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What’s Inside
CHILD ABUSE IDENTIFICATION AND REPORTING: THE PENNSYLVANIA REQUIREMENT (MANDATORY) 1 [3 contact hours] The purpose of this course is to enable healthcare professionals in all practice settings to define child abuse and identify the children who are affected by violence. This course describes how a victim can be accurately diagnosed and identifies the community resources available in the state of Pennsylvania for child abuse victims. THIS COURSE SATISFIES THE CHILD ABUSE RECOGNITION AND REPORTING REQUIREMENT SUBSTANCE USE DISORDERS AND PAIN MANAGEMENT: MATE ACT TRAINING (MANDATORY) 20 [8 contact hours] The purpose of this course is to provide clinicians who prescribe or distribute controlled substances with an appreciation for the complexities of managing patients with substance use disorders and comorbid pain in order to provide the best possible patient care and to prevent a growing social problem. THIS COURSE SATISFIES THE 8-HOUR DEA REQUIREMENT ON THE TREATMENT AND MANAGEMENT OF PATIENTS WITH OPIOID OR OTHER SUBSTANCE USE DISORDERS THIS COURSE ALSO SATISFIES THE 2-HOUR REQUIREMENT FOR PAIN MANAGEMENT, ADDICTION, AND OPIOID PRESCRIBING
CARIES-PRONE PATIENTS: PREVENTION, ASSESSMENT, AND INTERVENTIONS, 3RD EDITION [4 contact hours] The purpose of this course is to equip all members of the dental team with the skills needed to implement the advances available for early caries detection, recommend anticaries treatments, and offer nutritional analysis and counseling.
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FINAL EXAM ANSWER SHEET
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©2024: All Rights Reserved. Materials may not be reproduced without the expressed written permission or consent of Colibri Healthcare, LLC. The materials presented in this course are meant to provide the consumer with general information on the topics covered. The information provided was prepared by professionals with practical knowledge in the areas covered. It is not meant to provide medical, legal or professional services advice. Colibri Healthcare, LLC recommends that you consult a medical, legal or professional services expert licensed in your state. Colibri Healthcare, LLC has made all reasonable efforts to ensure that all content provided in this course is accurate and up to date at the time of printing, but does not represent or warrant that it will apply to your situation or circumstances and assumes no liability from reliance on these materials.
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DENTAL CONTINUING EDUCATION
Book code: DPA1525
Frequently Asked Questions
What are the requirements for license renewal? Licenses Expire CE Credit Hours
Mandatory Subjects
2 hours of child abuse reporter training 2 hours of opioid continuing education (for providers who prescribe controlled substances) 8 hours of treatment and management of patients with opioid or substance use disorders (for DEA-registered practitioners)
Dentists - 30 hours (15 hours may be completed online)
Licenses expire March 31 of every odd-numbered year
How much will it cost? If you are only completing individual courses in this book, enter the code that corresponds to the course below online. Course Title Hours Price Course Code Child Abuse Identification and Reporting: The Pennsylvania Requirement (Mandatory) 3 $27.00 DPA03CA Substance Use Disorders and Pain Management: MATE Act Training (Mandatory) 8 $64.00 DPA08SA Caries-Prone Patients: Prevention, Assessment, and Interventions, 3rd Edition 4 $36.00 DPA04CP 15 $120.00 DPA1525
How do I complete this course and receive my certificate of completion? See the following page for step-by-step instructions to complete and receive your certificate. Are you a Pennsylvania board-approved provider?
Yes, NetCE courses are accepted by the State Board of Dentistry. NetCE is an approved Child Abuse Recognition and Reporting Continuing Education Provider (Pennsylvania Department of State – Child Abuse Recognition and Reporting Training Provider # CACE000020). Are my credit hours reported to the Pennsylvania board? Yes, we will only report your 3-hour Child Abuse Identification and Reporting: The Pennsylvania Requirement to the Pennsylvania Department of State within one business day. What information do I need to provide for course completion and certificate issuance? The Pennsylvania Department of State requires us to obtain your date of birth and last 4 numbers of Social Security number in order to report your hours. Please also provide your license number on the test sheet to receive course credit. Is my information secure? Yes! We use SSL encryption, and we never share your information with third parties. We are also rated A+ by the National Better Business Bureau. What if I still have questions? What are your business hours? No problem, we have several options for you to choose from! Online at EliteLearning.com/Dental you will see our robust FAQ section that answers many of your questions, simply click FAQs at the top of the page, e-mail us at office@elitelearning. com, or call us toll free at 1-866-344-0972, Monday - Friday 9:00 am - 6:00 pm and Saturday 10:00 am - 4:00 pm, EST. Important information for licensees: Always check your state’s board website to determine the number of hours required for renewal, mandatory topics (as these are subject to change), and the amount that may be completed through home-study. Also, make sure that you notify the board of any changes of address. It is important that your most current address is on file. Licensing board contact information: Pennsylvania Department of State | Bureau of Professional and Occupational Affairs| State Board of Dentistry 2525 N. 7th Street | Harrisburg, PA 17110 | Phone: (717) 783-7162 Website: https://www.pa.gov/en/agencies/dos/department-and-offices/bpoa/boards-commissions/dentistry.html
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Book code: DPA1525
DENTAL CONTINUING EDUCATION
How To Complete This Book For Credit
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IF YOU’RE ONLY COMPLETING CERTAIN COURSES IN THIS BOOK: • Go to EliteLearning.com/Book and enter the code that corresponds to the course below, then click GO. Each course will need to be completed individually, and the specified course price will apply. • Affirm that you have read the course material, proceed to checkout and complete your purchase. If you already have an account, sign in with your username and password. If you do not have an account, you’ll be able to create one now. • Proceed to your courses to finalize your purchase and the mandatory course evaluation. Upon completion, you’ll receive access to your completion certificate.
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COURSES YOU’VE COMPLETED
CODE TO ENTER
ALL 15 HOURS IN THIS CORRESPONDENCE BOOK DPA1525 If you are only completing individual courses in this book, enter the code that corresponds to the course below online. Child Abuse Identification and Reporting: The Pennsylvania Requirement DPA03CA Substance Use Disorders and Pain Management: MATE Act Training DPA08SA Caries-Prone Patients: Prevention, Assessment, and Interventions, 3rd Edition DPA04CP
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DENTAL CONTINUING EDUCATION
Book code: DPA1525
Child Abuse Identification and Reporting: The Pennsylvania Requirement _____________________________ DPA03CA — 3 CE CREDIT HOURS R elease D ate : 08/01/22 E xpiration D ate : 07/31/25
Child Abuse Identification and Reporting: The Pennsylvania Requirement
This course is approved by the Pennsylvania Department of Human Services to fulfill the requirement for 3 hours of Child Abuse Recognition and Reporting (Act 31) training for healthcare professionals applying for licensure. Provider number CACE000020.
in the area of psychology and sociology. Her research focus is on the area of culture and mental health in ethnic minority communities. Faculty Disclosure Contributing faculty, Alice Yick Flanagan, PhD, MSW, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned. Division Planner John M. Leonard, MD Jane C. Norman, RN, MSN, CNE, PhD James Trent, PhD Randall L. Allen, PharmD Senior Director of Development and Academic Affairs Sarah Campbell Division Planner/Director Disclosure The division planner and director have disclosed no relevant financial relationship with any product manufacturer or service provider mentioned. Audience The purpose of this course is to enable healthcare professionals in all practice settings to define child abuse and identify the children who are affected by violence. This course describes how a victim can be accurately diagnosed and identifies the community resources available in the state of Pennsylvania for child abuse victims. Accreditations & Approvals NetCE is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at www.ada.org/cerp.
HOW TO RECEIVE CREDIT • Read the entire course online or in print. • Depending on your state requirements you will be asked to complete: ‒ A mandatory test (a passing score of 75 percent is required). Test questions link content to learning objectives as a method to enhance individualized learning and material retention. • Provide required personal information and payment information. • Complete the mandatory Course Evaluation. • Print your Certificate of Completion. Faculty Alice Yick Flanagan, PhD, MSW, received her Master’s in Social Work from Columbia University, School of Social Work. She has clinical experience in mental health in correc- tional settings, psychiatric hospitals, and community health centers. In 1997, she received her PhD from UCLA, School of Public Policy and Social Research. Dr. Yick Flanagan completed a year-long post-doctoral fellowship at Hunter College, School of Social Work in 1999. In that year she taught the course Research Methods and Violence Against Women to Masters degree students, as well as conducting qualitative research studies on death and dying in Chinese American families. Previously acting as a faculty member at Capella University and Northcentral University, Dr. Yick Flanagan is currently a contributing faculty member at Walden University, School of Social Work, and a dissertation chair at Grand Canyon Uni- versity, College of Doctoral Studies, working with Industrial Organizational Psychology doctoral students. She also serves as a consultant/subject matter expert for the New York City Board of Education and publishing companies for online cur- riculum development, developing practice MCAT questions
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Book Code: DPA1525
_____________________________ Child Abuse Identification and Reporting: The Pennsylvania Requirement
Disclosure Statement It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distrib- uting or providing access to this activity to learners. Course Objective The purpose of this course is to enable healthcare professionals in all practice settings to define child abuse and identify the children who are affected by violence. This course describes how a victim can be accurately diagnosed and identifies the community resources available in the state of Pennsylvania for child abuse victims. Learning Outcomes Upon completion of this course, you should be able to: 1. Summarize the historical context of child abuse. 2. Discuss the emergence of the child welfare system in Pennsylvania. 3. Define child abuse and neglect and identify the different forms of child abuse and neglect. 4. Discuss the scope of child abuse and neglect in the United States and specifically in Pennsylvania. 5. Review the mandatory reporting process and man- dated reporters in the state of Pennsylvania, including possible barriers to reporting suspected cases of child abuse.
NetCE Nationally Approved PACE Program Provider or FAGD/MAGD credit. Approval does not imply acceptance by any regulatory authority or AGD endorsement.
10/1/2021 to 9/30/2027 Provider ID #217994.
NetCE is a Registered Provider with the Dental Board of Cali- fornia. Provider number RP3841. Completion of this course does not constitute authorization for the attendee to perform any services that he or she is not legally authorized to perform based on his or her permit type. NetCE is approved as a provider of continuing education by the Florida Board of Dentistry, Provider #50-2405. Designations of Credit NetCE designates this activity for 3 continuing education credits. AGD Subject Code 155. This course meets the Dental Board of California’s require- ments for 8 units of continuing education. Dental Board of California course #03-3841-00357. About the Sponsor The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare. Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.
Sections marked with this symbol include evidence-based practice recommendations. The level of evidence and/or strength of recommendation, as provided by the evidence-based source, are also included
so you may determine the validity or relevance of the information. These sections may be used in conjunction with the course material for better application to your daily practice.
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Child Abuse Identification and Reporting: The Pennsylvania Requirement _____________________________
As a result of Berge’s advocacy for children’s safety, other non- governmental 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 trau- matic 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.
HISTORICAL CONTEXT 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 punish- ment 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 punish- ment. 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 con- certed 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].
CHILD WELFARE IN PENNSYLVANIA
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 educat- ing 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].
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_____________________________ Child Abuse Identification and Reporting: The Pennsylvania Requirement
GENERAL PROTECTIVE SERVICES GPS is involved in non-abuse cases or acts that involve “non- serious injury or neglect” [38]. This includes children who experience “inadequate shelter, food, clothing, health care, truancy, inappropriate discipline, lack of supervision, hygiene issues, abandonment, or other problems that threaten a child’s opportunity for healthy growth and development” [38]. One of the following criteria must be met for GPS to be involved [55]: • Lack of parental control
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 Penn- sylvania delineates two functions for the local agencies: child protective services (CPS) and general protective services (GPS). In 2016, SB1311 (Act 115) was signed and went into effect. This Act provides for additional grounds for involuntary termi- nation of parental rights, provides for an additional grounds for aggravated circumstances, allows for the release of information in confidential reports to law enforcement when investigating cases of severe forms of trafficking in persons of sex trafficking, and adds a category of child abuse to include human trafficking. In 2017, Governor Tom Wolf approved Act 68 (also known as the Newborn Protection Act) to increase the number of loca- tions 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]. That same year, Act 54 was signed and required mandatory notification when a medical provider has determined that a child (younger than 1 year of age) was born affected by substance use or withdrawal symptoms resulting from prenatal drug or alcohol exposure. This Act also mandates the development of “interagency pro- tocols” to support local multidisciplinary teams to identify, assess, and develop a plan of safe care for infants born affected by substance use or withdrawal symptoms. In 2019, Act 88, relating to penalties for failure to report or refer, was enacted. CHILD PROTECTIVE SERVICES CPS is in place to address acts that are “non-accidental seri- ous physical or mental injury, sexual abuse, or exploitation, or serious physical neglect caused by acts or omissions of the parent or caretaker” [32]. In other words, these are cases in which there is reasonable cause to suspect child abuse and conduct an investigation. Case Scenario A young boy comes into the community health clinic for a physical exam. The boy’s mother hovers and does not seem to want to let her son answer any questions. During the exam, in the process of taking blood, the nurse notices some bruises and lacerations on the boy’s arm. Later, bruises in the shape of a belt are observed on the boy’s back as well. Upon questioning, the boy will only say that he was “bad.” In this case, the nurse should make a report to ChildLine. This would be classified as a CPS case, and an investigation would be conducted. More information will be presented about reporting in later sections of this course.
• Deprivation of the essentials of life • Illegal placement for adoption or care • Abandonment by parents or guardians • Chronic truancy
• Habitual disobedience • Formal adjudication • Commitment of a delinquent act at an age younger than 10 years • Defined as ungovernable • Born to parents with terminated parental rights Case Scenario Ms. J, a neighbor, notices E (5 years of age) and S (6 years of age) running around their front yard at 8 p.m. The front door of the house is wide open, and Ms. J asks if their mother is home. S states that her mother went out with her girlfriend to a party. Ms. J asks if a baby- sitter is at the house, and S answers “no” again. This is not the first time neighbors have noticed that the kids are left at home alone. The neighbors report that the mother often comes home late, intoxicated. In this case, a bystander (likely Ms. J or one of the neighbors) could call ChildLine, the local county agency, or even the police, and the case would be addressed by GPS. More infor- mation will be presented about reporting in later sections of this course.
DEFINITIONS OF CHILD ABUSE AND NEGLECT
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 Penn- sylvania law, child abuse refers to intentionally, knowingly, or recklessly doing any of the following [43; 54]:
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Child Abuse Identification and Reporting: The Pennsylvania Requirement _____________________________
In addition, the Code explicitly excludes specific acts and inju- ries from the definition of child abuse. Effective December 31, 2014, the following are considered exclusions to the definition of child abuse [44]: • 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 shall not apply to any child-care service, excluding an adoptive parent. • Practice of religious beliefs: If, upon investigation, the county agency determines that a child has not been provided needed medical or surgical care because of sincerely held religious beliefs of the child’s parents or relative within the third degree of consanguinity and with whom the child resides, which beliefs are consistent with those of a bona fide religion, the child shall not be deemed to be physically or mentally abused. In such cases the following shall apply: ‒ 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. ‒ 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. ‒ The family shall be referred for general protective services, if appropriate. ‒ This subsection shall not apply if the failure to provide needed medical or surgical care causes the death of the child. ‒ This subsection shall not apply to any child-care service as defined in this chapter, excluding an adoptive parent. • Use of force for supervision, control, and safety purposes: Subject to the rights of parents, 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.
• 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 that 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 • Engaging in any of the following recent acts: ‒ 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 duration of the restraint or confinement ‒ Forcefully shaking a child younger than 1 year of age ‒ Forcefully slapping or otherwise striking a child younger than 1 year of age ‒ Interfering with the breathing of a child ‒ Causing a child to be present at a location while a violation relating to the operation of methamphetamine laboratory is occurring, provided that the violation is being investigated by law enforcement ‒ Leaving a child unsupervised with an
individual, other than the child’s parent, who the actor knows or reasonably should have known a) is required to register as a Tier II or Tier III sexual offender, where the victim of the sexual offense was younger than 18 years
of age when the crime was committed; b) has been determined to be a sexually violent predator; or c) has been determined to be a sexually violent delinquent child • 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
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_____________________________ Child Abuse Identification and Reporting: The Pennsylvania Requirement
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]: • 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
‒ The use of reasonable force is necessary to quell a disturbance or remove the child from the scene of a disturbance that threatens physical injury to persons or damage to property; to prevent the child from self- inflicted physical harm; for self-defense or the defense of another individual; or to obtain possession of weapons or other dangerous objects or controlled substances or paraphernalia that are on the child or within the control of the child. • Rights of parents: Nothing in this 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. • Participation in events that involve physical contact with child: An individual participating in a practice or competition in an interscholastic sport, physical education, recreational activity, or 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. • Defensive force: Reasonable force for self-defense or the defense of another individual shall not be considered child abuse. ‒ Child-on-child contact: Harm or injury to a child that results from the act of another child shall not constitute child abuse unless the child who caused the harm or injury is a perpetrator. Notwithstanding this, the following shall apply: Acts constituting any of the following crimes against a child shall be subject to the reporting requirements: rape, involuntary deviate sexual intercourse, sexual assault, aggravated indecent assault, indecent assault, and 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
for the child’s welfare, including a person who provides temporary or permanent care,
supervision, mental health diagnosis or treatment, or training or control of a child in lieu of parental care, supervision, and control • 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 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 In a significant revision to the definition of perpetrator, school personnel and other childcare providers are consid- ered “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]: • 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 and responsible for the child’s welfare or who resides in the same home as the child
FORMS OF CHILD ABUSE AND NEGLECT
to make a report to the department if the person allegedly responsible for the child abuse is a nonperpetrator child.
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.
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.
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Child Abuse Identification and Reporting: The Pennsylvania Requirement _____________________________
Bodily Injury Bodily injury, or 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 profes- sionals. Physical injuries that may be indicative of abuse include bruises/welts, burns, fractures, abdominal injuries, lacera- tions/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 Patterns such as the shape of the article (e.g., a cord, belt buckle, teeth, hand) used to inflict the bruise or welt are com- mon. 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].
‒ 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
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.
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 indi- vidual 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
(https://acsearch.acr.org/docs/69443/Narrative. Last accessed July 26, 2022.) Level of Evidence : Expert Opinion/Consensus Statement
Sexual Abuse/Exploitation According to the Pennsylvania Code, sexual abuse or exploita- tion 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:
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_____________________________ Child Abuse Identification and Reporting: The Pennsylvania Requirement
Serious Mental Injury Under Pennsylvania law, serious mental injury (or emotional or psychological abuse) involves an act or failure to act by a perpe- trator 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
• 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 Serious 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 devel- opmental 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)
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.
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Child Abuse Identification and Reporting: The Pennsylvania Requirement _____________________________
There are several different types of child or minor human traf- ficking, 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 coer- cion, 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%)
• 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
EPIDEMIOLOGY OF CHILD ABUSE AND NEGLECT
NATIONAL PREVALENCE In 2020, there were 3.9 million referrals to child protective agencies in the United States [15]. More than 2.1 million (or 54%) were assessed to be appropriate for a response, and 27.6% of reports were made by health, social service, and/or mental health professionals [15]. Girls tend to be victims at a slightly higher rate (8.9 per 1,000 population) compared with boys (7.9 per 1,000 population) [15]. The most common perpetrators were parents; 90.6% of victims are maltreated by one or both parents [15]. Specifically, mothers are more often perpetra- tors compared with fathers (58.3% of victims were abused by a mother vs. 44.3% of victims were abused by a father) [15]. As of 2020, 8.4 of every 1,000 children in the United States were victims of abuse and/or neglect [15]. This is the unique rate, meaning each child is counted only once regardless the number of times a report may have been filed for abuse/ neglect. The fatality rate for 2020 was 2.38 deaths per 100,000 children [15]. Research has shown that racial and ethnic minority children (particularly African American, Native American/Alaska Native, and multi-racial children) tend to have higher rates of reported child maltreatment compared with their White counterparts ( Table 1 ) [15]. However, the lowest reported rate is among Asian American children [15]. PENNSYLVANIA STATE PREVALENCE According to the Annual Child Protective Services Report, a yearly statistical report that documents child abuse cases in Pennsylvania, the child abuse hotline registered a total of 39,093 reports of suspected abuse or neglect in 2022 [27]. Approximately 12.8% of these cases were substantiated, which translates to 4,992 cases of child abuse in 2022 [27]. This is an increase of 6,174 reports (18.7%) compared with 2020, a
• 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, transporta- tion, 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]:
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_____________________________ Child Abuse Identification and Reporting: The Pennsylvania Requirement
• History of parent “losing control” or “hitting too hard” Child risk indicators include [8; 10; 12; 16]: • Multiple school absences • Learning or developmental disabilities • History of multiple, unexplained illnesses, hospitalizations, or accidents • Poor general appearance (e.g., fearful, poor hygiene, malnourished appearance, inappropriate clothing for weather conditions) • Stress-related symptoms, such as headaches or stomachaches • Frozen watchfulness • Mental illness or symptoms, such as psychosis, depression, anxiety, eating disorders, or panic attacks • Regression to wetting and soiling • Sexually explicit play • Excessive or out-of-the-ordinary clinging behavior • Difficulties with concentration • Disruptions in sleep patterns and/or nightmares In addition, warning signs specifically associated with victims of child trafficking and/or exploitation include (but are not limited to): • A youth that has been verified to be younger than 18 years of age and is in any way involved in the commercial sex industry or has a record of prior arrest for prostitution or related charges • An explicitly sexual online profile • Excessive frequenting of Internet chat rooms or classified sites • Depicting elements of sexual exploitation in drawing, poetry, or other modes of creative expression • Frequent or multiple sexually transmitted infections or pregnancies • Lying about or not being aware of their true age • Having no knowledge of personal data (e.g., age, name, date of birth) • Having no identification • Wearing sexually provocative clothing • Wearing new clothes of any style, getting hair and/ or nails done with no financial means
decline attributed to the end of COVID-19 precautions and the return to usual contact between children and mandated reporters [27]. Of the substantiated child abuse cases, there were 60 fatalities, 13 less than in 2020 [27]. More than half (50.1%) of perpetrators of child abuse in 2022 were the parent of the child victim [27]. CHILD ABUSE VICTIMIZATION IN THE UNITED STATES ACCORDING TO RACE/ETHNICITY, 2020 Race/Ethnicity Child Abuse Rate per 1,000 Children Native American/Alaska Native 15.5 African American 13.2 Multi-race 10.3 Pacific Islander 9.0 Hispanic 7.8 White 7.4 Asian American 1.6 Source: [15] Table 1 RECOGNIZING WARNING SIGNS It is crucial that practitioners become familiar with the indica- tions of child abuse and neglect. These factors do not neces- sarily 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]: • Recounting of events that do not conform either with the physical findings or the child’s physical and/or developmental capabilities • Inappropriate delay in bringing the child to a health facility • Unwillingness to provide information or the information provided is vague • History of family violence in the home • Parental misuse of substances and/or alcohol • Minimal knowledge or concern about the child’s development and care • Environmental stressors, such as poverty, single parenthood, unemployment, or chronic illness in the family • Unwanted pregnancy • Early adolescent parent • Expression that the parent(s) wanted a baby in order to feel loved
• Being secretive about whereabouts • Having late nights or unusual hours
• Having a tattoo that s/he is reluctant to explain • Being in a controlling or dominating relationship • Not having control of own finances
• Unrealistic expectations of the child • Use of excessive physical punishment • Healthcare service “shopping”
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