Introduction

According to the Pennsylvania Department of Human Services (DHS), reports of child abuse have increased from 1.6 per 1,000 children in 2016 to 1.8 per 1,000 children in 2017.¹

The Child Protective Services Law (CPSL) continues to increase child abuse reporting by increasing the number of mandated reporters and expanding the list of individuals who could be identified as perpetrators of abuse. Pharmacists and pharmacy technicians, as members of the healthcare team, have an important responsibility to understand the signs of child abuse and report suspected cases in order to protect and promote the health and safety of the community.

Description of Child Welfare in Pennsylvania

The child welfare system is a group of services that promote the safety and well-being of children by protecting them from abuse and neglect. In Pennsylvania, the child welfare system is overseen by the DHS Office of Children, Youth and Families (OCYF) and administered by each county through County Children and Youth agencies.^2,3 These services are divided into Child Protective Services and General Protective Services.

Child Protective Services(CPS) are involved in cases of suspected child abuse and neglect. Cases of alleged abuse must fall under the definition of child abuse as detailed in the CPSL. These cases require a child abuse investigation.⁴

General Protective Services(GPS) are involved in cases of nonabuse where circumstances may interfere with a child’s growth and development. Examples of GPS cases include poor hygiene, lack of appropriate supervision, truancy, and inadequate shelter or clothing. Services are designed to help parents recognize and correct conditions that are harmful to their children. Examples of services offered include education on parenting skills, counseling, emergency shelter care, emergency medical services, and out-of-home placement services.^5,6

Reports: CPS vs GPS

When reports of suspected abuse or neglect are received either through ChildLine (1-800-932-0313) or online (www.compass.state.pa.us/cwls), they are evaluated by ChildLine staff to determine the most appropriate action.

When allegations are determined to meet the criteria of suspected child abuse according to the CPSL, the report is referred to CPS for investigation by the appropriate county or regional office. Once identified as CPS, cases require an investigation because the alleged act or failure to act has been identified as one of 10 categories of abuse per the CPSL.

When allegations do not meet the criteria for suspected child abuse according to the CPSL, the report is referred to GPS and the appropriate county agency for assistance. Cases identified as GPS require an assessment for services and supports to address the potential for harm to a child who meets one of nine specified conditions (e.g., being without parental care or control, subsistence, education; has been placed for care or adoption in violation of the law; has been abandoned parents or other legal guardians; is without a parent, guardian, or legal custodian; is habitually truant from school without justification).⁷

Components of Child Abuse

There are three components of child abuse⁸:

1. An act or a failure to act
   1. An act of abuse causes harm or potential harm to a child.
   2. Failure to act is the lack of an action to prevent harm or potential harm to a child.

Any act or failure to act committed within 2 years of the date of a report to the department or county agency is considered a recent act or failure to act.

2. Child: An individual under 18 years of age
3. Perpetrator: A person who has committed child abuse through acts of abuse or a failure to act

The perpetrator of an act may be any of the following:

• A parent of the child
• A spouse or former spouse of the child’s parent
• A paramour or former paramour of the child’s parent
• A person ≥14 years of age and responsible for the child's welfare or having direct contact with children as an employee of child-care services or a school or through a program, activity, or service
• An individual ≥14 years of age who resides in the same home as the child
• An individual ≥18 years of age who does not reside in the same home as the child but is related within the third degree of consanguinity (blood relation) or affinity by birth or adoption to the child
• An individual ≥18 years of age who engages a child in severe forms of trafficking in persons or sex trafficking

The perpetrator of failing to act may be any of the following:

• A parent of the child
• A spouse or former spouse of the child's parent
• A paramour or former paramour of the child's parent
• A person ≥18 years of age and responsible for the child's welfare
• A person ≥18 years of age who resides in the same home as the child

Perpetrators may also include any person responsible for the child’s welfare as defined as someone who provides permanent or temporary care, supervision, mental health diagnosis, treatment, or training of a child in lieu of parental care, supervision, and control. This term includes individuals who have direct contact with a child through programs, activities, or services such as camps; athletic programs; enrichment programs; and troops, clubs, or similar organizations. School employees and independent contractors are now considered persons responsible for a child’s welfare.

Definition of Child Abuse

Child abuse is defined by the CPSL as intentionally, knowingly, or recklessly doing any of the following⁸:

• 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
• 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

Child abuse also includes engaging in any of the following acts that may occur without any resulting injury or condition:

• 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 1 year of age
• Forcefully slapping or otherwise striking a child under 1 year of age
• Interfering with the breathing of a child
• Causing a child to be present at a location while a violation of 18 Pa.C.S. § 7508.2 (relating to operation of methamphetamine laboratory) is occurring, provided that the violation is being investigated by law enforcement
• Leaving a child unsupervised with an individual, other than the child's parent, who the actor knows or reasonably should have known was required to register as a Tier II or Tier III sexual offender or has been determined to be a sexually violent delinquent or predator

Categories of Child Abuse –

There are four categories of child abuse as defined by the CPSL⁸:

1. Bodily Injury is the impairment of physical condition or substantial pain.
2. Serious Mental Injury is a psychological condition, as diagnosed by a physician or licensed psychologist, including the refusal of appropriate treatment, that:

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

3. Serious Physical Neglect is 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

4. Sexual Abuse or Exploitation is 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

This paragraph does not include consensual activities between a child who is ≥14 years of age and another person who is ≥14 years of age and whose age is within 4 years of the child's age.

• Sexual abuse or exploitation also includes any of the following offenses committed against a child:
  • Rape
  • Incest
  • Prostitution
  • Sexual abuse
  • Sexual assault
  • Indecent assault
  • Indecent exposure
  • Sexual exploitation
  • Statutory sexual assault
  • Institutional sexual assault
  • Aggravated indecent assault
  • Unlawful contact with a minor
  • Involuntary deviate sexual intercourse

Human Trafficking

As it pertains to children, human trafficking is a form of child abuse and a violation of federal and Pennsylvania state laws. It tends to encompass all of the other categories of abuse as listed above. Sex trafficking occurs when a person is induced to perform a commercial sex act through force, fraud, or coercion, or any commercial sex act induced in a person younger than 18 years of age. Human trafficking laws also prohibit the recruitment, harboring, transporting, provision, or obtaining of a person for labor of services, through the use of force, fraud, or coercion for the purpose of subjection to involuntary servitude, peonage (paying off debt through work); debt bondage (debt slavery, bonded labor or services for a debt or other obligation); or slavery.

The federal government has enacted several laws to address the human trafficking problem. These include The Trafficking Victims and Protection Act of 2000, Preventing Sex Trafficking and Strengthening Families Act of 2014, and the Justice for Victims of Trafficking Act of 2015.

Pennsylvania in turn enacted human trafficking legislation (Act 94 of 2015, Act 105 of 2015, and Act 115 of 2016) to amend titles 23 (Domestic Relations), 42 (Judiciary and Judicial Procedure), and 18 (Crimes and Offenses).

A separate PowerPak program addresses human trafficking in detail.

Exclusions to Reporting (Privileged/Confidential Communications)

Exclusions to reporting describe specific situations that do not require a mandated report of suspected child abuse. To address the issue of privileged and confidential communications, the following changes were made to statute § 6311.1, which also describes confidential communications with the clergy.⁸

Privileged Communications:

• The privileged communications between a mandated reporter and a patient or client of the mandated reporter will not:
  • Apply to a situation involving child abuse
  • Relieve the mandated reporter of the duty to make a report of suspected child abuse

Confidential Communications:

• Confidential communications made to a member of the clergy are protected under 42 Pa.C.S. § 5943
• Confidential communications made to an attorney are protected so long as they are within the scope of 42 Pa.C.S. §§ 5916 and 5928, the attorney work product doctrine, or the rules of professional conduct for attorneys.

Exclusions to Child Abuse (Substantiating a Report)

Exclusions to child abuse are cases in which harm to a child must be reported, but the investigation team may determine that no child abuse has occurred. Section 6304 details exclusions to child abuse. It is important to note that these are not exclusions to reporting suspected child abuse. Exclusions are divided into seven areas:

1. Environmental Factors: Children are not 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.

2. 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 will not be deemed to be physically or mentally abused. In such cases the following will apply:

• The county agency will closely monitor the child and the child's family and will 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 will not reference child abuse and will acknowledge the religious basis for the child's condition.
• The family will be referred for GPS, if appropriate.

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

3. Use of Force for Supervision, Control, and Safety Purposes: The use of reasonable force on or against a child by the child's own parent or person responsible for the child's welfare will 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

4. Rights of Parents: Parents may use reasonable force on or against their children for the purposes of supervision, control, and discipline of their children. Such reasonable force does not constitute child abuse.

5. Participation in Events that Involve Physical Contact with a 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 the CPSL.

6. Child-on-child Contact: Harm or injury to a child that results from the act of another child does not constitute child abuse unless the child who caused the harm or injury is a perpetrator

• Notwithstanding paragraph (1), the following will apply:
  • Acts constituting any of the following crimes against a child will be subject to the reporting requirements:
    • Rape
    • Sexual assault
    • Indecent assault
    • Indecent exposure
    • Aggravated indecent assault
    • Involuntary deviate sexual intercourse
  • No child will 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), if the person allegedly responsible for the child abuse is a nonperpetrator child

7. Defensive Force: Reasonable force for self-defense or the defense of another individual, consistent with the provisions of 18 Pa.C.S. §§ 505 and 506, is not considered child abuse.

It is not the reporter’s responsibility to determine if the person who allegedly committed child abuse or harm to a child is a perpetrator. Exclusions are applied when substantiating a report, not when making a report. There are no exclusions to reporting.

Provisions and Responsibilities for Reporting Suspected Child Abuse

A mandated reporter is required to make a report immediately to ChildLine (1-800-932-0313, 24 hours per day, 7 days per week) when he or she has a reasonable cause to suspect that a child is the victim of child abuse or neglect. These calls are accepted by trained professionals. Electronic submissions on the website (www.compass.state.pa.us/cwls) can be made only by mandated reports such as pharmacists; pharmacy technicians, as permissive reporters, can make reports only through the toll-free number.

In Pennsylvania, all professionals who apply for licensure through state boards are considered mandatory reporters. Other examples of mandatory reporters include⁸:

1. A person licensed or certified to practice in any health-related field under the jurisdiction of the Department of State
2. Medical examiners, coroners, and funeral directors
3. Employees of a healthcare facility or provider licensed by the Department of Health, who are engaged in the admission, examination, care or treatment of individuals
4. School employees
5. Employees of a child-care service who have direct contact with children in the course of employment
6. Clergymen and women, priest, rabbi, minister, Christian Science practitioner, religious healer, or spiritual leader of any regularly established church or other religious organization
7. An individual paid or unpaid, who, on the basis of the individual’s role as an integral part of a regularly scheduled program, activity, or service, is responsible for the child’s welfare or has direct contact with children
8. Employees of a social services agency who have direct contact with children in the course of employment
9. Peace officers or law enforcement officials
10. Emergency medical services providers certified by the Department of Health
11. Employees of a public library who have direct contact with children in the course of employment
12. An individual supervised or managed by a person listed under paragraphs (1), (2), (3), (4), (5), (6), (7), (8), (9), (10), (11), and (13), who has direct contact with children in the course of employment
13. Independent contractors
14. Attorneys affiliated with an agency, institution, organization, or other entity, including a school or regularly established religious organization that is responsible for the care, supervision, guidance, or control of children
15. Foster parents
16. An adult family member who is a person responsible for the child’s welfare and provides services to a child in a family living home, community home for individuals with an intellectual disability, or host home for children that is subject to supervision or licensure by the department

A permissive reporter is a person who is encouraged to report suspected child abuse but is not required to do so by law. Pharmacy technicians fall into this category since they are not currently registered or licensed in Pennsylvania. Permissive reporters can make a report at any time they suspect a child is the victim of child abuse and, as with mandated reporters, they do not have to determine whether or not the person meets the definition of perpetrator in order to make the report.

Reasonable Cause to Suspect Versus Conducting an Investigation

Mandated reporters are required to report suspected child abuse if they have reasonable cause to suspect that a child is a victim of child abuse under any of the following circumstances⁸:

• The mandated reporter comes into contact with the child in the course of employment, occupation, and practice of a profession or through a regularly scheduled program, activity, or service.
• The mandated reporter is directly responsible for the care, supervision, guidance, or training of the child, or is affiliated with an agency, institution, organization, school, regularly established church or religious organization, or other entity that is directly responsible for the care, supervision, guidance, or training of the child.
• A person makes a specific disclosure to the mandated reporter that an identifiable child is the victim of child abuse.
• An individual 14 years of age or older makes a specific disclosure to the mandated reporter that the individual has committed child abuse.

Nothing in this section requires a child to “come before” the mandated reporter in order for the mandated reporter to make a report of suspected child abuse. The law does not require the mandated reporter to identify the person responsible for the child abuse to make a report of suspected child abuse.

Mandated reporters should not attempt to conduct an investigation and do not have to determine, and should not attempt to determine, whether or not the person meets the definition of perpetrator in order to make the report. If the reporter believes the child to be in imminent danger, an official who has the legal authority to detain the child and place him or her in protective custody must be contacted.

Streamlining the Reporting Process

If any mandated reporter has reason to suspect that a child is or has been abused, he or she is required to directly report these suspicions immediately; it is no longer acceptable to provide this information to another party to report. ChildLine is mandated by state law to receive, record, and refer reports of suspected child abuse and neglect. The system is available 24 hours per day, 7 days per week, and information is accepted by trained professionals. Electronic reports can be made only by mandated reporters. Reports are referred to County Children and Youth Agencies, law enforcement officials for investigation, or the DHS program offices for review and possible licensing action.^8–11

Oral Report – ChildLine

An oral report of suspected child abuse may be submitted by calling ChildLine at 1-800-932-0313. ChildLine is a statewide toll-free telephone number. Calls are received by trained professionals. Oral reports require a written report within 48 hours to the department or county agency assigned to the case. The approved written form, Report of Suspected Child Abuse (CY47), can be found on www.keepkidssafe.pa.gov under the forms tab.

Written Report – Child Welfare Portal

A written report of suspected child abuse may be submitted electronically on the Child Welfare Portal (www.compass.state.pa.us/cwis). Electronic submissions can be made only by mandated reporters. No other forms are needed after submission.^8–11

After making a report, a person who is required to report in the capacity as a member of the staff of a medical or other public or private institution, school, facility, or agency must immediately notify the person in charge of the institution, school, facility, or agency. ^8–11

Contents of Report

When calling ChildLine or submitting an electronic report (Figure 1), the report should include the following information, if known^8–11:

• The names and addresses of the child, the child's parents, and any other person responsible for the child's welfare
• Where the suspected abuse occurred
• The age and sex of each subject of the report
• The nature and extent of the suspected child abuse, including any evidence of prior abuse to the child or any sibling of the child
• The name and relationship of each individual responsible for causing the suspected abuse and any evidence of prior abuse by each individual
• Family composition
• The source of the report
• The name, telephone number and e-mail address of the person making the report
• The actions taken by the person making the report, including those actions taken under section 6314 (relating to photographs, medical tests, and X-rays of child subject to report), 6315 (relating to taking child into protective custody), 6316 (relating to admission to private and public hospitals), or 6317 (relating to mandatory reporting and postmortem investigation of deaths)
• Any other information required by Federal law or regulation
• Any other information that the department requires by regulation

Figure 1. Mandated reporters can submit reports through a state portal located at www.compass.state.pa.us/cwis

After Report Submission

ChildLine receives the report and determines who is to respond to the report based on the information reported. ChildLine then transmits the report to the appropriate county agency and/or law enforcement official, as outlined below^8–11:

• If a person identified falls under the definition of perpetrator, ChildLine will refer the report to the appropriate county agency for an investigation.
• If the person identified is not a perpetrator and the behavior reported includes an alleged criminal violation, ChildLine will refer the report to law enforcement officials.
• If a person identified falls under the definition of perpetrator and the behavior reported includes a criminal violation, ChildLine will refer the report to the appropriate county agency and law enforcement officials.
• If a report indicates that a child may be in need of other protective services, ChildLine will refer the report to the proper county agency to assess the needs of the child and provide services, when appropriate.

If the report is determined to require CPS, ChildLine forwards the report of suspected child abuse to the local county children and youth agency to investigate and determine if the allegations can be substantiated as child abuse or neglect. CPS will then arrange for or provide services that are needed to prevent further mistreatment of the child and preserve the family unit.^8–11

For CPS reports, the county children and youth agency must begin an investigation within 24 hours. This must be completed within 30 days unless the agency provides justification as to why the investigation cannot be completed, including attempts being made to obtain medical records or interview subjects of the report.^8–11

If a report indicates that a child may be in need of other protective services, ChildLine will refer the report to the proper county agency to assess the needs of the child and provide services. Agencies follow the list of requirements for GPS reports when a report is labeled as GPS. Mandated reporters are not responsible for distinguishing between the two types of reports.^8–11

Protections for Reporters

Pennsylvania law protects reporters of suspected child abuse by assuring immunity from civil or criminal liability when a report is made in “good faith.” The CPSL provides further detail as below⁸:

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

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

Departmental and county agency immunity: An official or employee of the department or county agency who refers a report of suspected child abuse for general protective services to law enforcement authorities or provides services as authorized by this chapter will have immunity from civil and criminal liability that might otherwise result from the action.

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

Penalties for Failure to Report

A person or official required to report a case of suspected child abuse or to make a referral to the appropriate authorities commits an offense if the person or official willfully fails to do so. Legal penalties include fines and/or incarceration, and these penalties increase with repeated violations. An offense under this section is a felony of the third degree if^8,12:

• The person or official willfully fails to report;
• The child abuse constitutes a felony of the first degree or higher; and
• The person or official has direct knowledge of the nature of the abuse

A report of suspected child abuse to law enforcement or the appropriate county agency by a mandated reporter, made in lieu of a report to the department, will not constitute an offense under this subsection, provided that the report was made in a good faith effort to comply with the requirements of this chapter.^8,12

Continuing Course of Action

If a person's willful failure to report continues while the person knows or has reasonable cause to believe the child is actively being subjected to child abuse, the person commits a misdemeanor of the first degree, except that if the child abuse constitutes a felony of the first degree or higher, the person commits a felony of the third degree.

Multiple offenses

A person who commits a second or subsequent offense commits a felony of the third degree, except that if the child abuse constitutes a felony of the first degree or higher, the penalty for the second or subsequent offenses is a felony of the second degree.

Mandated Reporters Right-to-Know⁸

Mandated reporters of suspected child abuse who make a report of abuse have the right to limited information about the disposition of the case. The DHS is required to release the following information to the mandated reporter within three business days of the department's receipt of the results of the investigation:

• The final status of the report - Whether the child abuse report is founded, indicated or unfounded
• Any services provided, arranged for or to be provided by the county agency to protect the child

Recognition of Child Abuse^13,14

What Is Bodily Injury?

Bodily injury is intentional or reckless physical injury inflicted by a parent, caregiver, or other person responsible for the child. Injuries vary in frequency and severity ranging from minor bruising to severe fracture or death as a result of beating, kicking, shaking, hitting, burning, or otherwise harm. Consider the possibility of bodily injury when the child displays one or more of the following:

Physical Indicators

• Has unexplained burns, bites, bruises, broken bones, or black eyes
• Has fading bruises or other marks noticeable after an absence from school
• Bruises located on the face, ears, neck, buttocks, back, chest, thighs, back of legs, or genitalia
• Bruises that resemble objects such as a hand, fist, belt buckle, or rope
• Injuries that are inconsistent with a child's age/developmental level

Behavioral Indicators

• Seems frightened of the parents and protests or cries when it is time to go home
• Appears extremely apprehensive/vigilant
• Displays pronounced aggression or passivity
• Shrinks or flinches at the approach of adults
• Reports injury by a parent or another adult caregiver
• Abuses animals or pets
• Unbelievable or inconsistent explanations of injuries

Consider the possibility of physical abuse when the parent or other adult caregiver displays one or more of the following:

• Offers conflicting, unconvincing, or no explanation for the child’s injury, or provides an explanation that is not consistent with the injury
• Uses harsh physical discipline with the child
• Has a history of abuse as a child
• Has a history of abusing animals or pets

What Is Serious Mental Injury?

Serious mental injury includes behaviors, speech, and actions that negatively impact a child’s mental well-being. Such injury often results in difficulty learning, problematic behaviors, and increased incidences of physical and mental health issues. Consider the possibility of serious mental injury when the child displays one or more of the following:

Physical Indicators

• Frequent psychosomatic complaints (nausea, stomachache, headache, etc.)
• Bed-wetting
• Self-harm
• Speech disorders
• Is delayed in physical development

Behavioral Indicators

• Reports a lack of attachment to the parent
• Has attempted suicide
• Shows extremes in behavior, such as overly compliant or demanding behavior, extreme passivity or aggression
• Expresses feelings of inadequacy
• Eating disorders
• Is either inappropriately adult (parenting other children, for example) or inappropriately infantile (frequently rocking or head-banging, for example)
• Is delayed in emotional development

Consider the possibility of emotional abuse when the parent or other adult caregiver displays one or more of the following:

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

What Is Serious Physical Neglect?

Serious physical neglect occurs when the parent or person responsible for the child’s welfare fails to provide the necessary care as a result of carelessness, indifference, or unwillingness. Consider the possibility of serious physical neglect when the child displays one or more of the following:

Physical Indicators

• Lack of adequate medical and dental care
• Lack of shelter
• Persistent hunger, poor hygiene or inappropriate dress
• Child's weight is significantly lower than what is normal for his/her age and gender
• Distended stomach or emaciated body
• Delayed physical development
• Substance abuse
• Steals food or begs
• Exposure to hazards (e.g., illegal drugs, mold)
• Clothing that is dirty, inappropriate for the weather, too small or too large

Behavioral Indicators

• Habit disorders (e.g., sucking, rocking)
• Regularly displays fatigue or listlessness
• Inadequate or inappropriate supervision
• Poor impulse control
• Frequently fatigued

Consider the possibility of serious physical neglect when the parent or other adult caregiver displays one or more of the following:

• Disinterest in or rejection of child
• Deserting or avoiding child
• Ignoring medical problems of child
• Placing child in dangerous situations
• Failing to meet child's physical/emotional needs

What Is Sexual Abuse or Exploitation?

Sexual abuse or exploitation includes all offenses that involve sexually touching a child as well as non-touching offenses and sexual exploitation. Consider the possibility of sexual abuse or exploitation when the child displays one or more of the following:

Physical Indicators

• Has difficulty walking or sitting
• Reports nightmares or bedwetting
• Experiences a sudden change in appetite
• Becomes pregnant or contracts a venereal disease, particularly if <14 years of age
• Excessive or injurious masturbation

Behavioral Indicators

• Displays sexually promiscuous behavior
• Cruelty to animals or other people
• Suddenly refuses to change for gym or to participate in physical activities
• Demonstrates bizarre, sophisticated, or unusual sexual knowledge or behavior
• Runs away
• Reports sexual abuse by a parent or another adult caregiver
• Attaches very quickly to strangers or new adults in their environment

Consider the possibility of sexual abuse or exploitation when the parent or other adult caregiver displays one or more of the following:

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

Conclusion

Child abuse and neglect have negative effects on the health and well-being of society and the future of affected children. The goal of recognizing and reporting child abuse is to stop and prevent its occurrence. As part of the healthcare team, it is important for pharmacists and pharmacy technicians to recognize potential indicators of child abuse. As mandated reporters, pharmacists and technicians are obligated to report suspected cases in a streamlined reporting process. There are defined protections for reporters as well as penalties for individuals who fail to report. These laws help protect the well-being of Pennsylvania’s children to promote a safer and healthier society.

References

1. Child Protective Services. 2017 Annual Report. Pennsylvania Department of Human Services. Available from http://www.dhs.pa.gov/cs/groups/webcontent/documents/document/c_275378.pdf.
2. Child Welfare Information Gateway. (2013). What is child welfare? A guide for health-care professionals. Washington, DC: U.S. Department of Health and Human Services, Children’s Bureau. Available from https://www.childwelfare.gov/pubs/cw-healthcare/.
3. Child Welfare Information Gateway. (2013). How the child welfare system works. Washington, DC: U.S. Department of Health and Human Services, Children’s Bureau. Available from https://www.childwelfare.gov/pubPDFs/cpswork.pdf#page=1&view=Introduction.
4. Pennsylvania Code. Subchapter A. Child Protective Services. Available from https://www.pacode.com/secure/data/055/chapter3490/subchapatoc.html.
5. Pennsylvania Code. General Protective Services. Available from https://www.pacode.com/secure/data/055/chapter3490/subchapCtoc.html.
6. Pennsylvania General Assembly (PGA). (2014). Title 23, § 6375. County agency requirements for general protective services. Available from http://www.legis.state.pa.us/cfdocs/legis/li/consCheck.cfm?txtType=HTM&ttl=23&div=00.&chpt=063.&sctn=075.&subsctn=000.
7. Pennsylvania Department of Public Welfare. Pennsylvania Child Welfare Information Solution. Frequently asked questions. Available from https://www.compass.state.pa.us/CWIS/Public/FAQ.
8. Title 23. Chapter 63. Pennsylvania General Assembly (PGA). Available from https://www.legis.state.pa.us/CFDOCS/LEGIS/LI/consCheck.cfm?txtType=HTM&ttl=23&div=00.&chpt=063.&CFID=246217912&CFTOKEN=44782272.
9. PA Family Support Alliance: Protecting Children from Abuse. Reporting Abuse – ChildLine. Available from https://www.pa-fsa.org/Mandated-Reporters/Recognizing-Child-Abuse-Neglect/Reporting-Abuse-ChildLine.
10. The Center for Children’s Justice. (2016) Children’s Justice & Advocacy Report. http://www.c4cj.org/files/ChildLineFAQ52016.pdf.
11. Pennsylvania Department of Human Services. (2018). ChildLine and Abuse Registry. Available from http://www.dhs.pa.gov/provider/childwelfareservices/childlineandabuseregistry/.
12. Child Welfare Information Gateway. (2015). Penalties for Failure to Report and False Reporting of Child Abuse and Neglect. Washington, DC: U.S. Department of Health and Human Services, Children’s Bureau. Available from https://www.childwelfare.gov/pubPDFs/report.pdf.
13. Pennsylvania Department of Human Services. (2018.) Signs of Abuse/Neglect. Available from http://keepkidssafe.pa.gov/about/signs/index.htm.
14. Child Welfare Information Gateway. (2013). What is child abuse and neglect? Recognizing the signs and symptoms. Washington, DC: U.S. Department of Health and Human Services, Children’s Bureau. Available from https://www.childwelfare.gov/pubPDFs/whatiscan.pdf.

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