Pennsylvania Physician Ebook Continuing Education

This interactive Pennsylvania Physician Ebook contains 24 hours of continuing education. To complete click the Complete Your CE button at the top right of the screen.

Pennsylvania Continuing Medical Education

2024 Pennsylvania Medical Licensure Program

2 HOURS

SATISFIES MANDATORY REQUIREMENT FOR TWO (2) CREDIT HOURS IN CHILD ABUSE Child Abuse

2 HOURS

SATISFIES MANDATORY REQUIREMENT FOR TWO (2) CREDIT HOURS IN OPIOID EDUCATION - PRESCRIBING OPIOIDS Prescribing Opioids 12 HOURS SATISFIES MANDATORY REQUIREMENT FOR TWELVE (12) CREDIT HOURS IN PATIENT SAFETY Patient Safety

INCLUDES: DEA’s new one-time MATE requirement

CME FOR:

AMA PRA CATEGORY 1 CREDITS ™ MIPS MOC STATE LICENSURE

PA.CME.EDU

InforMed is Accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

2024 PENNSYLVANIA

CHILD ABUSE RECOGNITION AND REPORTING IN PENNSYLVANIA COURSE ONE | 2 CREDITS* InforMed reports all Child Abuse credits to the Pennsylvania Licensing System (PALS). The date of completion submitted to PALS is the same date of completion that appears on your certificate. ALTERNATIVES TO OPIOIDS FOR PAIN MANAGEMENT COURSE TWO | 2 CREDITS** ASSESSMENT AND PREVENTION OF SUICIDE COURSE THREE | 6 CREDITS*** GUIDANCE ON PROFESSIONAL BOUNDARIES AND SEXUAL MISCONDUCT COURSE FOUR | 2 CREDITS***

INTIMATE PARTNER VIOLENCE: COMPASSIONATE CARE, EFFECTIVE ASSESSMENT COURSE FIVE | 2 CREDITS*** MEDICAL ERRORS AND THE UNITED STATES HEALTHCARE SYSTEM COURSE SIX | 2 CREDITS*** SUBSTANCE USE DISORDERS: A DEA REQUIREMENT COURSE SEVEN | 8 CREDITS+ LEARNER RECORDS: ANSWER SHEET & EVALUATION REQUIRED TO RECEIVE CREDIT

105

117

152

*Satisfies Mandatory Requirement for Two (2) Credit Hours in Child Abuse **Satisfies Mandatory Requirement for Two (2) Credit Hours in Opioid Education - Prescribing Opioids ***Satisfies Mandatory Requirement for Twelve (12) Credit Hours in Patient Safety +Satisfies the DEA’s New One-time MATE Requirement

Program Options

Price

Option

Code

Credits

$200 ENTIRE PROGRAM (INCLUDES ALL COURSES IN THIS BOOK)

PA24CME 24 Credits

Child Abuse Recognition and Reporting in Pennsylvania Alternatives to Opioids for Pain Management Assessment and Prevention of Suicide Guidance on Professional Boundaries and Sexual Misconduct Intimate Partner Violence: Compassionate Care, Effective Assessment Medical Errors and the United States Healthcare System Assessment and Prevention of Suicide Guidance on Professional Boundaries and Sexual Misconduct Intimate Partner Violence: Compassionate Care, Effective Assessment Medical Errors and the United States Healthcare System

$145

16 Credits

PA24CME-95

$125

12 Credits

PA24CME-75

$50 Child Abuse Recognition and Reporting in Pennsylvania

PA24CME-501 2 Credits

CME that counts for MOC Participants can earn MOC points equivalent to the amount of CME credits claimed for designated activities (see page iii for further details). InforMed currently reports to the following specialty boards: the American Board of Internal Medicine (ABIM), the American Board of Anesthesiology (ABA), the American Board of Pediatrics (ABP), the American Board of Otolaryngology–Head and Neck Surgery (ABOHNS), and the American Board of Pathology (ABPath). To be awarded MOC points, you must obtain a passing score, complete the corresponding activity evaluation, and provide required information necessary for reporting.

InforMed has joined the Elite Learning family Two of the nation’s top healthcare education providers have joined forces with one goal in mind: to offer physicians a state-of-the-art learning experience that fulfills your state requirements and empowers you with the knowledge you need to provide the best patient care. Here’s what you can expect from our new partnership: • COURSES: In addition to the mandatory courses you need to renew your state license, you’ll now have access to dozens of hours of elective courses and an expanded content library. • ACCOUNTS: You’ll also have access to a personalized learner account. In your account you can add, organize, and track your ongoing and completed courses. For instructions on how to set up your account, email us at office@elitelearning.com. • BOOK CODES: You may notice a book code on the back cover of the latest InforMed program you’ve received in the mail. When entered on our new site, this code will take you directly to the corresponding self-assessment. See more information below. How to complete Please read these instructions before proceeding. Read and study the enclosed courses and answer the self-assessment questions. To receive credit for your courses, you must provide your customer information and complete the mandatory evaluation. We offer two ways for you to complete. Choose an option below to receive credit and your certificate of completion. Scan this QR code to complete your CE now ! Fastest way to receive your certificate of completion

• Go to BOOK.CME.EDU . Locate the book code PA24CME found on the back of your book and enter it in the box then click GO . • If you already have an account created, sign in to your account with your username and password. If you do not have an account already created, you will need to create one now. • Follow the online instructions to complete your self- assessment. Complete the purchase process to receive course credit and your certificate of completion. Please remember to complete the online evaluation. • To find elective hours, please visit PA.CME.EDU ONLINE FASTEST AND EASIEST!

Enter book code

PA24CME

If you need help finding your code, Browse Book Code FAQs

• Fill out the answer sheet and evaluation found in the back of this booklet. Please include a check or credit card information and e-mail address. Mail to InforMed, PO Box 2595, Ormond Beach, FL 32175-2595 . • Completions will be processed within 2 business days from the date it is received and certificates will be e-mailed to the address provided. • Submissions without a valid e-mail will be mailed to the address provided. BY MAIL

BOOK.CME.EDU

BOOK CODE: PA24CME

1-800-237-6999

DATA REPORTING: Federal, State, and Regulatory Agencies require disclosure of data reporting to all course participants. InforMed abides by each entity’s requirements for data reporting to attest compliance on your behalf. Reported data is governed by each entity’s confidentiality policy. To report compliance on your behalf, it’s mandatory that you must achieve a passing score and accurately fill out the learner information, activity and program evaluation, and the 90-day follow up survey. Failure to accurately provide this information may result in your data being non-reportable and subject to actions by these entities.

INFORMED TRACKS WHAT YOU NEED, WHEN YOU NEED IT

Pennsylvania Professional License Requirements

The Pennsylvania State Boards of Medicine and Osteopathic Medicine require all physicians (MD/DO) maintaining a current license to complete one-hundred (100) credits of continuing medical education during the current licensure cycle, unless exempt. For MDs at least twenty (20) of these credits shall be AMA PRA Category 1 Credits ™ and for DOs at least twenty (20) of these credits shall be AOA Category 1. CONTINUING MEDICAL EDUCATION REQUIREMENT FOR LICENSE RENEWAL DEA ONE-TIME MATE REQUIREMENT (NEW) Effective June 27, 2023 , renewing DEA-registered practitioners must complete eight (8) hours of one-time training on the treatment and management of patients with opioid or substance use disorders.

MANDATORY CME REQUIREMENTS

CHILD ABUSE Act 31 of 2014 states that all health-related licensees applying for the renewal of a license are required to complete at least two (2) hours of Board-approved continuing education in child abuse recognition and reporting requirements

as a condition of renewal. OPIOID EDUCATION

According to 9.1(a)(2) of ABC-MAP, in order for physicians (MD/DO), physician assistants (PA), and nurse- midwives with prescriptive authority to renew their license or prescriptive authority approval for the next renewal period, prescribers with a DEA registration must complete at least two (2) hours of continuing education in pain management or the identification of addiction or the practices of prescribing or dispensing of opioids. The continuing education requirements of ABC-MAP will count towards the total number of continuing education credits required for renewal. PATIENT SAFETY The Pennsylvania State Boards of Medicine and Osteopathic Medicine require at least twelve (12) credit hours to be completed in the area of patient safety/risk management .

We are a nationally accredited CME provider. For all board-related inquiries please contact:

LICENSE RENEWAL

State Board of Medicine 2525 N 7th Street Harrisburg, PA 17110

DEADLINE:

P: (717) 783 -1400 F: (717) 787-7769 State Board of Osteopathic Medicine 2525 N 7th Street Harrisburg, PA 17110 P: (717) 783 -4858 F: (717) 787-7769

DO 10/31/2024

MD & PA 12/31/2024

Disclaimer: The above information is provided by InforMed and is intended to summarize state CE/CME license requirements for informational purposes only. This is not intended as a comprehensive statement of the law on this topic, nor to be relied upon as authoritative. All information should be verified independently.

Table 1. MOC Recognition Statements Successful completion of certain enclosed CME activities, which includes participation in the evaluation component, enables the participant to earn up to the amounts and credit types shown in Table 2 below. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit. Board Programs ABA American Board of Anesthesiology’s redesigned Maintenance of Certification in Anesthesiology TM (MOCA®) program, known as MOCA 2.0® MOC/MIPS CREDIT INFORMATION In addition to awarding AMA PRA Category 1 Credits TM , the successful completion of enclosed activities may award the following MOC points and credit types. To be awarded MOC points, you must obtain a passing score and complete the corresponding activity evaluation.

ABIM

American Board of Internal Medicine’s Maintenance of Certification (MOC) program

American Board of Otolaryngology – Head and Neck Surgery’s Continuing Certification program (formerly known as MOC)

ABOHNS

ABPath

American Board of Pathology’s Continuing Certification Program

ABP

American Board of Pediatrics’ Maintenance of Certification (MOC) program

Table 2. Credits and Type Awarded

Activity Title

ABA ABIM ABOHNS

ABPath

ABP

AMA PRA Category 1 Credits TM

2 Credits LL 2 Credits LL 6 Credits LL & PS 2 Credits LL

2 Credits MK 2 Credits MK 6 Credits MK & PS 2 Credits MK

2 Credits SA 2 Credits SA 6 Credits SA & PS 2 Credits SA

2 Credits LL 2 Credits LL 6 Credits LL 2 Credits LL

2 Credits LL+SA 2 Credits LL+SA 6 Credits LL+SA 2 Credits LL+SA

2 AMA PRA Category 1 Credits T M

2 AMA PRA Category 1 Credits TM

6 AMA PRA Category 1 Credits T M

2 AMA PRA Category 1 Credits TM

2 Credits LL

2 Credits MK

2 Credits SA

2 Credits LL

2 Credits LL+SA

2 AMA PRA Category 1 Credits TM

2 Credits LL 8 Credits LL

2 Credits MK 8 Credits MK

2 Credits SA 8 Credits SA

2 Credits LL 8 Credits LL

2 Credits LL+SA

2 AMA PRA Category 1 Credits TM

Substance Use Disorders: A DEA Requirement 8 Credits LL+SA Legend: LL = Lifelong Learning, MK = Medical Knowledge, SA = Self-Assessment, LL+SA = Lifelong Learning & Self-Assessment, PS = Patient Safety 8 AMA PRA Category 1 Credits T M Table 3. CME for MIPS Statement Completion of each accredited CME activity meets the expectations of an Accredited Safety or Quality Improvement Program (IA PSPA_28) for the Merit-based Incentive Payment Program (MIPS). Participation in this Clinical Practice Improvement Activity (CPIA) is optional for eligible providers.

iii

Release Date: 3/1/2020 Review Date: 12/1/2021 Exp. Date: 12/31/2024 COURSE DATES:

MAXIMUM CREDITS:

FORMAT:

CHILD ABUSE RECOGNITION & REPORTING IN PENNSYLVANIA

2 AMA PRA Category 1 Credits ™

Enduring Material (Self Study)

TARGET AUDIENCE This course is designed for Pennsylvania health care professionals and other mandatory reporters licensed through the Pennsylvania Department of State who are required to participate in approved child abuse recognition and reporting training as a condition of licensure. COURSE OBJECTIVE The purpose of this course is to educate health care providers about child abuse prevention, recognition, and reporting in accordance with state statutory requirements.

HOW TO RECEIVE CREDIT:

• Read the course materials.

• Complete the self-assessment

questions at the end. A score of 70% is required.

• R eturn your customer information/ answer sheet, evaluation, and payment to InforMed by mail or complete online at BOOK.CME.EDU .

Completion of this course will better enable the course participant to: 1. Discuss the statutory requirements of mandatory reporters within the Commonwealth. 2. Recognize specific signs of child abuse. 3. Assess and document cases of suspected abuse. 4. Describe the reporting procedure for mandatory reporters of child abuse. LEARNING OBJECTIVES

IMPLICIT BIAS IN HEALTHCARE Implicit bias significantly affects how healthcare professionals perceive and make treatment decisions, ultimately resulting in disparities in health outcomes. These biases, often unconscious and unintentional, can shape behavior and produce differences in medical care along various lines, including race, ethnicity, gender identity, sexual orientation, age, and socioeconomic status. Healthcare disparities stemming from implicit bias can manifest in several ways. For example, a healthcare provider might unconsciously give less attention to a patient or make assumptions about their medical needs based on race, gender, or age. The unconscious assumptions can lead to delayed or inadequate care, misdiagnoses, or inappropriate treatments, all of which can adversely impact health outcomes. Addressing implicit bias in healthcare is crucial for achieving equity in medical treatment. Strategies to combat these biases involve education and awareness programs for healthcare professionals. These programs help individuals recognize and acknowledge their biases, fostering a more empathetic and unbiased approach to patient care. Additionally, implementing policies and procedures prioritizing equitable treatment for all patients can play a pivotal role in reducing healthcare disparities. Ultimately, confronting implicit bias in healthcare is essential to creating a more just and equitable healthcare system where everyone receives fair and equal treatment regardless of their background or characteristics.

ACCREDITATION STATEMENT

InforMed is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

DESIGNATION STATEMENT InforMed designates this enduring material for maximum of 2 AMA PRA Category 1 Credits ™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

FACULTY

COURSE SATISFIES

Mitchell Goldstein, MD, MBA Assistant Professor of Pediatrics Johns Hopkins University School of Medicine Medical Director, Urgent Care Services Johns Hopkins University School of Medicine

Child Abuse Recognition & Reporting 2

Medical Director, Johns Hopkins Child Protection Team Johns Hopkins University School of Medicine

V. Silverstein, MD Medical Writer Eagle Creek Medical Communications

PENNSYLVANIA SPECIAL APPROVAL Provider Number: CACE000042 This course is approved by the Pennsylvania Department of Human Services and Department of State for two (2) hours of child abuse recognition and reporting training. Completion of this course satisfies the education requirements for training in child abuse recognition and reporting for license renewals. All health-related licensees applying for the renewal of a license issued by the Board are required to complete at least two (2) hours of Board-approved continuing education in child abuse recognition and reporting requirements.

ACTIVITY PLANNER Michael Brooks CME Director InforMed

DISCLOSURE OF INTEREST: In accordance with the ACCME Standards for Commercial Support of CME, InforMed implemented mechanisms, prior to the planning and implementation of this CME activity, to identify and resolve conflicts of interest for all individuals in a position to control content of this CME activity.

STAFF AND CONTENT REVIEWERS InforMed staff, input committee and all content validation reviewers involved with this activity have reported no relevant financial relationships with commercial interests. FACULTY/PLANNING COMMITTEE DISCLOSURE The following faculty and/or planning committee members have indicated they have no relationship(s) with industry to disclose relative to the content of this CME activity: • Mitchell Goldstein, MD, MBA • V. Silverstein, MD • Michael Brooks DISCLAIMER *2024. All rights reserved. These materials, except those in the public domain, may not be reproduced without permission from InforMed. This publication is designed to provide general information prepared by professionals in regard to the subject matter covered. It is provided with the understanding that InforMed, Inc is not engaged in rendering legal, medical or other professional services. Although prepared by professionals, this publication should not be utilized as a substitute for professional services in specific situations. If legal advice, medical advice or other expert assistance is required, the service of a professional should be sought.

• Involuntary termination of parental rights for parents required to register as sexual offenders (Act 29) • Requirements that all schools display approved posters with information for reporting suspected child abuse (Act 54) • New policies to allow indefinite maintenance of child protective services reports (Act 54) Health-care professionals play a crucial role in the health and well-being of children, youth, and families. Their contact with children and families during the different stages of a child's life gives them a unique opportunity to observe families' resilience and progress and to provide education and support. 2 When necessary, health-care professionals must report suspected child abuse and neglect. This CME monograph on recognizing and reporting child abuse will cover the most recent Pennsylvania state guidelines for reporting child abuse based on the most recently-available version of the CPSL. It will review signs and symptoms of child abuse as well as the prevalence of the problem in Pennsylvania. It will familiarize course participants with some of the characteristics of

individuals who may be victims of, or perpetrators of, child abuse. Finally, it will describe current mandatory reporting requirements, processes, and penalties for physicians and other professionals practicing in Pennsylvania. This program offers state-defined mandatory reporters, including physicians and other healthcare personnel, training for meeting their responsibilities for protecting vulnerable children from child abuse. What Is Child Welfare? Child welfare is an array of services designed to ensure that children are safe and that families have the necessary support to care for their children successfully. Child welfare agencies typically: 2 • Support or coordinate services to prevent child abuse and neglect • Provide services to families that need help protecting and caring for their children • Receive and investigate reports of possible child abuse and neglect and assess child and family needs, strengths, and resources • Arrange for children to live with kin or with foster families when safety cannot be ensured at home • Support the well-being of children living with relatives or foster families, including ensuring that their health and educational needs are addressed • Work with the children, youth, and families to achieve family reunification, adoption, or other permanent family connections for children and youth leaving foster care Each state or locality has a public child welfare agency responsible for receiving and investigating reports of child abuse and neglect and assessing child and family needs, however the child welfare system is not a single entity. Public child welfare agencies often collaborate with private child welfare agencies, community-based organizations, and other public agencies to ensure that families receive the services they need, such as supportive child care, parenting programs, in-home family preservation services, health and mental health services, and substance abuse treatment. 2 The administrative framework for child welfare services and programs varies from state to state. All states are responsible for compliance with federal and state requirements, however, they may differ in the way child welfare services are operated and delivered. The different types of administration determine the degree of centralization of authority and responsibility for child welfare funding, policymaking, licensing, and training for workers. Federal Child Abuse Prevention and Treatment Act The key federal legislation addressing child abuse and neglect is the Child Abuse Prevention and Treatment Act (CAPTA), originally enacted in 1974 (Public Law 93-247). 3

Introduction The problem of child abuse and victimization is nationwide in scope but of particular interest in the Commonwealth of Pennsylvania. In 2020, Pennsylvania received 32,919 reports of suspected abuse or neglect, 4,593 of which were substantiated, which was a percentage increase from 11.5% in 2019 to 14% in 2020. 1 There were 73 substantiated child fatalities in 2020 and 115 near-fatalities. 1 Sexual abuse remains the leading type of child abuse in Pennsylvania (39.1%), followed by physical abuse (28%). Parents continue to be the persons most responsible for abusing children. 1 Pennsylvania’s Child Protective Services Law (CPSL) continues to evolve, with the following legislative changes being approved by the Governor in 2018: 1 • Expansion of the definition of child abuse to include when a person leaves a child unsupervised with an individual, other than the child’s parent, who they know or reasonably should have known, to be a sexually violent predator or to be subject to lifetime registration (Act 29)

Figure 1. Trends in Child Abuse in Pennsylvania 1

The pathway or response assignment depends on an array of factors, such as the presence of imminent danger, level of risk, number of previous reports, source of the report, and/or presenting case characteristics, such as the type of alleged maltreatment and the age of the alleged victims. Referral Intervention Each referral is evaluated at ChildLine (the state’s 24-hour hotline to accept reports of child abuse) by a trained caseworker who determines the most appropriate course of action. These actions include forwarding a report to a county agency for investigation as child abuse, a general protective services referral, or forwarding the referral to the appropriate law enforcement official(s). A General Protective Services (GPS) referral is when the referral in question does not meet the criteria of suspected child abuse, as defined by the Pennsylvania CPSL. GPS referrals are provided to the appropriate county agency, who will in turn screen the referral to determine if an assessment of the situation is needed. In some cases, services may be offered to the child and family. A referral is a Registered/CPS referral when the allegations are determined to meet the criteria of suspected Child Abuse, as defined by the CPSL. CPS referrals are investigated by the appropriate county or regional office, who will in turn render a decision as to the appropriate status of the referral. Differentiating Child Protective Services from General Protective Services Child Protective Services (CPS) are services and activities provided by each county agency for child abuse cases. These services are provided in child abuse cases, that is when the abuse constitutes child abuse as defined in the law. Services may include counseling, classes to strengthen parenting skills, self-help groups, emergency medical services, and, as a last resort, placement outside the home. CPS cases require that the alleged abuse falls under the definition of child abuse as provided in the CPSL and such cases require an investigation. General Protective Services (GPS) is a governmental structure that supports and provides services when protective services are required in non-abuse cases. GPS protects children under non-abuse circumstances that, nevertheless, may interfere with a child’s growth and development. Such cases may involve children in the following conditions: 1. Lack of proper parental care or control, subsistence, education as required by law, or other care or control necessary for his or her physical, mental, or emotional health, or morals. 2. Placement for care or adoption in violation of law.

Figure 2. Relationship of Perpetrator to Victims in Substantiated Reports of Child Abuse in Pennsylvania 1

This Act was amended several times and was most recently amended and reauthorized on December 20, 2010, by the CAPTA Reauthorization Act of 2010. It was amended in 2015, 2016, and 2018, and most recently, certain provisions of the act were amended on January 7, 2019, by the Victims of Child Abuse Act Reauthorization Act of 2018 (P.L. 115-424). 3 CAPTA provides Federal funding and guidance to states in support of prevention, assessment, investigation, prosecution, and treatment activities and also provides grants to public agencies and nonprofit organizations, including Indian Tribes and Tribal organizations, for demonstration programs and projects. Additionally, CAPTA identifies the Federal role in supporting research, evaluation, technical assistance, and data collection activities; establishes the Office on Child Abuse and Neglect; and establishes a national clearinghouse of information relating to child abuse and neglect. CAPTA also sets forth a Federal definition of child abuse and neglect. In 2015, the Federal definitions of “child abuse and neglect” and “sexual abuse” were expanded by the Justice for Victims of Trafficking Act to include a child who is identified as a victim of sex trafficking or severe forms of trafficking in persons. Pennsylvania became CAPTA- compliant in 2006.

Structure of Pennsylvania Child Welfare System Pennsylvania’s child welfare system is one of 12 that operates as state-supervised, but county- administered. In Pennsylvania, child welfare and juvenile justice services are organized, managed, and delivered by 67 County Children and Youth Agencies, with staff in these agencies hired as county employees. The Department of Human Services’ Office of Children, Youth and Families is the state agency that plans, directs, and coordinates statewide children’s programs including social services provided directly by the county children and youth agencies. There are some intrinsic differences in operating a state- supervised and county-administered system, which impact statewide outcomes for children and families. Within this structure, Pennsylvania provides the statutory and policy framework for delivery of child welfare services and monitors local implementation. Differential Response Child Welfare services in Pennsylvania are divided into Child Protective Service (CPS) and General Protective Services (GPS). The use of two or more discrete responses of intervention such as CPS and GPS is known as Differential Response, which is the creation of multiple responses for reports of maltreatment that are screened for response.

3. Abandonment by parents, a guardian, or other custodian. 4. Lack of a parent, guardian, or legal custodian. 5. Habitual truancy (without justification) while subject to compulsory school attendance. 6. Commission of a specific act of habitual disobedience of the reasonable and lawful commands of a parent, guardian, or other custodian and who is ungovernable and found to be in need of care, treatment, or supervision. 7. Being under 10 years of age and having committed a delinquent act. 8. Having been formerly adjudicated under section 6341 of the Juvenile Act (relating to adjudication), and being under the jurisdiction of the court, subject to its conditions or placements and who commits an act which is defined as ungovernable in subparagraph (6). 9. Referral under section 6323 of the Juvenile Act (relating to informal adjustment), and who commits an act which is defined as ungovernable in subparagraph (6). GPS services can help parents recognize and correct conditions that are harmful to their children. Reports that involve non-serious injury or neglect are treated by the agency as General Protective Service (GPS) cases and can include inadequate shelter, truancy, inappropriate discipline, hygiene issues, abandonment, lack of appropriate supervision, or other problems that threaten a child’s opportunity for healthy growth and development. These services can assist parents in being able to recognize and correct conditions that are harmful to their children. Child Protective Services (CPS) cases require that the alleged abuse falls under the definition of child abuse as provided in the Child Protective Services law.

Potential perpetrators for committing an act 4 • 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 or older who is responsible for the child’s welfare or has direct contact with children as an employee of child-care services, a school or through a program, activity or service • A resident of the child’s home who is 14 years or older • An individual 18 years or older who does not reside in the same house as the child but is related within the third degree of consanguinity or affinity by birth or adoption to the child • An individual 18 years of age or older who engages a child in severe forms of trafficking in persons or sex trafficking, as those terms are defined under Section 103 of the Trafficking Victims Protection Act of 2000 (114 Stat. 1466, 22 U.S.C. § 7102) Potential perpetrators for failing to act 4 • 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 or older responsible for the child’s welfare • A person 18 or older who resides in the same home as the child Person responsible for the child’s welfare: a person who provides permanent or temporary care, supervision, mental health diagnosis or treatment, training or control of a child in lieu of parental care, supervision and control. The term includes any such person who has direct regular contact with a child through any program, activity or service sponsored by a school, for profit organization or religious or other not-for-profit organization. Important note: “perpetrator” now includes any person responsible for the child’s welfare. Direct Contact with Children: the care, supervision, guidance or control of children, or routine interaction with children. Program, Activity or Service: a public or private educational, athletic or other pursuit in which children participate. The term includes, but is not limited to, the following: • A youth camp or program • A recreational camp or program • A sports or athletic program

• A community or social outreach program • An enrichment program • A troop, club or similar organization School Employee: 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. Important note: “perpetrator” now includes school employees and independent contractors. School employees and independent contractors are now included as persons responsible for a child’s welfare or having direct contact with children as an employee of childcare services, a school or through a program, activity or service. Prior to December 31, 2014, only incidents of sexual abuse or exploitation and serious bodily injury by a school employee were considered child abuse under the CPSL. There was a separate reporting and investigation process in place for other types of abuse. Now the current law allows for school employees to be considered perpetrators under the definition provided for “person responsible for the child’s welfare having direct contact with children as an employee of child-care services, a school or through a program, activity or service. ” Student: an individual enrolled in a public or private school, intermediate unit or area vocational- technical school who is under 18 years of age. What is Child Abuse Under Pennsylvania CPSL Child Abuse Laws? The CPSL (§ 6303. b.1) defines “child abuse” as intentionally, knowingly, or recklessly doing any of the following: 4 • 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 to the child through any recent act. • 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.

Key Terms Related to Child Abuse

Child: an individual under 18 years of age.

Act of abuse: something done to harm or

cause potential harm to a child.

Failure to act: something that is not done to

prevent harm or potential harm to a child.

Recent act or failure to act: any act or failure to act committed within two years of the date of the report to the department or county agency. Perpetrator: a person who has committed child abuse as defined in this section. The current law broadens the definition of perpetrator and clarifies acts of abuse versus failures to act.

− Indecent exposure as defined in (18 Pa.C.S. § 3127) − Incest as defined in (18 Pa.C.S. § 4302) − Prostitution as defined in (18 Pa.C.S. § 5902) − Sexual abuse as defined in (18 Pa.C.S. § 6312) − Unlawful contact with a minor as defined in (18 Pa.C.S. § 6318) − Sexual exploitation as defined in (18 Pa.C.S. § 6320) Sexual Misconduct: any act, including but not limited to, any verbal, nonverbal, written, or electronic communication, or physical activity, directed toward or with a child or a student regardless of the age of the child or student, that is designed to establish a romantic or sexual relationship with the child or student. Such prohibited acts include, but are not limited to: 1. Sexual or romantic invitations 2. Dating or soliciting dates 3. Engaging in sexualized or romantic dialogue 4. Making sexually suggestive comments 5. Self-disclosure or physical exposure of a sexual, romantic or erotic nature 6. Any sexual, indecent, romantic, or erotic contact with the child or student

• 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 U.S.C. § 7102) Child abuse also includes certain acts in which the act itself constitutes abuse without any resulting injury or condition. These acts include any of the following: 4 • 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 during the operation of a methamphetamine laboratory, 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 parent knows or reasonably should have known was required to register as a Tier II or III sexual offender or has been determined to be a sexually violent predator or sexually violent delinquent.

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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 or 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. Sexual abuse or exploitation: any of the following: ° 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. − Note: 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. ° Any of the following offenses committed against a child: − Rape as defined in (18 Pa.C.S. § 3121) − Statutory sexual assault as defined in (18 Pa.C.S. § 3122.1) − Involuntary deviate sexual intercourse as defined in (18 Pa.C.S. § 3123) − Sexual assault as defined in (18 Pa.C.S. § 3124.1) − Institutional sexual assault as defined in (18 Pa.C.S. § 3124.2) − Aggravated indecent assault as defined in (18 Pa.C.S. § 3125) − Indecent assault as defined in (18 Pa.C.S. § 3126)

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Human Trafficking: defined 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, through the use of force, fraud, or coercion for the purpose of subjection to involuntary servitude, peonage, debt bondage, or slavery. 3. Sex Trafficking: The term “sex trafficking” means the recruitment, harboring, transportation, provision, or obtaining of a person for the purpose of a commercial sex act.

Specific Acts of Child Abuse Defined in Detail: 4

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Bodily Injury: impairment of a physical condition or substantial pain rather than severe pain or lasting impairment Serious bodily injury: bodily injury which creates a substantial risk of death or which causes serious permanent disfigurement or protracted loss or impairment of function of any bodily member or organ. 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.

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Important Changes Made to Specific Definitions of Child Abuse in Pennsylvania

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Restatement of Culpability The definition of child abuse has been amended to require that acts or failures to act be committed intentionally, knowingly, or recklessly. Conduct that causes injury or harm to a child or creates a risk of injury or harm to a child shall not be considered child abuse if there is no evidence that the person acted intentionally, knowingly, or recklessly when causing injury or harm to the child or creating a risk of injury or harm to the child.

Standards of Culpability •

• 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 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. • 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: ° 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. ° The use of reasonable force is necessary: − to quell a disturbance or remove the child from the scene of a disturbance that threatens physical injury to persons or damage to property − to prevent the child from self-inflicted physical harm − for self-defense or the defense of another individual − to obtain possession of weapons or other dangerous objects or controlled substances or paraphernalia that are on the child or within the control of the child.

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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, in itself, constitute contact that is subject to the reporting requirements of this chapter. Child-on-Child Contact: ° Harm or injury to a child that results from the act of another child shall not constitute child abuse unless the child who caused the harm or injury is a perpetrator. ° Notwithstanding the previous paragraph, the following shall apply: ° Acts constituting any of the following crimes against a child shall be subject to the reporting requirements of this chapter: 1. Rape as defined in 18 Pa.C.S. § 3121 (relating to rape); 2. Involuntary deviate sexual intercourse as defined in 18 Pa.C.S. § 3123 (relating to involuntary deviate sexual intercourse); 3. Sexual assault as defined in 18 Pa.C.S. § 3124.1 (relating to sexual assault); 4. Aggravated indecent assault as defined in 18 Pa.C.S. § 3125 (relating to aggravated indecent assault); 5. Indecent assault as defined in 18 Pa.C.S. § 3126 (relating to indecent assault); and 6. Indecent exposure as defined in 18 Pa.C.S. § 3127 (relating to indecent exposure). ° No child shall be deemed to be a perpetrator of child abuse based solely on physical or mental injuries caused to another child in the course of a dispute, fight or scuffle entered into by mutual consent. ° A law enforcement official who receives a report of suspected child abuse is not required to make a report to the department under 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: reasonable force for self- defense or the defense of another individual, consistent with the provisions of 18 Pa.C.S. §§ 505 (relating to use of force in self- protection) and 506 (relating to use of force for the protection of other persons), shall not be considered child abuse.

Intentionally: A person acts intentionally with respect to a material element of an offense when: (i) if the element involves the nature of his conduct or a result thereof, it is his conscious object to engage in conduct of that nature or to cause such a result; and (ii) if the element involves the attendant circumstances, he is aware of the existence of such circumstances or he believes or hopes that they exist. Knowingly: A person acts knowingly with respect to a material element of an offense when: (i) if the element involves the nature of his conduct or the attendant circumstances, he is aware that his conduct is of that nature or that such circumstances exist; and (ii) if the element involves a result of his conduct, he is aware that it is practically certain that his conduct will cause such a result. Recklessly: A person acts recklessly with respect to a material element of an offense when he consciously disregards a substantial and unjustifiable risk that the material element exists or will result from his conduct. The risk must be of such a nature and degree that, considering the nature and intent of the actor’s conduct and the circumstances known to him, its disregard involves a gross deviation from the standard of conduct that a reasonable person would observe in the actor’s situation.

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Exclusions to the definition of “Child Abuse” Although there are legal exclusions to the definition of child abuse, the investigating agency makes that determination when substantiating a report. These are not exclusions to reporting suspected child abuse. Only suspicion, not proof, is needed when making the report. A report should be made when a person has reasonable cause to suspect that a child is a victim of child abuse. The term “child abuse” does not include any conduct for which an exclusion is provided in section 6304 including: • 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 does not apply to any child-care service as defined in this chapter, excluding an adoptive parent.

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Recognition of Child Abuse (i.e., indicators) In order to help abused children, clinicians must first learn to recognize the symptoms of child abuse. Although child abuse is divided into five types — physical abuse, sexual abuse, emotional maltreatment, neglect, and human trafficking — the types often overlap.

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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.

− Loop-shaped marks can be caused by whipping a child with a cord or belt; no disease or accident looks like a loop or belt mark. − Cords or ropes tied around a child’s ankles or neck may result in a bruise or a rope burn. − If a child is slapped or hit, a mark in the shape of the offender’s fingers or hand may be left. ° Placement − Loose tissues, with little bony structure underneath (e.g., eyelids, genitals), bruise most easily and retain bruises longest; injuries at those locations often are not accidental. − Clinicians should be suspicious if a caretaker delays seeking treatment for a child with a genital injury. For example, the injury may have been caused by pinching a boy’s penis to punish him for touching himself or by using a string or rubber band around the penis (causing grooves) to prevent the child from wetting the bed. − Some individuals mistake the presence of Mongolian spots (birthmarks) as an indicator of abuse. These spots usually are grayish-blue, clearly defined spots on the buttocks, back, or extremities. They are most common in African-American and American Indian babies. Lacerations ° In cases of abuse, lacerations often occur on soft tissue areas, such as the abdomen, the throat, the buttocks, and the thighs. ° Some areas of the body are normally protected from lacerations by being inside or covered by other body parts (e.g., the side of the arm that normally lies against the body when in a standing position). It is difficult to fall and injure these areas. ° Lacerations of the ear, the nose, or the throat do not tend to occur accidentally. ° A torn frenulum of the upper lip (the tissue that connects the upper lip to the upper gum) may be an indicator of abuse if there is no reasonable explanation, especially in the case of infants. Bites ° Human bites appear as oval or horseshoe- shaped marks in which tooth impressions look like bruises facing each other. ° If the distance between the canines (the third tooth on each side) is greater than 3 centimeters, the bite is most likely from an adult. Adult bite marks are a sign of serious danger to a child. ° Depending on the location of the bite, the victim’s teeth should be examined and measured to exclude the possibility of a self-inflicted bite.

A physically abused child for example is often emotionally maltreated as well, and a sexually abused child may be also neglected. Any child at any age may experience any of the types of child abuse. Children over age five are more likely to be physically abused and to suffer moderate injury than are children under age five. 5

• Describes the child as “evil” or in some other very negative way • Uses harsh physical discipline with the child • Has a history of abuse as a child • Has a history of abusing animals or pets Additional signs of possible physical abuse may include: 6 • Fractures unexpectedly discovered in the course of an otherwise routine medical examination (e.g., discovering a broken rib while listening to the child’s heartbeat) • Injuries that are inconsistent with, or out of proportion to, the history provided by the caretaker or with the child’s age or developmental stage (e.g., a 3-month old burning herself by crawling on top of the stove) • Multiple fractures, often symmetrical (e.g., in both arms or legs), or fractures at different stages of healing • Fractures in children who are not able to walk • Skeletal trauma (e.g., fractures) combined with other types of injuries, such as burns and subdural hematomas (bleeding between the brain and its outer lining caused by ruptured blood vessels) • Burns on the buttocks, around the anogenital region, on the backs of the hands, or on both hands, as well as those that are severe.

Child Physical Abuse

What Is Physical Abuse? The physical abuse of children can include physical injury knowingly, intentionally, or recklessly caused by the child’s caretaker. Physical abuse can vary greatly in frequency and severity. It may include injuries sustained from burning, beating, kicking, or punching. Physical abuse may result from punishment that is inappropriate to the child’s age, developmental level, or condition. Additionally, it may be caused by a parent’s recurrent lapses in self- control that are brought on by immaturity, stress, or the use of alcohol or illicit drugs. Caretakers may physically abuse children during discipline or as a way to “teach the child a lesson.” What is Physical Abuse under Pennsylvania CPSL Child Abuse Laws? • Physical abuse rises to the level of child abuse when an individual intentionally, knowingly, or recklessly: ° Causes bodily injury to a child 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: which requires impairment of a physical condition or substantial pain rather than severe pain or lasting impairment.

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Bruises ° Color

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− Bruises go through a cycle of color. They are initially red, violet, black, or blue and later turn brown, green, or yellow. The color is affected by the depth and the placement of the bruise, as well as by the skin color and the quality of the light at the location where the bruise is being viewed. − Estimating the age of a bruise by its color is imprecise, but in general: − A bruise with any yellow is usually older than 18 hours. − Red, blue, purple, or black colors in a bruise may occur anytime from within 1 hour of bruising to resolution (i.e., when the bruise coloration disappears). − A red color may be present at any stage of the bruise. − Bruises of identical age and cause on the same person may not appear with the same coloration and may not change color in the same manner. ° Site − Ears and buttocks usually are not injured accidentally. − Knees, shins, foreheads, and elbows are normal bruising areas, particularly for toddlers. ° Shape − Bruises caused by pinching often have a symmetrical pattern.

What are the Signs of Physical Abuse?

Consider the possibility of physical abuse when the child: 5 • Has unexplained burns, bites, bruises, broken bones, or black eyes • Has fading bruises or other marks noticeable after an absence from school • Seems frightened of the parents and protests or cries when it is time to go home • Shrinks at the approach of adults • Reports injury by a parent or another adult caregiver • Abuses animals or pets Consider the possibility of physical abuse when the parent or other adult caregiver: 5 • Offers conflicting, unconvincing, or no explanation for the child’s injury, or provides an explanation that is not consistent with the injury

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