fingarson & Pierce, 2012.
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
Presence of the following parent/guardian 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
MUNCHAUSEN SYNDROME BY PROXY
A rare form of child abuse known as Munchausen syndrome by proxy occurs in a medical setting and is characterized by unexplainable, persistent, or recurrent illnesses and discrepancies among the history, clinical findings, and child’s general health. This type of abuse is a combination of physical abuse, medical neglect, and emotional abuse. It is the child’s parent (almost always the biological mother) who creates a fictitious illness in the child by giving the child medications, inducing bruising or fever, and often causing the child to become hospitalized. Munchausen Syndrome by Proxy should be suspected in cases where children have unusual illnesses and/or do not respond to treatment (USDHHS, 2015b).
The characteristics of the parents in this syndrome are predictable. The child’s mother frequently has past experience in healthcare and is often a nurse. She gets along well with the hospital staff and appears to be a devoted mother and never leaves the child’s side. She may demonstrate a lack of emotion or an inappropriate affect when discussing the child’s illness. The mother often reports a history of past abuse and may report falsehoods about her life, such as having earned a law degree. In addition, the mother has both poor relationship and coping skills. If there is a father, he may not ever visit the hospital, and he presents as dependent with a high level of denial and a very supportive attitude towards the mother.
Some of the warning signs of the syndrome are that the signs and symptoms of the child’s illness only occur in the mother’s presence, the mother never leaves the child alone in the hospital, and the child is intolerant of the prescribed treatment. The mother may interact more with the medical staff than she does with the child. Diagnosis of Munchausen Syndrome by Proxy may require a multidisciplinary team approach in the hospital setting.
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)
A child may demonstrate indicators of serious mental injury such as:
- 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
(Child Welfare Information Gateway, 2013)
Beginning at age 8, Riley, the youngest of four children, has spent every other week at his father’s apartment without his siblings so that he and his father can have “one-on-one time.” When Riley’s parents divorced, and although the judge was aware that Riley’s father was possibly abusive, it was the philosophy of the court that children suffer more damage when they have no contact at all with their parents.
At age 9, Riley was developing obvious signs of anxiety, such as running away from Little League baseball games because he did not enjoy playing while people watched. His father ridiculed him and physically picked him up and put him back on the field in anger in the middle of the game. The coach tried to intervene, but the father prevailed, and Riley stood motionless in the field.
By age 10, Riley was resisting visitation with his father, and a neighbor called 911 after observing Riley’s father yelling at him and forcing him into the car, followed by Riley trying to jump out of the moving vehicle. Riley’s teacher also reported to the authorities that he arrived late to school 10 days in a row following a visitation to his father and requested to go home to his mother on a daily basis because he had a “stomach ache.”
An investigation revealed that Riley was having severe separation anxiety from his mother and siblings and that the apartment where he stayed with his father was filled with storage items, leaving little room for the child. There was no bed at the residence for Riley, who slept on a mat on the floor, nor was there food in the refrigerator. Riley’s father said that the child was “fat” and that he did not want to keep any food around for that reason.
Riley was screened in to CPS because he was diagnosed with a severe anxiety disorder by the school psychologist. A multidisciplinary team helped Riley and his family. Riley began seeing the school counselor, and at the recommendation of CPS, his visitation schedule was amended to exclude overnights with his father. In addition, his father was ordered by the court to attend parenting classes. Riley’s symptoms improved within a few months after counseling, treatment with anti-anxiety medication, and the revised visitation schedule.
Recognizing Sexual Abuse
The category of sexual abuse or exploitation is described in the CPSL as including:
- 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:
- 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.
- 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.
- Actual or simulated sexual activity or nudity for the purpose of sexual stimulation or gratification of any individual.
- Actual or simulated sexual activity for the purpose of producing visual depiction, including photographing, videotaping, computer depicting or filming.
- Any of the following offenses committed against a child:
- Sexual assault
- Involuntary deviate sexual intercourse
- Indecent assault
- Indecent exposure
- Unlawful contact with a minor
- Sexual exploitation
Sexual abuse as defined above 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.
Detecting child sexual abuse can be very difficult. Physical evidence is not apparent in most cases, and victims fear the consequences of reporting their “secret.” Most perpetrators of child sexual abuse are people who are known to the victim. In more than half of cases of repeated abuse, the perpetrator is a member of the family. 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.
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. The majority of perpetrators of child sexual abuse were once victims themselves, but not all victims will become perpetrators.
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.
PHYSICAL INDICATORS OF SEXUAL ABUSE
Physical evidence of sexual abuse may be 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 insure that the relationship will continue. If physical indicators occur, they may include:
- Symptoms of sexually transmitted infections
- 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 recurring bladder or urinary tract infections
- Foreign bodies in the vagina or rectum
- Painful bowel movements
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
Sexually abusive parents/guardians 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
(Prevent Child Abuse New York, 2015)
COMMERICAL SEXUAL EXPLOITATION OF CHILDREN (CSEC)
The crime of sex trafficking of children 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.” CSEC victims are abused physically, psychologically, and emotionally. The perpetrator controls these victims even when they are not physically restrained or confined by their trafficker.
An estimated 80% to 90% of trafficked adolescents were victims of child sexual abuse. Experts suggest that a runaway adolescent is likely to be approached by a pimp or invited to participate in a form of commercial sex within 48 hours of being on the street. The average age of entry into the commercial sex industry is 12 to 14 years.
Impacts of CSEC
Commercially sexually exploited youth frequently suffer from injuries and other physical and mental health issues:
- 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 pulled out
- Pregnancy and abortion
- Sexually transmitted infections
- 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, and guilt
- Fear for the safety of family
- Posttraumatic stress disorder (PTSD) and memory loss
Screening for CSEC
Victims of sex trafficking are often accompanied by their pimp, whom they may refer to as their “boyfriend.” If trafficking is suspected, the two must be separated by the healthcare professional, for instance, assuring them that privacy for a physical exam is standard practice. Suggested questions when speaking with a child suspected to be a victim of trafficking include:
- Are you able to go to your home or job at will? Are you able to leave when you want to?
- Are you ever locked in at home or at work?
- Has anyone ever hurt you at home or on the job?
- Is anyone making you to do things you do not want to do at home or at work?
- Do you have full access to food, the bedroom, and the bathroom, or do you have to ask permission ?
- Has anyone ever taken away your food or water?
- Has anyone ever not allowed you to sleep?
- Have you ever wanted to go the doctor or dentist, but you weren’t allowed?
- Has anyone ever threatened your family?
- Has anyone taken your driver’s license/passport/papers?
Source: USDHHS, 2013; Becker & Bechtel, 2015.
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).
Indicators of physical neglect include:
- Consistent hunger
- Begging or stealing food
- Poor hygiene (skin, teeth, ears, etc.)
- Inappropriate dress for the season
- Failure to thrive (physically or emotionally)
- Positive indication of toxic exposure, especially in newborns, such as drug withdrawal symptoms, tremors, etc.
- 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
- Early arrival to or late departure from school
- Constant fatigue, listlessness, or falling asleep in class
- Delinquency, such as thefts
- Reports there is no caretaker at home
- Runaway behavior
Robert attends fifth grade. His mother provides him with lunch money or prepares a lunch for him to bring to school. Recently, Robert began to come home from school hungry every day and told his mother that he had given his lunch or his money to his classmate Kevin. He also let Kevin borrow a jacket, and it was never returned. Robert’s mother queried him as to why he was doing this, and he said that Kevin was just really poor and hungry and cold every day. Robert denied any bullying behavior on Kevin’s part.
Robert’s mother contacted ChildLine about Kevin, suspecting neglect. A social worker responded, and Kevin was called into the school office to speak with her. A sensitive discussion revealed that Kevin’s parents were separated and that he was living with his father in a hotel room. His father was unemployed, and there was little money for food or clothing to care for Kevin’s needs. It was determined that this was not a case of neglect because of environmental factors that were beyond Kevin’s father’s control to provide for Kevin. With the help of General Protective Services, Kevin’s father obtained the assistance he needed to care for Kevin.
ABANDONMENT OF AN INFANT
Another form of neglect is abandonment of an infant. In order to help prevent tragic consequences resulting from unwanted babies, all 50 states have enacted some version of a “safe-haven” law that allows parents to relinquish an infant to the state by leaving the newborn in a safe location such as a hospital, fire department, or police station. The purpose of these statutes is to decriminalize leaving unharmed infants anonymously in a safe location in order to save the lives of these unwanted infants.
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 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 the 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 your initial response of shock.
- Thank the child for telling you.
- Use age-appropriate language, and use the 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.
Victimized children may cry out in a variety of nonverbal or indirect ways, for example, a drawing left behind for the teacher, the counselor, or a trusted relative to see. Some children report vague somatic symptoms to the 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 don’t 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 Abuse
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 CPS 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.
This multidisciplinary interview team (MDIT) 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 (Child First PA, 2014).
A mother brought her 12-year-old daughter, Haley, to the emergency department. She said that her daughter had been complaining about painful urination and wanted to check if she might have a bladder infection. The triage nurse, Janelle, asked the mother, who appeared to be in the last trimester of pregnancy, to fill out some paperwork while she took the girl to the bathroom for a urine specimen.
Janelle noticed that the daughter appeared fearful and sat in silence while her mother did all of the talking. When they were alone behind closed doors, Janelle asked Haley if there was anything that she wanted to talk about privately. The child responded by shaking her head no, but the nurse sensed that she was holding something back.
Haley was able to produce a clear, pale yellow urine specimen and then followed the nurse to an exam room. Janelle asked her if she had any pain when she urinated, and Haley said yes. The nurse asked her if she had begun menstruating, and the child said she had not.
Janelle brought the mother into the exam room to wait with her daughter. After obtaining a brief history from the mother, the doctor ordered a urinalysis. The urinalysis was negative. The doctor did an external genital exam that revealed numerous vesicular lesions on her labia. The child denied any sexual activity. The doctor cultured the lesions for herpes and asked the mother to step into his office to discuss his findings.
Once Janelle and Haley were alone again in the room, the child burst into tears and told the nurse that her mother’s boyfriend had been rubbing his “private” on her and said that if she told anyone, her mother would die. The nurse stopped questioning the child and reported her suspicion of child sexual abuse to CPS. The nurse knew that victims of child sexual abuse should only be minimally questioned until they can undergo a forensic interview.
On the following day, Haley was interviewed by a child forensic interview specialist in a child-friendly advocacy center. She and her mother, who was also a victim of child sexual abuse, received counseling for over a year. The mother’s boyfriend was convicted of sexual abuse.
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).
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 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.
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 their evaluation of the circumstances, observations, and familiarity with the family or pattern of events (Pennsylvania Medical Society, 2014).
State legislation effective January 1, 2015, expanded the list of mandated reporters in an effort to increase reporting. The list of mandated reporters now 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 new 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.”
All of the following persons are now mandated reporters 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:
- A person who is licensed or certified to practice in any health-related field under the jurisdiction of the Department of State
- Medical examiner, coroner, or funeral director
- 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
- School employee
- Employee of a childcare service who has direct contact with children in the course of employment
- Clergyman, priest, rabbi, minister, Christian Science practitioner, religious healer, or spiritual leader of any regularly established church or other religious organization
- 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
- Employee of a social services agency who has direct contact with children in the course of employment
- Peace officer or law enforcement official
- Emergency medical services provider certified by the Department of Health
- Employee of a public library who has direct contact with children in the course of employment
- 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
- An independent contractor
- 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
- Foster parent
- 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
Source: 23 Pa. C.S. § 6311.
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 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:
- The names and addresses of the child, the child’s parents, and any other person responsible for the child’s welfare
- Where the suspected abuse occurred
- The age and sex of each subject of the report
- The nature and extent of the suspected child abuse, including any evidence of prior abuse to the child or any sibling of the child
- The name and relationship of each individual responsible for causing the suspected abuse and any evidence of prior abuse by each individual
- Family composition
- The source of the report
- The name, telephone number, and email address of the person making the report
- The actions taken by the person making the report, including those actions taken under section 6314 (relating to photographs, medical tests, and X-rays of 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 (PA DPW, 2012).
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. The new 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 (Pennsylvania 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. 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)
There is some evidence that the national incidence of child abuse is declining. The Children’s Bureau research on child welfare issues includes a series of annual Child Welfare Outcomes Reports to Congress. In the most recent report, national rates of child victimization dropped 3.3%, or approximately 30,000 fewer victims in 2012 compared with 2008. In addition, the overall rates of CPS response to children increased by 4.7%, from 40.8 to 42.7 per 1,000 children nationally (USDHHS, 2015a).
Research on child abuse and neglect over the past 20 years indicates that the incidence of child maltreatment can be reduced and its harmful effects can be diminished through prevention and treatment. The Institute of Medicine and the National Research Council formed a committee to make recommendations for further research in the area of child maltreatment. This committee advocates a national strategic plan with a coordinated agenda for child abuse and neglect research. They propose the establishment of standardized definitions of child abuse and neglect and a national surveillance system for data collection (Petersen et al., 2014).
Child maltreatment, abuse, and neglect negatively impact the health and well-being of society. Child victimization is not only a social problem but also a serious public health issue. Child abuse and neglect affect not only the victims while they are children but also shape the adults these children will become. 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.
Individuals, communities, and society must change in order to provide safe environments for children. In Pennsylvania, recent changes to child abuse laws strengthen 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. New penalties are in place for those who fail to report, alongside new 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.
Child Welfare Information Solution (CWIS) (Online reporting)
ChildLine Abuse Hotline: 800-932-0313
Coalition Against Domestic Violence
CY–47 Forms (PA Report of Suspected Child Abuse Form)
National Center for Missing and Exploited Children
National Domestic Violence Hotline
800-799-7233 / 800-787-3224 (TTY)
NOTE: Complete URLs for references retrieved from online sources are provided in the PDF of this course (view/download PDF from the menu at the top of this page).
Becker HJ & Bechtel K. (2015). Recognizing victims of human trafficking in the pediatric emergency department. Pediatric Emergency Care, 31(2), 144–7. doi 10.1097/PEC.0000000000000357
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
Centers for Disease Control and Prevention (CDC), National Center for Injury Prevention and Control, Division of Violence Prevention. (2015a). Child maltreatment: prevention strategies. Retrieved from http://www.cdc.gov
Centers for Disease Control and Prevention (CDC), National Center for Injury Prevention and Control, Division of Violence Prevention. (2015b). Child maltreatment: risk and protective factors. Retrieved from http://www.cdc.gov
Centers for Disease Control and Prevention (CDC), National Center for Injury Prevention and Control, Division of Violence Prevention. (2014). ACE study. Retrieved from http://www.cdc.gov
Child First Pennsylvania. (2014). Child First PA update, October 2013. Retrieved from http://www.childfirstpa.com
Child Welfare Information Gateway. (2015). Pennsylvania state statutes: definitions of child abuse and neglect. Retrieved from https://www.childwelfare.gov
Child Welfare Information Gateway. (2014). Child abuse and neglect fatalities 2012: statistics and interventions. Retrieved from http://www.childwelfare.gov
Child Welfare Information Gateway. (2013). What is child abuse and neglect? Recognizing the signs and symptoms. Retrieved from https://www.childwelfare.gov
Fingarson A & Pierce M. (2012). Identifying abusive head trauma. Contemporary Pediatrics, February 2012. Retrieved from http://www.modernmedicine.com
Keep Kids Safe PA. (2015). Keep kids safe PA. Retrieved from http://www.keepkidssafe.pa.gov
Narang S. (2014). Abusive head trauma: past, present, and future. J Child Neurol., 29(12), 1747–56. Doi: 10.1177/0883073814549995. Retrieved from http://www.ncbi.nlm.nih.gov
National Council on Child Abuse and Family Violence (NCCAFV). (2015). Parental substance abuse a major factor in child abuse and neglect. Retrieved from http://www.nccafv.org
New York State Office of Children and Family Services (NYS OCFS). (2006). New York State mandated reporter participant guide. Retrieved from http://www.ocfs.state.ny.us
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
Pennsylvania Department of Human Services (PA DHS). (2015c). Fact sheet: Pennsylvania’s Safe Haven Law. Retrieved from http://www.secretsafe.org
Pennsylvania Department of Public Welfare (PA DPW). (2015). Recognizing and reporting child abuse in Pennsylvania: a guide for mandated reporters. Retrieved from http://wc-hs.org
Pennsylvania Department of Public Welfare (PA DPW). (2012). Mandated reporters. Retrieved from http://www.dpw.state.pa.us
Pennsylvania Family Support Alliance (PFSA). (2015). Summary of child protection legislative amendments 2013–2014: updated Child Protection Services Law, chapter 63, title 23. Retrieved from https://www.pa-fsa.org
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
Petersen AC, Joseph J, Feit M (Eds.). Committee on Child Maltreatment Research, Policy, and Practice for the Next Decade: Phase II; Board on Children, Youth, and Families; Committee on Law and Justice; Institute of Medicine; National Research Council. (2014). New directions in child abuse and neglect research. Washington (DC): National Academies Press.
Prevent Child Abuse New York. (2015). Factsheet: child sexual abuse. Retrieved from http://www.preventchildabuseny.org
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
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. (2006). Mandated reporter training: identifying and reporting child abuse and maltreatment/neglect. Buffalo, NY: author. Retrieved from http://www.ocfs.state.ny.us
U.S. Department of Health and Human Services (USDHHS), Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. (2015a). Child maltreatment 2013. Retrieved from http://www.acf.hhs.gov
U.S. Department of Health and Human Services, MedlinePlus. (2015b). Munchausen syndrome by proxy. Retrieved from http://www.nlm.nih.gov
U.S. Department of Health and Human Services (USDHHS), Children’s Bureau, National Child Abuse and Neglect Training and Publications Project. (2014). Child Abuse Prevention and Treatment Act: 40 years of safeguarding America’s children. Washington D.C.: Retrieved from https://childlaw.sc.edu
U.S. Department of Health and Human Services (USDHHS), Administration for Children, Youth, and Family (ACYF). (2013). Guidance to states and services on addressing human trafficking of children and youth in the United States. Retrieved from http://www.acf.hhs.gov
U.S. Department of Health and Human Services (USDHHS), Children’s Bureau. (2012). Child Maltreatment 2012. Retrieved from http://www.acf.hhs.gov
U.S. Legal, Inc. (2014). Pennsylvania safe haven laws. Retrieved from http://safehavenlaws.uslegal.com
Ward MGK, Ornstein A, Niec C, Murray CL. (2013). The medical assessment of bruising in suspected child maltreatment cases: a clinical perspective. Paediatr Child Health, 18(8), 433–7. Retrieved from http://www.cps.ca