HARRISBURG — The Shapiro administration and the legislature have been slow to act on recommendations from a state-commissioned report that found the commonwealth needs a consistent system for determining when children have been abused.
In some counties, child abuse allegations are exclusively investigated by caseworkers. Others include the expertise of specialized doctors and nurses in such inquiries, and have checks in place if there are disagreements about what caused a child’s injury.
Without a medical assessment, abuse can go undetected and adults can be falsely accused, argued Cathleen Palm, founder of the Center for Children’s Justice.
In 2023, Palm was part of a coalition of pediatricians, state and county officials, advocates, and law enforcement that reviewed how Pennsylvania investigates child abuse.
The report that the Keystone State Child Abuse Medical Forum produced found carefully designed oversight systems in some parts of the commonwealth, like Westmoreland County, and unstructured ones elsewhere.
The coalition was especially worried about child abuse investigations being conducted without the input of people with medical training. That expertise can be crucial for assessing harm, especially when a child cannot communicate because of their age, or a disability.
Several authors of the report spoke with Spotlight PA for this story, and said little has changed since its release.
“It's somewhere between nothing or not enough,” said Palm of Pennsylvania’s progress. She argued that the Shapiro administration could and should be doing more to help counties incorporate clinical expertise into investigations.
Pennsylvania’s Child Protective Services Law says that county agencies “may require” a medical examination during investigations. But it does not mandate this.
Some advocates argued the executive branch could step in to ensure these checks. But the Pennsylvania Department of Human Services said it lacks the regulatory authority to force counties to change how they evaluate cases.
Gaining that power, wrote DHS spokesperson Brandon Cwalina in an emailed statement, “would require the General Assembly to make changes to the state’s Child Protective Services Law.”
The legislature has taken no such action.
In the meantime, Cwalina said the agency has started connecting medical experts to its regional Child and Family Services offices, as well as to child advocacy centers — nonprofits that specialize in supporting kids who have been abused.
“We are currently working to develop intergovernmental agreements between each regional office and their regional academic medical center to provide this medical expertise,” he said, noting the overall shortage of these providers.
How big is the problem? No one knows.
The number of Pennsylvania kids whose cases warrant clinical assessment but aren't evaluated is unknown. There are no statewide data because counties do not record this information in a standard way.
And the state lacks a central database or master list of which hospitals have medical experts that assess child abuse, Cwalina told Spotlight PA.
That lack of data worries Sheridan Miyamoto, the founder and director of Penn State's telehealth system for sexual assault examinations.
Not only do caseworkers lack medical training, she noted, but Pennsylvania does not require them to have social work degrees, and many counties, like Chester, Jefferson, and Pike, don’t either. That means child welfare professionals are making critical decisions with minimal training.
"If we're going to have people who really have no medical training and then no real social work training out in the field, then they have to have a clear protocol," said Miyamoto, who was part of the group that studied the existing system.
Miyamoto argued the state should map out where kids aren’t getting medically evaluated and then determine where medical experts are located. That way, policymakers could direct resources to underserved communities.
When a clinician is included in an investigation, it's often at one of Pennsylvania's 40 child advocacy centers, or CACs. These nonprofits coordinate with social and medical services, law enforcement, and advocates to ensure abuse investigations are thorough and don’t further traumatize the child.
Three CACs serving a combined 15 counties got a boost in June, when Pennsylvania issued nearly $1.5 million in grants to fund programs to connect kids who have been sexually assaulted to nurses trained to conduct forensic medical exams.
The grants do not address physical abuse.
Still, those funds are needed, as 25% of U.S. kids who sought services from these organizations in 2024 received a medical evaluation, according to data from the National Children’s Alliance, a nonprofit that represents CACs.
Report authors who spoke with Spotlight PA say they’ve seen at least one promising response to their recommendations: the hiring of Rachel Berger, a respected pediatrician and researcher, as medical director of the Office of Children, Youth, and Families within the state Department of Human Services. The report argued the role was needed because DHS did not have consistent access to professionals with specialized training.
Cwalina told Spotlight PA via email that Berger is beginning that work, but said it is “still in the early stages.”
Palm called Berger “incredibly skilled,” but would still like to see more on-the-ground progress.
"In Luzerne County and Blair County and Monroe County, are there trained folks, pediatricians or specialized nurses, or some kind of telehealth situation set up? I think we still have a big challenge," she said.
Speciality questioned
Spotlight PA reached out to several pediatricians who contributed to the 2023 report, but none agreed to speak with the newsroom.
The silence comes as these specialists are under increased scrutiny.
Nationwide, parents, attorneys, and other physicians have accused these doctors of incorrectly diagnosing abuse and neglect. They argue that social services are too deferential to doctors who may not consult other physicians when making a diagnosis.
That includes families who are suing Lehigh Valley Reilly Children's Hospital and its former child abuse pediatrician.
In the suits, parents say physician Debra Esernio-Jenssen erroneously accused them of medical child abuse. The condition, formerly called Munchausen syndrome by proxy, is when caregivers intentionally harm their children, or fabricate their kids’ symptoms, in order to seek attention and sympathy.
Attorneys for Esernio-Jenssen, who contributed to the forum’s report, declined a request for comment.
DHS declined to answer whether there are mechanisms in place for families or welfare agencies to seek second opinions if they have concerns about a clinician's conclusion.
The weight given to a pediatrician's opinion is ultimately at the discretion of county welfare agencies or local prosecutors. But when a specialist is confident abuse is the cause of an injury, caseworkers are unlikely to disagree, said Brian Bornman, executive director of the Pennsylvania Children and Youth Administrators Association, which represents agencies statewide.
This trust gives these doctors a lot of power in these investigations, he noted. But he’s found that these specialists generally soothe concerns.
For example, a family doctor might contact social services after misdiagnosing skull fissures as fractures from abuse, but a child abuse pediatrician can tell the difference.
"Those are the kinds of things you don't see because you're never involved in those cases," said Bornman. "You are only ever involved in the ones being brought to court."
And because caseworkers aren't doctors, Bornman said, he'd like to see policies that make these doctors more widely available.
A promising system
The report had high praise for how Westmoreland County, east of Pittsburgh, investigates child abuse.
When abuse is alleged, the county automatically assigns a nurse to a case if a child is under three, the case involves domestic violence, or there are concerns around medical neglect, bodily injuries, or inappropriate discipline. The system started in Allegheny County, which also uses the rubric.
This allows caseworkers to triage investigations more objectively and keep kids safer, argued Jason Ware, casework manager for Westmoreland County’s children’s bureau.
The report commended the way the county brings together its welfare agency and medical experts. When a child is assessed by a physician, explained Ware, that’s just one piece of the overall puzzle rather than the most decisive perspective.
Nurses there also seek input from the family's pediatrician and review medical records to form a more holistic understanding of the child's health and well-being.
At the same time, when investigating alleged abuse, caseworkers speak with the child, their family, school, and law enforcement, and assess the condition of the home.
But this level of investment is the exception in Pennsylvania, and would be hard to scale up due to the finite number of clinicians trained to diagnose child abuse and neglect. Nationwide, just 377 physicians have a current certification for this kind of work, according to 2024 data from the American Board of Pediatrics.
Counties near one of the state's six children's hospitals tend to have better access, the forum report found. But these doctors also have patients and generally aren't consulting full-time on investigations, said Bornman.
Sometimes, general pediatricians, such as Jennifer Janco, chair of pediatrics at St. Luke's University Health Network, can pitch in. She told Spotlight PA there are instances where a child's injuries are clearly abuse.
Ultimately, Bornman said money needs to be allocated at the state level. Even then, it may take some time to hire enough qualified clinicians.
In the meantime, he added, social workers try to be judicious when reaching out to pediatricians with their questions: "You're essentially asking docs to do you a favor because they're doing this in addition to their actual job."