1. What’s New? Updating the Care of Pediatric Sexual Abuse Patients
Cheryl Wier RN SANE-A SANE-P
Forensic Program Coordinator
Bradford Regional Medical Center

2. Objectives
Define the recent best practice resources implemented to standardize and improve the care of the pediatric patient who has been sexually abused.
Describe how to apply the concepts of child focused, patient centered, and trauma focused care in the medical assessment and treatment of the child who has been sexually abused.
Demonstrate an individualized treatment and discharge plan to address the safety and well-being of the child and their family.

3. Recent advances in forensic patient care resources
A National Protocol for Sexual Abuse Medical Forensic Examinations Pediatric (April 2016)
Care of Prepubescent Pediatric Sexual Abuse Patients in the Emergency Care Setting (ENA/IAFN Joint Position Statement 2016)
Updated Guidelines for the Medical Assessment and Care of Children Who May Have Been Sexually Abused (April 2016)
National Children’s Alliance Standards for Accredited Members 2017 Edition
Felony Non-fatal Strangulation Law went into effect December 26, 2016 in Pennsylvania
Human Trafficking: A Guide to Identification and Approach for the Emergency Physician (October 2016)

4. Scope of the Problem Pennsylvania Department of Human Services 2016 Annual Child Protective Services Report
In 2016 in PA there were 46 child fatalities and 79 near fatalities
“Sexual abuse remains the leading category of abuse, followed by physical abuse.”
“The average rate of substantiated reports was significantly higher for rural counties (2.6/1000) than for urban counties (1.6/1000).”
Counties with highest rates per capita of substantiated reports:
Forest
Tioga
Mifflin
McKean
Clarion
Venenago
Bradford
Greene

5. Trauma informed Child focused Victim (Patient) Centered
A National Protocol for Sexual Abuse Medical Forensic Examinations Pediatric
Child focused
Developmentally, linguistically and culturally appropriate
Victim (Patient) Centered
Timely, compassionate, respectful and appropriate care
Trauma informed
Seeks to support healing and avoiding retraumatization

6. How does exposure to trauma affect our pediatric patients. https://www
Adverse Childhood Experiences can include:
Physical abuse
Sexual abuse
Emotional neglect
Physical neglect
Mother treated violently
Household substance abuse
Household mental illness
Parental separation or divorce
Incarcerated household member
Health Consequences:
Adolescent pregnancy
Alcoholism and alcohol abuse
Depression
Illicit drug use
Heart disease
Liver disease
Multiple sexual partners
Intimate partner violence
Sexually transmitted diseases (STDs)
Smoking
Suicide attempts
Unintended pregnancies
Eating Disorders
Sexual and intimate partner victimization
Obesity/eating disorders

7. The Multidisciplinary Response
The Multidisciplinary Team Approach
The Multidisciplinary Response
Medical/SANE: conduct a specialized medical evaluation in cases of suspected abuse, collect and identify medical-legal evidence if present. The primary purpose of the medical evaluation is to make sure your child is physically and medically healthy.
Child Protective Services: responsible for the immediate safety of children who are allegedly being abused and/or neglected. The role of the CYS caseworker is to protect children and assist the caregiver(s) with the necessary services needed to ensure children’s safety.
Law Enforcement: responsible for investigating and determining whether a crime has been committed. They interview caregivers, suspects and other witnesses, and gather evidence from the scene of the alleged incident.
Victim Advocacy: work with children and families to provide up to date information regarding their case, as well as ongoing support. They assist with court preparation and help victims and families to understand the legal process. Advocacy does not play an investigative role, but rather a healing through empowerment role.
The Children’s Advocacy Center: provides coordination of the MDT managing the process from the initial contact to completion of services. Works with team members and families, coordinating and tracking the investigation, prosecution, child protection and treatment efforts.
District Attorney’s Office: responsible for determining whether a crime has occurred, filing charges and prosecuting cases of child abuse. The prosecutor has the final decision as to if charges will be filed. The DA’s office carefully reviews information provided by the assigned investigator to decide if he/she can prove beyond a reasonable doubt, in a courtroom, the incident happened.
Mental Health: offers trauma-informed treatment to children and families through a referral process

8. A National Protocol for Sexual Abuse Medical Forensic Examinations Pediatric
Refers to prepubescent children only
Tanner stages 1 and 2, not chronological age
Tanner stages 3 and above, regardless if premenarchal, are adolescents
Health care providers, not law enforcement or child protective services should determine the urgency of care
Timely medical examinations, regardless of probability of evidence
Protocol development with multidisciplinary teams
Child’s description of events and/or report of related symptoms are essential parts of the medical examination
Although the history is very important, evaluate children objectively and interpret findings based on current literature.

9. A National Protocol for Sexual Abuse Medical Forensic Examinations Pediatric
Initial Response
Priority patients
Advocacy
Minimal facts
Mandatory reporting
Safety concerns
Medical screening
Determine urgency of forensic examination

10. National Children’s Alliance Standards for Accredited Members 2017 Edition Timing of medical examination: Emergent Urgent Non-urgent Follow-up 5 P’s: Pain/bleeding Potential for STIs Perpetrator exposure Pornography Patient/parent concern

11. Medical History http://www. nationalchildrensalliance
Past Medical History (PMHx):
Significant Illnesses/Surgeries/Hospitalization s
Development (including sexual development and menstrual history in girls)
Behavioral, educational or mental health issues
Prior abuse and sexual history (current and past legal-aged, consensual partners)
Medications, allergies and vaccination history (esp. HPV and Hep B)
Family History (FamHx):
Significant health problems in parents, siblings and close relatives
History of Present Illness (HxPI):
History of the event: What happened, when, where, who was involved
History of the contact: Body sites involved, actions involved, associated symptoms
What has happened since the event?
Physical/emotional symptoms/behavioral response
Safety threats, bullying, school performance
Family relationships
What response has already occurred?
Prior medical exam and treatment
Interview by investigators or CAC staff
Counseling/mental health screening
Social History (SocHx):
Home composition, violence in the home, substance abuse by patient or those in the home.
Does the patient feel safe and supported by current caretakers?
Prior child welfare involvement in the family.

12. Physical exam
Labia majora
Clitoris
Labia minora
Urethra
Hymen
Vagina

13. Physical Examination: Head to toe
HEENT
Respiratory
Cardiac
Hematology (bruising, bleeding)
Endocrine (glands, weight loss/gain)
Neuro (headaches, seizures)
GI (N/V/D, constipation, rectal pain, bleeding or discharge)
GU (discharge, burning, dysuria, bleeding, pain, lesions)
Musculoskeletal
Skin (rashes, lesions, bruises, tattoos)

14. Sexually transmitted infections: Medical treatment and forensic evidence
Factors that indicate the need for STI testing for prepubescent children, regardless whether the case is acute or nonacute (CDC 2015; Jenny, Crawford-Jakubiak, & Committee on Child Abuse and Neglect, 2013).
Child had experienced penetration or there is evidence of recently healed penetrative injury to genitals, anus, or oropharynx
Child has been abused by a stranger
Child has been abused by a perpetrator known to be infected with a STI or at high risk for STIs (e.g. intravenous drug abusers, men who have sex with men, people with multiple sex partners, and those with histories of STIs)
Child has a sibling or other relative or person in the household with a STI
Child lives in an area with a high rate of STIs in the community
Child has signs or symptoms of STIs (e.g., vaginal discharge or pain, genital itching or odor, urinary symptoms, and genital lesions or ulcers)
Child has already been diagnosed with one STI
Child or caregiver requests STI testing

15. Sexually transmitted infections: Medical treatment and forensic evidence

16. Sexually transmitted infections: Medical treatment and forensic evidence

17. Sexually transmitted infections: Infants and prepubertal children (Consider vertical, perinatal or transfusion exposure in positive results)
Treatment per CDC guidelines assault.htm
Infection confirmed
Evidence for sexual abuse
Reporting guidelines
Gonorrhea
Diagnostic
Report
Syphilis
HIV
Chlamydia
Trichomonas
Highly suspicious
Genital herpes
Anogenital warts
Suspicious
Consider report
Bacterial vaginosis
Inconclusive
No report

18. Discharge/Safety planning
Access to alleged perpetrator
May include admission to facility
In conjunction with law enforcement and CYS
Validate feelings
Health and welfare
Provide written discharge plan:
Review what was done and findings
Psychosocial interventions
Explain multidisciplinary response
Medical follow up

19. A National Protocol for Sexual Abuse Medical Forensic Examinations Pediatric : Documentation
Consents
Written
History and physical examination
Diagrams
Photography
Standard of care
Diagnostic quality still images or video for quality assurance, teaching, and legal proceedings
Description of findings
Testing and treatment
Discharge
Follow up
Referrals
Safety plan
Interpretation

20. Interpretation of findings Updated Guidelines for the Medical Assessment and Care of Children Who May Have Been Sexually Abused
Flattened anal folds and anal dilatation are no longer attributed to sexual abuse trauma 3/pdf “Indeterminate” category now relabeled as “No Consensus” A deep notch in the inferior hymenal rim is a “No Consensus” finding!
Be confident explaining a normal exam does not indicate abuse did not occur!
“Examination Findings in Legally Confirmed Child Sexual Abuse: It's Normal to be Normal.” (1994, Adams et al)
“The importance of the child’s history in the diagnosis of sexual abuse can not be overstated.”

21. Interpretation of findings Updated Guidelines for the Medical Assessment and Care of Children Who May Have Been Sexually Abused
Must be able to recognize, differentiate and describe:
Acute and healed injuries
Normal genital variations vs abnormal or indicative of abuse
Physiological changes
Interpretation categories:
Normal-Findings found in newborns, non-abused children, commonly mistaken for abuse or caused by medical conditions unrelated to abuse.
No Consensus-Findings significant in small studies, also found in non-abused populations, or no research to associate with abuse.
Caused by trauma and /or sexual contact

22. Interpretation of findings Updated Guidelines for the Medical Assessment and Care of Children Who May Have Been Sexually Abused
Normal Examination/
Normal Variants
No Consensus
(With respect to sexual contact or trauma)
Abnormal/Findings caused by trauma and/or sexual contact
What's New?
Any hymenal notch or cleft regardless of depth above 3-9:00 position. Superficial notches at or below the 3-9:00 position.
Molluscum contagiosum
Visualization of pectinate/dentate line
Partial dilatation of external anal sphincter with internal sphincter closed
Red/purple discoloration of genital structures from lividity post-mortem
Notch or cleft in the hymen rim at or below 3-9:00 position deeper than superficial but not complete transection
Genital or anal condyloma first noted in child older than 5 may be more likely the result of sexual transmission
Injuries to genital/anal tissues:
Petechiae or abrasions to hymen
Vaginal lacerations
Perinanal laceration with exposure of tissues below the dermis
Healed hymenal transection/complete hymen cleft between 4-8:00 that extends to base with no hymenal tissue
Hymen/Vaginal/Penile
Hymen: mounds, bumps, narrow posterior rim, external rim redundancy, variations in structure, or tags.
Acute lacerations or bruising to labia, penis, scrotum, perianal tissues, perineum, posterior fourchette, or vestibule.
Acute laceration or bruising to hymen, a defect in the inferior half of the hymen wider than a transection with an absence of hymenal tissue extending to the base.
Urethral/vaginal
Periurethral or vestibular bands, intravaginal ridges or columns, dilatation of the urethral opening, vaginal discharge, urethral prolapse
Semen in forensic specimens taken directly from the child’s body or pregnancy
Labia/vestibule
Linea vestibularis, hyperpigmentation of labia minora or perianal tissues in children of color, erythema, increased vascularity, friability of posterior fourchette, lichen sclerosis, vulvar ulcers, failure of midline fusion.
Genital or anal condyloma in the absence of other indicators of abuse. Herpes type 1 or 2 confirmed by culture or PCR testing in the genital/anal area with no other indicators of abuse
Scar of posterior fourchette or fossa,
Anal
Perianal skin tags, diastasis ani, anal fissures, venous congestion/pooling, rectal prolapse
Complete anal dilatation with relaxation of both sphincters in the absence of constipation, encopresis, sedation, anesthesia and neuromuscular conditions.
Perianal scar

23. Maintaining clinical competency
Clinical experience
Current literature
Continuing education
Minimum of 8 hours in the field of child abuse every 2 years for CAC examiners
Case/Peer review
Improves diagnostic accuracy
Improves professional practice patterns
Confirmation and verification of exam findings
Quality assurance
Education
Oversight of cases

24. Expert review
Per NCA 2017 Standards: Standards-for-Accredited-Members-2017.pdf
“All medical professional providing services to CAC clients must demonstrate, at a minimum, that 50% of all finding deemed abnormal or “diagnostic” of trauma from sexual abuse have undergone expert review by an advanced medical consultant.”
Acute or healed ano-gential findings that may indicate abuse/assault has occurred
Log of abnormal exams and those sent for expert review
Per 2016 National Pediatric Protocol:
“ The consulted expert reviews the medical report and photo-documentation an subsequently should provide formal written documentation of review and conclusions.”
Include in medical record

25. Expert review National Children’s Alliance Standards for Accredited Members 2017 Edition
Who is an expert?
Child Abuse Pediatrician, Physician or Advanced Practice Nurse who:
Has met the minimum training outlined for a CAC provider
Performed at least 100 child sexual abuse examinations
Current in continuing education requirements
Participates in expert review of their own cases

26. Human Trafficking: A Guide to Identification and Approach for the Emergency Physician
In the US, 63% of human trafficking victims report they were seen in an emergency department
Common presenting complaints:
Back pain
Headaches
Fractures
Contusions
Burns
Dental complaints
Vaginal bleeding
Pelvic pain
Sexually transmitted infections
Unwanted pregnancy
Anxiety
Depression
Suicidal ideation
Substance use
HIV
Hepatitis

27. Human Trafficking: A Guide to Identification and Approach for the Emergency Physician
Red flags:
Person accompanying reluctant to leave patient
Vague or inconsistent history of illness or injury
Patient has unexpected demeanor
Patient apprehensive or hostile when law enforcement referenced
May not know home address
May not be in possession of own identification or personal items
It is the position of the Emergency Nurses Association that:
1. Emergency nurses play a vital role in recognizing and responding to the needs of victims of human trafficking by ensuring their immediate safety and reducing the possibility of further harm.
2. Emergency nurses are proactive in educating staff on human trafficking trends, vulnerabilities for victimization, signs of victimization, and barriers to disclosure.
3. Emergency nurses collaborate with multiple disciplines and forensic nurse examiners, when available, to provide safety, shelter, and healing to victims of human trafficking.
4. Emergency nurses promote prevention and work collaboratively with law enforcement, school, and other community outreach interprofessionals to provide educational materials and training opportunities.
5. Emergency nurses actively participate in policy development at local, state, and national levels to address all aspects of human trafficking.

28. Strangulation Training Institute on Strangulation Prevention
Assessment questions:
Are you having or did you have difficulty breathing?
Do you have a cough or change in your voice?
Did you lose or nearly lose consciousness?
Did you lose control of your bowel or bladder?
Did you think you were going to die?

29. Strangulation Training Institute on Strangulation Prevention

30. Thank you! www.facebook.com/paiafn

31. 2015 Sexually Transmitted Diseases Treatment Guidelines. (2015)
2015 Sexually Transmitted Diseases Treatment Guidelines. (2015). Sexual Assault and Abuse and STDs. Retrieved from Adams, J, Harper, K, Knudson, S, & Revilla, J. (1994, Feb). Examination Findings in Legally Confirmed Child Sexual Abuse: It’s Normal to be Normal. Pediatrics, 94, Adams, JA, Kellogg ND, Farst KJ, Harper NS, Palusci VJ, Frasier LD, Levitt CJ, Shapiro RA, Moles RL, Starling SP. (2016, April). Updated Guidelines for the Medical Assessment and Care of Children Who May Have Been Sexually Abused. Journal of Pediatric and Adolescent Gynecology. 29 (2), Age of Consent. (2014). Understanding the Age of Consent in Pennsylvania. Retrieved from consent Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Violence Prevention. (2016, April). Adverse Childhood Experiences (ACEs). Retrieved from Centers for Disease Control and Prevention website National Children’s Alliance. (2015, January). Standards for Accredited Members 2017 Edition. Washington, D.C. Shandro, J, Chisolm-Straker, M, Duber, H, Findlay, S, Munoz, J, Schmitz, G, Stanzer, M, Stoklosa, H, Wiener, D, & Wingkun, N. (2016, October). Human Trafficking: A Guide to Identification and Approach for the Emergency Physician. Annals of Emergency Medicine, 68(4), Training Institute on Strangulation Prevention. (2016). Signs and Symptoms of Strangulation. Retrieved from Training Institute on Strangulation Prevention website U.S. Department of Justice Office on Violence Against Women. (2016, April). A National Protocol for Sexual Abuse Medical Forensic Examinations Pediatric. Washington, D.C.
Please do not reproduce any portion of this presentation without permission from presenter. Contact: Cheryl Wier RN SANE-A SANE-P 116 Interstate Parkway Bradford, PA