Child Abuse: Pennsylvania Mandated Reporter Training, 2 hours - License Renewal

Labor Trafficking: Labor obtained by the use of threat of serious harm, physical restraint, or abuse of legal process (DHS, 2024b).

Examples: Being forced to work for little or no pay (frequently in factories or farms); domestic servitude (providing services within a household from 10-16 hours per day such as but not limited to: childcare, cooking, cleaning, yard work, gardening) (DHS, 2024b).

The following youth populations are those who are most at risk for being victims of human trafficking (DHS, 2024b):

• Youth in the foster care system
• Youth who identify as LGBTQIA+
• Youth who are homeless or a 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

Victim identification or warning signs for youth who might be involved in the commercial sex act industry include the following, but are not limited to (DHS, 2024b):

• A youth that has been verified to be under 18 and is in any way involved in the commercial sex industry, or has a record of prior arrest for prostitution or related charges
• Has an explicitly sexual online profile
• Excessively frequents internet chat rooms and classified sites
• Is found in a hotel, street track, truck stop, or strip club
• Lies about or has no identification or knowledge of personal data, such as but not limited to age, name, and/or date of birth
• Does not have insurance or control over their finances
• Wears new clothes, gets hair and nails done without financial means
• Has multiple cells phones or very expensive items that they have no way of purchasing on their own
• Has unaddressed medical issues
• Goes to the clinic or ER with an unrelated adult
• Avoids answering questions and lets someone else speak for them
• Has a tattoo that they are reluctant to explain
• Uses terms like “trick”, “the life”, or “the game”
• Has multiple bruises or cuts in various stage of healing
• Depicts elements of sexual exploitation in drawing poetry, or other modes of creative expression
• Frequent or multiple sexually transmitted diseases or pregnancies
• Wearing sexually provocative clothing
• Wears clothing that is dirty and inappropriate for the weather; it may be too large or too small
• Secrecy about whereabouts
• Having late nights or unusual hours
• Being in a controlling or dominating relationship
• Exhibit hyper-vigilance or paranoid behaviors
• Expresses interest in or is in relationships with adults or much older men/women
• Has significant change in behavior, including increased social media and new associates or friends at school
• Has unexplained injuries and/or unbelievable or inconsistent explanations of injuries

Mandated Reporters are persons required to report suspected child abuse.

The following adults shall make a report of suspected child abuse, subject to subsection (b) (relating to basis to report), if the person has reasonable cause to suspect that a child is a victim of child abuse (23 Pa.C.S. § 6311) (PA General Assembly, n.d.):

• A person licensed or certified to practice in any health-related field under the jurisdiction of the Department of State
• A medical examiner, coroner, or funeral director
• An employee of a health care facility or provider licensed by the Department of Health who is engaged in the admission, examination, care, or treatment of individuals
• A school employee
• An employee of a childcare service who has direct contact with children in the course of employment
• A clergyman, priest, rabbi, minister, Christian Science practitioner, religious healer or spiritual leader of any regularly established church or other religious organization
• 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 a person responsible for the child’s welfare or has direct contact with children
• An employee of a social services agency who has direct contact with children in the course of employment
• A peace officer or law enforcement official
• An emergency medical services provider certified by the Department of Health
• An employee of a public library who has direct contact with children in the course of employment
• An individual supervised or managed by a person listed above, who has direct contact with children in the course of employment
• An independent contractor who has direct contact with children
• An attorney if he/she is 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
• A foster parent
• 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 which are subject to supervision or licensure by DHS under Articles IX and X of the act of June 13, 1967 (P.L.31, No.21) known as the Human Services Code (formerly the Public Welfare Code)

Health Care Provider Reporting:

Health Care Provider is a licensed hospital or health facility or person who is licensed, certified or otherwise regulated to provide health services under the laws of Pennsylvania, including a physician, podiatrist, optometrist, psychologist, physical therapist, certified nurse practitioner, registered nurse, nurse midwife, physician's assistant, chiropractor, dentist, pharmacist, or an individual accredited or certified to provide behavioral health services (Pennsylvania Code, 2024a).

A health care provider must immediately notify DHS if they are involved in the delivery or care of a child under one year of age and they have determined, based on standards of professional practice, that the child was born affected by:

• Substance use;
• Withdrawal symptoms resulting from prenatal drug exposure; or
• Fetal Alcohol Spectrum Disorder

This notification to DHS can be made to ChildLine electronically through the Child Welfare Portal or by calling 1-800-932-0313. This notification is for the purpose of assessing a child and the child’s family for a Plan of Safe Care and shall not constitute a child abuse report.

After this notification of a child born affected by substance use or withdrawal symptoms resulting from prenatal drug exposure or a Fetal Alcohol Spectrum Disorder is given (DHS, 2024b):

• A multidisciplinary team meeting must be held prior to the child's discharge from the health care facility.
• The meeting will inform an assessment of the needs of the child and the child’s parents and immediate caregivers to determine the most appropriate lead agency for developing, implementing, and monitoring a Plan of Safe Care.
• The child's parents and immediate caregivers must be engaged to identify the need for access to treatment for any substance use disorder or other physical or behavioral health condition that may impact the safety, early childhood development, and well-being of the child.
• Depending upon the needs of the child and parent(s)/caregiver(s), ongoing involvement of the county agency may not be required.

For the purpose of informing the Plan of Safe Care, the “multidisciplinary team” may include public health agencies, maternal and child health agencies, home visitation programs, substance use disorder prevention and treatment providers, mental health providers, public and private children and youth agencies, early intervention and developmental services, courts, local education agencies, managed care organizations and private insurers, and hospitals and medical providers (DHS, 2024b).

Privileged/Confidential Communications (PA General Assembly, n.d.; DHS, 2024b): Many Mandated Reporters feel there is a conflict between their legal obligation to report and their legal obligation to maintain client or patient confidentiality. Subject to 23 PA.C.S. section 6311.1 subsection (b) (relating to confidential communications) below, the privileged communications does not apply to a situation involving child abuse. Additionally, privileged communication between a Mandated Reporter and a client does not relieve the Mandated Reporter of the duty to make a report of suspected child abuse.

Exceptions are (PA General Assembly, n.d.):

• 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 (relating to confidential communications to attorney) and 5928 (relating to confidential communications to attorney), the attorney work product doctrine or the rules of professional conduct for attorneys.

If a child is in immediate danger, call 911.

The Mandated Reporter is required to report even if their knowledge is incomplete. The role of the Mandated Reporter is to assess for reasonable cause to suspect abuse. The Mandated Reporter identifies reasonable cause and leaves the investigation to specially trained workers in the designated child welfare agency (PA General Assembly, n.d.).

The Mandated Reporter does not (PA General Assembly, n.d.):

• Investigate
• Interrogate
• Determine the perpetrator and their relationship to the child

When talking with children to establish reasonable cause, find a private place, and remain calm. Be honest, open, and upfront with the child. Be supportive. Listen to the child and stress that it's not the child's fault. Do not overreact, make judgments, make promises, nor interrogate or investigate.

There is no legal requirement to inform the parent or other persons legally responsible for the child’s care that you are making a report to ChildLine (PA General Assembly, n.d.). In fact, informing the parents of the report may place the child at risk of harm. Do not assume that the parent will support the child.

In the case of suspected sexual abuse, avoid talking in detail with the child about the incident. There are special guidelines that apply to the case of suspected sexual abuse. Usually, the designated child welfare agency and law enforcement work together to interview the child at the same time using specially trained professionals (PA General Assembly, n.d.).

Reasonable cause to suspect may be a determination you make based on your training/experience and all known circumstances – to include “who”, “what”, “when”, and “how”, observations (e.g., indicators of abuse or "red flags", behavior/demeanor of the child(ren), behavior/demeanor of the adult(s), etc.), as well as familiarity with the individuals (e.g., family situation and relevant history or similar prior incidents, etc.) Some indicators may be more apparent than others depending on the type of abuse and/or depending on the child's health, developmental level, and well-being. For example, some indicators may be visible on the child's body while other indicators may be present in the child's behaviors (DHS, 2024b). If there is reasonable cause to suspect the child is being abused or maltreated, you must call ChildLine immediately (DHS, 2024b).

The individuals listed above are the Mandated Reporters for the state of Pennsylvania (DHS, 2024b). A Mandated Reporter shall immediately make an oral/verbal report of suspected child abuse to DHS via the Statewide toll-free telephone number under section 6332 (relating to establishment of Statewide toll-free telephone number) (1-800-932-0313) or a written report using electronic technologies under section 6305 (relating to electronic reporting) (via the self-service line here.

Mandated Reporters are required to make a report of suspected child abuse in accordance with section 6313 (relating to reporting procedure) if the Mandated Reporter has reasonable cause to suspect that a child is a victim of child abuse under any of the following circumstances (DHS, 2024b; PA General Assembly, n.d.):

• They come 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.
• They are directly responsible for the care, supervision, guidance, or training of the child, or are 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 section 6311 of the PA CPSL (relating to persons required to report suspected child abuse) shall require a child to come before the Mandated Reporter in order to make a report of suspected child abuse (DHS, 2024b).

Nothing in section 6311 of the PA CPSL (relating to persons required to report suspected child abuse) shall require the Mandated Reporter to identify the person responsible for the child abuse in order to make a report of suspected child abuse.

• Crimes committed against the child should be reported directly to law enforcement. If you are uncertain if the incidence is criminal, you can contact the designated child welfare agency anyway. If the child is in imminent danger, contact law enforcement immediately.

Whenever a person is required to report under subsection (b) (relating to basis to report) in the capacity as a member of the staff of a medical or other public or private institution, school, facility, or agency, that person shall report immediately in accordance with section 6313 (relating to reporting procedure) and shall immediately thereafter notify the person in charge of the institution, school, facility, or agency or the designated agent of the person in charge. Upon notification, the person in charge or the designated agent, if any, shall facilitate the cooperation of the institution, school, facility, or agency with the investigation of the report. Any intimidation, retaliation, or obstruction in the investigation of the report is subject to the provisions of 18 Pa.C.S. § 4958 (relating to intimidation, retaliation, or obstruction in child abuse cases).

The PA CPSL does not require more than one report from any such institution, school, facility, or agency, but the report should include the names and contact information of everyone who has knowledge of the situation (DHS, 2024b).

Reports of child abuse may be reported to ChildLine electronically if the situation does not require an emergency response. Mandated Reporters can report electronically here.

Establishment of Statewide toll-free telephone number (23 Pa.C.S. § 6332): The Statewide toll-free telephone number is available for all persons, whether mandated by law or not, to use to report cases of suspected child abuse or children allegedly in need of general protective services. You should call the Child Abuse Hotline, ChildLine at 1-800-932-0313 in the following situations:

• You do not know the county where the incident occurred
• The suspected abuse and/or neglect you are reporting occurred outside the state of Pennsylvania
• You are unsure if the child is at imminent risk of harm
• You have more than eight alleged perpetrators and/or the child has a list of extensive injuries
• You are unable to provide a Pennsylvania address for any person on the report

This toll-free hotline number is available 24 hours a day, seven days a week.

A Mandated Reporter making an oral/verbal report of suspected child abuse to the DHS via the Statewide toll-free telephone number under section 6332 (relating to establishment of Statewide toll-free telephone number) shall also make a written report (CY-47), which may be submitted electronically, within 48 hours to DHS or county agency assigned to the case in a manner and format prescribed by DHS.

This form can be obtained here at the top of the page. A direct download link is available here.

You can also obtain a copy from the county Children and Youth Services Agency.

The failure of the Mandated Reporter to file the written report (CY-47) shall not relieve the county agency from any duty under the PA CPSL, and the county agency shall proceed as though the Mandated Reporter complied.

If a report is made electronically, no form CY-47 is required to be completed.

Be prepared to articulate your concerns in a clear and concise manner when you call ChildLine. The following is a list of information that the Mandated Reporter is asked to provide in the written report if it is known (DHS, 2024b):

• 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:
  • Relating to photographs, medical tests, and X-rays of child subject to report (taken under section 6314)
  • Relating to taking child into protective care (section 6315)
  • Relating to admission to private and public hospitals (section 6316)
  • Relating to mandated reporting and postmortem investigation of deaths (section 6317)
• Any other information required by Federal law or regulation
• Any other information that the Department of Human Services requires by regulation

It is important to note here that the specific type of abuse is not required to be identified when making a report of suspected child abuse (DHS, 2024b). Permissible under Pennsylvania law, an individual who suspects possible child abuse may request photograph, a radiologic examination, and/or other medical testing of the child, depending on what is clinically indicated (Pennsylvania Code, 2024b). In the event that any of this takes place, it should accompany the report. All of the aforementioned images or medical summaries should be submitted with the written report or sent within 48 hours after the report is made electronically (Pennsylvania Code, 2024b).

Regarding confidentiality of reports (23 Pa.C.S. § 6339), except as otherwise provided in subchapter C of the PA CPSL (relating to powers and duties of department) or by the Pennsylvania Rules of Juvenile Court Procedure, reports made pursuant to the PA CPSL, including, but not limited to, report summaries of child abuse and reports made pursuant to section 6313 (relating to reporting procedure) as well as any other information obtained, reports written, or photographs or X-rays taken concerning alleged instances of child abuse in the possession of DHS or a county agency shall be confidential (DHS, 2024b).

The law requires that Mandated Reporters identify themselves and where they can be reached (DHS, 2024b). This information is helpful if the caseworker needs additional information. However, the identity of the person making the report is kept confidential, apart from being released to law enforcement officials or the district attorney's office (DHS, 2024b).

Release of Information in Confidential Reports (23 Pa.C.S. § 6340): Except for reports under section 6340(a)(9) and (10) of the PA CPSL and in response to a law enforcement official investigating allegations of false reports under 18 Pa.C.S. § 4906.1 (relating to false reports of child abuse), the release of data by DHS, county, institution, school, facility, or agency or designated agent of the person in charge that would identify the person who made a report of suspected child abuse or who cooperated in a subsequent investigation is prohibited. Law enforcement officials shall treat all reporting sources as confidential informants.

A Mandated Reporter who makes a report of suspected child abuse or who makes a report of a crime against a child to law enforcement officials shall not be in violation of the act of July 9, 1976 (P.L.817, No.143), known as the Mental Health Procedures Act, by releasing information necessary to complete the report (DHS, 2024b).

Mandated Reporting and Postmortem Investigation of Deaths (PA General Assembly, n.d.; DHS, 2024c): A person or official required to report cases of suspected child abuse, including employees of a county agency, who has reasonable cause to suspect that a child died as a result of child abuse shall report that suspicion to the appropriate coroner or medical examiner. The coroner or medical examiner shall accept the report for investigation and shall report his findings to the police, the district attorney, the appropriate county agency, and, if the report is made by a hospital, the hospital (DHS, 2024c).

If your agency or organization is an institution, facility, or agency which cares for children and is subject to supervision by PA DHS under Article IX of the Human Services (formerly Public Welfare) Code, make sure to look into your employer’s internal policies related to reporting suspected child abuse.

When a county agency or law enforcement receives a report or referral, they first ensure the safety of the child and any other children in the same home (DHS, 2024b). Next, they must notify DHS (DHS, 2024b).

According to 23 Pa.C.S. § 6334 (Disposition of Complaint Received) and 23 Pa.C.S. § 6334.1 (Responsibility for Investigation), when DHS/ChildLine receives a referral/report, DHS/ChildLine will immediately evaluate and transmit the information to the appropriate agency for assessment or investigation.

Referral to county agency (CPS) – If the suspected child abuse is alleged to have been committed by a perpetrator, DHS/ChildLine will transmit the information to the county agency where the suspected child abuse is alleged to have occurred for investigation of the allegation(s).

Referral to county agency and law enforcement officials (LEO) – If the suspected child abuse is alleged to have been committed by a perpetrator and the behavior constituting the suspected child abuse may include a violation of a criminal offense, DHS/ChildLine will transmit the information to the appropriate law enforcement official in the county where the suspected child abuse is alleged to have occurred for a joint investigation of the allegation(s).

Referral to law enforcement officials only (LEO) – If the person suspected of committing child abuse is not a perpetrator but the behavior constituting the suspected child abuse may include a violation of a criminal offense, DHS/ChildLine will transmit the information to the appropriate law enforcement official in the county where the suspected child abuse is alleged to have occurred for investigation of the allegation(s).

Referral to county agency (GPS) – If the referral/report does not suggest the child is in need of protective services but suggests the child is in need of other services, DHS/ChildLine will transmit the information to the appropriate county agency for assessment of the needs of the child. (DHS, 2024b).

The local county Children and Youth Services Agency also arranges for or provides the services that are needed to prevent the further maltreatment of the child and to preserve the family unit (DHS, 2024c). Services that are available include (DHS, 2024c):

• Counseling
• Classes to strengthen parenting skills
• Self-help groups
• Emergency medical services

The county Children and Youth Services Agency must begin an investigation of child abuse within 24 hours (DHS, 2024b). A thorough inquiry is conducted to determine if the child was abused and what services are appropriate for the child and family. 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 (DHS, 2024b; DHS, 2024c).

Confirmation of Reports (Electronic reporting: 23 Pa.C.S. § 6305; Investigation of reports 23 Pa.C.S. § 6368): A confirmation by DHS of the receipt of a report of suspected child abuse submitted electronically shall relieve the person making the report of making an additional oral/verbal or written report of suspected child abuse, subject to section 6313 (relating to reporting procedure).

If a report was made by a Mandated Reporter, DHS is required to notify that Mandated Reporter who made the report of suspected child abuse of whether the child abuse report was determined to be founded, indicated or unfounded as well as what services, if any, are being provided arranged for, or to be provided by the county agency to protect the child (DHS, 2024b). This notification by DHS must be made within three business days of DHS’s receipt of the results of the investigation (DHS, 2024b).

Mandated Reporters are immune from any criminal or civil liability if the report was made in good faith (DHS, 2024b). “Good faith” for the Mandated Reporter is presumed. This means if someone accuses you of making a false report that they have to prove you acted with gross negligence or willful misconduct (Law.com, 2024).

Immunity from Liability (23 Pa.C.S. § 6318):

• General rule – A person, hospital, institution, school, facility, agency, or agency employee acting in good faith shall 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 the PA CPSL.
  • Cooperating or consulting with an investigation under the PA CPSL, 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 23 Pa.C.S. § 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 DHS 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 the PA CPSL shall have immunity from civil and criminal liability that might otherwise result from the action.

Protection from Employment Discrimination (23 Pa.C.S. § 6320):

• Basis for relief – A person may commence an action for appropriate relief if all of the following apply:
  • The person is required to report suspected child abuse under section 6311 (relating to persons required to report suspected child abuse) or encouraged to report suspected child abuse under section 6312 (relating to persons encouraged to report suspected child abuse).
  • The person acted in good faith in making or causing the report of suspected child abuse to be made.
  • As a result of making the report of suspected child abuse, the person is discharged from employment or is discriminated against with respect to compensation, hire, tenure, terms, conditions, or privileges of employment.
• Applicability – This section does not apply to an individual making a report of suspected child abuse who is found to be a perpetrator because of the report or to any individual who fails to make a report of suspected child abuse as required under section 6311 (relating to persons required to report suspected child abuse) and is subject to conviction under section 6319 (relating to penalties) for failure to report or to refer.

We will now discuss some penalties as per 23 Pa.C.S. § 6319 (DHS, 2024b):

Failure to report or refer:

• A person or official required by the PA CPSL 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.
• An offense under this section is a felony of the third degree if:
  • 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.
• An offense not otherwise specified in the bullet point immediately above is a misdemeanor of the second degree.
• 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 DHS, shall not constitute an offense under this subsection, provided that the report was made in a good faith effort to comply with the requirements of the PA CPSL.

Continuing course of action: If a person’s willful failure to report an individual suspected of child abuse continues while the person knows or has reasonable cause to suspect a child is being subjected to child abuse by the same individual, or while the person knows or has reasonable cause to suspect that the same individual continues to have direct contact with children through the individual’s employment, program, activity, or service, the person commits a felony of the third degree…except that, if the child abuse constitutes a felony of the first degree or higher, the person commits a felony of the second degree (DHS, 2024b).

Multiple offenses: A person who, at the time of sentencing for an offense under this section, has been convicted of a prior offense under this section 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.

The statute of limitations for an offense such as these defaults to either the statute of limitations specifically for the crime committed against the minor child or five years, whichever is greater (DHS, 2024b).

Mandated Reporters will receive information from the Department regarding the final status of the report, whether it was unfounded, indicated or founded, and the services planned or provided to protect the child (DHS, 2024b; DHS, 2024c).

ACEs have been shown to impact a person’s functioning, physical and mental health, and overall well-being throughout their lives (CDC, 2024d). These effects can then be seen well into adulthood. In fact, the very first ACE study was conducted by the CDC and Kaiser Permanente from 1995 to 1997 (National Conference of State Legislatures [NCSL], 2022). Of the more than 17,000 adults surveyed about childhood experiences (including emotional, physical, and sexual abuse, neglect, and household dysfunctions of separation from a parent, substance use disorder, incarceration, violence, and/or mental illness), approximately two-thirds of respondents indicated a history of at least one ACE and more than 20% noted three or more (NCSL, 2022).

Other factors can intensify the effects of ACEs. These factors can include (NYS, 2022):

• Racism
• Poverty
• Generational trauma
• Repetitious unintended or indirect discrimination

As mentioned above, exposure to ACEs has been correlated with increased risk for certain behavioral issues and health conditions. Additional research has determined that ACE exposure increases a child's risk of obesity, autoimmune diseases, depression, and substance use disorders (NCSL, 2022; Webster, 2022).

A direct correlation has been noted:

The more ACEs one is exposed to, the greater the risk for negative effects.

But why is this? The underlying mechanism here is associated with the "toxic stress" that ACEs are said to exert their effects on health as well as growth and development (NCSL, 2022). Although some stress is normal and even essential to proper growth and learning, sustained chronic, toxic stress is damaging to both the body and to the brain (NCSL, 2022). Toxic stress follows when a person experiences severe, prolonged adversity without sufficient support. Toxic stress means that the stress response stays continuously activated in the body (NYS, 2022). This toxic stress can literally build up in the body, interfere with proper neural, hormonal, and immune development and ultimately alter DNA expression (NCSL, 2022). This change in DNA expression can result in lifelong effects on behavior, attention, decision-making abilities, and one's response to stress (NCSL, 2022). Toxic stress impacts children developmentally and behaviorally (NYS, 2022).

ACEs can have a lasting impact on children, as we have seen, but also on caregivers and Mandated Reporters.

Because ACEs can have lifelong negative effects on the health and overall well-being of a child or adolescent, it is important that we do what we can to mitigate them once they have occurred or prevent them outright (CDC, 2024b).

The following strategies for mitigation and prevention have been presented by the National Conference of State Legislatures (2018) report after reviewing an extensive number of publications in the research done following the original ACE study (Bellazaire, 2018):

• Achieving strong physical health: Obtaining adequate sleep, eating well, and participating in regular exercise.
• Building resilience: Increasing positive parenting skills and creating safe, stable relationships in the home.
• Incorporation of home visits: State-employed nurses, social workers, and teachers trained to visit family homes during pregnancy and early childhood to teach and provide support services.
• Offering early childcare services: Expanding access to early childhood programs to bolster learning, social and emotional development, and the building of self-confidence.
• Supporting the reduction of parental stress: Consider providing economic support, family-friendly workplaces, paid family and/or sick leave, and affordable housing.
• Increasing mental health screening and treatment: Expand access to and coverage for comprehensive health and mental health services.

The CDC outlines these additional strategies for preventing ACEs altogether (CDC, 2024d):

• Promoting social norms: Advertising public education campaigns, legislative approaches, and bystander approaches to teach and inform in a manner that helps to protect against violence and adversity.
• Teaching vital skills: Prioritizing social-emotional learning, safe dating, healthy relationship building, family relationships, mentoring programs, and after-school programs.
• Intervening early and often: Engaging children in primary care, family therapy when needed, individual therapy when needed, and family-centered treatment for households with someone suffering from a substance use disorder. 

It is important to continue to raise awareness of ACEs to help either prevent them or work to prevent the long-term sequelae that result without adequate intervention (CDC, 2024d; Webster, 2022). The focus needs to be taken off the individual and, more so, shifted onto the community to help lessen the risk of ACEs and their effects. The more children and adolescents are able to reach their full potential, the more the communities these future adults will live in will benefit (CDC, 2024d).

The CDC’s Office of Readiness and Response (ORR) in collaboration with SAMHSA’s National Center for Trauma-Informed Care (NCTIC) developed trauma-informed practice training that included six main principles (CDC, 2022). These principles include (CDC, 2022):

1. Safety
2. Peer support
3. Trustworthiness & transparency
4. Collaboration & mutuality
5. Cultural, historical, & gender issues
6. Empowerment & choice

Based on these principles, to be trauma-informed means asking the patient permission before completing an examination, allowing them to remain clothed per their comfort level, assessing them in a place that is comfortable to them, and informing them of the steps in what you are doing so they can know what to expect each step of the way (Tracy & Macias-Konstantopoulos, 2023). The patient should also be asked what their expectations are for your time with them and how you can help them feel as comfortable as possible throughout the proceedings, which often could mean even leaving the door open slightly ajar (Tracy & Macias-Konstantopoulos, 2023). It is also helpful for these patients to identify a "safe word" or a "signal" that patients can utilize if they begin to feel unsafe or distressed during the visit (Tracy & Macias-Konstantopoulos, 2023).

Engaging in TIC is not accomplished by using a singular checklist (CDC, 2022). Instead, it requires continual attention, compassionate awareness, sensitivity, and oftentimes some level of cultural change within the organization in general (CDC, 2022).

Employing TIC for these patients is extremely important. It helps the patient trust the healthcare personnel and best opens the lines for communication (Tracy & Macias-Konstantopoulos, 2021; Gaillard-Kenney et al., 2020).

A bias is a personal and sometimes unreasonable judgment against a person, place, or thing (U.S. Department of Justice, 2021). We all have our own biases. We are human beings. Our life experiences are what help inform our future experiences. There are two main types of bias that we will discuss here.

Implicit bias is a bias or prejudice that is present but not consciously held or recognized so we are often unaware that they exist (U.S. Department of Justice, 2021).

Explicit bias is a personal judgment that we have about a person, place, or thing on a conscious level, or one that we are aware of (U.S. Department of Justice, 2021).

Whether these biases are implicit or explicit, they are capable of affecting our actions, beliefs, and decisions. These biases, including how a person sounds, looks, and even where they live, may influence our decision-making process (NYS, 2022; U.S. Department of Justice, 2021).

Both of these types of bias can emerge as prejudice, discrimination, and/or oppression on individual, group, or systemic levels (NYS, 2022; U.S. Department of Justice, 2021). Individual biases are often so deeply ingrained and are born out of a long history of unequal treatment of different social groups, the person’s upbringing, cultural conditioning, discrimination, oppression, and stereotypical portrayals (NYS, 2022; U.S. Department of Justice, 2021). The influence of decisions made that are rooted in biases often have a substantial impact on individuals, social groups, and communities (NYS, 2022; U.S. Department of Justice, 2021).

A benefit of being aware of the potential impression of your own biases is that you can choose to take the initiative in lowering their impact on your decision-making (NYS, 2022; U.S. Department of Justice, 2021).

National research demonstrates that disparities have existed historically throughout the child welfare system (Ellis, 2019). These disparities are still very much alive today (Ellis, 2019; National Center for Youth Law [NCYL], n.d.).

Data illustrates a historical overrepresentation of children and families of color in the child welfare system (Ellis, 2019; NCYL, n.d.). Children of color have been more likely to be placed in foster care than nonminority children (NYS, 2022; Ellis, 2019; NCYL, n.d.). In fact, in one study, African American children were over 2 times more likely to be placed in foster care when compared to white children (Ellis, 2019).

Research has also shown that income status of families and overall socioeconomic status is a significant predictor of involvement with the child welfare system (Ellis, 2019; NYS, 2022). Poverty, in and of itself, does not and should not equate to child abuse or maltreatment (Ellis, 2019; NYS, 2022). This disparity can have devastating and long-lasting effects on both families and communities (NYS, 2022).

Now, let’s review the physical indicators of child maltreatment and abuse.

What does child maltreatment and abuse physically look like?

Physical indicators of abuse can include (Mayo Clinic, 2022; Moore, 2023):

• Unexplained bruises:
  • Bruising of the torso, buttocks, and thighs
  • Bruising in various stages of healing
  • Clustered bruises forming regular patterns that might reflect the shape of the article used to inflict the injury
  • Bruising on several different parts of the body
  • Bruises regularly appear after absence, weekend, or vacation
  • Suspicious bruising that does not match the story that was told as to how it was obtained
• Unexplained fractures:
  • To the nose, skull, or facial structure
  • In various stages of healing
  • Multiple or spiral fractures
• Unexplained burns:
  • Cigar, cigarette burns, especially on the soles of the feet, palms, back, and buttocks
  • Immersion burns that are often appearing sock-like, glove-like, or even doughnut-shaped on the buttocks or genitalia
  • Pattern-like burn in the shape of an electric burner or an iron
  • Rope burns on the arms, legs, neck, or torso
• Unexplained welts
• Unexplained lacerations:
  • To the mouth, lips, gums, or eyes
  • To external genitalia
  • On the back of the arms, legs, or torso
  • Human bite marks
• Unattended physical problems, medical, or dental needs
• Pain or itching in the genital area
• Difficulty in walking or sitting
• Pregnancy, especially in early adolescent years
• Sexually transmitted disease (especially in pre-adolescent children)
• Delays in physical development or growth
• Frequent injuries that are accidental or unexplained

Image #2:
Handprint Injury on Child’s Face

(AbuseWatch.net, n.d.)

Image #3:
Bruising of Torso, Buttocks, and Thighs

(AbuseWatch.net, n.d.)

Image #4:
Spiral Fracture of the Humerus

(AbuseWatch.net, n.d.)

Image #5:
Cigarette Burn to Finger

(AbuseWatch.net, n.d.)

Image #6:
Glove-Like Burn of the Hands

(AbuseWatch.net, n.d.)

Image #7:
Sock-Like Burn of the Feet

(AbuseWatch.net, n.d.)

Image #8:
Steam Iron Burn to the Arm

(AbuseWatch.net, n.d.)

Image #9:
Looped Cord Injury

(AbuseWatch.net, n.d.)

As mentioned above, injury or bruising that is most suspicious for child abuse is that in which (Mayo Clinic, 2022; Moore, 2023):

• The place/body part of the injury may be abnormal
• The injury does not match with the child’s current developmental level
• The explanation given regarding the injury does not add up
• The laceration or bruise is shaped like a specific object (like a handprint, looped cord, or belt)

Let’s take a look at sites of bruising that would be considered normal for children and those that are more suspicious for possible child abuse.

Image #10:
Normal vs. Suspicious Bruising

(AbuseWatch.net, n.d.)

In addition to the location of the bruise, the size and the shape of the injury needs to be considered.

Children are susceptible to injuries in relation to their developmental stage. If a plausible explanation is offered, consider the age of the child and the location of a suspicious injury when developing your thoughts about “reasonable cause to suspect.”

Accidental injuries usually involve injury to the boney prominences of the body, i.e., shins, elbows, knees. For example:

• Toddlers fall while learning to walk.
• Young children “skin” elbows and knees when learning to ride a bicycle or playing on playground equipment.

Suspicious injuries usually occur in areas not susceptible to accidental, age-appropriate areas, as you have seen in the image above.

Consider the size and shape of the injury, as well as the location of the injury. Consider the relationship of the mechanism of injury (explanation of how the injury occurred) to the child’s developmental stage. For example, as we have talked about, toddlers fall when they learn to walk, and young children scrape their knees when learning to ride a bicycle.

Let’s think about a specific case example:

Think about if the story that was given as an explanation for an injury would produce the physical indicators that are present. For instance, a toddler falls to the floor while walking, not striking anything when he falls. That toddler has bruises on the back of his legs. One would expect that from a fall while walking, the toddler would have bruises and scrapes on his hands, knees, and shins and not bruises on the back of his legs. This would elicit some suspicion from you.

See the image below for additional information regarding physical indicators of abuse.

Image #11:
Physical Indicators of Abuse

(AbuseWatch.net, n.d.)

As mentioned above, take a look at any bruises, welts, or burns carefully. Is it possible the injury is making a specific shape? Just like the image of the iron burn above, many tools can create visible markings that would specify what was used on the child. 

The following image gives you some additional ideas of what to look out for.

Image #12:
Clues to the Mechanism of Injury

(AbuseWatch.net, n.d.)

The following image depicts a child who has been neglected. He is severely underweight and had been diagnosed with failure to thrive. The signs of his malnutrition is evident, even in this picture.

Image #13:
Neglect: Failure to Thrive

(AbuseWatch.net, n.d.)

Now, let’s review the child’s behavioral indicators of child abuse.

The behavioral signs that might be questionable for possible child abuse include (Mayo Clinic, 2022; Moore, 2023):

• Avoiding physical contact or touch
• Being afraid and trying to avoid going home
• Acting on edge, on high alert always
• Withdrawing from friends
• Withdrawing from extracurricular activities
• Wearing clothing that does not match the current weather (long sleeves to cover wounds)
• Using drugs or alcohol
• Stealing or asking for food
• Self-destructive behaviors
• Loss of self-confidence
• Delayed emotional development
• Depression
• Declining school performance

Caregiver behavioral indicators of physical abuse may include when they (Mayo Clinic, 2022; Moore, 2023):

• Seem unconcerned about the child
• Take an unusual amount of time to obtain medical care for the child
• Offer inadequate or inappropriate explanations for the injury
• Give different explanations for the same injury (the story changes)
• Misuse drugs or alcohol
• Discipline the child too harshly considering the child’s age or what the child has done wrong
• Describe the child as bad or evil
• Have a history of abuse as a child
• Attempt to conceal the child’s injury
• Take a child to a different hospital or doctor for each injury (so as not to be identified)
• Have poor impulse control
• Expect the child to provide them attention and care
• Limit the child’s contact with others

Serious mental injury occurs when a child is subjected to repeated negative treatment made to make them feel unloved or worthless (Kids Helpline, 2023; Morin, 2022). Serious mental injury can also be described as verbal abuse or psychological abuse (Kids Helpline, 2023; Morin, 2022).

Serious mental injury can be remarkably detrimental to a child’s self-confidence and wellbeing (Kids Helpline, 2023; Morin, 2022). This can include yelling, screaming, criticism, exposure to family violence, humiliation, withholding love and support, socially isolating, threatening harm, the incitation of fear, bullying, teasing, rejection, or hostility (Kids Helpline, 2023; Morin, 2022).

The physical indicators of serious mental injury that can be seen in children can include (Kids Helpline, 2023; Morin, 2022):

• Fighting in school
• Rocking
• Sucking fingers
• Neurotic disorders such as speech disorders
• Trouble sleeping
• Psychoneurotic reactions such as phobias, hysterical reactions, compulsions, or hypochondria
• Delays in physical development

The behavioral indicators of serious mental injury in children may be (Kids Helpline, 2023; Morin, 2022):

• Antisocial behaviors
• Demanding or destructive behaviors
• Overly adaptive behavior (such as inappropriately adult-like or infantile)
• Developmental delays
• Extremes of behavior (compliance, passiveness, aggressiveness)
• Self-injurious behavior
• Suicide attempt
• Seeking attention from other adults
• Loss of interest in their activities
• Drug or alcohol use
• Decline in schoolwork

The behavioral indicators of serious mental injury that can be seen in caregivers can include (Kids Helpline, 2023; Morin, 2022):

• Treats children in the family unequally
• Does not seem to care much about the child’s problem
• Blames or belittles the child
• Seems cold and rejecting
• Inconsistent behavior toward the child

As briefly mentioned above, there might be physical indicators and behavioral indicators that a child is being sexually abused (Mayo Clinic, 2022; Moore, 2023; NYS, 2022). But this is not always the case. Sexual abuse is the act of sexual activities with dependent, developmentally immature children, to which they are unable to provide consent for (Zeanah & Humphreys, 2018). Because of the fact that many individuals who sexually abuse children are family members or friends, it makes disclosure of the abuse very difficult. Oftentimes, child victims feel shame and guilt and are afraid to disclose because of what might result.

The physical indicators that might point to sexual abuse include (Moore, 2023):

• Difficulty walking or sitting down
• Torn, stained, or bloody underclothing
• Painful or irritation in genital/anal area
• Difficulty urinating
• Pregnancy
• Sexually-transmitted diseases/infections

Behavioral indicators that a child might be a victim of sexual abuse can include (Moore, 2023; DHS 2024b):

• Child is not willing to change to participate in physical education (PE) class at school
• Self-injurious behavior, suicide attempts
• Poor peer relationships
• Withdrawn
• Fantasy behavior
• Fire setting
• Anxious
• Bedwetting
• Sleep disturbances
• Excessive or injurious masturbation
• Cruelty to animals or other people
• Age-inappropriate sexual play and/or drawings
• Sexual promiscuity
• Regressive, infantile behavior
• Aggressiveness
• Delinquency, running away, school truancy
• Reports of sexual assault by caretakers
• Exaggerated fear of closeness or physical contact

But what about their caregivers? There are certainly signs that a parent or caregiver might demonstrate that would point to possible sexual abuse. These caregiver behavioral signs can include (Moore, 2023):

• Protective or jealous of the child
• Misuses alcohol or drugs
• Has low self-esteem
• Encourages the child to engage in things not appropriate for age
• Is geographically isolated or lacking in social and emotional contacts outside of the family

Abuse should never be assumed as your first and last thought. Carefully consider any of your previous experiences with this child and whether there is a difference between those experiences and what you are currently seeing (NYS, 2022). It is important to make an objective evaluation, free from any bias (NYS, 2022).

Each indicator, as listed above, needs to be taken into consideration in relation to the child’s developmental age and circumstances (NYS, 2022). These indicators must be considered in relation to the child’s condition. They should be considered in the overall context of the child’s physical appearance and their behavior (NYS, 2022). Sometimes a single indicator is self-evident or points to abuse or maltreatment/neglect. Often several indicators must be pulled together or clusters of indicators used to develop reasonable cause. It is important to remember NOT to just view indicators in isolation (NYS, 2022).

Emma, a 13-year-old female, has come into the emergency room with a rash in her vaginal area. She shares with you that she has been engaging in sexual intercourse with her mother’s 42-year-old boyfriend for the past four months. Emma’s mom’s boyfriend has resided in the house with the child and her mother for the past three years and is responsible for her care when the mother is working as a bartender.

1. What indicators are present?
2. Is there a reasonable cause to suspect abuse or maltreatment?
3. Is there a parent or other person responsible for the suspected abuse or maltreatment?
4. What are your next steps?

Tommy, a five-year-old male, came into his pediatrician’s office for a sports physical so he can play soccer at school. You notice that he has a bruise on the left side of his face with scrapes along his left arm and hand. Tommy claimed he fell off the monkey bars at school. He lives with his mother who is a single parent. Tommy’s mother says that he is a very active child and at times can misbehave at school.

1. What indicators are present?
2. Is there a reasonable cause to suspect abuse or maltreatment?
3. Is there a parent or other person responsible for the suspected abuse or maltreatment?
4. What are your next steps?

Pamela, a 32-year-old female, is admitted to the obstetric unit at your hospital. She delivers her child, Sarah. After 36 hours of birth, the nurse notices that Sarah has tremors and increased muscle tone. Sarah is soon diagnosed with neonatal abstinence syndrome (NAS) by the neonatologist, as she is showing signs of drug withdrawal from when Pamela was pregnant with her. When talking to Pamela, you learned she has not prepared at all for her baby to come home.

1. What indicators are present?
2. Is there a reasonable cause to suspect abuse or maltreatment?
3. Is there a parent or other person responsible for the suspected abuse or maltreatment?
4. What are your next steps?

Seven-year-old Nick comes to the emergency room with an injured arm. His mother says he fell off the trampoline when he was jumping around and playing with his friend. An X-ray is ordered to assess for any breaks. When Nick’s arm is X-rayed, a spiral fracture of his humerus is identified.

1. What indicators are present?
2. Is there a reasonable cause to suspect abuse or maltreatment?
3. Is there a parent or other person responsible for the suspected abuse or maltreatment?
4. What are your next steps?

Four-month-old Sabrina is brought into the emergency room for being unresponsive. Mom accompanies Sabrina. Mom indicates that Sabrina was fine until they got back home from running errands. Mom says that her boyfriend, Rick, was watching her while she took a shower. She said that she heard Sabrina crying. When the crying had been continuous for ten minutes and then abruptly stopped, she heard Rick yell that he was going to pick up some cigarettes from the gas station and then slam the door. Mom finished getting dressed and went back to Sabrina’s room to check on her. Mom initially thought she was asleep in her crib, but on closer examination, she was not breathing. Mom notes that Rick does have a temper and that he frustrates easily with Sabrina.

1. What indicators are present?
2. Is there a reasonable cause to suspect abuse or maltreatment?
3. Is there a parent or other person responsible for the suspected abuse or maltreatment?
4. What are your next steps?

Benjamin is a 19-year-old who attends the school you teach at. Benjamin is in your English class but has not come to school in a few weeks. You reach out to his mother who tells you he is absolutely refusing to go to school and there is nothing she can do to get him to go. She said that he has a job at the local convenience store and spends all of his time there.

1. What indicators are present?
2. Is there a reasonable cause to suspect abuse or maltreatment?
3. Is there a parent or other person responsible for the suspected abuse or maltreatment?
4. What are your next steps?

You are discussing with the mother of a two-year-old about how much stress she currently is dealing with. She admits that she leaves her son, Elijah, at home alone at least once a week so that she can run to the corner store to buy groceries. She says that he is just fine and that she tells her neighbors that she’ll be back in 15 to 20 minutes and just to listen out for him.

1. What indicators are present?
2. Is there a reasonable cause to suspect abuse or maltreatment?
3. Is there a parent or other person responsible for the suspected abuse or maltreatment?
4. What are your next steps?

Case Study 1

What indicators are present? Sexual abuse and verbal disclosure

Is there reasonable cause to suspect abuse or maltreatment? Yes 

Is there a parent or other person responsible for the suspected abuse or maltreatment? The 42-year-old boyfriend is an adult living in the home acting as a caregiver when the mother is away at work.

What are your next steps? Call ChildLine.

Case Study 2

What indicators are present? Bruises, scrapes

Is there reasonable cause to suspect abuse or maltreatment? No, the story is consistent with a playground injury. Injuries sustained in an accidental fall would be along one side of the child’s body.

Is there a parent or other person responsible for the suspected abuse or maltreatment? No

What are your next steps? Prioritize the treatment of the child’s injury. You do not need to report this.

Case Study 3

What indicators are present? Neonatal drug withdrawal and no plan for when the baby comes home from the hospital

Is there reasonable cause to suspect abuse or maltreatment? No, infants born affected by prenatal drug exposure does not constitute child abuse. Prenatal drug exposure and the mother not having a plan for the baby coming home from the hospital is concerning, however.

Is there a parent or other person responsible for the suspected abuse or maltreatment? While there are no concerns that meet the definition of child abuse, there are concerns about the mother.

What are your next steps? Call ChildLine. This notification is for the purpose of assessing a child and the child’s family for a Plan of Sare Care and shall not constitute a child abuse report.

Case Study 4

What indicators are present? Spiral fracture, the explanation for the injury is not plausible

Is there reasonable cause to suspect abuse or maltreatment? Yes

Is there a parent or other person responsible for the suspected abuse or maltreatment? Mother

What are your next steps? Call ChildLine.

Case Study 5

What indicators are present? Mom’s boyfriend was taking care of the baby, Sabrina was fine one minute and then not breathing the next, reported to the ER for unconsciousness, boyfriend has a temper, boyfriend left suspiciously for cigarettes

Is there reasonable cause to suspect abuse or maltreatment? Yes

Is there a parent or other person responsible for the suspected abuse or maltreatment? Mother’s boyfriend, Rick

What are your next steps? This case is suspicious for shaken baby syndrome and should be worked up as such in the ER. Call ChildLine.

Case Study 6

What indicators are present? Benjamin is not going to school anymore

Is there reasonable cause to suspect abuse or maltreatment? No, it seems mom has tried. Additional attention can be given specifically to Benjamin to confirm mom’s story

Is there a parent or other person responsible for the suspected abuse or maltreatment? No

What are your next steps? According to the compulsory attendance law in Pennsylvania, children between the ages of six and eighteen are required to attend school regularly (Pennsylvania Department of Education, 2020). You do not need to report.

Case Study 7

What indicators are present? Mom is under a lot of stress; she also admits to leaving two-year-old Elijah home alone while she runs to the store

Is there reasonable cause to suspect abuse or maltreatment? No. While there is no reason to suspect abuse, the mother’s decision to leave the child alone while she runs to the store is concerning.

Is there a parent or other person responsible for the suspected abuse or maltreatment? Mother

What are your next steps? Although there is no law in the state of Pennsylvania, this would generally be considered inadequate supervision (Cumberland County Pennsylvania, n.d.). Mom should never do this. Someone must be physically present with Elijah while she is out in the case of an emergency. Call ChildLine to report.