Only a few years ago, Pennsylvania had one of the narrowest definitions of child abuse in the country.
Statistically, it showed. According to a June 2011 article by Rachel Berger MD of Children's Hospital of Pittsburgh appearing in the Pittsburgh Post-Gazette, 1.4 per 1,000 children in 2010 were victims of child abuse, compared to the national rate of 9.3 percent.
However, since then, Pennsylvania's Child Protective Services Law (CPSL) was amended and a number of changes have occurred. Changes included expanding the definition of abuse, lowering the threshold for abuse, and requiring physicians as mandated reporters to make child abuse reports even if they learn about the suspected abuse outside of the work environment.
What those changes might mean to the state's child abuse statistics is yet to be seen, but for sure many agree that health care professionals will be able to do more to protect children.
"There's no doubt that there's more concern about child abuse today than there was ever before," says Karen Rizzo MD, president of the Pennsylvania Medical Society (PAMED). "Hindsight is 20/20 for everyone but it's good that the state took recent actions to make it tougher for abusers to get away with such actions and to further protect children."
Dr. Rizzo, who practices in Lancaster, adds that groups like PAMED are working with physicians statewide and partnering with other organizations to provide education and training on these changes and the role of physicians.
According to past Annual Child Abuse Reports from what was then called the Pennsylvania Department of Public Welfare -- now Pennsylvania Department of Human Services -- Pennsylvania's hospitals, private physician offices, and private psychiatrists have historically been among the mandated reporting groups with higher reporting figures of child abuse. Combining the three, the only higher reporting groups were schools and social services. Between 2004 and 2013, yearly reports ranged from a low of 2,601 to a high of 3,151 for hospitals, 432 and 626 for private physician offices, and 416 and 555 for private psychiatrists.
In 2014, according to the most recent Child Abuse Report, hospitals reported 3,284 possible cases of child abuse, while private physician offices and private psychiatrists noted 503 and 443 respectively.
Of the substantiated abuse referrals in 2014, 24 percent came from within healthcare. Social service agencies and schools were responsible for 26 percent and 11 percent respectively.
One of the recent changes is the threshold for physical abuse. The old definition set the threshold as "serious" physical injury, which meant causing severe pain or significantly impairing the child's physical functioning. The new definition lowers the reporting bar to bodily injury, defined as causing substantial pain or any impairment in physical condition.
The new definition also identifies culpable conduct that is per se child abuse; that is, intentionally, knowingly, or recklessly engaging in this conduct constitutes child abuse regardless of whether an injury results.
Another change in the law expands physician responsibility for reporting. Physicians now must report suspected child abuse identified in certain circumstances outside their professional capacity.
"Emergency departments have some of the best trained staffs to identify child abuse, and to put into action a plan to protect the child," says Todd Fijewski, president of the Pennsylvania College of Emergency Physicians who practices in Pittsburgh. "Most times when a child shows up in an emergency department, it's not due to child abuse, but when we do spot it, we act quickly and appropriately."
Dr. Fijewski continues, "With changes in the law, if a physician is away from work, maybe even in a social situation, and is made aware of child abuse, the physician is required to report it."
According to PAMED's Dr. Rizzo, this change did worry some physicians. "Initially, while some physicians who do not see patients were dismayed by having to report, the overall public good that comes of reporting is something that's positive that we are helping promote to physicians statewide," says Dr. Rizzo.
"Physicians are not only community sentinels for child maltreatment but also are trusted professionals who can help prevent child abuse by recognizing children at risk for abuse, referring these children and parents to community-based services, and providing a medical home to help assure service needs are being met," says David Turkewitz, MD, FAAP, chair of pediatrics at York Hospital and past president of the Pennsylvania Chapter, American Academy of Pediatrics.
So what are some of the signs that suggest to physicians child abuse may have occurred? According to Dr. Turkewitz physicians consider abuse in the following situations:
• Physical injuries not compatible with the history provided
• Denial of trauma in a child with significant injury
• History incompatible with child's development
• History that changes over time
• Unexpected and unexplained delay in seeking treatment
"Sexual abuse in children may present differently based on the youth's developmental stage and the nature of the relationship with the abuser," says Gail A. Edelsohn, MD, MSPH, who chairs the child and adolescent psychiatry committee at the Pennsylvania Psychiatric Society. "A child or adolescent who has been sexually abused may develop a variety of distressing behaviors, thoughts, and feelings."
According to Dr. Edelsohn, who practices in Exton, Pa., children typically five years and older who have cared about the abuser may feel horribly stuck as they sense the sexual activities are wrong while they may be facing threats of violence and loss of affection from the abuser. Victims may become withdrawn, mistrustful of adults, feel worthless, or may show sexualized behaviors. Physical warning signs include wetting and soiling accidents unrelated to toilet training, pain during bowel movements or urination, and pain, bleeding, or discharges in the genitals, anus, or mouth. Most often the sexual abuse is discovered when the victim makes a disclosure.
Symptoms or behaviors that might be present in sexually abused children include
• Sleep problems or nightmares
• Depression or withdrawal from family and friends
• Exhibits adult sexualized behaviors, language, and knowledge
• Statements their bodies are dirty or damaged
• Refusal to go to school and or drop in grades
• Delinquency/conduct problems
• Depression, anxiety
• Suicide attempts
• Has money, toys, or other gifts without reason
• Sexualized drawings, games, fantasies
• Self injurious behaviors (cutting, burning)
• Unusual aggressiveness
• Suicidal behavior
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