Medical Protocol

The medical evaluations of child abuse cases can be complex, and involve physical, emotional, and psychosocial issues, as well as custody and legal ramifications. Suspected abuse is uncovered through the presenting symptoms, by a child’s disclosure, or by suspicions of a child’s caregiver, or another reporter. Medical providers are faced with the dual task of ensuring the health and safety of the patient while remaining objective and thorough in assisting with their obligation to report their findings for the investigation and management of these cases by the Department of Child Safety, the Office of Child Welfare Investigations and Law Enforcement. A calm, nonconfrontational approach to informing family members of this duty, without judgment or speculation is essential. (See Appendix A, A.R.S. §13-3620) The Southern Arizona Children’s Advocacy Center provides physicians and sexual assault nurse examiners (S.A.N.E.) who have the education, training and experience to perform forensic examinations of children and provide expert testimony in judicial procedures. The Children’s Advocacy Center is designed to reassure the patient and family, and coordinate with a multi-disciplinary team approach. Referrals for medical examinations come from DCS, OCWI, law enforcement, and from community physicians for second opinions or follow-up. (See Appendix D) The Children’s Advocacy Center provides 24 hour services, including forensic medical exams, advocacy and information. Alleged physical abuse, physical neglect, or sexual abuse can be assessed, and the appropriate timing of the exam maximized to obtain forensic evidence with the goal of minimizing re-traumatization to the child. As a rule, the forensic examiner will not accept a case until there is Law Enforcement and/or DCS involvement. Concerning the issue of Emergency Treatment and Labor Act (EMTALA) the transfer of a suspected child abuse victim from an Emergency Department to the Children’s Advocacy Center can be done after the medical screening exam (MSE) has been completed. Unless there is concern for significant pain, bleeding or discharge, the genital and anal exam can be deferred to the Children’s Advocacy Center forensic examiner, if DCS and/or Law Enforcement is ready to transport. If the referring physician requests direct contact with the Children’s Advocacy Center forensic examiner, the Advocates will facilitate this communication. Medical records from initial evaluations must be released to Law Enforcement and/or DCS per ARS §13-3620, upon their written request and signature on a medical release. The release of medical records does not require the parent/guardian’s permission; and should be expeditious, as these records will be needed in the investigations. The Medical Evaluation: Children examined at the Children’s Advocacy Center receive a comprehensive physical exam to assess and document growth, sexual maturity, signs of injury, neglect, and sexual abuse, as well as self-injurious behaviors. Although the majority of “after 72 hours” sex abuse exams do not show evidence of acute infection or injury, this does not preclude the possibility that the abuse occurred. The most October 2014 – Pima County Protocols for the Multidisciplinary Investigation of Child Abuse, page 21 important part of the evaluation is the history given by the child. Even in the situation of a full and detailed disclosure, a medical exam is beneficial in order to ensure the health of the patient. Similarly, an exam in a non-verbal or pre-verbal child might reveal physical findings not otherwise suspected. Sexual Abuse A. The Forensic Interview and Videotaping: In most cases a forensic interview precedes the medical examination. Either the interviewer or one of the investigators (DCS or Law Enforcement) will share information obtained from this process with the medical forensic examiner by, and that person will be present at the time of the exam. The child should not be re-interviewed by the medical forensic examiner. However, brief questions directing the medical assessment and biological collection may be necessary. Any information offered by the victim during the exam should be documented in exact quotes. B. The Medical Evaluation 1. Urgent Forensic Medical Exams (usually within 12 hours at the Advocacy Center or another facility with trained personnel) a. Genital/Rectal Pain, Bleeding - Children experiencing these symptoms need to be seen as soon as possible to identify the cause, and determine if injury is present or symptoms of sexually-transmitted or non-sexually-transmitted infection is present. b. Recent Anal, Vaginal or Oral Penetration - Pre-pubertal children need to be examined within 24 hours to collect forensic evidence, as their body swabs deteriorate quickly. Sperm may be recovered up to 72 hours for older children. Examinations and collection of biological evidence beyond these time periods may still occasionally yield evidence and may be conducted at the discretion of the investigators and forensic examiner. c. Anogenital Injuries - Evidence of healing trauma may be more difficult to detect after 4-14 days, and the magnification and lighting of the colposcopy may be needed to define these changes. d. Sexually Transmitted Diseases i. Gonorrhea, Syphilis, Chlamydia, trichomonas, genital herpes and venereal warts are infections that require a medical examination. ii. HIV positive children who acquired this disease in an unknown manner require an evaluation. If the child is older than 12 months, the medical forensic examiner should not assume that the victim acquired the virus through the delivery process from an infected mother. iii. Gardnerella (Bacterial Vaginitis) or Monilia (yeast) Infections do not need to be seen for forensic exams. e. Pregnancy - If a child less than 15 years of age is pregnant, or possibly pregnant, an evaluation is needed. If there is a possibility of molestation or if there is a question as to whether sexual contact was “consensual” vs. “nonconsensual” in an adolescent 15 or older. (See Appendix A regarding mandatory October 2014 – Pima County Protocols for the Multidisciplinary Investigation of Child Abuse, page 22 reporting) If termination is planned, Law Enforcement should be notified so that fetal tissue can be obtained for paternity testing when appropriate. The County Attorney should be consulted in any questionable cases. f. Family or Child in Crisis - In the setting of a disclosure, even when the child has no physical symptoms or forensic evidence is unlikely, an urgent exam should be obtained to give reassurance to the child and family if they are having severe emotional conflict. 2. Non-Urgent Forensic Medical Exam (scheduled during the regular medical exam hours) a. On-going chronic sexual abuse – Those cases with disclosure indicating more remote (weeks & months) activity. b. Extreme Sexualized Behavior – Exam needed if child gives a history of molestation, or a therapist after working with a child for a while feels that sexual abuse has most likely occurred. c. Custody Disputes - Allegations of potential abuse are handled in the same manner as in non-custodial cases. If a verbal child does not disclose sexual abuse during his/her forensic interview, and there’s no other indication of sexual victimization, no medical evaluation shall be necessary. If a medical exam has been conducted, repetitive exams will be avoided unless additional history is very suggestive of medical necessity. The forensic examiner may have to involve other medical or psychosocial personnel in the event of a parent requesting frequent exams which cause anxiety and emotional conflict for children. d. Non-verbal, pre-verbal, or special needs children (without symptoms) – One medical evaluation should ideally be conducted when an allegation of sexual abuse is made. However, some children may be referred to the Advocacy Center for second opinions after a community caregiver has done the initial exam. Procedures for Forensic Sexual Abuse Evaluation: These aspects of the exam are pertinent to all cases, regardless of the time interval from the incident. A. Complete medical history (including immunizations) will be obtained at the time of the exam (by guardian, DCS, the child or the family). B. Child is offered a choice of having the exam with or without a supportive person (of his/her choosing). If this person is disruptive or inappropriate, the adult shall be asked to leave. C. After the completed physical exam, the genital and anal areas will be examined with good lighting, and whenever possible with the colposcopy for magnifications, and in some case, colposcopy photographs. D. Any signs of trauma, recent or remote will be documented on body diagrams, and photos, whenever possible (with documentation and reference standards). Medically directed forensic photography through the use of agency personnel may be conducted to further document non-genital injury. October 2014 – Pima County Protocols for the Multidisciplinary Investigation of Child Abuse, page 23 E. Appropriate lab testing for pregnancy, sexually and non-sexually transmitted diseases will be obtained. F. A forensic medical report will be completed and used for documentation, and recommendations addendums will be provided if any follow-up exams or test results return with positive findings. Acute Assault Exams: Use of the sexual assault kit, in appropriate settings includes the following: A. Paper bagging of individualized items of clothing. B. Collecting specimens from body orifices via swabs. C. Collecting other debris (trace evidence) which may be present. D. Collecting specimens via swabs of the areas that may have perpetrator body fluids (bite marks, semen dried on skin) using the Wood’s lamp. E. Proper drying using swab drying device (using non heated air) and handling all materials with gloves F. Maintaining the chain of custody. The collection described above is optimal when done prior to bathing, changing clothes, or urination/defecation. Pregnancy and STD prophylaxis need to be considered and offered where appropriate. See Appendix P for triage procedures for Emergency Sexual Abuse Exams. Procedures for Physical Abuse & Neglect Evaluations A. Physical abuse ranges from minor injury to death. The most serious injuries, and the most frequent deaths are in children “too young to get away” and too young to tell,” or those who have special needs or behavior problems. B. Urgent examination is necessary for obvious, visible injuries, but the potential of hidden internal and skeletal injuries must also be excluded when physical abuse is suspected. These exams require facilities that are able to do diagnostic procedures and consult specialty staff (skeletal surveys, CTS, MRIs, ophthalmologists for retinal injuries, etc.). C. Injuries sustained by children that are non-accidental are suspected when there is inconsistent or absent history. When there are multiple injuries in different stages of healing, locations not commonly injured (abdomen, genitals, etc.), or delay in obtaining medical care. Changing doctors frequently, and using different urgent care treatment centers to avoid detection of the frequency of a child’s visits is also suspicious. D. Non-emergency medical evaluations should be scheduled at the Children’s Advocacy Center after a child has had a forensic interview, if possible. Medical exams are needed in most physical abuse incidents wherein legal proceedings are anticipated. It will be necessary to collect physical evidence related to the child’s condition or injuries. This includes all the injuries, and not just the most obvious or serious ones. E. Reference standards (measuring tapes, gray scale, and color wheels) and multiple angle shots are necessary to photographing bruises and injuries that will be documented in the forensic medical record. October 2014 – Pima County Protocols for the Multidisciplinary Investigation of Child Abuse, page 24 F. The forensic examiner may need to review all past medical records, tests and pertinent information in order to give an opinion in establishing a physical abuse or neglect case. Referral to specialists for diagnostic procedures (i.e., skin biopsy) may also be included in these cases. In some cases, appropriate lab studies may be necessary to exclude bleeding disorders or inherited disorders. Communication and Information Sharing with the Southern Arizona Children’s Advocacy Center All medical records released to DCS and/or Law Enforcement should be made available to the forensic examiner at the Children’s Advocacy Center, and all pertinent past medical history (including immunizations) should be obtained if a family member doesn’t accompany the child. Information regarding the disclosure (who, what, when, where, why, and how) needs to be available to the forensic examiner at the time of the exam. Children with positive test results for sexually transmitted diseases need to have the written report accompany the child. DCS or the child’s guardian is required to sign a request for the HIV testing. Following the exam, the forensic examiner summarizes the findings, recommendations, and any follow-up needed. In joint investigations, it is expected that this information will be shared between the investigators in a timely manner. The child’s guardian is given whatever information is necessary for the health and welfare of the patient, and encouraged to contact the Children’s Advocacy Center if any new symptoms develop. Results of positive labs are shared with the patient (when appropriate), guardian, DCS, and Law Enforcement, as well as suggestions for medical follow-up if necessary. The guardian is given information on the health and welfare of the patient, as well as information on any needed medical follow-up and/or further testing or to establish primary care. A complete medical report and psychosocial report are distributed to DCS and Law Enforcement. Records, including lab reports, may be forwarded to community physicians but require a parental or custodial (DCS) signed release. Medical personnel will take precautions to maintain patient confidentiality, and will contact patient/family members with DCS involvement if further information is needed. It is expected that unusual situations or difficult issues may arise which require a team staffing to facilitate the overall management of a case.

https://www.pcao.pima.gov/documents/2014_Child_Abuse_Protocol%20Final.pdf