#67542: Child Abuse Identification and Reporting: The Pennsylvania Requirement

Today, there is an established system in the United States to respond to reports of child abuse and neglect; however, this has not always been the case. This is not because child abuse, neglect, and maltreatment are new social phenomena. Rather, the terms "child abuse," "child neglect," and "child maltreatment" are relatively new, despite the fact that this social problem has existed for thousands of years [1]. Cruelty to children by adults has been documented throughout history and across cultures. In China, infant girls were often neglected during times of famine or sold during times of extreme poverty. There is also historical evidence that cultures have taken steps to stop child abuse and cruelty. For example, 6,000 years ago in Mesopotamia, orphans had their own patron goddesses for help and protection [2].

In many cases, the physical abuse of children has been linked to punishment. Throughout history, physical child abuse was justified because it was believed that severe physical punishment was necessary to discipline, rid the child of evil, or educate [2,13]. It was not until 1861 that there was a public outcry in the United States against extreme corporal punishment. This reform was instigated by Samuel Halliday, who reported the occurrence of many child beatings by parents in New York City [2].

Sexual abuse of children, particularly incest (defined as sex between family members), is very much a taboo. The first concerted efforts to protect children from sexual abuse occurred in England during the 16th century. During this period, boys were protected from forced sodomy and girls younger than 10 years of age from forcible rape [2]. However, in the 1920s, sexual abuse of children was described solely as an assault committed by "strangers," and the victim of such abuse was perceived as a "temptress" rather than an innocent child [2].

The first public case of child abuse in the United States that garnered widespread interest took place in 1866 in New York City. Mary Ellen Wilson was an illegitimate child, 10 years of age, who lived with her foster parents [3]. Neighbors were concerned that she was being mistreated; however, her foster parents refused to change their behaviors and said that they could treat the child as they wished [2]. Because there were no agencies established to protect children specifically, Henry Berge, founder of the Society for the Prevention of Cruelty to Animals, intervened on Mary's behalf [3]. He argued that she was a member of the animal kingdom and deserved protection. The case received much publicity, and as a result, in 1874 the New York Society for the Prevention of Cruelty to Children was formed [3]. Because of this case, every state now has a system in place for reporting child abuse. The Pennsylvania Department of Public Welfare (now known as the Department for Human Services) was established in 1921 and part of its original intent was to care for "dependent, defective, and delinquent children" [7].

As a result of Berge's advocacy for children's safety, other nongovernmental agencies were formed throughout the United States, and the establishment of the juvenile court was a direct result of the Society for the Prevention of Cruelty to Children [13]. By 1919, all but three states had juvenile courts. However, many of these nongovernmental agencies could not sustain themselves during the Depression [13].

The topic of child abuse and neglect received renewed interest in the 1960s, when a famous study titled "The Battered-Child Syndrome" was published [1,4]. In the study, researchers argued that the battered-child syndrome consisted of traumatic injuries to the head and long bones, most commonly to children younger than 3 years of age, inflicted by parents [1,4]. The study was viewed as the seminal work on child abuse, alerting both the general public and the academic community to the problems of child abuse [1,2]. Soon, all 50 states required physicians to report child abuse [14]. In the early 1970s, Senator Walter Mondale noted that there was no official agency that spent its energies on preventing and treating child maltreatment [13]. Congress passed the Child Abuse Prevention and Treatment Act (CAPTA) of 1974, which targeted federal funds to improve states' interventions for the identification and reporting of abuse [13]. In 2010, additional prevention and treatment programs were funded through CAPTA, and in 2012, the Administration on Children, Youth, and Families began to focus on protective factors to child abuse and neglect [61].

Today, child abuse and neglect are considered significant social problems with deleterious consequences. As noted, a system has been implemented in all 50 states to ensure the safety of children, with laws defining what constitutes abuse and neglect and who is mandated to report.

The Children's Aid Society of Pennsylvania, one of the first organizations to advocate for children and their welfare in the United States, was founded in 1882 [62]. In the following years, the Children's Aid Society was instrumental in educating the public about the unsanitary and unsafe conditions in almshouses, which were sometimes used for orphaned or abandoned children. Subsequently, legislation was passed in Pennsylvania to ensure that children were not permanently placed in almshouses [62].

In the state of Pennsylvania, Act 91 was passed in 1967 and gave child welfare agencies in all counties the responsibility to investigate child abuse reports made by physicians [18]. Three years later, Act 91 was modified to include school nurses and teachers as mandated reporters [18].

Pennsylvania was also the first state to take a noncriminal view of child abuse [22,26]. In 1975, the Child Protective Services Law was enacted, which established a child abuse hotline and a statewide central registry in Pennsylvania in order to encourage the reporting of child abuse [18,26].

The child welfare system in Pennsylvania is supervised by the state but administered by the different local counties [27]. This means that there are a total of 67 county agencies that administer the child welfare and juvenile justice services [27]. Aside from frank abuse, reports of other acts that might affect the well-being of a child are also accepted. The State of Pennsylvania delineates two functions for the local agencies: child protective services (CPS) and general protective services (GPS).

In 2017, Governor Tom Wolf approved Act 68 (also known as the Newborn Protection Act) to increase the number of locations for parents to give up their newborn without criminal liability [63]. In 2018, Act 29 was signed and expanded the definition of child abuse in Pennsylvania to include leaving a child unsupervised with a sexual predator [64].

The federal definition of child abuse is evident in CAPTA, published as a product of federal legislation. CAPTA defines a child to be any individual younger than 18 years of age, except in cases of sexual abuse. In cases of sexual abuse, the age specified by the child protection laws varies depending on the state in which the child resides [5]. CAPTA defines child abuse as, "any recent act or failure to act on the part of a parent or caretaker, which results in death, serious physical or emotional harm, sexual abuse, or exploitation, or an act or failure to act that presents an imminent risk of serious harm" [6].

In Pennsylvania, the child abuse law takes a very comprehensive approach to defining of child abuse [26]. According to Pennsylvania law, child abuse refers to intentionally, knowingly, or recklessly doing any of the following [43,54]:

In addition, the Code explicitly excludes specific acts and injuries from the definition of child abuse. Effective December 31, 2014, the following are considered exclusions to the definition of child abuse [44]:

It is important to note that exclusions are utilized by the CPS agency when investigating suspected abuse and should not be considered exclusions from reporting suspected abuse.

For the purposes of this course, a perpetrator is defined as a person who has committed child abuse. According to the Pennsylvania Code, the term includes only [42,54]:

In a significant revision to the definition of perpetrator, school personnel and other childcare providers are considered "individuals responsible for the child's welfare" and may be perpetrators of child abuse; there is no longer a separate definition for student abuse [42]. As such, a perpetrator may be any such person who has direct or regular contact with a child through any program, activity, or services sponsored by a school, for-profit organization, or religious or other not-for-profit organization.

In addition, only the following may be considered a perpetrator for failing to act [42,54]:

FORMS OF CHILD ABUSE AND NEGLECT

There are several acts that may be considered abusive, and knowledge of what constitutes abuse is vital for healthcare providers and other mandated reporters. In this section, specific behaviors that fall under the category of abuse and neglect will be reviewed.

Physical Abuse

Physical abuse injuries can range from minor bruises and lacerations to severe neurologic trauma and death. Physical abuse is one of the most easily identifiable forms of abuse and the type most commonly seen by healthcare professionals. Physical injuries that may be indicative of abuse include bruises/welts, burns, fractures, abdominal injuries, lacerations/abrasions, and central nervous system trauma [8,34].

Bruises and welts are of particular concern, especially those that appear on:

• The face, lips, mouth, ears, eyes, neck, or head

• The trunk, back, buttocks, thighs, or extremities

• Multiple body surfaces

According to the American College of Radiology, fractures highly suggestive of physical abuse include rib fractures, classic metaphyseal lesions, those unsuspected or inconsistent with the history or age of the child, multiple fractures involving more than one skeletal area, and fractures of differing ages.

(https://acsearch.acr.org/docs/69443/Narrative Last Accessed: July 26, 2022)

Level of Evidence: Expert Opinion/Consensus Statement

Patterns such as the shape of the article (e.g., a cord, belt buckle, teeth, hand) used to inflict the bruise or welt are common. Cigar or cigarette burns may be present, and they will often appear on the child's soles, palms, back, or buttocks. Patterned burns that resemble shapes of appliances, such as irons, burners, or grills, are of concern as well.

Fractures that result from abuse might be found on the child's skull, ribs, nose, or any facial structure. These may be multiple or spiral fractures at various stages of healing. When examining patients, note bruises on the abdominal wall, any intestinal perforation, ruptured liver or spleen, and blood vessel, kidney, bladder, or pancreatic injury, especially if accounts for the cause do not make sense. Look for signs of abrasions on the child's wrists, ankles, neck, or torso. Lacerations might also appear on the child's lips, ears, eyes, mouth, or genitalia. If violent shaking or trauma occurred, the child might experience a subdural hematoma [8,34].

Sexual Abuse/Exploitation

According to the Pennsylvania Code, sexual abuse or exploitation is defined as [45]:

• The employment, use, persuasion, inducement, enticement, or coercion of a child to engage in or assist another individual to engage in sexually explicit conduct, which includes, but is not limited to, the following:

  • Looking at the sexual or other intimate parts of a child or another individual for the purpose of arousing or gratifying sexual desire in any individual

  • Participating in sexually explicit conversation either in person, by telephone, by computer, or by a computer-aided device for the purpose of sexual stimulation or gratification of any individual

  • Actual or simulated sexual activity or nudity for the purpose of sexual stimulation or gratification of any individual

  • Actual or simulated sexual activity for the purpose of producing visual depiction, including photographing, videotaping, computer depicting, or filming

• Any of the following offenses committed against a child:

  • Rape

  • Statutory sexual assault

  • Involuntary deviate sexual intercourse

  • Sexual assault

  • Institutional sexual assault

  • Aggravated indecent assault

  • Indecent assault

  • Indecent exposure

  • Incest

  • Prostitution

  • Sexual abuse

  • Unlawful contact with a minor

  • Sexual exploitation

This 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.

Child sexual abuse can be committed by a stranger or an individual known to the child. Sexual abuse may be manifested in many different ways, including [9,10]:

• Verbal: Obscene phone calls or talking about sexual acts for the purpose of sexually arousing the adult perpetrator

• Voyeurism: Watching a child get dressed or encouraging the child to masturbate while the perpetrator watches

• Child prostitution: Involving the child in sexual acts for monetary profit

• Child pornography: Taking photos of a child in sexually explicit poses or acts

• Exhibitionism: Exposing his/her genitals to the child or forcing the child to observe the adult or other children in sexual acts

• Molestation: Touching, fondling, or kissing the child in a provocative manner; for example, fondling the child's genital area or long, lingering kisses

• Sexual penetration: The penetration of part of the perpetrator's body (e.g., finger, penis, tongue) into the child's body (e.g., mouth, vagina, anus)

• Rape: Usually involves sexual intercourse without the victim's consent and usually involves violence or the threat of violence

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

Physical Neglect

Pennsylvania law defines serious physical neglect of a child as repeated, prolonged, or egregious failure to supervise a child in a manner that is appropriate considering the child's developmental age and abilities, and/or the failure to provide a child with adequate essentials of life, including food, shelter, or medical care, 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. Due to the ambiguity of definitions of child abuse and neglect, CAPTA provides minimum standards that each state must incorporate in its definition of neglect. Examples of child neglect may include [6,11,12]:

• Failure to provide adequate food, clothing, shelter, hygiene, supervision, and protection

• Refusal and/or delay in medical attention and care (e.g., failure to provide needed medical attention as recommended by a healthcare professional or failure to seek timely and appropriate medical care for a health problem)

• Abandonment, characterized by desertion of a child without arranging adequate care and supervision. Children who are not claimed within two days or who are left alone with no supervision and without any information about their parents'/caretakers' whereabouts are examples of abandonment.

• Expulsion or blatant refusals of custody on the part of parent/caretaker, such as ordering a child to leave the home without adequate arrangement of care by others

• Inadequate supervision (i.e., child is left unsupervised or inadequately supervised for extended periods of time)

Emotional Abuse

Under Pennsylvania law, emotional abuse involves an act or failure to act by a perpetrator that causes nonaccidental serious mental injury. 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 his or her life or safety is threatened, or that seriously interferes with a child's ability to accomplish age-appropriate development and social tasks" [45].

The following behaviors could constitute emotional abuse [6,11,12]:

• Verbal abuse: Belittling or making pejorative statements in front of the child, which results in a loss or negative impact on the child's self-esteem or self-worth

• Inadequate nurturance/affection: Inattention to the child's needs for affection and emotional support

• Witnessing domestic violence: Chronic spousal abuse in homes where the child witnesses the violence

• Substance and/or alcohol abuse: The parent/caretaker is aware of the child's substance misuse problem but chooses not to intervene or allows the behavior to continue

• Refusal or delay of psychological care: Failure or delay in obtaining services for the child's emotional, mental, or behavioral impairments

• Permitted chronic truancy: The child averages at least five days per month of school absence and the parent/guardian does not intervene

• Failure to enroll: Failure to enroll or register a child of mandatory school age or causing the child to remain at home for nonlegitimate reasons

• Failure to access special education services: Refusal or failure to obtain recommended services or treatment for remedial or special education for a child's diagnosed learning disorder

Trafficking and Exploitation

It can be difficult to identify and intervene to stop human trafficking and exploitation, because it is hidden and even people who interact with victims may not recognize that it is happening. However, in many cases, women and children are considered the typical victims of human trafficking. Trafficking and exploitation are real risks to child safety and well-being and are reportable as forms of abuse.

There are several different types of child or minor human trafficking, but the term is generally defined as the recruitment, transportation, provision, or obtaining of a child for labor or services through the use of force, fraud, or coercion. Severe forms of human trafficking include sex and labor trafficking, including debt bondage and slavery.

Labor Trafficking

Labor trafficking is defined as labor obtained by the use of threat of serious harm, physical restraint, or abuse of the legal process. Severe labor trafficking includes 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 (i.e., paying off debt through work), debt bondage (i.e., debt slavery, bonded labor or services for a debt or other obligation), or slavery (i.e., a condition compared to that of a slave in respect of exhausting labor or restricted freedom).

Typically, children involved in forced labor are being given little or no pay. In the United States, forced labor is predominantly found in five sectors [57]:

• Prostitution and sex industry (46%)

• Domestic servitude (27%)

• Agriculture (10%)

• Sweatshops and factories (5%)

• Restaurant and hotel work (4%)

Among child victims, forced domestic servitude is a serious concern, particularly related to the provision of domestic services for 10 to 16 hours per day on activities such as child care, cooking, cleaning, and yard work/gardening.

Sex Trafficking

The Victims of Trafficking and Violence Protection Act defines sex trafficking as, "the recruitment, harboring, transportation, provision, or obtaining of a person for the purpose of a commercial sex act" [58]. A commercial sex act is, "any sex act on account of which anything of value is given to or received by any person" [58]. In other words, it involves the illegal transport of humans to be exploited in a sexual manner for financial gains [59]. Victims of sex trafficking could be forced into prostitution, stripping, pornography, escort services, and other sexual services [60]. Under federal law, sex trafficking (such as prostitution, pornography, or exotic dancing) does not require there be force, fraud, or coercion if the victim is younger than 18 years of age.

The term "domestic minor sex trafficking" has become a popular term used to connote the buying, selling, and/or trading of children for sexual services within the country, not internationally [60]. In the United States, the children most vulnerable to domestic minor trafficking are [60]:

• Youth in the foster care system

• Youth who identify as LGBTQIA+

• Youth who are homeless or runaway

• Youth with disabilities

• Youth with mental health or substance abuse disorders

• Youth with a history of sexual abuse

• Youth with a history of being involved in the welfare system

• Youth who identify as native or aboriginal

• Youth with family dysfunction

It is crucial that practitioners become familiar with the indications of child abuse and neglect. These factors do not necessarily conclusively indicate the presence of abuse or neglect; rather, they are clues that require further interpretation and clinical investigation. Some parental risk indicators include [8,10,12,16]:

Child risk indicators include [8,10,12,16]:

In addition, warning signs specifically associated with victims of child trafficking and/or exploitation include (but are not limited to):

Some of the types of behaviors and symptoms discussed in the definitions of physical, sexual, and emotional abuse/neglect are also warning signs. For example, any of the injuries that may result from physical abuse, such as a child presenting with bruises in the shape of electric cords or belt buckles, should be considered risk factors for abuse.

The consequences of child abuse and neglect vary from child to child, and these differences continue as victims grow older. Several factors will mediate the outcomes, including the [17]:

In examining some of the effects of physical abuse, it is helpful to frame the consequences along a lifespan perspective [3]. During infancy, physical abuse can cause neurologic impairments. Most cases of infant head trauma are the result of child abuse [19]. Neurologic damage may also affect future cognitive, behavioral, and developmental outcomes. Some studies have noted that, in early childhood, physically abused children show less secure attachments to their caretakers compared to their non-abused counterparts [20].

By middle to late childhood, the consequences are more notable. Studies have shown significant intellectual and linguistic deficits in physically abused children [3]. Other environmental conditions, such as poverty, may also compound this effect. In addition, a number of affective and behavioral problems have been reported among child abuse victims, including anxiety, depression, low self-esteem, excessive aggressive behaviors, conduct disorders, delinquency, hyperactivity, and social detachment [3,8,10,12].

Surprisingly, there has been little research on the effects of childhood physical abuse on adolescents [3]. However, differences have been noted in parents who abuse their children during adolescence rather than preadolescence. It appears that lower socioeconomic status plays a lesser role in adolescent abuse as compared with abuse during preadolescence [21]. In addition, parents who abuse their children during adolescence are less likely to have been abused as children themselves compared with those parents who abused their children during preadolescence [21]. It is believed that the psychosocial effects of physical abuse manifest similarly in late childhood and adolescence.

Research findings regarding the effects of childhood physical abuse on adult survivors indicate an increased risk for major psychiatric disorders, including depression, post-traumatic stress disorder, and substance abuse [36]. Some adult survivors function well socially and in terms of mental and physical health, even developing increased resilience as a result of their experiences, while others exhibit depression, anxiety, post-traumatic stress, substance abuse, criminal behavior, violent behavior, and poor interpersonal relationships [3,17,46]. A meta-analysis found that adult survivors of child abuse were more likely to experience depression than non-abused counterparts, with the rates varying according to the type of abuse sustained (1.5-fold increase for physical child abuse, 2.11-fold increase for neglect, and 3-fold increase for emotional abuse) [24]. Similar results were found in a longitudinal study that compared a child welfare cohort to a group with no child welfare involvement. The child welfare group was twice as likely to experience moderate-to-severe depression and generalized anxiety compared with the control group [25]. There is some evidence that vulnerability to long-term effects of maltreatment in childhood may be at least partially genetically mediated [50].

Although not all adult survivors of sexual abuse experience long-term psychological consequences, it is estimated that 20% to 50% of all adult survivors have identifiable adverse mental health outcomes [23]. Possible psychological outcomes include [10]:

Adult male survivors of child sexual abuse are three times as likely to perpetrate domestic violence as non-victims. In addition, female survivors of child sexual abuse are more vulnerable to bulimia, being a victim of domestic violence, and alcohol use disorder [28].

In more recent years, research has focused on the impact of adverse childhood experiences (ACEs) in general. ACEs are defined as potentially traumatic experiences that affect an individual during childhood (before 18 years of age) and increase the risk for future health and mental health problems (including increased engagement in risky behaviors) as adults [47]. Abuse and neglect during childhood are clear ACEs, but other examples include witnessing family or community violence; experiencing a family member attempting or completing suicide; parental divorce; parental or guardian substance abuse; and parental incarceration [47]. Adults who experienced ACEs are at increased risk for chronic illness, impaired health, violence, arrest, and substance use disorder [28,52].

Pennsylvania has a delineated process in place to facilitate the reporting of suspected child abuse. In addition, in 2014, Governor Corbett signed four new bills intended to streamline and clarify the child abuse reporting process in Pennsylvania. These bills were spurred by the Sandusky child sexual abuse case.

In the following case scenarios, consider if the case should be reported as possible child abuse in accordance with Pennsylvania law.

A young girl, 2 years of age, is brought to the emergency department by her mother and stepfather for a scalp laceration. The girl is very quiet and appears listless and out of sorts. Her mother reports that she was injured when she fell onto a rock outside, but that the injury occurred when the girl was being watched by the stepfather. The girl undergoes assessment for traumatic brain injury, including assessment of function using the modified Glasgow Coma Score. The toddler is found to have mild impairment (a score of 13), and the follow-up test two hours later indicates normal functioning. The nurse notices that the toddler appears to be afraid of the stepfather, leaning away and crying when he is near her. The stepfather also appears to be easily frustrated with the child, saying that he does not know why she cries so much.

A boy, 13 years of age, is undergoing a routine physical exam with his family physician. The physician asks the boy if he is excited to start school in the next few weeks and how his baseball team is doing. The boy becomes quiet and states that he is nervous about an upcoming trip with his baseball team but does not give additional information. When asked directly, the boy says that he is uncomfortable with the new assistant coach, who watches pornography with them during out-of-town tournaments and supplies them with pornographic magazines. However, the boy states that he doesn't think it's a big deal and that "all of the other kids seem to really like it."

Child abuse and neglect are considered significant social problems with deleterious consequences. As noted, a system has been implemented in all 50 states to ensure the safety of children, with laws defining what constitutes abuse and neglect and who is mandated to report. Healthcare professionals, regardless of their discipline or field, are in a unique position to assist in the identification, education, and prevention of child abuse and neglect.

It is the duty of all mandated reporters in the state of Pennsylvania to know their responsibilities and the laws that govern the reporting process. All reporters should adhere to the established laws and rules that govern child abuse reporting, taking into account the expanded definition of perpetrator, the updated processes in place for reporting cases of suspected child abuse, and the delineated roles of mandated reporters. Doing so will help ensure the safety of millions of children in Pennsylvania.