Child Abuse Recognition and Reporting for Pennsylvania Nursing CE Course

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Child Abuse Recognition and Reporting for Pennsylvania Nurses

Disclosure Statement

This course aims to ensure that nurses understand Pennsylvania’s Child Protective Services Law (CPSL) 23 Pa.C.S. Chapter 63 and their role in identifying and reporting potential child abuse cases, including child neglect or exploitation.

Upon completion of this module, the nurse will be able to:

• define the key terms and categories of child abuse as outlined in the Pennsylvania CPSL
• consider the incidence and prevalence of child abuse in PA and the US
• identify the common indicators of suspected child abuse which serve as the basis for reporting "reasonable cause to suspect" the presence of abuse
• discuss the roles and responsibilities of mandated reporters in Pennsylvania if they come into contact with a suspected victim of abuse, are directly responsible for the care of a suspected victim of abuse, or receive a specific disclosure of alleged abuse in an identifiable child
• outline the requirements and procedure for reporting suspected child abuse, including that the mandated reporter is not responsible for identifying the type of abuse, the identity of the abuser, or considering all exclusions from child abuse prior to filing a report
• summarize the penalties for mandated reporters who fail to report suspected child abuse
• outline the regulations and protections regarding mandated reporters in Pennsylvania who are presumed to have acted in good faith when reporting suspected child abuse

Child Maltreatment

Former First Lady and Secretary of State Hilary Clinton noted that “it takes a village to raise a child” in her 1996 book, bringing attention to the enormous responsibility of raising children (Clinton, 1996, p. 5). Government agencies, healthcare workers, teachers, family, friends, parents, and caregivers are all partners in children's growth, development, and safety. In a perfect world, all these components would work together for the good of the child, but statistics demonstrate that children frequently experience maltreatment and abuse. Laws protect parents’ ability to raise their children as they deem appropriate but also hold them accountable for maintaining their safety and protecting them from abuse. The US Constitution gives this right to families in the 14^th Amendment, which states that no state shall deprive any person of life, liberty, or property without due process of law. The US Supreme Court also defines liberty in the 14^th Amendment as freedom from bodily restraint and the right of the individual to establish a home and raise their children (Cornell Law School, n.d.). While the US Constitution gave the parental right to have children, no laws protected children initially. The Child Abuse Prevention and Treatment Act of 1974 (CAPTA), enacted in 2000, was the first federal law to protect children and improve the response to child abuse. This act authorizes law enforcement to implement child abuse laws and promotes child abuse prevention programs. It also develops a system to track suspected child abuse offenders. Updates to CAPTA occurred as follows: in 2015, with a focus on victims of human trafficking; in 2016, with updates related to infants born affected by substance abuse; and in 2018, with amendments promoting opioid recovery and protection for individuals making good-faith child abuse reports. In 2019, Act 88 (HB 1051) was amended to increase and clarify the penalties for mandated reporters who fail to report suspected child abuse with different penalties based on certain situational factors. In 2021, the CAPTA Reauthorization Act was placed on the Senate Legislative Calendar with no further actions (Child Welfare Information Gateway, 2019a; Pennsylvania General Assembly [PGA], 2019).

Definitions

The following terms and definitions are based on the guidelines of the PGA (n.d.-a) for recognizing and reporting child abuse in the Commonwealth of Pennsylvania by the Child Protective Services Law (23 Pa.C.S. Chapter 63).

Table 1

Definitions 

(23 Pa.C.S. Chapter 63)

Data/Statistics

According to the US Department of Health and Human Services, Administration for Children and Families (ACF), in 2021, 3,987,000 referrals involving 7,176,000 children were received nationally across the US by CPS departments nationwide alleging maltreatment of a minor; of these, approximately 3,016,000 children received either an investigation or alternative response, equating to 40.7 per 1,000 children. This rate decreased from 42.0 per 1,000 children in 2020. Of these minors, 600,000 were determined to be victims of maltreatment; of the victims, 76% were neglected, 16% were physically abused, 10.1% were sexually abused, and 0.2% were sex trafficked. In 2021, 1,820 fatalities were reported due to abuse or neglect, equating to a rate of 2.46 per 100,000 children. This rate increased by 7.7% since 2017. Children under three accounted for 66.2% of all child fatalities, and 45.6% were children under one (ACF, 2023).

Of the 600,000 US minors determined to be victims, the highest rate was among children younger than 1, with 88,571 cases equating to a rate of 25.3 per 1,000 children. The victimization rate of girls (8.7 per 1,000) is higher than that of boys (7.5 per 1,000); however, the fatality rate is higher among boys at 3.01 per 100,000 compared to girls with a rate of 2.15 per 100,000. American Indian and Alaska Native children experience the highest victimization rates at 15.2 per 1,000, and African American children had the second highest at 13.1 per 1,000. The data from 2021 showed that 90.6% of victims were maltreated by one or both of their parents. The parents could have acted together, alone, or with up to two others in the child's maltreatment. Victimization by the mother alone accounted for 38% (210,746) of cases, the father acting independently accounted for 23.9% (132,363) of cases, and victimization by both parents accounted for 20% (111,100) of cases. Of those individuals who victimized a child, 14.5% were not the victim's parent. Of the nonparents, 5.6% were relatives of the child, 3.3% were unmarried partners of the parent, and 3.1% were categorized as other, which can include non-related adult or child, babysitter, foster sibling, clergy, or school personnel (ACF, 2023).

In 2021, 34,167 children in PA received an investigation or alternative response, a decrease of 20.3% since 2017. Of these, 4,683 were substantiated with the child determined to be a victim, with 2,103 (44.9%) being victims of sexual abuse, 2,093 (44.7%) victims of physical abuse, 499 (10.7%) victims of neglect, and 47 (1%) victims of sex trafficking. In 2021, there were 65 child fatalities due to abuse or neglect. Girls had a higher rate of victimization at 2.3 per 1,000 children (equating to 2,987 victims) than boys, who had a rate of 1.2 per 1,000 children (equating to 1,696 victims). Like the national data, children under 1 year had the highest victim rate at 3.0 per 1,000, equating to 383 children (ACF, 2023).

Pennsylvania Child Protective Services Law

General Purpose

The Pennsylvania Child Protective Services Law (CPSL), 23 Pa.C.S. Chapter 63, was enacted in 1975 to protect children from abuse. This protection allows children to grow and develop healthily while stabilizing the family unit when possible. It also guides the practices and functions of state and county agencies in the protection and care of potential victims of child abuse. The CPSL does not infringe on the generally recognized rights of parents to use reasonable control and supervision to raise their children (PGA, n.d.-a).

Recent Amendments

Act 54

In 2018, the CPSL Act 54 was implemented, requiring the notification of substance-affected infants by healthcare providers and Plan of Safe Care. This act notes that healthcare providers must alert the PA DHS if they are involved in the delivery or care of a patient under one year they suspect was born affected by substance use or withdrawal from drug exposure or a fetal alcohol spectrum disorder based on the standards of professional practice. This notification can be submitted to ChildLine, electronically through the Child Welfare Portal, or via phone at 1-800-932-0313. While notifying the department does not constitute a report of child abuse, it is to assess the child and the child’s family for a Plan of Safe Care. It is intended to optimally manage the affected infant's treatment needs and any associated family members. After notification, a multidisciplinary team (MDT) meeting must be scheduled prior to the infant’s discharge from the facility to determine the needs of the child, parents, and immediate caregivers. The parents and caregivers must be assessed for treatment needs related to substance use disorder or other physical or behavioral health concerns that may impact the safety, early childhood development, and well-being of the child. This meeting will determine the most appropriate county/lead agency to develop, implement, and monitor a Plane of Safe Care. This MDT 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 and private insurers, and hospitals and medical providers (PGA, 2018).

Act 88

In 2019, Act 88 (HB 1051) was amended to increase and clarify the penalties for mandated reporters who fail to report suspected child abuse with different penalties based on certain situational factors (PGA, 2019). This topic is discussed in detail in the Failure to Report section of this learning activity.

Act 53 

In 2021, § 6388 was added to Act 53. § 6388 addressed the creation of a task force on child pornography. The task force aims to review any current inadequacies related to a child pornography offense within 18 Pa.C.S. 6312. § 6388 outlines the required members of this task force and membership requirements (PGA, n.d.-a).

Act 115

In 2016, Act 115 related to human trafficking was passed. This stipulates the required termination of parental rights related to human trafficking, additional grounds for aggravated circumstances, and discusses the confidential disclosure of data to law enforcement officials in cases of severe trafficking in persons. It categorizes involvement of a child in severe forms of trafficking in persons or sex trafficking, as defined in the Trafficking Victims Protection Act of 2000. It further defines a perpetrator as an individual (age 18+) who engages a child in severe trafficking in persons or sex trafficking (PGA, 2016).

Pennsylvania Child Welfare System 

The state supervises the Pennsylvania child welfare system. However, it is administered by the individual county and has two main functions: child protective services (CPS) and general protective services (GPS). Both types of reports should contain the same details, and both can be submitted electronically or through the ChildLine phone number detailed below in the section regarding mandated reporting (PGA, n.d.-a).

Child Protective Services 

CPS is a general term for services and activities provided by each county agency and by DHS for child abuse cases. CPS cases require an investigation to ensure that the alleged act or failure to act meets the definition of child abuse outlined in the PA CPSL. The PA CPSL recognizes ten separate categories of child abuse (see Table 1 above). CPS reports can be made by either mandated or permissive reporters (PA DHS, 2023).

General Protective Services

GPS pertains to services and activities provided by each county agency for cases requiring protective services as defined by the DHS regulation. The difference between the state’s CPS and GPS within the child welfare system is a critical distinction in PA. A GPS report alleges the potential need for intervention by the county to prevent serious harm to a victim who is under 18 years of age but may not rise to the level of suspected abuse. Either mandated or permissive reporters can make GPS reports. GPS aims to provide services that will hopefully prevent the potential for harm to a child by providing or arranging for the services necessary to ensure the child is safeguarded and preserve and stabilize the family unit. Examples include:

• individuals under the age of 18 without proper care or control, subsistence, education (as required by law), or other care or control to maintain physical, mental, or emotional health or morals
• children placed for care or adoption in violation of law
• children who have been abandoned by their parents/guardian/custodian or are without a parent/guardian/legal custodian
• children who have committed a specific act of habitual disobedience of the reasonable and lawful commands of their parents/guardians/other custodian and who are ungovernable and in need of care/treatment/supervision
• children who are habitually and without justification truant from school while subject to compulsory school attendance
• children who are under the age of 10 who have committed a delinquent act
• children who have been abandoned by or are without their parents, guardian, or another custodian of care
• children who have been formerly adjudicated dependent under § 6341 of the Juvenile Act (relating to adjudication) and are under the jurisdiction of the court, subject to its conditions or placements, and who commit an act which is defined as ungovernable
• children who have been referred under § 6323 of the Juvenile Act (relating to informal adjustment) and who commit an act that is defined as ungovernable (PA DHS, 2023; PGA, n.d.-b).

Recognizing Suspected Child Abuse

Key Components of Child Abuse 

A key component of child abuse is the presence of a child, defined as an individual under 18. There must also be an act or failure to act, a recent act or failure to act, or a series of acts or failures to act. The act is done to the child to cause harm or potential harm. A failure to act occurs when something is not done to prevent harm or potential harm to the child. A recent act is defined as within two years of the report to DHS or the county agency. The act or failure to act must also be performed intentionally, knowingly, or recklessly (PGA, n.d.-a). See Table 1 for definitions.

Perpetrator 

A perpetrator is an individual who has committed child abuse as defined by the PA CPSL (see Table 1). This individual may be the parent of the child, a spouse/paramour or former spouse/paramour of the child's parent, an individual over 14 years old that resides in the same house as the child or is responsible for the child's welfare or with direct contact with children as an employee of childcare services, a school, or through a program, activity, or service, an individual over the age of 18 that does not live in the child's home but is related within three degrees of consanguinity by birth, adoption, or marriage to the child, or any individual older than 18 that engages a child in severe forms of trafficking including sex trafficking. In the cases of child abuse due to a failure to act, the perpetrator can only be a parent of the child, a spouse/paramour or former spouse/paramour of the child's parent, or an individual older than 18 who is responsible for the welfare of the child or who resides in the same home as the child (PGA, n.d.-a).

Categories and Indicators 

Differentiating accidental injuries and purposeful physical injuries and abuse can be challenging for nurses. Indicators of deliberate physical injuries or abuse fall into two categories: physical indicators and behavioral indicators (PA DHS, n.d.-b).

Bodily Injury

Bodily injury is impairment of physical condition or substantial pain due to physical abuse. The child's ability to function is reduced, either temporarily or permanently. Substantial pain is anything a reasonable person considers substantial (PGA, n.d.-a). Physical indicators that a child has experienced a bodily injury related to abuse include:

• injuries that are unable to be explained or there is no reasonable explanation provided
• bruising, burns, or welts with specific shapes (e.g., belt buckle, hand, fist, rope, or round burns from cigarettes)
• several bruises or other injuries (e.g., fractures) in different healing stages
• bruising or injuries to the face, ears, or neck or areas of the body that would not typically be visible through clothing (e.g., the buttocks, back, chest, thighs, back of legs, or genitalia)
• injuries incompatible with a child’s age or developmental level (PA DHS, n.d.-b; PA Family Support Alliance, n.d.)

Behavioral indicators that a child has experienced bodily injury as a result of abuse include:

• fear of going home
• extreme apprehensiveness/vigilance
• pronounced aggression or passivity
• avoiding being touched or flinching easily
• play that incorporates abusive talk or behavior
• unexplained injuries
• inability to recall how injuries occurred or an inconsistent account
• unbelievable or inconsistent story that does not align with the nature of the injury, the child's age/developmental level, or the caregiver’s report
• fear of the caregiver (PA DHS, n.d.-b; PA Family Support Alliance, n.d.)

Serious Mental Injury 

Serious mental injury is a psychological condition diagnosed by a physician or licensed psychologist. It can damage a child’s developing brain and lead to long-term learning difficulties. Serious mental injury can cause the child to become chronically and severely anxious, agitated, depressed, or psychotic. It may include the refusal of appropriate treatment. The affected child may also be socially withdrawn and live in fear that their life is in danger. Experiencing a serious mental injury may lead to developmental delays and affect the child's ability to perform age-appropriate social tasks (PGA, n.d.-a). Serious mental injury can be much more challenging to recognize and prove than other types of abuse, as it may be subtle and seem like a particular parenting style. Indicators of serious mental injury include:

• the presence of speech disorders
• reports of psychosomatic symptoms such as headaches, stomachaches, or non-descript reports of feeling bad
• completing self-harm acts (e.g., cutting)
• overly compliant
• bedwetting in previously toilet-trained children
• feelings of inadequacy
• fearful of trying new things
• excessive dependence on adults
• presence of an eating disorder
• engaging in habitual motor behavior such as rocking or thumb sucking
• poor relationships with their peers (PA DHS, n.d.-b; Safe Kids Thrive, n.d.)

Serious Physical Neglect

Serious physical neglect is repeated, prolonged, or egregious failure to supervise a child in a manner that is appropriate considering the child's developmental age and abilities, which 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. This may include the failure to provide adequate essentials of life, such as food, shelter, or medical care (PGA, n.d.-a). The potential indicators of serious physical neglect in a child include:

• a lack of adequate dental, medical, or mental healthcare
• often hungry
• lack of shelter
• delayed development
• extremely low weight for age, gender, and height
• persistent, untreated conditions (e.g., diaper rash, lice, or scabies)
• exposure to health hazards (e.g., illegal drugs, rodent feces, or mold)
• clothing that is inappropriate for the weather, dirty, too small, or too large
• inadequate impulse control
• frequently fatigued
• failure to register for or attend school consistently
• supervision that is either inadequate or inappropriate (e.g., a four-year-old child watching a six-month-old baby while their parent is away)
• parentified behaviors (e.g., changing the diaper of a sibling or rendering punishment for behaviors; PA DHS, n.d.-b; Safe Kids Thrive, n.d.)

Sexual Abuse or Exploitation 

Sexual abuse or exploitation has many forms. Sexual abuse is not limited to touching or penetrating the child. It can also include acts intended to arouse the abuser sexually, such as sexual interactions between two children or an adult and child, fondling, voyeurism (looking at a person’s naked body, in this case, a child's naked body), masturbation in the presence of a minor or forcing the minor to masturbate, exhibitionism (exposing oneself to another, in this case, a minor), sexting or sexually suggestive online interactions or phone calls, or producing, owning, or sharing pornographic images, movies, or online materials of children. The child may describe or act out the actions, although they are commonly threatened or intimidated into keeping the activity secret (The National Child Traumatic Stress Network [NCTSN], n.d.). A child victim of sexual abuse or exploitation (as defined in Table 1) may exhibit physical and behavioral changes (Pekarsky, 2022; Safe Kids Thrive, n.d.). Indicators of sexual abuse or exploitation include:

• a change in toileting habits, such as difficult urination or bedwetting
• pain, bleeding, irritation, or bruising in the genital/anal area
• sleep disturbances
• the presence of sexually transmitted infections (STIs)
• pain or difficulty when trying to sit or walk
• pregnancy
• engaging in excessive or injurious masturbation
• sexual promiscuity
• withdrawal from friends and family
• developmental age-inappropriate sexual play or drawings
• cruelty to animals or others
• committing acts of arson (setting fires)
• anxious (PA DHS, n.d.-b; PA Family Support Alliance, n.d.; Pekarsky, 2022; Safe Kids Thrive, n.d.)

Severe Forms of Trafficking in Persons 

Severe forms of trafficking in persons include sex trafficking and labor trafficking (see Table 1 above). Any child can be targeted for trafficking, but the National Center for Missing and Exploited Children (NCMEC, n.d.) states that specific characteristics or life situations make certain children more at risk of becoming victims of trafficking. The NCMEC lists the following groups as being especially vulnerable:

• runaway or missing children
• those who are experiencing homelessness or lack stable housing
• children with family dysfunction
• children with a history of abuse, trauma, or violence, including sexual abuse
• a child who is involved with government systems such as the foster care system or welfare services
• children who have a history of mental health disorders, including substance use disorder
• children identifying as LGBTQ+
• children who identify as Native or aboriginal
• children with developmental delays or physical disabilities (NCMEC, n.d.; PA DHS, n.d.-a)

In 2022, approximately 25,000 children in the US were considered runaways, and one in six was likely the victim of child trafficking. In 2022, the NCMEC received over 19,000 reports of suspected child trafficking. The average age of runaway persons is 15 years. There are many indicators of sex trafficking among children, but no single indicator confirms that a child is a victim of trafficking (NCMEC, n.d.). There are several red flags, both behavioral and physical, that may indicate that a child is a victim of severe forms of trafficking, including:

• being under the age of 18 and in any way involved in a commercial sex act industry or a prior arrest for prostitution or related charges
• having a sexually explicit online presence
• frequenting online chat rooms and classified sites
• depicts elements of sexual exploitation in drawing, poetry, or other modes of creative expression
• secrecy about whereabouts
• has late nights or unusual hours
• a history of being diagnosed with frequent/multiple sexually transmitted infections or pregnancies
• lying about or having no identification/knowledge of their age, name, and date of birth
• does not have insurance or control over their finances
• wearing clothing that is dirty, inappropriate for the weather, too large, too small, or sexually provocative
• wears new clothes of any style, gets hair and/or nails done with no financial means
• in a controlling or dominating relationship
• the presence of specific tattoos or burn marks that they're reluctant to explain
• a child with unaddressed medical issues who presents to an ED or clinic without an adult or with an adult who is not related
• exhibits hypervigilance or paranoid behaviors
• experiencing a significant change in behavior, such as increased use of social media or a new group of friends
• allows others to talk for them and avoids answering questions when asked
• expresses interest in or is in a relationship with a much older adult
• unexplained injuries or unbelievable/inconsistent explanations of injuries
• multiple bruises/cuts in various stages of healing
• uses terminology that is specific to child trafficking, such as “trick,” “the game,” or “the life”
• having several cell phones or other expensive items that they have no way of purchasing on their own
• a child who is recovered or found at a truck stop, hotel, street track, or strip club (PA DHS, n.d.-a)

If a child or adolescent is suspected of being a victim of trafficking, a report should be filed with ChildLine. Additional resources can also be found on the Human Trafficking page of the state website, pa.gov. The US ACF supports the National Human Trafficking Hotline. It focuses on identifying those impacted by human trafficking and connects victims with services and support to help them leave their current situation and stay safe. Since its inception in 2007, the hotline has received 7,764 signals (hotline calls, SMS text, online report, email, or web chat), with 1,897 cases of human trafficking and 4,048 victims identified. In 2021, 1,080 signals were received from the hotline in PA, with 341 of those from victims or survivors of human trafficking. From these signals, 192 cases of human trafficking were identified involving 315 victims (National Human Trafficking Hotline, n.d.).

Exclusions from Child Abuse

Restatement of culpability is defined in § 6303 of the PA CPSL as conduct that causes injury or harm to a child or creates a risk of injury or harm shall not be considered child abuse if there is no evidence that the person acted intentionally, knowingly, or recklessly (see definitions in Table 1). According to § 6304 of the PA CPSL, some circumstances exclude certain acts from being considered child abuse. Despite these exclusions, nothing in the PA CPSL requires the person making a report of suspected child abuse to consider exclusions from child abuse before making a report. DHS or the investigating agency determines if exclusions apply to the case after receiving a referral or report of suspected child abuse. It is also the agency's responsibility to determine if the perpetrator acted intentionally, knowingly, and recklessly (PGA, n.d.-a). The following circumstances are considered exclusions from the child abuse classification (PGA, n.d.-a):

• Environmental factors. No child shall be deemed to be physically or mentally abused based on injuries that result solely from environmental factors—such as inadequate housing, furnishings, income, clothing, and medical care—that are beyond the control of the parent or person responsible for the child’s welfare with whom the child resides. This subsection shall not apply to any childcare service, as defined in this chapter (excluding an adoptive parent).
• Practice of religious beliefs. If, upon investigation, the county agency determines that a child has not been provided needed medical or surgical care because of sincerely held religious beliefs of the child’s parents or a relative within the third degree of consanguinity with whom the child resides, and these beliefs are consistent with those of a bona fide religion, the child shall not be deemed to be physically or mentally abused. In such cases, the following shall apply:
  • The county agency shall closely monitor the child and the child’s family and 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 the 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 GPS, if appropriate.
  • This subsection does not apply if the failure to provide needed medical or surgical care causes the child's death.
  • This subsection does not apply to any childcare service, as defined in this chapter, excluding an adoptive parent.
• Use of force for supervision, control, and safety purposes. Subject to the subsection on the rights of the parents, the use of reasonable force on or against a child by the child’s parent or a person responsible for the child’s welfare shall not be considered child abuse if any of the following conditions apply:
  • The use of reasonable force constitutes incidental, minor, or reasonable physical contact with the child or other actions designed to maintain order and control.
  • The use of reasonable force is necessary:
    • to quell a disturbance or remove the child from the scene of a disturbance that threatens physical injury to persons or damage to property
    • to prevent the child from self-inflicted physical harm
    • for self-defense or the defense of another individual
    • to obtain possession of weapons, other dangerous objects, controlled substances, or paraphernalia on the child or within the child's control.
• Rights of parents. Nothing in the PA CPSL shall be construed to restrict parents' generally recognized existing rights to use reasonable force on or against their children to provide supervision, control, and discipline. The use of reasonable force shall not constitute child abuse.
• Participation in events that involve physical contact with a child. An individual participating in a practice or competition in an interscholastic sport, physical education, a recreational activity, or an extracurricular activity involving physical contact with a child does not meet the reporting requirements for child abuse.
• Child-on-child contact. Harm or injury to a child that results from the act of another child shall not constitute child abuse unless the child who caused the harm or injury is a perpetrator, as defined by the CPSL. Aside from this, the following shall apply:
  • Acts constituting any of the following crimes against a child shall be subject to the reporting requirements of the PA CPSL:
    • rape as defined in 18 Pa.C.S. § 3121 (relating to rape),
    • involuntary deviate sexual intercourse as defined in 18 Pa.C.S. § 3123 (relating to involuntary deviate sexual intercourse)
    • sexual assault as defined in 18 Pa.C.S. § 3124.1 (relating to sexual assault)
    • aggravated indecent assault as defined in 18 Pa.C.S. § 3125 (relating to aggravated indecent assault),
    • indecent assault as defined in 18 Pa.C.S. § 3126 (relating to indecent assault)
    • indecent exposure as defined in 18 Pa.C.S. § 3127 (relating to indecent exposure).
  • No child shall be deemed to be a perpetrator of child abuse based solely on physical or mental injuries caused to another child during a dispute, fight, or scuffle entered into by mutual consent.
  • A law enforcement official who receives a report of suspected child abuse is not required to make a report to the Department under § 6334(a) (relating to the disposition of reports received) if the person allegedly responsible for the child abuse is a nonperpetrator child.
• Defensive force. Reasonable force for self-defense or the defense of another individual, consistent with the provisions of 18 Pa.C.S. §§ 505 (relating to the use of force in self-protection) and 506 (relating to the use of force for the protection of other persons), shall not be considered child abuse (see Dec. 18, 2013, P.L.1170, No.108, eff. Dec. 31, 2014).

While these situations are identified in the PA statutes as exclusions to substantiating a report, they are not exclusions for reporting. If a mandated reporter suspects that child abuse has occurred, a report must still be made. The determination of abuse will be made by county agencies responsible for investigating child abuse reports. PGA Statute § 6311 outlines that exclusions to reporting, including the privileged and confidential communications made to a clergy member or an attorney, do not apply to child abuse situations. As detailed below, the list of mandated reporters in Pennsylvania includes all clergy of established religious organizations but only those attorneys employed by agencies, institutions, or organizations responsible for a child's care, supervision, guidance, or control (PGA, n.d.-a).

Reporting Suspected Child Abuse 

There are two types of reporters under the Commonwealth of PA: those who are encouraged to report suspected child abuse (permissive reporters) and those who are required to report suspected child abuse based on their role within the community or profession (mandated reporters; Pennsylvania Child Welfare Information Solution, n.d.)

Persons Encouraged to Report 

A permissive reporter is a person who is encouraged to report suspected child abuse. This can be anyone who identifies a suspected victim of child abuse or has reasonable cause to suspect child abuse is occurring. A report can be filed orally utilizing the Child Abuse Hotline, ChildLine at 1-800-932-0313 or submitted electronically, or in person to a county agency or law enforcement. Employees/call screeners operate the toll-free number 24 hours a day, seven days a week. If the situation needs emergent attention, the reporter should call emergency services via 911 and then contact the Child Abuse Hotline. The electronic submission system via the child welfare portal is not available to permissive reporters. A permissive reporter is not required to give their name; however, these details can clarify the situation and allow the retrieval of additional information if needed (Pennsylvania Child Welfare Information Solution, n.d.).

Persons Required to Report 

 A mandated reporter is anyone required to report any situations they suspect to be considered child abuse. Nurses should be familiar with the policies and procedures in their workplace based on the state laws where they work. Specific people working in specified professions are mandated reporters by the PA CPSL. These persons are required to report suspected child abuse if there is a reasonable cause to suspect the child is a victim of abuse (PGA, n.d.-a). The following adults are considered mandated reporters by PA DHS:

• anyone licensed or certified to practice in any health-related field that falls under the jurisdiction of the Department of State (i.e., nurses)
• a medical examiner, coroner, or funeral director
• healthcare employees of facilities or providers that are licensed by the Department of Health working in admissions, examinations, care, or treatment of individuals (e.g., medical assistant)
• school employees
• childcare service employees having direct contact with children in the course of employment (i.e., daycare employees)
• clergy, priests, rabbis, ministers, Christian Science practitioners, religious healers, or spiritual leaders of any regularly established church or other religious organization
• individuals, either paid or unpaid, who, as an integral part of a scheduled program, activity, or service, are responsible for children’s welfare or have direct contact with children
• social service agency employees who have direct contact with children in the course of their employment
• peace officers or law enforcement officials
• emergency medical service providers who are certified by the Department of Health (e.g., paramedics)
• employees of a public library who have direct contact with children during their employment
• independent contractors
• individuals supervised or managed by any of the previously listed roles who have direct contact with children in the course of employment
• attorneys affiliated with an agency, institution, or organization, including a school or regularly established religious organization that is responsible for the care, supervision, guidance, or control of children
• foster parents
• adult family members who are responsible for a child’s welfare and provide services to a child in a family living home, a community home for individuals with intellectual disabilities, or a host home for children who are subject to supervision or licensure by the Department under Articles IX and X of the act of June 13, 1967 (P.L.31, No.21) known as the Human Services Code (formerly the Public Welfare Code; Pennsylvania Child Welfare Information Solution, n.d.; PGA, n.d.-a)

Basis to Report 

If there is reasonable cause to suspect that a child is a victim of abuse, mandated reporters must immediately report that alleged abuse. The report should be submitted to ChildLine electronically via the Child Welfare Information Solution website or by phone to ChildLine at 1-800-932-0313 (Pennsylvania Child Welfare Information Solution, n.d.). The situations that require reporting include:

• the mandated reporter 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
• the mandated reporter 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 for the care, supervision, guidance, or training of the child
• a person makes a specific disclosure to the mandated reporter that an identifiable child is the victim of child abuse
• an individual 14 years of age or older makes a specific disclosure to the mandated reporter that the individual has committed child abuse (Pennsylvania Child Welfare Information Solution, n.d.; PGA, n.d.-a)

It is a general rule that the privileged communication between a mandated reporter and a patient or client of the mandated reporter shall not apply to a situation involving child abuse. The concept of privileged communication does not relieve the mandated reporter of the duty to make a report of suspected child abuse. Despite this, confidential communications made to a member of the clergy or an attorney are protected as long as the communication falls under the protections outlined in Title 42 § 5943, § 5916, § 5928, the attorney work product doctrine, or the rules of professional conduct for attorneys (PGA, n.d.-a). Reasonable cause to suspect may be determined based on training/experience and all known circumstances. This includes who, what, when, how, observations of potential indicators or red flags of abuse, behavior/demeanor of the victim(s), as well as familiarity with the victim/family, relevant history, and prior similar incidents. Some indicators may be more obvious, based on the type of abuse and the health, developmental level, and well-being of the child (PA DHS, n.d.-c)

Reporting Procedure

When there is suspected child abuse, the mandated reporter must immediately make a report to DHS via the toll-free telephone number or electronically using the Child Welfare Portal. If a report is made via the toll-free number, a written report (CY-47) must also be submitted within 48 hours to DHS or the county agency assigned to the case. Failure of the mandated reporter to file such a written report shall not relieve the county agency from any duty under the PA CPSL, and the agency must proceed as though the reporter complied. It is not required that the child come before the mandated reporter or name the suspected perpetrator to make a report when there is suspected abuse. The mandated reporter is not required under PA CPSL to identify the person responsible or the type of abuse in order to file a report. An investigation by the mandated reporter is not required, as the county agency in charge will complete an investigation and determine further actions. Reports should be submitted electronically whenever possible and directly by the individual who suspects that child abuse has occurred to streamline the reporting process. However, certain information is needed for reporting where possible (PGA, n.d.-a). Section 6313 lists the following information that should be included when making a report if known:

• the names and addresses of the child, their parents, and any person responsible for the child's welfare
• where the suspected abuse occurred
• the age and sex of everyone included in the report
• the nature and extent of the suspected child abuse, including any evidence of prior abuse to the child in the report or any sibling of the child
• the name and relationship to the child of each suspected perpetrator and any evidence of previous acts of abuse by each individual
• the composition of the family unit
• the source of the original report of abuse
• the name and contact information of the person making the report (permissive reporters may remain anonymous)
• the actions taken by the person making the report, including those actions taken under § 6314 (relating to photographs, medical tests, and x-rays of a 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/regulation or DHS regulation (PGA, n.d.-a)

• PaC.S. § 6311 states that any mandated reporter, when acting as a staff member of a private or public institution, school, facility, or agency, must immediately make a report of suspected child abuse and then must alert the leadership or person in charge of the institution, school, facility, or agency or the designated agent of the person in charge. Upon notification, the person in charge or designated agent facilitates the cooperation of the institution, school, facility, or agency with the investigation of the report. Any obstruction, retaliation, or intimidation in the investigation of the report is subject to the provisions of Title 18 § 4958. The PA CPSL does not require more than one report from any institution, school, facility, or agency. The obligation to report suspected child abuse by a mandated reporter supersedes concerns regarding confidentiality and HIPAA. All information in the report and gathered during the investigation is confidential, including the identity of the individual who made the initial report. PaC.S. § 6313 indicates that a mandated reporter who makes a report of suspected child abuse or who makes a report of a crime against a child to law enforcement officials shall not be in violation of the act of July 9, 1976 (P.L.817, No.143), known as the Mental Health Procedures Act, by releasing information necessary to complete the report. PaC.S. § 6383 (relating to education and training) states that agencies/organizations that care for children and are supervised by PA DHS under Article IX of the Human Services (formerly Public Welfare) Code must also include training on their internal policies related to reporting suspected child abuse. Other participants should inquire with their employer regarding any internal policies related to reporting suspected child abuse that they may have. PaC.S. § 6339 states that all reports made pursuant to the PA CPSL shall be confidential. This includes, but is not limited to, reports made, report summaries of child abuse, and any other information obtained, reports written, photographs, or x-rays taken concerning alleged instances of child abuse in the possession of DHS or a county agency. Exceptions are provided in subchapter C of the PA CPSL (relating to powers and duties of department) or within the Pennsylvania Rules of Juvenile Court Procedure PaC.S. § 6340 specifies that law enforcement officials must treat all reporting sources as confidential informants and the release of data by DHS, county, institution, school, facility, or agency or designated agent of the person in charge that would identify the person who made a report of suspected child abuse or who cooperated in a subsequent investigation is prohibited. Exceptions are reports under subsection (a)(9) and (10) and in instances of an investigation into allegations of false reports under 18 Pa.C.S. § 4906.1 (PGA, n.d.-a).

After a Referral is Made 

When a county agency or law enforcement official (LEO) receives a report or referral, the immediate safety of the identified child and any other children in the same home must be ensured. The county agency or LEO must notify PA DHS of the referral or report. When ChildLine receives a report or referral, its experts evaluate the information provided and then transmit the report to the appropriate agency for assessment or investigation:

• the county agency (CPS) where the suspected abuse is alleged to have occurred for investigation if the suspected abuse is alleged to have been committed by a perpetrator,
• the appropriate LEO if the suspected abuse may include violation of a criminal offense but the person suspected of committing the abuse is not a perpetrator,
• both the county agency (CPS) and LEO (joint investigation) if the suspected abuse is alleged to have been committed by a perpetrator AND the behavior may include a violation of a criminal offense
• the county agency [GPS] where the suspected abuse is alleged to have occurred for a needs assessment if the child is not in need of protective services but in need of other services).

Once there is confirmation by DHS of the receipt of a report of suspected child abuse submitted electronically, it shall relieve the person making the report of making an additional oral/verbal or written report of suspected child abuse. After the investigation by various agencies, the outcomes and assessment findings are submitted, reviewed, and finalized by the ChildLine experts. Within three days of receiving the final results of the investigation, DHS provides notification of whether the report was founded, indicated, or unfounded and any services provided or arrangements made to protect the child (PGA, n.d.-a).

Immunity from Liability

Nurses are required to report any suspicion of abuse. Reasonable cause is based on the nurse’s professional training and experience or observation or suspicions that imminent danger of harm by a caregiver to a child exists. According to § 6318, any person, institution, school, facility, or agency that is making a report in good faith has immunity from civil and criminal penalties that may result from

• making the report of suspected child abuse or a referral to GPS,
• cooperating with an investigation under the PA CPSL or providing information to a child fatality or near-fatality review team,
• testifying in court regarding the case,
• engaging in any action authorized under § 6314 (relating to photographs, medical tests, and x-rays of a child subject to report), § 6315 (relating to taking a child into protective custody), § 6316 (relating to admission to hospitals), or § 6317 (relating to mandatory reporting and postmortem investigation of deaths; PGA, n.d.-a)

Immunity is also extended to the officials and employees of DHS or county agencies who investigate reports or make referrals to GPS and law enforcement authorities. For the purpose of any civil or criminal proceeding, the good faith of a person required to report suspected child abuse and of any person required to make a referral to law enforcement officers under the PA CPSL shall be presumed. Individuals required to report suspected child abuse are further protected from employment discrimination within § 6320 if the individual is discharged from employment or is discriminated against with respect to compensation, hire, tenure, terms, conditions, or privileges of employment. This protection does not apply to an individual making a report of suspected child abuse who is found to be a perpetrator because of the report or to any individual who fails to make a report of suspected child abuse as required under § 6311 (relating to persons required to report) and is subject to conviction under § 6319 (relating to penalties) for failure to report or refer (PGA, n.d.-a).

A false report is made to harass or harm another person, for personal financial gain, or personal gain related to the child, including acquiring custody. Any person who makes a false report of suspected child abuse intentionally against a school, detention facility, private residential rehabilitation center, or any of their employees no longer has immunity and is committing a second-degree misdemeanor (Pennsylvania Child Welfare Information Solution, n.d.).

Penalties

Failure to report suspected abuse could result in severe consequences for the child. Title 23 on Domestic Relations § 6319 outlines the penalties for a failure to report child abuse. Mandated reporters who willfully fail to report suspected child abuse or alert the proper authorities are at risk of facing criminal penalties. If the mandated reporter willfully fails to make a report, the child abuse consists of a felony of the first degree or higher, and the mandated reporter has direct knowledge of the nature of the abuse, the failure to report is a felony of the third degree. Any other type of failure to report is a misdemeanor of the second degree. If the mandated reporter continues to willfully fail to report while knowing or having reasonable cause to suspect the abuse is ongoing or has reasonable cause to suspect that the same individual continues to have direct contact with children through the individual’s employment, program, activity, or service, the reporter will be charged with a felony of the third degree unless the abuse consists of a potential first-degree or higher felony in which the continued failure to report is a felony of the second degree. If there are multiple failures to report child abuse constituting a felony in the first degree or higher, the penalty is a felony of the second degree. Any other mandated reporter who is convicted of repeat offenses of failure to report will be charged with a felony of the third degree. The statute of limitations for failing to report shall be either the statute of limitations for the crime committed against the minor child or five years, whichever is greater. If a mandated report of suspected abuse is made to law enforcement or the appropriate county agency (CPS) in lieu of a report to DHS, this shall not constitute an offense under this subsection, assuming the report was made in good faith to comply with PA CPSL requirements (PGA, 2014).

Case Studies 

Case Study 1:

The nurse is working in a pediatric emergency department (ED) and caring for a young child who has a fractured right arm. The child is clinging to their caregiver and crying throughout the assessment. The nurse notices that the child has a long-sleeved shirt on, even though it is the middle of summer. When the nurse rolls back the sleeve, the child has multiple bruises; some are yellow, while others are blue and black. The caregiver notices the nurse is assessing the child's arm and begins explaining that the child is "clumsy" and falls all the time. The child looks down with a sad expression when their caregiver talks about the injuries. The nurse asks to take the child to the radiology department for their x-ray, hoping to find time alone with them. The caregiver refuses to allow the nurse to take the child away alone, stating that they will go with them.

• What red flags related to abuse should the nurse recognize in this scenario?
• How should the nurse proceed?

Considerations: The child has a fractured arm, has long sleeves on in summer, and has bruises in multiple stages of healing. The nurse should initiate a call to ChildLine and make a report. 

Case Study 2

An off-duty nurse is dropping their young child off at school when the first-grade teacher asks the nurse to step into the office to get advice. The teacher states that the information must be kept confidential, but they need someone to help them make the right decision. One of the children in their class missed two days of school last week and returned to school the next day, unable to sit still. The student repeatedly asked to go to the bathroom and seemed uncomfortable sitting. The student could not concentrate and seemed distracted during activities they had previously enjoyed. The teacher also noted that the child had extremely chapped lips and said their mouth was hurting.

The child’s personality recently changed since one of their caregivers started a night shift job, and the child's other caregiver is watching them. The child is having difficulty transitioning to the other caregiver completing the morning and bedtime routines. The teacher is worried the child may be a victim of sexual abuse. However, the teacher knows the student’s caregivers. What must the nurse now do?

Considerations: The nurse and teacher are mandated reporters in the state of Pennsylvania. They are legally required to report reasonable cause to suspect child abuse in good faith. 

Case Study 3

The school nurse is completing some medical history forms with a new student. The adolescent states to the nurse that they identify as transgender and are currently in foster care. Their caregivers threw them out of their home after the patient revealed that they were transgender. Since then, they have been in four foster homes and are currently attending their third school in the past year. Their grades have started to decline with the repeated school transitions. What should the nurse be concerned about as potential risks for this patient?

Considerations: This adolescent is not currently displaying any indicators of abuse or trafficking, but there are several risk factors present for child abuse and severe forms of trafficking in persons, including:

• a child who is involved with government systems such as the foster care system or welfare services 
• children identifying as LGBTQ+ (NCMEC, n.d.; PA DHS, n.d.-a)

The nurse should provide the adolescent with resources, including a referral to local transgender support organizations, and discuss their concerns with the patient’s primary healthcare provider or the foster care point of contact for their school district to discuss further education needs for this adolescent. However, a ChildLine report is not necessary unless specific indicators of abuse or trafficking are present.

Case Study 4

An adolescent is at the family practice office for evaluation of stomachache. The nurse notes several recent visits in the patient's chart for somewhat vague symptoms such as headaches and fatigue. The adolescent seems overly compliant and excessively dependent on their caregiver/parent during the visit. The caregiver reports that the adolescent spends all their time in their room and "has no friends anymore". When the caregiver leaves the room to take a work call, the adolescent confides in the nurse that they have recently been restricting their calories to 1000/day in order to lose weight. The nurse worries that the adolescent may be exhibiting various indicators of serious mental injury. What should the nurse do next?

Considerations: The nurse should attempt to discuss the situation with the patient and allow them to voice their concerns. This family would likely benefit from counseling and mental health services, at a minimum. The nurse must gather more information to determine if this qualifies as reasonable cause to suspect abuse and if a referral should be made to ChildLine on their behalf.

Case Study 5

A nurse witnesses a young child climbing on a cabinet in the examination room at a medical clinic. The child’s caregiver grabs their arm and pulls the child down from the cabinet, exclaiming that they will hurt themself. As the child’s caregiver pulls their arm, the child pulls away from them and falls, injuring their arm as they hit the floor.

Does this situation demonstrate child abuse? Should the nurse consider reporting this situation?

Considerations: This scenario would not be considered child abuse. The caregiver used "reasonable force" (grabbing the child's arm and pulling them down) as noted within statute § 6304 to prevent their child from sustaining an injury. The use of reasonable force on or against a child by the child’s parent or a person responsible for the child’s welfare shall not be considered child abuse if the use of force constitutes reasonable physical contact with the child designed to maintain order and control or to prevent the child from self-inflicted physical harm. To qualify as abuse, an act or failure to act must also be performed intentionally to cause harm, knowing that harm is the likely result of the behavior or act, or recklessly with a conscious disregard for the risk of injury (PGA, n.d.-a). Mandated reporters who are unsure may file a report in good faith and allow the trained professionals within the county to determine if any abuse occurred.

References

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Child Welfare Information Gateway. (2019a). About CAPTA: A legislative history. US Department of Health and Human Services, Children's Bureau. https://www.childwelfare.gov/pubPDFs/about.pdf

Child Welfare Information Gateway. (2019b). What is child abuse and neglect? Recognizing the signs and symptoms. https://www.childwelfare.gov/pubpdfs/whatiscan.pdf

Clinton, H. R. (1996). It takes a village: And other lessons children teach us. Simon & Schuster.

Cornell Law School. (n.d.). 14th amendment. Retrieved May 25, 2023, from https://www.law.cornell.edu/constitution/amendmentxiv

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Pekarsky, A. R. (2022). Overview of child maltreatment. Merck Manual Professional Version. https://www.merckmanuals.com/professional/pediatrics/child-maltreatment/overview-of-child-maltreatment

Pennsylvania Child Welfare Information Solution. (n.d.). Learn more. Pennsylvania Department of Human Services. Retrieved May 25, 2023, from https://www.compass.state.pa.us/CWIS/Public/ReferralsLearnMore

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Pennsylvania Department of Human Services. (n.d.-c). Trainings for mandated reporters: Curriculum approval guidelines. https://www.dhs.pa.gov/KeepKidsSafe/Pages/Trainings.aspx

Pennsylvania Department of Human Services. (2023). Child Protective Services 2022 annual report. https://www.dhs.pa.gov/docs/OCYF/Documents/2022-PA-CHILD-PROTECTIVE-SERVICES-REPORT_8-10-2023_FINAL.pdf

Pennsylvania General Assembly. (n.d.-a). Title 23, Chapter 63 child protective services. Retrieved May 25, 2023, from https://www.legis.state.pa.us/CFDOCS/LEGIS/LI/consCheck.cfm?txtType=HTM&ttl=23&div=00.&chpt=063.&CFID=246217912&CFTOKEN=44782272

Pennsylvania General Assembly. (n.d.-b). Title 42 §6302. Retrieved April 12, 2024, from https://www.legis.state.pa.us/cfdocs/legis/LI/consCheck.cfm?txtType=HTM&ttl=42&div=0&chpt=63&sctn=2&subsctn=0

Pennsylvania General Assembly. (2014). Domestic relations code (23 PA. C. S.) - Persons required to report suspected child abuse, privileged communications, and penalties for failure to report or refer. https://www.legis.state.pa.us/cfdocs/legis/li/uconsCheck.cfm?yr=2014&sessInd=0&act=32

Pennsylvania General Assembly. (2016). Domestic relations code (23 PA. C. S.)- Grounds for involuntary termination and release of information in confidential reports. https://www.legis.state.pa.us/cfdocs/legis/li/uconsCheck.cfm?yr=2016&sessInd=0&act=115

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