Child Abuse Recognition and Reporting (Pennsylvania)

3.0 Contact Hours

ANCC Accreditation notice for nurses licensed in Pennsylvania state: 
This course is approved by the Pennsylvania Department of State for 3 CE hours. It is currently not approved for ANCC contact hours and will not be applicable towards general CE requirements. If you would like a notification when this course is approved for ANCC hours, or a certificate for your completion of this course, please email [email protected]


The purpose of this module is to provide comprehensive information on Pennsylvania’s Child Protective Services law 23 Pa.C.S. Chapter 63 pertaining to child protection. Pennsylvania healthcare providers are required to recognize and report indications of child abuse. This module was developed to assist in providing awareness for nurses while highlighting the guidelines for recognition and reporting in the Commonwealth of Pennsylvania.

At the completion of this module the participant will:

  • Describe national statistics associated with child maltreatment.
  • Explain responsibilities of a mandatory reporter.
  • Understand steps of the reporting process, as well as proceedings after a report is made
  • Describe barriers that contribute to under recognition and underreporting of suspected cases of child maltreatment.
  • Describe the role of the sexual assault nurse examiner.
  • Identify the major types of child abuse and neglect according to the Commonwealth of Pennsylvania
  • Define the terms, medical neglect, educational neglect, emotional neglect, economic abuse, and abandonment.
  • Explain how parent substance use disorder affects the child.
  • Identify risk factors for child maltreatment.
  • Identify protective factors that reduce the risk of child maltreatment.
  • Describe actions the nurse should take when assessing a child when maltreatment is suspected.
  • Explain how to document the care of a child who has a physical injury and physical abuse is suspected.
  • Discuss the responsibility of the nurse when working with clients experiencing intimate partner violence.
  • Identify the components of primary, secondary, and tertiary prevention levels of intervention.
  • Discuss actions for the nurse to take when experiencing moral distress.
  • Locate the number for the national hotline which can be used to determine where to report suspected abuse.

Overview

Child welfare is state supervised, and county administered in the Commonwealth of Pennsylvania. The two-essential functions of county children and youth agencies is: 1) Child Protective Services (CPS) and 2) General Protective Services (GPS).

CPS describes services and activities available through the Department and each county agency for child abuse cases. When a referral is made in Pennsylvania, if the information provided in the referral meets the Child Protective Services Law (CPSL) definition of child abuse, then it will be categorized as a CPS case and investigated by the appropriate parties. Some examples of CPS cases:

  1. Causing bodily injury to a child through any recent act or failure to act
  2. Fabricating, feigning or intentionally exaggerating or inducing medical symptoms or diseases which results in 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
  5. Creating a reasonable likelihood of bodily injury to a child through a recent act or failure to act
  6. Creating a likelihood of sexual abuse or exploitation of a child through any act of failure to act
  7. Causing serious neglect of a child
  8. Engaging in recent “per se acts” (defined below)
  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

Conversely, GPS pertains to services and activities available through county agencies for cases requiring protective services determined by the department in regulations. Cases identified as GPS require an assessment for services and supports as the concern has not met the definition of child abuse as per the CPSL.  The GPS services are to assist parents in being able to recognize and correct conditions that are harmful to their children.  Examples of children in such conditions are:

  1. Is without proper parental care or control, subsistence, education as required by law, or other care or control necessary for the child’s physical, mental, or emotional health, or morals
  2. Has been placed for care or adoption in violation of law
  3. Has been abandoned by their parents, guardian or other custodian
  4. Is without a parent, guardian or legal custodian.
  5. Is habitually and without justification truant from school while subject to compulsory school attendance
  6. Has committed a specific act of habitual disobedience of the reasonable and lawful commands of his parent, guardian or other custodian and who is ungovernable and found to be in need of care, treatment or supervision.
  7. Is under 10 years of age and has committed a delinquent act
  8. Has been formerly adjudicated dependent under section 6341 of the Juvenile Act (relating to adjudication), and is under the jurisdiction of the court, subject to its conditions or placements and who commits an act which is defined as ungovernable in subparagraph (vi)
  9. Has been referred under section 6323 of the Juvenile Act (relating to informal adjustment), and who commits an act which is defined as ungovernable in subparagraph (vi).


Department of Health & Human Services Child Maltreatment Statistics and Data 2016

Between 2012 to 2016 children receiving child protective services investigation response or alternative response increase by 9.5 percent, from 3, 172, 000 to 3, 472, 000.

-Approximately 74.8% of victims were neglect

-18.2% were physically abused

-8.5% were sexually abused

-In 2016, 1,750 children died from abuse and neglect (2.36 per 100, 000 children in the population).


Definitions

The following is a list of terms and definitions used throughout this learning activity and serve as a general guide unless otherwise indicated. These terms and definitions are based on the guidelines for recognition and reporting of child abuse and neglect in the Commonwealth of Pennsylvania by the Child Protective Services Law (23 Pa.C.S. Chapter 63.)


Abandonment occurs when the parent leaves the child behind and his or her whereabouts are unknown. Some states identify abandonment as a form of neglect.

Act is defined as something that is done to harm or cause potential harm to a child

Bodily injury is defined as impairment of physical condition or substantial pain

Child an individual under 18 years of age

Child abuse shall mean intentionally, knowingly, or recklessly doing 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 of the child through any recent act. (See below: Factitious Disorder Imposed on Another)
  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.
  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 (also known as “per se” acts of abuse):
    • Kicking, biting, throwing, burning, stabbing or cutting a child in a manner that endangers the child.
    • Unreasonably restraining or confining a child, based on consideration of the method, location or the duration of the restraint or confinement.
    • Forcefully shaking a child under one year of age.
    • Forcefully slapping or otherwise striking a child under one year of age.
    • Interfering with the breathing of a child.
    • Causing a child to be present at a location while a violation of 18 Pa.C.S. § 7508.2 (relating to operation of methamphetamine laboratory) is occurring, provided that the violation is being investigated by law enforcement.
    • 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 Tier II or Tier III sexual offender under 42 Pa.C.S. Ch. 97 Subch. H (relating to registration of sexual offenders), where the victim of the sexual offense was under 18 years of age when the crime was committed.
      • Has been determined to be a sexually violent predator under 42 Pa.C.S. § 9799.24 (relating to assessments) or any of its predecessors.
      • Has been determined to be a sexually violent delinquent child as defined in 42 Pa.C.S. § 9799.12 (relating to definitions).
  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 (114 Stat. 1466, 22 U.S.C §7102).

"Intentionally" The term shall have the same meaning as provided in 18 Pa.C.S. § 302 (relating to general requirements of culpability). A person acts intentionally when they consciously engage in conduct of that nature or cause such a result and are aware of such circumstances or believe or hope that they exist. 18 Pa.C.S. § 302 (relating to general requirements of culpability).

"Knowingly" The term shall have the same meaning as provided in 18 Pa.C.S. § 302 (relating to general requirements of culpability). A person acts knowingly when they are aware that their conduct is of that nature or that such circumstances exist, and they are aware that it is practically certain that their conduct will cause such a result. 18 Pa.C.S. § 302 (relating to general requirements of culpability).

"Recklessly" The term shall have the same meaning as provided in 18 Pa.C.S. § 302 (relating to general requirements of culpability).  A person acts recklessly when they consciously disregard a substantial and justifiable risk that the material element exists or will result from their conduct. The risk must be of such a nature and degree that, considering the nature and intent of the conduct and the circumstances known to them, its disregard involves a gross deviation from the standard of conduct that a reasonable person would observe in the situation. 18 Pa.C.S. § 302 (relating to general requirements of culpability).

Child Labor Trafficking is the use of force, fraud, or coercion for the purpose of subjection in involuntary servitude, peonage, debt bondage, or slavery. Examples of labor trafficking include agricultural or domestic service workers who are underpaid or not paid at all, physically abusive traveling sales crews that force children to sell legal items (e.g., magazines) or illegal items (e.g., drugs) or to beg, and workers in restaurants and hair and nail salons who are abused, confined, and/or not paid. See section on Human Trafficking below (https://www.childwelfare.gov)

Child Protective Services Law (CPSL) also known as 23 Pa.C.S. Chapter 63, guides the practices and functions of state and county agencies in the protection and care of potential victims of child abuse and neglect

Child Protective Services (CPS) a general term for actions afforded to state and county agencies for the prevention of child abuse and neglect, as well as the intervention and protection of children that are victims of abuse and neglect

Child Sex Trafficking Any child under the age of 18 who is induced to engage in commercial sex is a victim of sex trafficking. Examples of sex trafficking of children includes prostitution, pornography, and sex tourism. See section on Human Trafficking below (https://www.childwelfare.gov)

"County agency" The county children and youth social service agency established pursuant to section 405 of the act of June 24, 1937 (P.L.2017, No.396), known as the County Institution District Law, or its successor, and supervised by the department under Article IX of the act of June 13, 1967 (P.L.31, No.21), known as the Public Welfare Code.

Defensive force is defined as reasonable force for self-defense or the defense of another individual and is not considered child abuse.

"Department" The Department of Human Services of the Commonwealth.

Direct contact is defined as the care, supervision, guidance or control of children or routine interaction with children.

Economic Abuse is the failure to provide for the needs of the child when adequate funds are available.

Educational Neglect is the failure to provide education for the child, including special education when needed.

Emotional Abuse includes behavior that minimizes the child’s feelings of self-worth or humiliates, threatens, or intimidates. Blaming the child for situations over which he or she has no control, isolating the child from friends, and punitive, inconsistent discipline are examples of emotional abuse.

Emotional Neglect is the failure to provide a child the love and support needed to thrive and to develop into a healthy adult.

Failure to act is defined as something that is not done to prevent harm or potential harm to a child.

Factitious Disorder Imposed on Another is the updated nomenclature for Munchhausen by Proxy Syndrome, and is addressed in the second definition of child abuse by the CPSL.

General Protective Services (GPS) pertains to services and activities available through county agencies for cases requiring protective services determined by the department in regulations.

Intimate Partner Violence (IPV) also known as domestic violence is the use of behavior that is used by an intimate partner to gain control or to maintain power and control of the other intimate partner.

Mandated Reporter. A person who is required to make a report of suspected child abuse due to a reasonable cause to suspect the perpetration of child abuse. A Mandated Reporter should report without having to determine the relationship of the perpetrator to the victim child.

Medical Neglect is the failure to provide needed medical care including untreated medical or mental health conditions, dental care, or glasses.

Mental abuse is defined as causing or substantially contributing to serious mental injury to a child through an act or failure to act or a series of such acts or failures to act.

Moral Distress is defined as an individual knowing the right thing to do in a particular situation but is constrained from doing the right thing.

Perpetrator A person who has committed child abuse. The following shall apply:

  1. The term includes 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 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 services, a school or through a program, activity, or service. (School employees can fall under this category )
    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 is related within the third degree of consanguinity or affinity by birth or adoption of 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.

  2. Only the following may be considered a perpetrator for failing to act, as provided in this section:
    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. Person 18 years of age or older and responsible for the child’s welfare.
    5. Person 18 years of age or older who resides in the same home as the child.

Inclusion of School Employees

Current law allows for school employees to be considered perpetrators under the definition provided for “person responsible for the child’s welfare” or person “having direct contact with children.”

Person responsible for the child’s welfare is 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.

Per Se is defined as meaning the act itself, apart from the outcome, is considered child abuse.

Physical Abuse is defined as causing bodily injury through any recent act or failure to act. Creating a reasonable likelihood of bodily injury to a child through any recent act or failure to act. Bodily injury is impairment of physical condition or substantial pain.

Recent act or Failure to act is any act or failure to act committed within two years of the date of the report to the department or county agency.

School employees is defined as an individual who is employed by a school or who provides a program, activity or service sponsored by a school. The term does not apply to administrative or other support personnel unless the administrative or other support personnel have direct contact with the children.

Serious mental injury is a psychological condition, as diagnosed by a physician or licensed psychologist, including the refusal of appropriate treatment

Severe forms of sex trafficking in persons are defined under section 103 of the Trafficking Victims Protection Act of 2000 (Act of Oct. 28, 2016, P.L. 966, No. 115) as:

  1. Sex trafficking in which a commercial sex act is induced by force, fraud, or coercion, or in which the person induced to perform such act has not attained 18 years of age; or
  2. The recruitment, harboring, transportation, provision, or obtaining of a person for labor or services, using force, fraud, or coercion for subjection to involuntary servitude, peonage, debt bondage, or slavery.

Substance Use Disorder is also included in the definition of child maltreatment

“Sexual abuse or exploitation” 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 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 sexual stimulation or gratification of any individual.
    3. Actual or simulated sexual activity or nudity for sexual stimulation or gratification of any individual.
    4. Actual or simulated sexual activity for producing visual depiction, including photographing, videotaping, computer depicting or filming.
  2. Any of the following offenses committed against a child:
    1. Rape
    2. Statutory sexual assault
    3. Involuntary deviate sexual intercourse, as defined in 18 PA.C.S. §3123 (relating to involuntary deviate sexual intercourse).
    4. Sexual assault
    5. Institutional sexual assault
    6. Aggravated indecent assault
    7. Indecent assault
    8. Indecent exposure
    9. Incest
    10. Prostitution
    11. Sexual abuse
    12. Unlawful contact with a minor
    13. Sexual exploitation

[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.]


Serious mental injury.  A psychological condition, as diagnosed by a physician or licensed psychologist, including the refusal of appropriate treatment, that:

  • Renders a child chronically and severely anxious, agitated, depressed, socially withdrawn, psychotic or in reasonable fear that the child’s life or safety is threatened; or
  • Seriously interferes with a child’s ability to accomplish age-appropriate developmental and social tasks.

Serious physical neglect Any of the following when committed by a perpetrator that endangers a child’s life or health, threatens a child’s well-being, causes bodily injury or impairs a child’s health, development of functioning:

  •  A repeated, prolonged or egregious failure to supervise a child in a manner that is appropriate considering the child’s developmental age and abilities.
  • The failure to provide a child with adequate essentials of life, including food, shelter or medical care. 


Recognizing Child Abuse

With the legal definitions of abuse in Pennsylvania in mind, it is critical that all health care providers who work with children have the requisite knowledge and skills to recognize, act against, and report when there are indications of child maltreatment. Below are the risk factors of child abuse and maltreatment as well as some primary signals of various forms of abuse.


Risk Factors of Abuse and Maltreatment

Child Maltreatment Risk Factors

  • Children younger than 4 years of age
  • Special needs that may increase caregiver burden (e.g., disabilities, mental retardation, mental health issues, and chronic physical illnesses)

Perpetrators of Abuse Risk Factors

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

Family Risk Factors

  • Social isolation
  • Family disorganization, dissolution, and violence, including intimate partner violence
  • Parenting stress, poor parent-child relationships, and negative interactions

Individual Risk Factors for Violence

  • History of being abused or exposure to violence
  • Low self-esteem
  • Fear and distrust of others
  • Poor self-control
  • Inadequate social skills
  • Minimal social support/isolation
  • Immature motivation for marriage or childbearing
  • Weak coping skills

Community Risk Factors

  • Community violence
  • Concentrated neighborhood disadvantage (e.g., high poverty and residential instability, high unemployment rates, and high density of alcohol outlets) and poor social connections.

Social and Community Violence Risk Factors

  • Work stress
  • Unemployment
  • Media exposure to violence
  • Crowded living conditions
  • Poverty
  • Feelings of powerlessness
  • Social isolation
  • Lack of community resources (playgrounds, parks, theaters)


Indicators of Various Forms of Child Abuse and Maltreatment

Bodily Injury

Bodily Injury can range from minor bruises to broken bones or even death. Such injuries are considered abuse even when the caregiver did not intent to harm the child. Obvious indications of physical abuse include bruises that are in various stages of healing and look like they are from a hand or belt, burns from cigarettes or scalding water, fractures, internal bleeding, strangulation marks on the neck, injuries to the face or head and perforated ear drum. Less obvious indications of violence include headaches, dizziness, falls, insomnia, and depression. Consider the possibility of abuse if you notice that the child shrinks when touched or seems frightened by the caretaker. The nurse should be alert when there are frequent visits to the health care setting and/or the caregiver labels the child as “accident prone.”

Physical Indicators

  • Unexplained injuries
  • Unbelievable or inconsistent explanations of injuries
  • Multiple bruises in various stages of healing
  • Bruises located on faces, ears, necks, buttocks, backs, chests, thighs, back of legs, and genitalia
  • Bruises that resemble objects such as a hand, fist, belt buckle, or rope
  • Injuries that are inconsistent with a child’s age/developmental level
  • Burns

Behavioral Indicators

  • Fear of going home
  • Extreme apprehensiveness/vigilance
  • Pronounced aggression or passivity
  • Flinches easily or avoids being touched
  • Play includes abusive behavior or talk
  • Unable to recall how injuries occurred or account of injuries is inconsistent with the nature of the injuries
  • Fear of parent or caregiver


Serious Mental Injury

Physical Indicators:

  • Frequent psychosomatic complaints (nausea, stomachache, headache, etc.)
  • Bed-wetting
  • Self-harm
  • Speech disorders

Behavioral Indicators:

  • Expressing feelings of inadequacy
  • Fearful of trying new things
  • Overly compliant
  • Poor peer relationships
  • Excessive dependence on adults
  • Habit disorders (sucking, rocking, etc.)
  • Eating disorders

Child Welfare Information Gateway (CWIG) provides information about possible indications of emotional abuse displayed by the child:

  • Displays extremes in behavior, such as overly compliant or demanding behavior.
  • Is either inappropriately adult or inappropriately infantile (head banging).
  • Is delayed in physical or emotional development.
  • Has attempted suicide.
  • Reports a lack of attachment to a parent.

Possible indications of emotional abuse displayed by the caregiver(s) includes:

  • Constantly blames, belittles, or berates the child.
  • Is unconcerned about the child or refuses to consider offers of help for the child’s problems.
  • Overtly rejects the child.

Visit this link to review the child maltreatment statues in your state.


Serious Physical Neglect

Physical Indicators:

  • Lack of adequate medical and dental care
  • Often hungry
  • Lack of shelter
  • Child’s weight is significantly lower than what is normal for his/her age and gender
  • Developmental delays
  • Persistent (untreated) conditions (e.g. head lice, diaper rash)
  • Exposure to hazards (e.g., illegal drugs, rodent/insect infestation, mold)
  • Clothing that is dirty, inappropriate for the weather, too small or too large

Behavioral Indicators:

  • Not registered in school
  • Inadequate or inappropriate supervision
  • Poor impulse control
  • Frequently fatigued
  • Parentified behaviors


Factitious Disorder Imposed on Another (previously known as Munchausen by Proxy Syndrome)

The second definition of child abuse describes an act commonly known as Munchausen by Proxy Syndrome (MbPS), though recently redefined in the DSM-V as Factitious Disorder Imposed on Another (FDIA.) The primary elements of this abuse is a parent or caregiver’s fabrication, misrepresentation or, often more dangerous, induction of symptoms in a child in order to place them in medical care. This type of abuse is difficult to detect and monitor for several reasons, the primary being that it is most often acted upon in the home, far away from possible observation. Moreover, FDIA is more actively injurious to the internal organs of a child than presentation via external symptoms. This can be due to overmedication or unnecessary medical intervention, but can also be a result of the caregiver’s actions to ensure the child’s exhibition of symptoms. Documentation of past cases indicates that perpetrators can be ingenious and stealthy to avoid being caught. This can range anywhere from inducing symptoms in the child via medication or poison, to tampering with medical evidence to present false symptoms for the child.

The best practices against FDIA/MbPS have been established through case study, and often require the cooperation of a team in order to properly diagnose and treat victims and perpetrators. Prevention of FDIA/MbPS is particularly hard when operating in a medical capacity, as it is nurses’ and doctors’ obligation to treat children for alarming symptoms presented by their caregivers. Children who are frequently admitted to the emergency department should be monitored closely. As with other forms of child abuse, pay close attention to the caregivers’ stories behind the symptoms – are there discrepancies between one story to the next? Remember: nurses with pediatric patients have an obligation to their well-being and care, which can begin by reporting suspected abuse in any capacity.


Sexual Abuse or Exploitation

Physical Indicators

  • Sleep disturbances
  • Bedwetting
  • Pain or irritation in genital/anal area
  • Difficulty walking or sitting
  • Difficulty urinating
  • Pregnancy
  • Positive testing for sexually transmitted disease or HIV
  • Excessive or injurious masturbation

Behavioral Indicators

  • Sexually promiscuous
  • Developmental age-inappropriate sexual play and/or drawings
  • Cruelty to others
  • Cruelty to animals
  • Fire setting
  • Anxious
  • Withdrawn

CWIG provides information about possible indications of sexual abuse displayed by the child:

  • Has difficulty walking or sitting.
  • Experiences nightmare.
  • Wets the bed.
  • Refuses to change clothes for gym.
  • Demonstrates bizarre, sophisticated, or unusual sexual knowledge or behavior.
  • Becomes pregnant or acquires a sexually transmitted infection.
  • Attaches quickly to strangers.

CWIG provides information about possible indications of sexual abuse displayed by the caregiver:

  • Is unduly protective of the child or severely limits the child’s contact with other children, especially of the opposite sex.
  • Is secretive and isolated.
  • Is jealous or controlling with family members.

Rape is forced sexual intercourse, a non-consensual activity that involves penetration of the vagina or anus or oral cavity by a body part or inanimate object. Both men and women can be victims of rape. However, statistics show that the highest risk is for females under the age of 34, in a low-income bracket, and living in a rural community.

A sexual assault nurse examiner (SANE) is a registered nurse who has special training to conduct sexual assault evidentiary examination for rape victims. The SANE is also qualified to serve as an expert witness in court. Be prepared to assist the SANE with the physical examination and support the client during the examination. Sexual assault evidence kits are used for collecting blood, oral swabs, hair samples, nail swabs, or scrapings and genital, anal, or penile swabs.

Another form of abuse, human trafficking, is particularly associated with sexual abuse and exploitation.


Human Trafficking

Human Trafficking: The recruitment, harboring, transportation, provision or obtaining a child for labor or services through the use of force, fraud, or coercion. Under federal law, sex trafficking (such as prostitution, pornography, exotic dancing, etc.) does not require there be force, fraud, or coercion if the victim is under 18.

The International Labour Organization (ILO) is an agency of the United Nations that works with governments, employers and workers of 187-member states to promote decent working conditions for all.  The ILO maintains statistical databases related to labor issues.  According to ILO estimates, in 2016 there were 5.4 trafficking victims for every 1,000 people in the world and one in four of these was a child.  This means there were 40.3 million victims at any one time in 2016.  Of these, 24.9 million were in forced labor including 4.8 million in sexual exploitation and 15.4 million in forced marriage.  Ninety-nine percent of those in the sex industry were women and children.  Actual numbers of trafficked persons are almost certainly higher because of underreporting.   The hidden nature of human trafficking with its associated lack of public awareness and misconceptions about what it is are factors responsible for underreporting.  Also contributing is the reluctance of victims to self-identify out of fear or shame.

There is no official estimate of the number of human trafficking victims in the United States.  However, the National Human Trafficking Hotline, which maintains one of the largest data bases on human trafficking in the United States, reports that in 2017, 26, 557 calls (phone calls, emails or on-line reports), were received and there were reports of 8524 cases with evidence of potential Human Trafficking.  The highest number of cases were in California, Texas and Florida with 1305, 792 and 604 respectively.  Of the total cases, 6081 were identified as sex trafficking with and 1249 cases involved Labor trafficking. Sex trafficking victims work in illicit massage parlors and spas, hotel and motels, residential brothels, strip clubs, through escort services and on-line ads with location unknown.  Labor trafficking victims are found in homes, on farms and in both small and large businesses.  They may be involved in residential domestic work as maids and nannies, in agriculture or horticulture, construction, manufacturing, food services such as catering and restaurants, and contract cleaning.

Labor trafficking
Labor trafficking is labor obtained by use of threat of serious harm, physical restraint, or abuse of legal process. Examples: being forced to work for little or no pay (frequently in factories or farms); domestic servitude (providing services within a household for 10-16 hours per day such as but not limited to: child care, cooking, cleaning, yard work, gardening)

Severe forms of trafficking in persons
Sex trafficking in which a commercial sex act is induced by force, fraud, or coercion, or in which the person induced to perform such act has not attained 18 years of age; or

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)

Commercial sex act: any sex act on account of which anything of value is given to or received by any person


Children & Youth who are at risk for human trafficking:

  • Youth in the foster care system
  • Youth who identify as LGBTQ
  • Youth who are homeless or runaway
  • Youth with disabilities
  • Youth with mental health and/or substance abuse disorders
  • Youth with a history of sexual abuse
  • Youth with a history of being involved in the child welfare system
  • Youth with family dysfunction


Human Trafficking Identification/Warning Signs:

  • A youth that has been verified to be under 18 and is in any way involved in the commercial sex industry, or has a record of prior arrest for prostitution or related charges
  • Has an explicitly sexual online profile
  • Excessive frequenting of internet chat rooms or classified sites
  • Depicts elements of sexual exploitation in drawing, poetry, or other modes of creative expression
  • Frequent or multiple sexually transmitted diseases or pregnancies
  • Lying about or not being aware of their true age
  • Having no knowledge of personal data, such as but not limited to: age, name, and/or date of birth
  • Having no identification
  • Wearing sexually provocative clothing
  • Wearing new clothes of any style, getting hair and/or nails done with no financial means
  • Secrecy about whereabouts
  • Having late nights or unusual hours
  • Having a tattoo that he/she is reluctant to explain
  • Being in a controlling or dominating relationship
  • Not having control of own finances
  • Exhibiting hyper-vigilance or paranoid behaviors
  • Expressing interest in or in relationships with adults or much older men/women


Other forms of Abuse and Maltreatment

While not specifically defined as abuse or neglect by CPSL, Intimate Partner Violence and Substance Abuse may indicate other forms of harm to the child.


Family Violence

According to the U.S. Department of Justice, intimate partner violence (IPV), also known as domestic violence, is the use of behavior by an intimate partner to gain control or to maintain power and control of the other partner. IPV can be physical, sexual, emotional, economic, or psychological actions or threats of actions that influence another person. This includes any behaviors that intimidate, manipulate, humiliate, isolate, frighten, terrorize, coerce, threaten, blame, hurt, injure, or wound someone.

Children who live in a home where there is violence may witness the violence first hand, come home to find the after-effects of violence, or see the perpetrator removed from the home by the police. IPV is associated with a number of long-term adverse effects on children including depression, low self-esteem, antisocial behavior, academic difficulty, seductive behavior, and difficulty with the law. Older children may attempt to run away from home.

There are three phases to the cycle of violence, the tension-building phase, the serious battering phase, and the honeymoon phase.


In the tension building phase, the abuser is jittery and has minor flare ups where the victim may be abused verbally or hit or slapped. The victim feels like they’re “walking on eggshells,” and feels helpless.

In the serious battering phase, serious injury can occur. The abuser’s mind set is “I just want to teach them a lesson.” The victim may be so tense; they provoke the abuser, “just to get it over with.” During this phase, the victim may come to the emergency department for medical care if there is severe physical injury. Emergency department nurses have a unique opportunity to identify intimate partner violence and to provide support and assistance to victims and their families. In this phase, the victim may conclude that they need a safe place to hide from the abuser, especially if they fear for their own life and the lives of their children.

In the honeymoon phase, the abuser displays loving behavior and may shower the victim with gifts. They apologize, promise to change. The victim responds because they want to believe that the abuser is able to change and hopes that the cycle will not start again.


Nurses who provide care for victims of abuse have the opportunity to support the victim and offer resources for assistance. The nurse should:

  • Start by establishing rapport with the victim. Reassure them that they did nothing wrong.
  • Ask the victim to tell what happened and allow the victim to tell their story without interruption.
  • Encourage the victim to work with a counselor who can direct them to resources and assist them to decide a plan of action.
  • Direct the victim to support groups to minimize their feelings of isolation.

Below are the questions from an extensively used Abuse Assessment Screen that was developed by Soeken and colleagues.

  • Within the year, have you been hit, slapped, kicked or otherwise physically hurt by someone?
  • Since you have been pregnant, have you been hit, slapped, kicked or otherwise physically hurt by someone?
  • Within the last year, has anyone forced you to have sexual activities?
  • Have you ever been emotionally or physically abused by your partner or someone important to you?
  • Are you afraid of your partner or anyone listed above?

As discussed above, the nurse should encourage the victim to talk about the incident, discuss the importance of personal safety, provide the victim with written information about local resources such as a mental health clinic and community advocacy groups. The nurse should offer support while remembering that it is the victim who makes the decision about what to do.

Looking from the outside in the question is, “Why don’t they leave?” The victim may choose to stay in the relationship for one or more reasons:

  • Fear of retaliation – the abuser may threaten to kill them or the children if they leaves.
  • Financial reasons – the victim may not have the money to leave or may not have job skills to support themselves and their children.
  • Lack of a support network – family members want them to stay in the relationship.
  • Fear of losing the children – they might lose custody of the children if they leave.
  • Lack of information about community safe houses and shelters.

Community safe houses and shelters provide the victim with a place where they can feel safe and protected. Additionally, facility staff provides victims with emotional support, group counseling, legal representation and social services.

The nurse should provide the victim with information about a nearby shelter even if the victim’s decision is to stay in the relationship at the present time. The nurse should also recommend that the victim pack a bag with needed items and place it somewhere that the abuser will not find it. A partial list is found below.

  • Money for living expenses
  • Emergency phone numbers
  • Clothing for self and children
  • Keys to the house and the car
  • Legal documents-birth certificates, driver’s license, social security cards
  • Items of sentimental value


Substance Abuse

Pennsylvania does not currently recognize Substance Use Disorder as a form of child abuse. However, according to CWIG the following parental actions constitute abuse:

  • Child harm due to the mother’s use of an illegal drug or substance during pregnancy
  • Manufacture of methamphetamine in the presence of a child
  • Selling, distributing, or giving illegal drugs to a child
  • Use of controlled substances by a caregiver that impairs the ability to provide care for the child

Check this website for more information about substance use disorder by a parent.

Pennsylvania does not currently classify the issue of parental substance use disorder as child abuse, though this may soon change due to proceedings by the Pennsylvania Supreme Court.
See: Related article by Pennsylvania Medical Society


Categories of Reporters

There are two major categories of reporters under the Commonwealth of Pennsylvania. The following is a detailed discussion of these categories.


Permissive Reporters

Permissive Reporters are persons encouraged to report suspected child abuse. Everyone, even if they do not regularly interact with children, is a Permissive Reporter. All members of the community are asked to remain vigilant and protect Pennsylvania’s children - there is no bar to reporting suspected child abuse. Any time one can positively identify a child that is a suspected victim of abuse, a report should be filed on the ChildLine or in writing.

Currently, only Mandated Reporters can report online.  Instead, Permissive Reporters should call ChildLine (800-932-0313) to make a report.  Permissive Reporters may make an oral or written report (hand written letter, emails, typed correspondence, etc.) of suspected child abuse, or cause a report of suspected child abuse to be made to the department, county agency or law enforcement, if that person has reasonable cause to suspect that a child(ren) are victim(s) of child abuse.


Mandated Reporters

Mandated Reporters are required by the Child Protective Services Law to make a report of suspected child abuse

The following adults shall make a report of suspected child abuse if the person has reasonable cause to suspect that a child is victim of child abuse:

  • A person licensed or certified to practice in any health-related field under the jurisdiction of the Department of State.
  • A medical examiner, coroner or funeral director.
  • An employee of a healthcare facility or provider licensed by the Department of Health, who is engaged in the admission, examination, care or treatment of individuals.
  • A school employee.
  • An employee of a child-care service who has direct contact with children in the course of employment.
  • A clergyman, priest, rabbi, minister, Christian Science practitioner, religious healer or spiritual leader of any regularly established church or other religious organization.
  • An individual paid or unpaid, who, on the basis of the individual's role as an integral part of a regularly scheduled program, activity or service, accepts responsibility for a child.
  • An employee of a social services agency who has direct contact with children in the course of employment.
  • A peace officer or law enforcement official.
  • An emergency medical services provider certified by the Department of Health.
  • An employee of a public library who has direct contact with children in the course of employment.
  • An individual supervised or managed by a person listed under paragraphs (1), (2), (3), (4), (5), (6), (7), (8), (9), (10) and (11), who has direct contact with children in the course of employment.
  • An independent contractor.
  • An attorney affiliated with an agency, institution, organization or other entity, including a school or regularly established religious organization that is responsible for the care, supervision, guidance or control of children.
  • A foster parent.
  • An adult family member who is a person responsible for the child’s welfare and provides services to a child in a family living home, community home for individuals with an intellectual disability or host home for children which are subject to supervision or licensure by the department under Articles IX and X of the act of June 13, 1967 (P.L. 31, No. 21), known as the Public Welfare Code.

Even when not operating in relation to one’s professional status, Mandated Reporters are still required to report suspected child abuse. Mandated Reporters may submit any report anonymously as a Permissive Reporter if they so choose by calling ChildLine.


Attorneys as Mandated Reporters

If an attorney is affiliated with an agency, institution, organization, or other entity, including a school or regularly established religious organization that is responsible for the care, supervision, guidance or control of children; they are required to report suspected child abuse.


Confidential Communications with Clergy

If an individual approaches a member of the clergy (or other spiritual leader) pursuant of their religious faculties for absolution and forgiveness the information is considered privileged. A member of the clergy that has reasonable cause to suspect the perpetration of child abuse in any other context is mandated to report. Two examples are below:


  • During confession hours, a father confesses to his priest that he often physically attacks his children for their behavior, and prays for forgiveness. The priest can instruct the father on better parenting practices, but cannot use this communication as the basis of a report. In this particular situation, the confidentiality afforded to communications with clergy supersedes the priest’s duties as a mandated reporter.


  • While at a community luncheon, a priest is asked by a concerned mother what she should do about her husband’s bad temper. She mentions violence in the home but is not specific if she is the only victim. Even though the mother was probably confiding in the priest as a trustworthy ally in family matters, she was not pursuing his religious duties by way of forgiveness and absolution. Therefore, this is not confidential communication and the mother’s story makes the priest a Mandated Reporter.


Reporting Process

Basis to report

The following discussion is important to note concerning reporting as it delineates the situations in which a Mandated Reporter must report their suspicion of child abuse. The Mandated Reporter does not have to determine the relationship of the perpetrator to the victim child in order to report their suspicions.

  1. A Mandated Reporter shall make a report of suspected child abuse if the Mandated Reporter has reasonable cause to suspect that a child is a victim of child abuse under any of the following circumstances:
    • 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.
  2. Nothing in this section shall require a child to come before the Mandated Reporter in order for the Mandated Reporter to make a report of suspected child abuse.
  3. Nothing in this section shall require the Mandated Reporter to identify the person responsible for the child abuse to make a report of suspected child abuse.

***It is not a reporter’s responsibility to determine if the person who allegedly committed child abuse or harm to a child is a perpetrator.***


Detail

A Mandated Reporter is never fully “off the clock.” A personal relationship with a potential victim or perpetrator is not required to substantiate the need for a report of suspected child abuse. If a Mandated Reporter discovers the possibility of child abuse and can positively identify the victim, they are obligated to file a report. Child abuse is not always overtly apparent, which is why Mandated Reporters are encouraged to report suspected abuse without calculating an individual’s culpability as perpetrator. Below are two examples:


A) John is a school nurse at the local middle school. A student is admitted to his office after sitting out of the physical education period. John notices the student has several stages of bruising on his arms, and seems to be in pain when sitting or standing. John also knows the student is not on any of the contact sports teams for the school.

--Since John is able to positively identify the child, he should call ChildLine and follow up with an online report. While it is possible that the child is not a victim of abuse, it seems unlikely by the nature of his injuries and the level of impairment the child experiences. It is not John’s obligation to investigate the home life or determine the source of the injuries before reporting. It is also not necessary for John to know the parents personally – an identification of the student is enough to report the suspected abuse.


B) Sandra is a summer camp counselor for teens. One of the 14-year-old campers openly brags about having an older boyfriend. She mentions that he is her mom’s coworker, but is usually the one that takes her home from school. The camper suggests they have a sexual relationship, especially when he has friends over to his apartment.

--Sandra should call ChildLine immediately, and follow up with an electronic report. Even though Sandra doesn’t know the boyfriend’s exact age, she is able to positively identify the child, and the boyfriend’s work relationship with the mother suggests he is much older. There are two potential perpetrators here: the boyfriend for illicit relations with a minor, and the mother for “per se” abuse (lack of intervention). More alarmingly, there could be implications of trafficking by the mother or boyfriend.



Staff members of institutions, etc.
Whenever a person is required to report in the capacity as a member of the staff of a medical or other public or private institution, school, facility or agency, that person shall report immediately and shall immediately thereafter notify the 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 the designated agent, if any, shall facilitate the cooperation of the institution, school, facility or agency with the investigation of the report. Any intimidation, retaliation or obstruction in the investigation of the report is subject to the provisions of 18 Pa.C.S. § 4958 (relating to intimidation, retaliation or obstruction in child abuse cases). This chapter does not require more than one report from any such institution, school, facility or agency.


In other words:

Upon suspicion of child abuse, a Mandated Reporter is obligated to file a report immediately, then inform their institutional superiors of the report. Ideally these events would happen simultaneously, but it is the staff member’s obligation to report the abuse to the state before informing their bosses, coworkers, etc. This provision is primarily in place for suspected abuse to be reported immediately upon discovery, as the power of county and state agencies is severely limited by delays in reporting. If you are a coworker or boss of a Mandated Reporter that has already filed a report, it is not necessary to make a separate report even if you can identify suspected victim or perpetrator.

It is especially important for nurses to serve as advocates for children who are maltreated. Nurses are frequently the first health care professional to encounter a child and his or her family and, in that case, should be the one to identify a potential incidence of child maltreatment. Oftentimes, nurses who work in an inpatient setting have lengthy interactions with children and their families which provides them the opportunity to identify subtle indications of abuse or neglect.


Nurses who work with children should always be aware of indications of neglect or abuse:

  • If the story does not fit the injury, be suspicious
  • Always perform a head-to-toe assessment
  • Child maltreatment occurs in all social, economic, racial, and ethnic groups


Streamlining the reporting process

ChildLine should only be used for reporting suspected abuse/neglect.  It is important to note that reports can be made immediately either orally to ChildLine (1-800-932-0313) or electronically through the Child Welfare portal at https://www.compass.state.pa.us/cwis/public/home. Oral reports must be followed up within 48 hours with a written report that is sent to the investigating agency, and can be found at www.keepkidssafe.pa.gov - the form is under the forms tab (located on the left-hand side of the main page). The form is Report of Suspected Child Abuse (CY47). This is only required if the report is completed orally and not done via electronic submission. If a reporter completes the electronic submission through the portal they have completed their mandated requirement without completing any other forms or notifications.


Oral Reporting – ChildLine

When making a ChildLine report of suspected child abuse or neglect, it is important to provide as much information as possible. The below list will give you a general idea of what information our trained specialists will ask you for:

  • Name and physical description of the child
  • Age or approximate age range of the child
  • Name, home address, and telephone number of legal guardian or parent of the child
  • Name or physical description of suspected child abuse perpetrator
  • Home address and telephone number of suspected child abuse perpetrator
  • Suspected perpetrator’s relationship to the child
  • Description of the suspected injury to the child
  • Where the incident took place
  • Any concern for the child's immediate safety
  • Your relationship to the child
  • Your contact information, although you may report anonymously if you are a Permissive Reporter


Report Follow up

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 or failed to act in the abuse or harm of a child. ChildLine will immediately transmit oral or electronic reports they receive to the appropriate county agency and or law enforcement official.

If the person identified falls under the definition of perpetrator as per the Child Protective Services Law, ChildLine will refer the report to the appropriate county agency for an investigation.

If the person identified is not a perpetrator as per the CPSL and/or the behavior reported includes a violation of a crime, ChildLine will refer the report to law enforcement officials.


Report by Mandated Reporter – Electronic submission

Mandated Reporters are obligated to file a report immediately upon suspicion of child abuse via the Statewide toll-free telephone number or a written report using electronic technologies. Electronic submissions can be made through the Pennsylvania Child Welfare portal: https://www.compass.state.pa.us/cwis/public/home 

Mandated Reporters are encouraged to create a profile for the electronic reporting system even without suspicion of perpetrated abuse – reporters can better serve their community by being prepared to report abuse at any time. With an account, reporters can file referrals of child abuse quicker, and process a Child Abuse History Clearance for their own record. Mandated Reporters can create accounts here.

If you are a Mandated Reporter that has filed an oral report through ChildLine, you are encouraged to make an electronic report within 48 hours of the initial report. Even if a reporter fails to make the electronic follow-up, the presiding county will still be directed to investigate the alleged abuse.

Filing an electronic report without an oral report is substantial fulfillment of the mandated reporting requirement.


Barriers to reporting
Even though nurses should take action when there is a reason to suspect child maltreatment, several barriers contribute to under recognition and underreporting of suspected cases of child maltreatment:

  • Health care providers, including nurses, may have an inadequate understanding of what child maltreatment is, how to identify at-risk children, and how to intervene. (See above: Recognizing Child Abuse and Maltreatment)
  • Often, health care workers are unfamiliar with the statutes in their state or jurisdiction that set out the Mandated Reporter obligations. (See above: Definition of Child Abuse)
  • The health care provider may lack the confidence to function in the role of Mandated Reporter. (See above: Basis for Report)
  • The reporter may fear litigation or retaliation for reporting suspected maltreatment. (See below: Protection for Reporters)
  • The health care provider may fear damage to the nurse-client relationship. A report to child protective service may put the child at greater risk because the family will discontinue the nurse-client relationship and avoid seeking treatment for the child. (See below: Child Abuse Prevention)


Protection for reporters

Immunity from liability.

A person, hospital, institution, school, facility, agency or agency employee acting in good faith shall have immunity from civil and criminal liability that might otherwise result from any of the following:

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

In other words:

Anyone who reports suspected child abuse or cooperates in the proceedings of a report will have immunity from civil and criminal liability that may result from said referral or cooperation. This does not apply if the investigation reveals details that implicate the reporter in said abuse, or reveals the reporter was not acting “in good faith.”


Presumption of good faith:
For the purpose of any civil or criminal proceeding, the good faith of a person required to report pursuant to section 6311 (relating to persons required to report suspected child abuse) and of any person required to make a referral to law enforcement officers under this chapter shall be presumed.”

In other words: Reports received by Mandated Reporters are always presumed to be filed “in good faith” – a presumption that the report was made without fraudulent or malicious intent.


Mandated Reporter’s Right-to-Know

If a report was made by a Mandated Reporter under section 6313 (relating to reporting procedure), the department shall notify the reporter of all of the following within three business days of the department's receipt of the results of the investigation:

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


Penalties for Failure to Report

  • Failure to report or refer.
    1. A person or official required to report a case of suspected child abuse or to make a referral to the appropriate authorities commits an offense if the person or official willfully fails to do so.
    2. An offense under this section 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.
    3. An offense not otherwise specified in paragraph (2) is a misdemeanor of the second degree.
    4. A report of suspected child abuse to law enforcement or the appropriate county agency by a Mandated Reporter, made in lieu of a report to the department, shall not constitute an offense under this subsection, provided that the report was made in a good faith effort to comply with the requirements of this chapter.
  • Continuing course of action. --If a person's willful failure under subsection (a) continues while the person knows or has reasonable cause to believe the child is actively being subjected to child abuse, the person commits a misdemeanor of the first degree, except that if the child abuse constitutes a felony of the first degree or higher, the person commits a felony of the third degree.
  • Multiple offenses. --A person who commits a second or subsequent offense under subsection (a) 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 an offense under subsection (a) shall be either the statute of limitations for the crime committed against the minor child or five years, whichever is greater. (Nov. 29, 2006, P.L.1581, No.179, eff. 180 days; Apr. 15, 2014, P.L.414, No.32, eff. 60 days)



Exclusions to Child Abuse

In some cases, reports of abuse may be titled “unfounded” – this section identifies factors that agencies must take into account before pursuing punitive action. The county children and youth agency will only consider exclusionary factors during the completion of the investigation if they are substantiated. This does not imply that there is exclusion in reporting any child abuse case. All reports of child abuse are filed and investigated for record, but these certain factors may lead the county agency to abstain from correctional measures.


Mandated and Permissive Reporters alike are not meant to use these exclusionary factors to keep themselves from reporting child abuse. This section is solely for the purpose of education and not as a basis for choosing when and when not to report suspected abuse.


Exclusionary factors have several forms:

  • 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 child-care services defined in this section, 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 relative within the third degree of consanguinity and with whom the child resides, which 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:
    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 cause the death of the child.
    5. This subsection shall not apply to any child-care services as defined in this chapter, excluding an adoptive parent.
  • Use of force for supervision, control, and safety purposes – Subject to subsection (d), the use of reasonable force on or against a child by the child’s own parent or person responsible for the child’s welfare shall not be considered child abuse if any of the following conditions apply:
    1. The use of reasonable force constitutes incidental, minor, or reasonable physical contact with the child or other actions that are designed to maintain order and control.
    2. The use of reasonable force is necessary:
      • 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; or
      • to obtain possession of weapons or other dangerous objects or controlled substances or paraphernalia that are on the child or within the control of the child.
  • Rights of parents – Nothing in this section shall be construed to restrict the generally recognized existing rights of parents to use reasonable force on or against their children for purposes of supervision, control, and discipline of their children. Such reasonable force shall not constitute child abuse
  • Participation in events that involve physical contact with child-An individual participating in a practice or competition in an interscholastic sport, physical education, a recreational activity, or an extracurricular activity that involves physical contact with a child does not constitute contact that is subject to the reporting requirements of this section
  • Child-on-child contact—
    1. 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.
    2. Notwithstanding paragraph (1), the following shall apply:
      1. Acts constituting any of the following crimes against a child shall be subjected to the reporting requirements of this section:
        • 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); and
        • indecent exposure as defined in 18 Pa. C.S. §3127 (relating to indecent exposure).
      2. No child shall be deemed to be a perpetrator of child abuse based solely on physical or mental injuries caused to another child during a dispute, fight or scuffle entered by mutual consent.
      3. A law enforcement official who receives a report of suspected child abuse is not required to make a report to the department under section 6334 (a) (relating to disposition of complaints received), if the person allegedly responsible for the child abuse is a non-perpetrator child.
  • Defensive force relating to the use of force in self-protection should be consistent with the provisions of 18 Pa. C.S. §§505 and 506 (relating to use of force for the protection of other persons), shall not be considered child abuse. (Dec. 18, 2013, P.L.1170, No. 108, eff. Dec. 31, 2014)

These definitions are solely for the use of county agencies in their investigation of child abuse. Reporters of child abuse should not use these factors to determine whether or not they should report suspected abuse. Even if one or many of these exclusionary factors are present in a report of suspected child abuse, the county agency will investigate the extent of the abuse before classifying the report as “unfounded.”


Protective Factors Against Abuse and Maltreatment

Protective factors against child mistreatment buffer children from being abused or neglected. These factors exist at various levels. Protective factors have not been studied as extensively or rigorously as risk factors. However, identifying and understanding protective factors are equally as important as researching risk factors. There is scientific evidence to support the following protective factors:


Family Protective Factors

  • Supportive family environment and social networks
  • Nurturing parenting skill
  • Stable family relationship
  • Household rules and child monitoring
  • Parental employment
  • Caring adults outside the family who can serve as role models or mentors

Community Protective Factors

  • Communities that support parents and take responsibility for preventing maltreatment
  • Access to healthcare and social service
  • Adequate housing


Nursing assessment of a child when maltreatment is suspected

  • Hold the interview in a private setting.
  • Be understanding and attentive.
  • Avoid using terminology that might place the parent on the defensive (for example, abuse or violence).
  • Initially interview the parent and the child together
  • Ask the parent about injuries to the child’s body.
  • Ask the parent if the child’s behavior has changed or if he/she has voiced new physical complaints.
  • Observe the infant for excessive crying or fussiness.
  • Observe the child for developmental delays.
  • For preschool children, observe how they play or what they draw.
  • If abuse is suspected, the nurse should ask the parent to speak with the child in private. Refusal could mean there is a problem.
  • Ask the child who takes care of them.
  • Ask the child what he/she does for fun.
  • Ask older children to tell you what worries them.
  • Ask older children if they are experiencing pain.
  • Ask what happens when someone in the household gets angry.
  • When abuse is suspected, let the parent know a report will be made to child protective services.

Accidental injuries usually occur along the boniest areas (knees, shins, elbows), whereas suspicious bruising can be seen in places like the inner thighs, stomach, feet, hands, back, buttocks, neck and back of arms and legs.



Documentation

It’s always important for the nurse perform accurate and complete documentation. This provides the nurse, the nurse’s coworkers and the agency legal protection and is the best defense against malpractice. Know your agency’s policies regarding documentation and follow the policies diligently in all situations, especially in high-risk situations such as suspected abuse. Include a description of the client’s medical history, the family’s psychosocial history, and observations you made regarding interaction among family members. Document direct quotes regarding when the injury occurred and who caused it. Document physical injuries in narrative form as well as in pictorial form such as a body map.



Prevention

Certain provision of prevention strategies and long-term intervention is the responsibility of the county children and youth agency and other agencies consulted to provide prevention and intervention strategies.  Nurses’ responsibilities toward prevention can be categorized as primary, secondary, and tertiary strategies.  Awareness allows nurses to be more sensitive and compassionate when interacting with those affected by neglect and abuse, as well as enable them to intervene properly when it comes to reporting suspected child abuse. 


Primary Prevention

  • Teach alternative methods of conflict resolution, anger management, and coping strategies in community settings.
  • Organize parenting classes to provide anticipatory guidance of expected age-appropriate behaviors, appropriate parental responses, and forms of discipline.
  • Educate clients about community services that are available to provide protection from violence.
  • Assist in removing or reducing factors that contribute to stress by referring caretakers to respite services, assisting an unemployed parent in finding employment, or increasing social support networks for socially isolated families.
  • Teach individuals that no one has a right to touch or hurt another person, and make sure they know how to report cases of abuse.


Secondary Prevention

  • Identify and screen those at risk for abuse and individuals who are potential abusers.
  • Assess and evaluate any unexplained bruises or injuries of any individual.
  • Screen all pregnant women for potential abuse. This might be the one time in some women’s lives that they can access the health care system on a regular basis.
  • Refer sexual assault or rape survivors to a local emergency department for assessment by a SANE/sexual assault abuse team. Caution the client not to bathe following the assault because it will destroy physical evidence.
  • Assess and counsel anyone contemplating suicide or homicide, and refer the individual to the appropriate services.
  • Support and educate the offender, even though a report must be made.
  • Assess and help offenders address and deal with the stressors that can be causing or contributing to the abuse, such as mental illness or substance use disorder.
  • Alert all involved about available resources within the community.
  • Advocate for legislation designed to assist caregivers and to increase funding for programs that supply services to low-income, at-risk individuals.


Tertiary Prevention

  • Establish parameters for long-term follow-up and supervision.
  • Make resources in the community available to survivors of violence (telephone numbers of crisis lines and shelters).
  • If court systems are involved, work with parents while the child is out of the home (in foster care).
  • Refer to mental health professionals for long-term assistance.
  • Provide grief counseling to families following the death of a family member to suicide or homicide.
  • Develop support groups for caregivers and survivors.
  • Caring for Clients Who Experience Violence
  • Build trust and confidence with a client.
  • Focus on the client rather than the situation.
  • Assess for immediate danger.
  • Provide emergency care as needed.


It is NOT the job of the nurse to interrogate or investigate; reasonable cause is all that is needed to report to the agencies who will investigate. If you suspect with reasonable cause that abuse may have occurred, complete mandatory reporting, following state and agency guidelines.


The Nurse’s Awareness of Personal Emotions and Thoughts

As a nurse who provides care for children who are victims of maltreatment, you must be aware of your own emotions. First examine your personal views about child maltreatment. It’s important, even though it may be difficult, to set aside negative bias in order to provide nonjudgmental care to the child and to the family. Some common emotions you might feel are as follows:

  • Anguish can occur when the nurse has been a victim of abuse.
  • Fear might be present if the perpetrator turns anger towards others (the nurse).
  • Confusion is experienced when the nurse realizes child maltreatment could be a problem with one’s own family.
  • Helplessness because the nurse cannot intervene to “fix the problem.”
  • Discouragement because the problem is still present and a long-term solution has not been achieved.
  • Embarrassment because the situation reminds the nurse of something in one’s own home.
  • Blame directed towards the victim for actions the nurse sees as provoking the perpetrator or when the nurse just feels overwhelmed.


Moral Distress

When nurses are unable to do what they feel is best for the client due to constraints such as family decisions, lack of resources, or agency policies, they can feel alone and frustrated. This phenomenon is known as moral distress. According to the American Association of Critical Care Nurses, the definition of moral distress is when a person knows the right thing to do, but is constrained from doing it.

Initial moral distress occurs in the acute phase of the dilemma. For example, a provider decides to pursue aggressive medical treatment for an infant who has a massive head injury with no hope of recovery. The nurse feels angry and resentful and has feelings of distress for the infant who must endure the medical treatment.

Residual moral distress is when, after a period of time, there is still no acceptable resolution to the problem.


The American Association of Critical Care Nurses recommends the 4 A’s to rise above moral distress:

Ask: Is this moral distress. During this step the nurse becomes aware of personal moral distress.

Affirm: Recognize moral distress and accept the professional and personal responsibly to resolve the issue.

Assess: View the situation and feelings of all persons involved including the client, the family, other health care providers and the agency. This allows you to begin to problem solve.

Act: Take deliberate action to reconcile differences and resolve the problem.


Experts in the field of ethics also suggest that nurses:

  • Follow the nurse’s code of ethics.
  • Create an environment where nurses feel free to speak up.
  • Bring disciplines together.
  • Hold frequent conferences with families.
  • Use resources provided by professional associations.
  • Offer counseling services for nurses who are distressed about workplace ethical dilemmas.


Contact Information

Each state has an agency designated to receive reports, it is usually child protective services (CPS). To determine who to report to, you can call the national hotline 1-800-4-A-CHILD or directly to the Pennsylvania ChildLine: 1-800-932-0313


Case Studies

The following case studies present scenarios in which child abuse may or may not be present. Use the information presented from the module to answer the following questions in each case:

  • Are there indications of child abuse present?
  • Who from the scenario could be considered a perpetrator?
  • What are your next steps?


Case 1
You learn from counseling a 13-year-old patient that her father is dealing drugs with her siblings present. At times he sends her to deliver the drugs to his customers and bring the money back.


Case 2
A single mother visiting your clinic for a checkup mentions that her children’s father spanks them during their court-ordered weekend visits. She admits that the children are not bruised or in pain at present.


Case 3
A mother comes into the ER with black eyes as a result of intimate partner violence. She has two young children with her. She says her husband beat her. She also states that he told her he would kill her and the two children if she told anyone.


Case 4
A mother brings her eight-year-old son into the ER with a broken arm, explaining that he fell off the bed. When the arm is x-rayed there is a spiral fracture to his humerus.


Case 5
During a community seminar, a 15-year-old girl discusses her relationship with her 28-year-old boyfriend. The boyfriend has resided in the home with the child and her mother for the past two months. The girl states that her mother knows the boyfriend and the child are sleeping together and engaging in sexual activity in the home.


References


  1. Berman, A., Snyder, S., & Frandsen, G. (2016). Kozier & Erbs fundamentals of nursing: Concepts, process, and practice (10th ed.). Upper Saddle River, NJ: Prentice-Hall.
  2. The Centers for Disease Control and Prevention (CDC, 2017) (Centers for Disease Control and Prevention [CDC], 2017)
  3. Dudek, S. G. (2014). Nutrition essentials for nursing practice (7th ed.). Philadelphia: Lippincott Williams & Wilkins.
  4. Eliopoulos, C. (2014). Gerontological nursing (8th ed.). Philadelphia: Lippincott Williams & Wilkins.
  5. Halter, M. J. (2014). Varcarolis’ foundations of psychiatric mental health nursing: A clinical approach (7th ed.). St. Louis, MO: Saunders.
  6. Hockenberry, M. J., & W Wilson, D. (2015) Wong’s nursing care of infants and children (10th ed.). St. Louis, MO: Mosby.
  7. Ignatavicius, D. D., & Workman, M. L. (2016). Medical‑surgical nursing (8th ed.). St. Louis, MO: Elsevier.
  8. Karakachain, A., Colbert, A., Moral Distress: A Case Study , Nursing 2017 47(10): 13-15, 2017.
  9. Kraus, D., Why is Child Abuse Awareness Important to Trauma Nurses? Journal of Trauma Nursing 23(3): 116, 2016.
  10. Jordan, K., Steelman, S., Child Maltreatment: Interventions to Improve Reporting, Journal of Forensic Nursing 11 (2) 107-113, 2015. 
  11. Lavigne, J., et.all, Pediatric Inpatient Nurses’ Perceptions of Child Maltreatment, Journal of Pediatric Nursing 34:17-22 (2017).
  12. Lowdermilk, D. L., Perry, S. E., Cashion, M. C., & Aldean, K. R. (2016). Maternity & women’s health care (11th ed.). St. Louis, MO: Elsevier.
  13. Marquis, B. L., & Huston, C. J. (2015). Leadership roles and management functions in nursing: Theory and application. (8th ed.). Philadelphia: Lippincott Williams & Wilkins.
  14. Potter, P. A., Perry, A. G., Stockert, P., & Hall, A. (2013). Fundamentals of nursing (8th ed.). St. Louis, MO: Mosby.
  15. Townsend, M., Morgan, K., (2017). Essentials of Psychiatric Mental Health Nursing: Concepts of Care in Evidenced-Based Practice (7th ed.) Philadelphia, F.A. Davis Company.
  16. U.S. Department of Health and Human Services. Administration on Children, Youth and Families, Children’s Bureau. 2016.  Child maltreatment 2014 [online] Available from: http://www.acf.hhs.gov/sites/default/files/cb/cm2014.pdf
  17. U.S. Department of Health and Human Services Administration for Children and Families Administration on Children, Youth and Families Children’s Bureau. [online] Available from: https://www.childwelfare.gov/pubPDFs/drugexposed.pdf
  18. .S. Department of Health and Human Services Administration for Children and Families Administration on Children, Youth and Families Children’s Bureau. [online] Available from:
    https://www.childwelfare.gov/pubPDFs/repproc.pdf
  19. Van der Zalm, Y. et.al, Psychiatric Nursing Care of Adult Survivors of Child Maltreatment: A Systematic Review of the Literature. Perspectives in Psychiatric Care 51: 71-78, 2014.
  1. Wood, D. Ten Best Practices for Addressing Ethical Issues and Moral Distress AMN Health Care News. March 2014)retrieved November 4, 2017 from https://www.amnhealthcare.com/latest-healthcare-news/10-best-practices-addressing-ethical-issues-moral-distress/
  2. Mayo Clinic. (2018, October 05). Child abuse symptoms & causes. Retrieved from https://www.mayoclinic.org/diseases-conditions/child-abuse/symptoms-causes/syc-20370864
  3. Weinstock, L. S., MD, Romito, K., MD, & University of Michigan. (2018, September 11). Munchausen Syndrome by Proxy. Retrieved from https://www.uofmhealth.org/health-library/hw180537#hw180539


ANCC Accreditation notice for nurses licensed in Pennsylvania state: 
This course is approved by the Pennsylvania Department of State for 3 CE hours. It is currently not approved for ANCC contact hours and will not be applicable towards general CE requirements. If you would like a notification when this course is approved for ANCC hours, or a certificate for your completion of this course, please email [email protected]