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

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

• Describe 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.
• Define the categories of child abuse and exclusions.
• Recognize indicators of child abuse and trafficking.
• Summarize responsibilities for reporting suspected child abuse.
• Identify the protections for reporters and penalties for failure to report.

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).

ChildLine is the centralized agency that receives reports of suspected child abuse and neglect. The agency also provides information, counseling, and referral services for families and children to ensure safety and well-being of the children of Pennsylvania. The toll-free intake line, 800-932-0313, is available 24 hours a day, seven days a week.

Bifurcated System / Two Track Services

Pennsylvania’s child welfare system is bifurcated into two categories: Child Protective Services (CPS) and General Protective Services (GPS). 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 offering assistance to parents in fulfilling their parental duties and by helping them to recognize and correct potentially harmful conditions.
  (PA DHS, 2021a)

DIFFERENTIATING BETWEEN CPS AND GPS

Child Protective Services (CPS): For situations that meet the definition of child abuse	General Protective Services (GPS): For situations that can cause harm to children but do not meet the definition of child abuse
(PA DHS, 2019)
Similar to a law-enforcement investigation May result in a perpetrator being identified May involve joint investigations with social services, law enforcement, and medical professionals	No attempt to identify a perpetrator or determine if abuse occurred
Urgent time frame	Time frame determined by the level of risk and imminent danger
Goal of investigation is to determine if abuse occurred	Goal of assessment is to determine family needs to promote child safety and well-being and then provide services
Not reassigned to GPS If situation is not determined to meet the definition of child abuse, case is classified as unfounded	Can be reassigned to CPS if situation is found to meet the definition of child abuse
Investigation must be completed in 30 days Investigation can be extended to 60 days if necessary in order to collaborate with law enforcement	County agency personnel must respond immediately if the child was placed in emergency protective custody, or if emergency placement is needed or may be needed but cannot be determined by the report Entire assessment must be completed in 60 days
Services are involuntary	Services are voluntary Services may be court-ordered if the family refuses services and a child’s safety is in question

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 “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:

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
      (23 Pa. C.S. § 6304)
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
      (23 Pa. C.S. § 6304)

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

A person who provides permanent or temporary care, supervision, mental health diagnosis or treatment, training or control of a child in lieu of parental care, supervision, and control. The term includes any such person who has direct or regular contact with a child through any program, activity, or service sponsored by a school, for-profit organization, or religious or other not-for-profit organization.

Exclusions

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

EXCLUSIONS TO REPORTING

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

• 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
• 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 that 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 TO SUBSTANTIATING A REPORT

Section 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.

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

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

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.

Caregiver Risk Factors

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.

The National Child Abuse and Neglect Data System (NCANDS) cites the following caregiver risk factors:

• Alcohol abuse that is chronic
• Domestic violence in which the caregiver is the perpetrator or the victim
• Drug abuse that is chronic
• Financial problems that do not allow the family to meet basic needs
• Inadequate housing or homelessness
• Public assistance participation
• Any caregiver disability
  (U.S. DHHS, 2021)

Child Risk Factors

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

• Children younger than 4 years of age
• Special needs that may increase caregiver burden
• Physical disability
• Intellectual disability
• Mental health issues
• Chronic physical illnesses
  (CDC, 2021a)

Additional risk factors include:

• Social isolation
• Family disorganization, dissolution, and violence, including intimate partner violence
• Parenting stress, poor parent-child relationships, and negative interactions
• Community violence
• Concentrated neighborhood disadvantage (e.g., high poverty and residential instability, high unemployment rates, and high density of alcohol sales outlets)
• Poor social connections
  (CDC, 2021a)

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

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

RECOGNIZING ABUSE

Recognizing Physical Abuse

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

PHYSICAL INDICATORS OF PHYSICAL ABUSE

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

Bruising

Some bruises indicate likely child 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 rule” (see below) is a mnemonic aid to remember when bruising requires immediate evaluation. Children who are under 4 years should not have any bruises in these areas, and infants under 4 months should have no bruises anywhere. The size of the bruise is not as important as the location.

TEN-4 RULE

T	Torso
E	Ears
N	Neck
4	Under 4

Suspicious bruises include the following;

• Bruises on babies who are not yet mobile (“cruising”)
• Bruises on the ears, neck, eyes, cheeks, buttocks, or torso (torso includes chest, back, abdomen, genitalia)
• Bruises that are clustered or patterned (e.g., handprints)
  (Norton Children’s, 2020)

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 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

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:

• Withdrawal from friends or usual activities
• Changes in behavior (e.g., aggression, anger, hostility, or hyperactivity)
• Changes in school performance
• Depression, anxiety or unusual fears, or a sudden loss of self-confidence
• An apparent lack of supervision
• Frequent absences from school
• Reluctance to leave school activities, as if not wanting to go home
• Attempts at running away
• Rebellious or defiant behavior
• Self-harm or attempts at suicide
  (Mayo Clinic, 2018)

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)

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
  (PA DHS, 2021c)

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

• 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 and/or repeated urinary infections
• Foreign bodies in the vagina or rectum
• Painful bowel movements
  (Clermont County CPS, 2021; RAINN, 2021)

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)

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

SEX 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.”

The term child prostitution is misleading when used in the context of commercial sexual exploitation of children (CSEC). The children who are involved in commercial sex are victims. Traffickers may beat, rape, torture, and use drugs, alcohol, and emotional tactics to gain control over their child victims.

Impacts of CSEC

Commercially sexually exploited youth frequently suffer from injuries and other health issues. Physical issues may include:

• Tuberculosis
• Infections
• Substance use, chemical dependency and withdrawal
• Malnutrition
• Physical injuries from violence
• Sexually transmitted infections, including HIV
• Pregnancy and pregnancy-related health issues
• Urinary tract infections

Mental health issues may include:

• Posttraumatic stress disorder (PTSD)
• Depression
• Suicidal ideation
• Suicide attempts
• Self-harm
• Depression
• Poor self-esteem
• Feelings of hopelessness
  (US DOJ, 2020; Hornor & Sherfield, 2018)

Screening for CSEC

Victims of sex trafficking seldom self-disclose, and many will resist disclosure because they have been threatened or feel shame, guilt, or loyalty to the trafficker. Some youth do not self-identify as victims. It is important for healthcare providers to ask about exploitation because 88% of adolescent victims of trafficking reported an encounter with a healthcare provider during the time that they were being exploited.

There are several validated screening tools for CSEC and a variety of known risk factors for victimization. Greenbaum and colleagues (2018) developed a short, six-question screening tool for CSEC that can be used effectively for youth in the healthcare setting. This short questionnaire also differentiates between victims of sex trafficking and youth who may have experienced sexual assault or abuse without sex trafficking. Each positive response is given a 1-point score. A cut-off score of 2 indicates a patient suspected for CSEC and indicates further questioning by someone trained in a trauma-informed approach.

1. Is there a previous history of drug and/or alcohol use?
2. Has the youth ever run away from home?
3. Has the youth ever been involved with law enforcement?
4. Has the youth ever broken a bone, had a traumatic loss of consciousness, or sustained a significant wound?
5. Has the youth ever had a sexually transmitted infection?
6. Does the youth have a history of sexual activity with more than five partners?

LABOR TRAFFICKING

Labor trafficking involves labor obtained by use of threat or serious harm, physical restraint, or abuse of legal process, including the recruitment, harboring, transportation, provision, or obtaining of a person for labor or services, through the use of force, fraud, or coercion for the purpose of subjection to involuntary servitude, peonage (paying off debt through work), debt bondage (debt slavery, bonded labor or services for a debt or other obligation), or slavery (a condition compared to that of a slave in respect to exhausting labor or restricted freedom).

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).

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

Recognizing Physical Neglect

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

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, 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
• 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 and/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, with the expectation that one interview rather than several by different concerned parties reduces the chances of traumatizing the child further (US DOJ, 2015).

Management

A physically abused child will need to be screened for emergent needs. Once stability has been established, the child will need 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 also must be evaluated for physical, mental, and psychosocial needs. Baseline testing is needed 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, 2021b).

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 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. If the immediate report is electronic, no additional report is needed. (See “Resources” at the end of this course.)

Permissive reporters can call ChildLine’s toll-free number to make a verbal report of suspected abuse but do not have access to the electronic reporting system (PA DHS, 2021a).

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:

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 regulation
    (23 Pa. C.S. § 6313b)

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.

Mandatory Notification of Substance Exposed Infants

Under Pennsylvania law (23 Pa. C.S. § 6386), a healthcare provider involved in the delivery or care of a child under one 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. 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

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.

Mandated Reporters Right-to-Know

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

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

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

CONCLUSION

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

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

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