Department of State Pa Child Abuse Continuing Education

About this course:

Approved by Pennsylvania Department of State - The purpose of this course is to ensure that nurses understand Pennsylvania's Child Protective Services law 23 Pa.C.S. Chapter 63 pertaining to child protection and their role in identifying and reporting potential cases of child abuse, including neglect and exploitation.

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Disclosure Form

The purpose of this course is to ensure that nurses understand Pennsylvania's Child Protective Services law 23 Pa.C.S. Chapter 63 pertaining to child protection and their role in identifying and reporting potential cases of child abuse, including neglect or exploitation.

By the completion of this activity, the nurse will be able to:

1. Describe the Child Welfare system and define the terms related to child abuse as recognized by the laws of Pennsylvania (PA)
2. Consider the incidence and prevalence of child abuse in PA and the US
3. Identify the risk factors that contribute to child abuse
4. Recognize the behaviors and physical indicators of child abuse
5. Discuss the provisions and responsibilities of nurses and other mandated reporters and the process of reporting suspected child abuse
6. Review the updates to the Child Protective Services Law (CPSL) by Act 54 of 2018 and Act 88 of 2019

Child Maltreatment/Abuse

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). The government, healthcare workers, teachers, family, friends, and parents are all partners in the growth, development, and safety of children. 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. Children have a right to be protected from harm, and when persons who are legally responsible fail to deliver proper care, the government has laws that protect them. Laws protect parents' ability to raise their children as they view appropriate but also hold them accountable for maintaining the child's safety and protecting them from abuse. The US Constitution gives this right to families in the 14^th Amendment, which states, "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 (Children's Bureau, n.d.).

The goal of governmental programs and child abuse laws are to develop and maintain a comprehensive child protection system that supports families, children, and their communities to prevent the occurrence of maltreatment (Prevent Child Abuse America, 2020b). The first federal law to protect children and improve the response to child abuse was The Child Abuse Prevention and Treatment Act of 1974 (CAPTA), which was enacted in the year 2000. 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 (US Department of Health and Human Services [HHS], 2014). 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 (Children's Bureau, 2019a). Individual states have laws that are consistent with CAPTA.

This module will focus on the PA laws and mandated reporting for child abuse, including neglect or exploitation, identification by healthcare professionals.

Definitions

The following terms and definitions are based on the guidelines of the Pennsylvania General Assembly (2020) for the recognition and reporting of child abuse 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 their whereabouts are unknown. Some states identify abandonment as a form of neglect.
  • Bodily injury is defined as causing a physical injury through any recent act or failure to act or creating a reasonable likelihood of injury to a child through any recent act or failure to act. This term has replaced the previously used term physical abuse and refers to an impairment of physical condition or substantial pain.
• A child is an individual under 18 years of age.
• Child abuse shall mean intentionally, knowingly, or recklessly doing the following:
  • Causing bodily injury to a child through any recent act or failure to act
  • Fabricating, feigning, or intentionally exaggerating or inducing a medical symptom or disease which results in a potentially harmful medical evaluation or treatment of the child through any recent act (see below: factitious disorder imposed on another)
  • Causing or substantially contributing to serious mental injury to a child through any act or failure to act or a series of such acts or failures to act
  • Causing sexual abuse or exploitation of a child through any act or failure to act
  • Creating a reasonable likelihood of bodily injury to a child through any recent act or failure to act
  • Creating a likelihood of sexual abuse or exploitation of a child through any recent act or failure to act
  • Causing serious physical neglect of a child
  • Engaging in 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 the operation of a methamphetamine laboratory) is occurring, provided that the violation is being investigated by law enforcement; or
    • 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), in which 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; or
      • has been determined to be a sexually violent delinquent child as defined in 42 Pa.C.S. § 9799.12 (relating to definitions).
• Causing the death of the child through any act or failure to act.
• Engaging a child in a severe form of trafficking in persons or sex trafficking, as those terms are defined under section 103 of the Trafficking Victims Protection Act of 2000 (114 Stat. 1466, 22 US 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. See 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

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will cause such a result. See 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. This falls under the general heading of human trafficking.

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.

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

Child sex trafficking is defined as any child under the age of 18 who is induced to engage in commercial sex. Examples of sex trafficking of children include prostitution, pornography, and sex tourism. This falls under the general heading of human trafficking.

The county agency is 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 a reasonable force for self-defense or the defense of another individual and is not considered child abuse.

Department refers to the Department of Human Services of the Commonwealth.

Direct contactis 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 a child when adequate funds are available.

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

Emotional abuse includes behavior that minimizes a child's feelings of self-worth or humiliates, threatens, or intimidates. Blaming the child for situations over which they have 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 (FDIA) 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) pertain 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 by an intimate partner to gain control or to maintain power over and control of the other intimate partner.

A mandated reporter is 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 child victim. Nurses and other healthcare professionals are mandated to report suspected child abuse in most cases.

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 who knows the right thing to do in a particular situation but is constrained from doing the right thing.

A perpetrator is a person who has committed child abuse. The following shall apply:

• The term includes only the following:
  • a parent of the child;
  • a spouse or former spouse of the child's parent;
  • a paramour or former paramour of the child's parent;
  • a person 14 years of age or older and responsible for the child's welfare or having direct contact with children as an employee of a childcare services, of a school, or through a program, activity, or service (including school employees);
  • an individual 14 years of age or older who resides in the same home as the child;
  • an individual 18 years of age or older who does not reside in the same home as the child and is related within the third degree of consanguinity or affinity by birth or adoption of the child; or
  • an individual 18 years of age or older who engages a child in severe forms of trafficking in persons or sex trafficking.
• Only the following may be considered a perpetrator for failing to act, as provided in this section:
  • a parent of the child,
  • a spouse or former spouse of the child's parent,
  • a paramour or former paramour of the child's parent,
  • a person 18 years of age or older who is responsible for the child's welfare, or
  • a person 18 years of age or older who resides in the same home as the child.
• The inclusion of school employeesindicates that current law allows for school employees to be considered perpetrators under the definition of "person responsible for the child's welfare" or person "having direct contact with children."
• A 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 semeans the act itself, apart from the outcome, is considered child abuse.

A 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.

A school employee 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, 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 includes any of the following when committed by a perpetrator that endangers a child's life or health, threatens a child's well-being, causes bodily injury, or impairs a child's health, development, or functioning:

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

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

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

labor trafficking is 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.

Sexual abuse or exploitation consists of any of the following:

• The employment or use of persuasion, inducement, enticement, or coercion of a child to engage in or assist another individual in engaging in sexually explicit conduct, which includes, but is not limited to, the following:
  • looking at the sexual or other intimate parts of a child or another individual for arousing or gratifying sexual desire in any individual;
  • participating in a sexually explicit conversation in person, by telephone, by computer, or by a computer-aided device for sexual stimulation or gratification of any individual;
  • actual or simulated sexual activity or nudity for sexual stimulation or gratification of any individual; or
  • actual or simulated sexual activity for producing visual depiction, including photographing, videotaping, computer depicting, or filming.
• Any of the following offenses committed against a child:
  • rape;
  • statutory sexual assault;
  • involuntary deviate sexual intercourse, as defined in 18 PA.C.S. §3123 (relating to involuntary deviate sexual intercourse);
  • sexual assault;
  • institutional sexual assault;
  • aggravated indecent assault;
  • indecent assault;
  • indecent exposure;
  • incest;
  • prostitution;
  • sexual abuse or exploitation;
  • unlawful contact with a minor; or
  • sexual exploitation (which 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).

Substance use disorder is the chronic, compulsive use of either prescription or illegal drugs (23 Pa.C.S. Chapter 63).

Epidemiology

According to the HHS (2018), over 3,534,000 children were subjects of investigation in 2018, and approximately 678,000 were determined to be victims of maltreatment, increasing from 674,000 in 2017. Of these, neglect was involved in 60.8% of cases, bodily injury in 10.7%, and sexual abuse in 7.0%. Over 15% of affected children were victims of two or more types of maltreatment. Due to abuse, child fatalities increased in 2018 to an estimated 1,770 children, up from 1,710 in 2017 (Administration for Children & Families, 2020).

The following are national statistics on child abuse:

• In 2017, approximately 71% of deaths related to abuse involved children under three years of age (Children's Bureau, 2019b).
• In 2017, parents either individually or with another parent were responsible for 80.1% of child abuse fatalities, with 30.5% of cases committed by the mother alone. Another 15.5% of these events were committed by the father alone, and both parents committed 20.2% of cases. Relatives, a partner of one of the parents, or childcare providers were responsible for 15.2% of child fatalities, and unknown perpetrators were responsible for 4.7% of the total deaths in 2017 (Children's Bureau, 2019b).
• The estimated cost of child abuse in 2015 in the US was $2 trillion (Peterson et al., 2018).

The Centers for Disease Control and Prevention (CDC, 2020) report that one in seven children have experienced abuse across the US in the past year, and children who live in poverty experience abuse rates that are five times higher than their higher socioeconomic counterparts. The lifetime economic burden associated with child abuse was estimated at over $428 billion in 2015 and comparable to high-cost diseases such as type 2 diabetes and stroke (CDC, 2020).

In PA, there were 42,252 total reports of suspected child abuse in 2019, marking a decrease from 44,063 in 2018. In 2019, 4,865 total cases were substantiated, of which 2,970 cases (61%) were female, and 1,895 (39%) were male. These numbers equate to 15.8 per 1,000 children in 2019 for suspected cases and 1.8 per 1,000 for substantiated child abuse cases. The following statistics were included in the 2019 PA Child Protective Services Report:

• Children experienced 51 fatalities.
• Children experienced 93 near fatalities.
• Children between the ages of 5 and 9 years were the highest group of substantiated reports at 1,477.
• Sexual abuse and exploitation remains the leading category of abuse, followed by bodily injury.
• Parents are chiefly responsible for the abuse of their children (PDHS, 2019).

Risk Factors

As noted by the CDC (2019), the risk factors for abuse in children include:

• children who are 4 years old or younger, particularly premature babies;
• children with special needs, either emotionally or physically, that can increase the caregiver burden.

According to 2019 data from PA, while children 4 years old or younger have a significant number of abuse cases (1,085), the highest group affected is children between the ages of 5 and 9 years (PDHS, 2019). Additionally, youth that identify as lesbian, gay, bisexual, transexual, or queer/questioning (LGBTQ) are overrepresented within the child welfare system and are more likely to be kicked out of their homes and become homeless due to lack of family support for their sexual identity. As much as 30% of LGBTQ youth report bodily injury at the hands of a family member after coming out (Youth.gov, n.d.).

Risk factors for a family member or caregiver to abuse a child include:

• domestic violence in the home, including abusive, coercive, forceful, or threatening acts or words by a member of the household to another (the caregiver may be the perpetrator or victim of the domestic abuse) or another form of violence, including a parent's personal history of surviving child abuse;
• financial problems within the family leading to the inability to provide appropriate resources to meet the minimum needs of the children and family;
• alcohol use disorder (AUD, defined as compulsive and chronic use of alcohol);
• substance use disorder (SUD);
• parenting stress or negative interactions/parent-child relationships;
• divorce, family break-ups, or social isolation;
• a parent's lack of understanding regarding the needs or development of their child;
• a lack of parenting skills;
• family mental health issues including depression;
• specific parent characteristics including young age, low education, single parenthood, a high number of dependent children, or low income; and
• transient, non-biological caregivers in the home, such as the mother's male partner (CDC, 2019; HHS, 2018).

Community risk factors that contribute to child abuse include:

• violence within the community; and
• neighborhood disadvantages, including high poverty rates, residential instability, high unemployment rates, poor social connections, and a high density of alcohol outlets (CDC, 2019).

Protective factors or those that decrease the risk of child abuse include:

• supportive family environments and social networks;
• provision of basic needs including housing, food, and safety;
• parenting skills education readily available;
• stability in family relationships;
• parental education and employment;
• access to healthcare and social services; and
• caring adults outside of the home that are serving as parental role models or mentors (CDC, 2019).

Indicators of Abuse

Bodily Injury

Differentiating between accidental injuries and purposeful physical injury and abuse can be challenging for nurses. Indicators of deliberate physical injuries or abuse fall into two categories: physical indicators and behavioral indicators.

Physical indicators include:

• unexplained injuries;
• fractures in multiple stages of healing or a history of repeated fractures;
• bruising, burns, or welts with specific shapes such as a belt buckle, handprint, or round burns from cigarettes, or those around the wrist or ankles indicating that the child was restrained and struggling;
• multiple bruises or other injuries in various stages of healing;
• injuries to the eyes or both sides of the head or body, as most accidental injuries are unilateral;
• bruising or injuries on areas of the body that would not typically be visible through clothing such as the buttocks, torso, thighs, back of legs, or genitalia;
• bruising or injuries to the face, ears, or neck;
• burns; and
• injuries inconsistent with a child's age or developmental level (PDHS, n.d.b).

Behavioral indicators include:

• fear of going home;
• extreme apprehensiveness/vigilance;
• pronounced aggression or passivity;
• flinching easily or avoiding being touched;
• play that includes abusive talk or behaviors;
• inability to recall how injuries occurred or accounts that are inconsistent with the nature of the injury;
• bedwetting in previously toilet-trained children;
• repeated ED visits due to physical injuries;
• a caregiver's report that is inconsistent with the child's explanation of the injury; and
• fear of the parent or caregiver (PDHS, n.d.c).

It is important to remember that abuse is not always limited to hitting or injuries resulting in bruising or visible signs. Other acts of bodily injury can include burns such as with hot water; holding a child underwater; throwing objects at children; using an object such as a paddle, belt, cord, limb from a tree, or shoes to beat a child; or physically restraining a child as a form of discipline (PDHS, n.d.b).

Sexual Abuse and Exploitation

A child who is a victim of sexual abuse or exploitation may exhibit sexual behavior beyond their age or may have a change in toileting habits such as frequent urination or difficulty with defecation. The child may also have itching, pain, bleeding, or bruising in the genital area. Other symptoms of sexual abuse may include both physical and behavioral indicators:

Physical indicators:

• sleep disturbances;
• internalized symptoms (e.g., upset stomach, headache);
• sexually transmitted disease symptoms;
• pain or discomfort when trying to sit or walk;
• pregnancy (PDHS, n.d.b; Schaefer et al., 2018).

Behavioral indicators:

• sexual promiscuity;
• withdrawal from friends and family;
• regression to earlier developmental stages such as bedwetting;
• refusal/reluctance to change clothes in front of others (e.g., gym class);
• developmental age-inappropriate sexual play or drawings;
• cruelty to animals or others;
• setting fires;
• anxiety (PDHS, n.d.b; Schaefer et al., 2018).

The child may describe the actions or may act them out, although they are commonly threatened or intimidated into keeping the activity secret. Sexual abuse and exploitation is not limited to touching or penetrating the child. It can also include acts intended to arouse the abuser sexually (The National Child Traumatic Stress Network [NCTSN], n.d.). Other acts that are regarded as sexual abuse and exploitation include:

• sexual interactions between two children or an adult and child;
• fondling;
• voyeurism (looking at a child's naked body);
• masturbation in the presence of a minor or forcing the minor to masturbate;
• exposing oneself to a minor (exhibitionism);
• text messages, online interactions, or sexually suggestive phone calls;
• sex trafficking;
• producing, owning, or sharing pornographic images, movies, or online materials of children; or
• any sexual conduct that is harmful to a child's emotional, mental, or physical welfare (NCTSN, n.d.).

Human Trafficking of Children

According to the Polaris Project (2016), there are over 40 million victims of human trafficking globally, and 25% of them are children. Any child can be targeted for human trafficking, but the National Center for Missing and Exploited Children (NCMEC, n.d.) lists the following groups as being especially vulnerable:

• runaway or missing children;
• children with a history of abuse, including sexual abuse or exploitation, and particularly if the child was removed from the home after the event;
• a child who is involved with government systems such as the foster system, child protective services, or the courts;
• children with SUD or those who live in a household with persons with SUD; or
• children identifying as LGBTQ whose families disapprove of their lifestyle and who have been forced out of their home.

In 2018, approximately 23,000 children in the US were considered runaways, and one in seven was likely the victim of sex 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. The NCMEC (n.d.) lists several human trafficking red flags, both behavioral and physical, that healthcare providers should be aware of when caring for children.

Physical indicators include:

• a child with unexplained sexual paraphernalia such as condoms, lubricant, etc.;
• a child with hotel room keys, receipts, or other items from hotels;
• an older boyfriend or girlfriend present who appears to control the child;
• a child with items or an appearance that is not congruent with their current situation, such as a child experiencing homelessness with new clothes, new shoes, or expensive electronics;
• a child with a notebook or slips of paper with names, phone numbers, addresses, and dollar amounts;
• a child with specific tattoos or burn marks that are considered branding; or
• a child with unaddressed medical issues who presents to an ED or clinic without an adult or with an adult who is not related and appears overly controlling (NCMEC, n.d.).

Behavioral indicators include:

• a significant change in behavior, such as increased use of technology or a new group of friends;
• a child who allows others to talk for them, avoids answering questions when asked, or looks to others when asked a question;
• a child who seems scared, resistant, or argumentative or who may appear coached in their responses to law enforcement;
• a child who lies about their age or identity;
• a child who uses terminology that is specific to child trafficking, such as "trick," "the game," or "the life";
• a child who is preoccupied with obtaining money;
• a child with several cell phones or electronic devices;
• a child with no ID or an ID in someone else's possession;
• a child with large amounts of cash or prepaid credit cards;
• multiple children present with unrelated adults;
• a child who refers to traveling to other cities or states, does not typically live in their current location, or cannot state their existing travel plans or location;
• a child who is recovered or found at a truck stop, hotel, or strip club;
• a child who talks about online classified ads or escort websites;
• a child who talks about traveling opportunities and jobs such as modeling, singing, dancing, or acting;
• a child who may not identify as a victim and may resist help from others even when offered (NCMEC, n.d.).

The federal Preventing Sex Trafficking and Strengthening Families Act was signed into law in 2014 with two purposes; "to protect and prevent at-risk children and youth from becoming victims of sex trafficking and to improve the safety, permanency, and well-being outcomes of children and youth in the child welfare system." The National Human Trafficking Hotline 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 2007, the hotline has had 5,651 contacts regarding residents of Pennsylvania, with 1,481 total cases identified. In 2019, 271 potential human trafficking cases were reported to the hotline from the state of Pennsylvania based on 746 contacts (National Human Trafficking Hotline, n.d.). In addition, the Polaris Project offers a BeFree text line for victims of human trafficking nationwide (Polaris Project, 2016).

Mental Abuse

Mental abuse can lead to "serious mental injury" and cause damage to a child's developing brain. It can lead to long-term learning difficulties, increased risk of mental health conditions, and problematic behaviors or acting out. Mental abuse can be much more challenging to recognize than other types of abuse, as it may be subtle and seem like a particular parenting style (Prevent Child Abuse America, 2020a). However, the actions become abuse if ongoing patterns of behaviors include any of the following:

• rejection of a child wherein the caregiver refuses to recognize the child's worth and their needs;
• isolating or cutting off a child from typical social experiences such as friendships, making the child believe they are alone in the world;
• terrorizing a child, creating an atmosphere of fear, or bullying a child and making them feel the world is hostile;
• ignoring a child or depriving them of essential stimulation and responsiveness;
• corrupting a child or encouraging the child to engage in destructive or antisocial behaviors that are not socially appropriate;
• verbally assaulting a child by humiliating them, name-calling, shaming, or sarcasm that injures the child emotionally; or
• over-pressuring a child or having expectations that are beyond the child's ability to achieve (Prevent Child Abuse America, 2020a).

The causes of mental abuse are multifaceted. The child, parent, community, and/or society may be involved at several levels. For example, a parent could have a mental illness such as depression or SUD, or the child may have a disability such as dyslexia. The parents may be upset about the child's school performance and begin to shame, verbally assault, or respond to them with negativity. Mental abuse can lead to the following physical and behavioral indicators:

Physical indicators:

• speech disorders;
• frequent psychosomatic complaints such as
  • nausea,
  • headache,
  • stomachache, or
  • non-descript complaints of feeling bad; or
• self-harm (PDHS, n.d.b).

Behavioral indicators:

• excessive compliance,
• bedwetting,
• expressing feelings of inadequacy,
• fear of trying new things,
• excessive dependence on adults,
• eating disorders,
• habit disorders such as rocking or sucking, or
• poor peer relationships (PDHS, n.d.b).

In some cases, mental abuse may lead to greater lifelong trauma than bodily injury (Prevent Child Abuse America, 2020a).

Neglect of a Child

Neglect is a type of child abuse that involves intentionally not caring properly for a child. This may include the failure to provide food, water, shelter, medical care, clothing, or any basic need. Child neglect can be difficult to identify. For example, a parent may have untreated depression or another mental health disorder and may be mentally unable to care for their child. AUD, SUD, or other serious medical conditions can significantly impair an adult's judgment and alter their ability to care for their child. Serious  physical neglect may result in malnutrition or starvation, infant failure-to-thrive syndrome, a delay or failure to seek medical care, or prolonged exposure to the elements (Mayo Clinic, 2018; PDHS, n.d.b).

The physical and behavioral indicators of neglect in a child include:

Physical indicators:

• a lack of appropriate dental, medical, or mental healthcare or failure to follow-up;
• poor hygiene (dirty hair, dirty skin, or body odor);
• periodic or frequent hunger;
• inadequate shelter;
• inappropriate growth for age;
• extremely low weight for age and height;
• weight gain or obesity;
• delay in mental or physical development;
• persistent and untreated conditions such as diaper rash, lice, or scabies;
• exposure to hazardous substances (e.g., illegal drugs, insect or rodent infestation, or mold); or
• inappropriate clothing or lack of clothing and supplies for physical needs (Mayo Clinic, 2018; PDHS, n.d.b).

Behavioral indicators include:

• inadequate impulse control;
• failure to register for or attend school consistently;
• extreme fatigue or falling asleep in class;
• demanding constant attention or affection in school or elsewhere;
• hiding food for later or for siblings;
• taking food or money without permission;
• 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);
• parental-type behaviors (e.g., changing the diaper of a sibling, rendering punishment for behaviors; Mayo Clinic, 2018; PDHS, n.d.b).

Signs of each type of neglect will vary. For instance, if a child does not have adequate food, they may be severely underweight for their age and height. In many cases, multiple types of neglect occur simultaneously (Mayo Clinic, 2018).

Factitious Disorder Imposed on Another (FDIA, previously Munchausen Syndrome by Proxy)

FDIA is a serious form of child abuse involving an intentional production of illness in another person to assume the sick role by proxy. The proxy is usually a parent or caregiver who intentionally makes a child sick or fabricates symptoms to gain attention. The diagnosis and treatment of this health disorder are complicated. Victims are typically under six years of age, and the cases are usually undiagnosed; FDIA wastes medical services and can lead to significant morbidity and mortality for children. Invasive diagnostic tests or treatments are often ordered, and the caregiver fabricates symptoms for various dysfunctional reasons (American Academy of Family Physicians, [AAFP], 2018).

In a case study by Gehlawat and colleagues (2015), a father and uncle brought in a nine-year-old boy who presented with complaints of "fit-like episodes and hematemesis for one year." The child appeared healthy, and his labs and other diagnostics, including an upper GI endoscopy, fiberoptic laryngoscopy, and bronchoscopy, were all unremarkable. The child had two episodes of "fit-like seizures," as reported by nursing, and two episodes of hematemesis. Each time, the father collected samples, which he presented to the doctors. The samples were sent to the lab with no clotting for two to three days; the samples did not contain blood. Eventually, the child was separated from his father and uncle and placed in a pediatric psychiatric unit; his mother remained at his side. There were no further behavioral or symptomatic issues, and the child finally admitted his father gave him betadine before obtaining the emesis. The mother reported to the doctors that her family was going through a difficult time and having financial issues. She was working, while the father and uncle stayed home with nothing to do. She felt their dysfunctional family situation led the father to fabricate her son's illness (Gehlawat et al., 2015). FDIA is a serious mental illness, and abusers may participate in the behavior for various reasons, including attention-seeking, manipulation, satisfaction from deceiving others, or gaining a sense of control. The prognosis for the child depends on the severity of the damage done by the abuser (AAFP, 2018).

Exclusions from Child Abuse per PA Statute § 6304

PA statues have identified the following situations that are excluded from child abuse classification:

§ 6304.  Exclusions from child abuse.

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.

b. 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, 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 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.

3.  The family shall be referred for general protective services, if appropriate.

4.  This subsection shall not apply if the failure to provide needed medical or surgical care causes the death of the child.

5.  This subsection shall not apply to any childcare service, as defined in this chapter, excluding an adoptive parent.

c. 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 parent or a 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:

(i)  to quell a disturbance or remove the child from the scene of a disturbance that threatens physical injury to persons or damage to property;

(ii)  to prevent the child from self-inflicted physical harm;

(iii)  for self-defense or the defense of another individual; or

(iv)  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.

d. Rights of parents.Nothing in this chapter shall be construed to restrict the generally recognized existing rights of parents to use reasonable force on or against their children for the purposes of supervision, control, and discipline of their children. Such reasonable force shall not constitute child abuse.

e. Participation in events that involve physical contact with a child.An individual participating in a practice or competition in an interscholastic sport, a physical education class, a recreational activity, or an extracurricular activity that involves physical contact with a child does not, in itself, constitute contact that is subject to the reporting requirements of this chapter.

f. 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:

i.  Acts constituting any of the following crimes against a child shall be subject to the reporting requirements of this chapter:

A.  rape as defined in 18 Pa.C.S. § 3121 (relating to rape),

B.  involuntary deviate sexual intercourse as defined in 18 Pa.C.S. § 3123 (relating to involuntary deviate sexual intercourse),

C.  sexual assault as defined in 18 Pa.C.S. § 3124.1 (relating to sexual assault),

D.  aggravated indecent assault as defined in 18 Pa.C.S. § 3125 (relating to aggravated indecent assault),

E.  indecent assault as defined in 18 Pa.C.S. § 3126 (relating to indecent assault), and

F.  indecent exposure as defined in 18 Pa.C.S. § 3127 (relating to indecent exposure).

ii.  No child shall be deemed to be a perpetrator of child abuse based solely on physical or mental injuries caused to another child in the course of a dispute, fight, or scuffle entered into by mutual consent.

iii.  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 the disposition of complaints received) if the person allegedly responsible for the child abuse is a nonperpetrator child.

g.  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). (23 Pa.C.S. Chapter 63)

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. Statute § 6311 outlines that exclusions to reporting, which only include the privileged and confidential communications made to a member of the clergy or an attorney, and do not apply to situations involving child abuse. As detailed below, the list of mandated reporters in Pennsylvania includes all clergy of established religious organizations but only includes those attorneys employed by agencies, institutions, or organizations that are responsible for the care, supervision, guidance, or control of children (23 Pa.C.S. Chapter 63). The most important thing to remember for a nurse who feels unsure is that the mandated reporter's job is not to determine guilt or innocence but simply to report what they see, hear, and witness.

An important factual distinction in Pennsylvania is the difference between the state's Child Protective Services (CPS) and General Protective Services (GPS) within the child welfare system. A report to CPS alleges potential or probable abuse against a child who is 17 years of or younger and must be reported/submitted prior to the alleged victim's 20^th birthday.  A GPS report alleges the potential need for intervention by the county to prevent serious harm to a victim that is 17 years of age or younger but may not rise to the level of suspected abuse (PDHS, 2017). For example, as described above in statute § 6304, children whose parents choose to withhold medical treatment due to religious beliefs are often referred to GPS for further monitoring, education, and support. Statute § 6374 describes the primary purpose of GPS is to "protect the rights and welfare of children so that they have an opportunity for healthy growth and development". 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.

Mandated Reporting

Nurses should be familiar with the policies and procedures in their workplace that are based on the laws pertaining to the state in which they work. The PA CPSL was enacted in 1975 to protect children from abuse and allow their healthy growth and development with a focus on maintaining a stable family unit. There are two types of reporters under the Commonwealth of PA: permissive and mandated . 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. A report should be filed using the ChildLine hotline, which is a division of the PDHS that is responsible for accepting reports of suspected child abuse 24 hours per day, seven days per week (PDHS, n.d.a). Additionally, permissive reporters can make an oral or written report via email, handwritten letters, or in-person to a county agency or law enforcement if they have reasonable cause to believe a child is a victim of abuse. The electronic submission system 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 (PDHS, n.d.e). Certain people who encounter children daily are considered mandated reporters by the CPSL. These adults are required to report suspected child abuse if there is a reasonable cause to suspect the child is a victim of any type of abuse.

The following adults are considered mandated reporters by PDHS:

• anyone licensed or certified to practice in any health-related 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 workplace (i.e., daycare employees);
• clergy, priests, rabbis, ministers, Christian Science practitioners, religious healers, and spiritual leaders of any established church or religious organization;
• paid or volunteer individuals who, as an integral part of a scheduled program, activity, or service, are responsible for children's welfare or have direct contact with children (e.g., dance instructor);
• social service agency employees who have direct contact with children in the course of their employment;
• peace officers or law enforcement officers;
• emergency medical service providers who are certified by the Department of Health (i.e., paramedics);
• employees of a public library who have direct contact with children during their employment;
• individuals supervised or managed by any of the previous listed roles who have direct contact with children during employment;
• attorneys associated with an agency, institution, or organization, including schools or a 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 home, a community home for individuals with intellectual disability, or a host home for children who are subject to supervision or licensure by the Department under Articles IX and X of the Human Services Code (PDHS, n.d.c, pp. 2-3).

Suspected abuse must be reported by mandated reporters immediately to ChildLine electronically via the Child Welfare Information Solution or by phone. An investigation is not required, as the county agency in charge will complete an investigation and determine further actions. In order to streamline the reporting process, reports should be submitted electronically whenever possible and directly by the individual who suspects abuse. However, certain information is needed for reporting where possible. Statute § 6313 lists the following information which should be included when possible:

• the name and physical description of the child, including age or approximate age range and sex;
• the name, home address, and telephone number of a legal guardian or parent of the child;
• the name, age, sex, or physical description of the suspected child abuse perpetrator;
• the suspected perpetrator's relationship to the child;
• a description of the suspected injury to the child, including nature and extent as well as the source of the report;
• the location where the incident took place;
• any concern for the child's immediate safety;
• the reporter's relationship to the child, and the actions that were taken by the person making the report, including photographs, medical tests, diagnostic tests; and
• the reporter's contact information, including name, telephone, and email, although permissive reporters may file anonymously.

ChildLine experts accept child abuse referrals and generalized child well-being concerns and then transmit the reports to the appropriate agency for follow-up investigations. After the investigation by the respective county children and youth agency, the outcomes and general protective service assessment findings are submitted, reviewed, and finalized by the ChildLine experts. The obligation to report suspected child abuse by a mandated reporter supersedes concerns regarding confidentiality and HIPAA. Nurses and other mandated reporters become permissive reporters (still encouraged to report) in circumstances where they can not identify the child in question. Identifying information does not have to include the child's name but may refer to an address, license plate number, or other identifying information (PDHS, n.d.a). Statute § 6311 also specifies that staff members of medical institutions, public or private, notify the "person in charge of the institution" immediately after filing the official report with the state in order to facilitate cooperation with any forthcoming investigation. Following a formal report submission, mandated reporters may request information about the report's final status under the state's Right-to-Know law. Mandated reporters may receive basic information regarding whether or not the case was un/founded or indicated, as well as any services that were provided or planned to protect the victim. This information may not be available immediately, as agencies have up to 30 days to complete a thorough investigation (PDHS, n.d.c).

Failure to report suspected abuse could result in severe consequences for the child. Nurses who fail to report suspected child abuse are at risk of offenses ranging from a misdemeanor in the second degree to a felony in the second degree for willful, repeat offenders. Below is IAW House Bill 436, which outlines the penalties for a failure to report child abuse:

 a.Failure to report or refer.

1. A person or official required by this chapter 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
   1. The person or official willfully fails to report,
   2. The child abuse constitutes a felony of the first degree or higher, and
   3. 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 good faith to comply with the requirements of this chapter.
5. Continuing course of action. If a person's willful failure under subsection (A) continues while the person knows or has reasonable cause to believe a child is actively being subjected to child abuse, the person commits a misdemeanor of the first degree. If the child abuse constitutes a felony of the first degree or higher, the person commits a felony of the third degree.
6. 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.
7. 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. (Pennsylvania Child Welfare Information Solution, n.d., para 2)

Penalties for a failure to report were updated in 2019 by Act 88, which is discussed in the section below on legislative updates for 2018 and 2019.

Legal Protections for Mandated Reporting

Nurses who are on duty are required to report any suspicion of abuse. If a nurse is off duty and suspects child abuse while not in their professional capacity, they are not legally obligated to report the abuse but still have a moral obligation to report. 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. Under the CPSL, Section 6311.4, immunity from liability, the amended law notes the following:

"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 unless actual malice is proven." (Pennsylvania Child Welfare Information Solution, n.d., para 3)

However, false reports are also covered in the same law, which notes:

"False reports. Any person who intentionally makes a false report of suspected child abuse against a school, private residential rehabilitative institution, detention facility, school employee, private residential rehabilitative institution employee, or detention facility employee commits a misdemeanor of the second degree." (Pennsylvania Child Welfare Information Solution, n.d., para 4)

False reports are those that are not true and are maliciously done for the purpose of harassing, embarrassing, or harming another person (e.g., reporting an ex-husband or ex-wife to cause them harm). Other false reports may be done by a non-custodial parent or guardian to gain custody of the child or by a person who seeks any kind of personal benefit by making the report (Pennsylvania Child Welfare Information Solution, n.d.).

Updates to Child Protective Service Laws Act 54 and Act 88

Act 54

In 2018, the CPSL Act 54 was implemented, requiring the mandatory referral of infants exposed to drugs or alcohol. This act notes that the healthcare provider must alert the PA Department of Health Services (DHS). This can be accomplished by submitting a report to ChildLine electronically or to the Child Welfare portal at 1-800-932-0313 on the delivery of a newborn or care of an infant (child under one year of age) who has been determined to be affected by "substance abuse or withdrawal symptoms resulting from prenatal drug exposure or fetal alcohol spectrum disorder." While submitting a notification either electronically or to the hotline does not constitute a report of child abuse, it is for the purpose of assessing the child and developing a Plan of Safe Care for the child and family. This includes coming into contact with a qualifying infant outside of a hospital setting. It is intended to best manage the treatment needs of the affected infant and associated family member (PDHS, n.d.d).

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. As previously stated, anyone who is mandated to report suspected child abuse and willfully fails to make a referral to the proper authorities commits an offense. The offense is a felony in the third degree if:

• there is willful intent to report,
• the child abuse infraction is a felony of the first degree or higher, and
• the mandated reporter has direct knowledge of the type of abuse.

For offenses outside of these parameters, a misdemeanor of the second degree would be warranted (23 Pa.C.S. Chapter 63).

Conclusion

Adverse experiences in childhood not only impact the child's mental and physical development but also influence future violence victimization and perpetration. Abuse, including neglect, may affect a child's lifelong mental and physical health and opportunities. Through early intervention and identification, nurses can protect children from further harm and allow entire families to experience life with safe, stable, and nurturing relationships that extend to future generations (CDC, 2020).

References

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The Centers for Disease Control and Prevention. (2020). Preventing child abuse & neglect. https://www.cdc.gov/violenceprevention/childabuseandneglect/fastfact.html

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