1. Important Considerations

2. Disclosure of Sexual Abuse
Very often, disclosure occurs long after abuse
“Accomodation Syndrome”
Secrecy
forced to keep abuse a secret
Helplessness
feels trapped and helpless
Entrapment/accomodation
child feels no one will believe story
Retraction
may occur if support is not provided

3. Explaining results to child & family
Be prepared to explain why exam is normal or non-specific
Family may be frustrated
May ask if sexual abuse can be proved
May ask whether child is virgin
May ask whether the hymen is intact
Encourage the family to normalize their behaviour
Advise the family to refrain from asking direct questions about the incident

4. When to see again or refer for follow-up
If findings were present and follow-up will ensure injuries have healed
If concerned re: psychosocial issues for child and/or family
If require 2nd opinion regarding findings

5. Custody Access Situations
3 year old girl joint custody b/n mother & father
Visits father on weekends
Sunday night returned from visit-redness and complaints of pain in vaginal area
Mother questioned girl “daddy tried to touch my pee-pee”
Mother reports to CAS/Police

6. Custody & Access Situations
Don’t be judgmental – not all C & A situations result or involve sexual abuse
Try to understand the issues
Poor communication and animosity b/n parents can cause issues
distrust
Father may not be cleaning properly
Inappropriate questioning
Inappropriate medical exams

7. Child Sexual Exploitation
3 main forms
Child pornography
Prostitution
Trafficking for sexual purposes
Unsure how many victims

8. Child Sexual Exploitation cont’d
Prostitution
Exposure to violence/assault
Physical/psychosocial implications
Pornography
Clear link between child pornography and sexual abuse
Medical role unclear
Used to make deviant behaviours seem normal
Help to seduce children by lowering their inhibitions or blackmailing them
Education!!!

9. Psychosocial Assessment

10. UNDERSTANDING CRISIS
Acute emotional upset arising from situational, developmental, or sociocultural sources
Temporary inability to cope by means of one’s usual problem solving devices
Hazardous event not in itself a crisis
Affected by one’s perception and interpretation
Resolution may be adaptive or maladaptive

11. Connect family with community resources
Follow-up

12. Why involve the psychosocial clinician?
Multidisciplinary team approach
Sexual abuse intervention expertise
Improved outcomes
Effective link with CAS, community resources

13. When to involve the psychosocial clinician
The nonoffending caregiver is experiencing difficulty coping
There is concern related to the child’s functioning
What to ask….

14. TRAUMA ASSESSMENT Verified sexual abuse
Structured process which elicits specific, detailed information directly from the child, collateral sources about the event(s) which occurred
Components
symptomological
relationship
situational
developmental

15. TREATMENT Multiple treatment modalities
Strong empirical support for Cognitive Behavioural Therapy

16. CBT with children associated with improved
depression
PTSD
behavioural problems
social competence
CBT with caregivers associated with
improved distress, support, perceptions
decreased symptoms in child

17. Practice Issues

18. Why review cases with peers?
Sexual abuse exam findings are subjective
Basic training does not include hands-on practical component
No certification process for clinicians
No continuing education program
Maintain skill with low volume of cases

19. Why review cases with peers?
Enhance credibility within court system
Exam 5 cases/month
Peer review 20 cases/month
A wrong diagnosis can result in:
Someone falsely accused of a crime
A child removed from a home unnecessarily

20. Evidence-Based Approach
Practice has evolved dramatically in 20yrs
Research methodology has improved: comparison studies to non-abuse
Adds credibility to the diagnosis and the examiner
Supports a subjective finding that can have significant medico-legal implications

21. What do you need to review cases?
Photodocumentation of examination
Colposcope/medscope
Digital camera
Regular structured time with all clinicians
Co-ordination of which cases to be review-all, random, not just the abnormal or interesting cases

22. Issues to consider Photodocumentation policy
Consent from families to review pictures
Process for conflicting diagnosis
Medico-legal implications for conflicting diagnosis – external reviewer??
Process to address identified poor competency

23. Current Models Sick Kids – SCAN Team Greater Toronto Area
Review all colposcopy pictures by team members
Discussion of more complex cases at weekly multi-disciplinary team meetings
Greater Toronto Area
Case review rounds using telehealth
Multi-disciplinary
Centers to bring own cases and pictures

24. Your Center
Whoever is examining children should be reviewing cases with clinical peers regularly
SANE nurses, ER doctors, Pediatricians, SACC doctors
Involve other team members: SW, psychologist

25. Multidisciplinary Review
Medical cases to begin initial process
Should move to include complex medical and psychosocial cases
Multidisciplinary team members involved

26. Case Presentation History Images Clinical Findings
Age, tanner stage, allegation, assault type (penile-vaginal penetration), timing of assault, reported symptoms
Images
Clinical Findings
Impression statement
Evidence to support

27. Where to get your support
SCAN Program
OHA manual
Current Literature
Conferences – SCAN Conference, Pediatric Training, San Diego, APSAC