Pediatric Sexual Abuse: An Evidence-Based Approach to Optimizing Care

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1 Pediatric Sexual Abuse: An Evidence-Based Approach to Optimizing Care 2017 NPSS Asheville, NC Kathleen S. Jordan, DNP, MS, FNP-BC, ENP-BC, SANE-P Clinical Assistant Professor UNC Charlotte Graduate School of Nursing Nurse Practitioner Mid-Atlantic Emergency Medicine Associates Charlotte, North Carolina

2 Pediatric Sexual Abuse: An Evidence-Based Approach to Optimizing Care The speaker has no disclosures for this presentation

3 Pediatric Sexual Abuse: An Evidence-Based Approach to Optimizing Care Objectives: 1. Describe the incidence, prevalence, and classifications of pediatric sexual abuse in the United States. 2. Based on current evidence, discuss the developmental approach to the history and physical examination of a child with suspected sexual abuse, identifying essential clinical information that should be included. 3. Integrate clinical practice guidelines into the management of a child with alleged sexual abuse.

4 Child maltreatment: the largest hidden epidemic in our country Bruises heal The pain lasts forever

5 Child Maltreatment Statistics in the U.S. (2015) > 3 million cases reported to DSS ~ 500,000 cases substantiated 1,670 fatalities 80% under the age of 4 60% of child deaths cause by abuse are not recorded as such on death certificates $124 billion/year National and State Child Abuse and Neglect Statistics

6 The United States has the worst record of all industrialized nations for child fatalities due to maltreatment US Department of Health and Human Services 2015

7 North Carolina Investigations (Unique children)

8 Classification of Child Maltreatment

Pediatric Sexual Abuse The involvement of a child in sexual activity that he or she does not fully comprehend and is unable to give informed consent Or That violates the laws or

9 Pediatric Sexual Abuse The involvement of a child in sexual activity that he or she does not fully comprehend and is unable to give informed consent Or That violates the laws or social taboos of society Can occur between a child and a person or persons of any age or relationship to the child The general intent is to gratify or satisfy the needs of the other person

U. S. Federal Law 18 U.S.C. 2246 Broadens the intent of sexual abuse to include to abuse, humiliate, degrade, arouse or gratify the sexual desire of any person Factors to consider: 1.

10 U. S. Federal Law 18 U.S.C Broadens the intent of sexual abuse to include to abuse, humiliate, degrade, arouse or gratify the sexual desire of any person Factors to consider: 1. Age of the child and/or perpetrator The age of consent is 16 years ( non-forcible ) < 4 years age difference Romeo and Juliet Law 2. Relationship between the child and the perpetrator

12 Who are the perpetrators? Usually someone known to the child most risk from relatives Juveniles Develop relationship with child s family to allow contact with the child Progression from seemingly innocent touching to inappropriate touching Grooming Internet has provided a new vehicle for perpetrators to gain access to child victims and provide rapport building opportunities Most often sexual desire is not the prime motivator A need for power and control

13 Acts of Sexual Abuse Touching Non-Touching Sexual Exploitation

14 Touching Sexual Abuse Offenses Fondling Forcing a child to touch an adult s sexual organs An adult touching a child s sexual organs Digital or object penetration of the anus or vagina that doesn t have a medical purpose

15 Disclosure as told by a 5 year old female to her Mother during her bath It hurts when you wash me down there Mommy. Jason must have licked me to hard this time

16 Non-Touching Sexual Abuse Offenses Indecent exposure Exposing children to pornographic material Deliberately exposing a child to the act of sexual intercourse Masturbation in front of a child

17 Sexual Exploitation Offences Engaging a child for the purposes of prostitution Human Trafficking Using a child to film, photograph or model pornography

18 Disclosure: 42 year old uncle speaking to an undercover police officer about his 8 year old niece Laughing. Do you believe that she actually came to me tonight to ask me if we could take more pictures after her Dad leaves for work?

19 Sexual Abuse vs. Sexual Play Developmentally consistent age and gender Consensual vs. Coercive Response of the child Lack of physical injury

20 Normal Sexual Behavior age 2-6 Touching/masturbating genitals in public or private Looking at or touching a peer's or new sibling's genitals Showing genitals to peers Standing or sitting too close to someone Trying to see peers or adults naked

21 Sexualized Behaviors: Occur frequently and cannot be redirected Causes emotional or physical pain or injury to themselves or others Is associated with physical aggression Involves coercion or force Simulates adult sexual acts AAP, 2016 Inserting objects into genitalia

22 Approach to the Child

alleged sexual abuse 73% of children do not tell anyone about the abuse for at least a year 45% of victims do not tell

23 Nurse practitioners must have the knowledge and skill set to care for this patient population Patients can be encountered in any setting or circumstance: Routine physical exams Sick child visit Consultation for behavioral issues Disclosure of alleged sexual abuse 73% of children do not tell anyone about the abuse for at least a year 45% of victims do not tell anyone for at least 5 years Clinical Pearl: Know the signs and symptoms Look beneath the surface Keep your index of suspicion high

Principles of Care Provide children with timely access to examinations, trained providers, and evidence-based quality care Child - Focused: Developmentally, linguistically, and culturally appropriate

24 Principles of Care Provide children with timely access to examinations, trained providers, and evidence-based quality care Child - Focused: Developmentally, linguistically, and culturally appropriate Patient - Centered: Timely, compassionate, respectful and appropriate care to promote healing Trauma Informed: Recognize the effects that trauma can have on children s behavior, coping strategies, relationships and ability to interact with health care providers, law enforcement, and other professionals

25 Obtaining the History The history is the most important part of the evaluation ~ 95% of physical exams are normal IT IS NORMAL TO BE NORMAL

26 8 Month old sexually abused by her mother s boyfriend posterior hymenal, fossa navicularis and posterior fourchette lacerations Day #1 Progressive healing Day #24

27 Key Elements in Obtaining a History #1. ESTABLISH THAT THE CHILD S NEEDS ARE YOUR CENTRAL CONCERN Interview the child alone Open-ended questions Non-leading questions Avoid yes-no questions #2 REMEMBER OUR PURPOSE IS ON DIAGNOSIS AND TREATMENT History is permitted as Medical exception to the hearsay rule only if we obtain the information #3. DOCUMENTATION IS CRITICAL, USE QUOTES

they feel safe disclosing They want to prevent more abuse They want to protect

28 Reasons Children Disclose They have a class that talks about abuse They watch a film/tv program that talks about abuse They move or the perpetrator moves so they feel safe disclosing They want to prevent more abuse They want to protect a sibling or friend from abuse Someone questions the reason for the child s behavior

29 Disclosure as told by a 16 year old female speaking of her biological father You go get in your bed and wait for me. After you do what I want you to do for me, I will let you go to your cousin s house and spend the night

30 Reasons Children Do Not Disclose: Lack of awareness Fear of incrimination Fear of rejection Fear of punishment Self-blame Embarrassment Coerced silence

31 Disclosure as told by a 10 year old female speaking of her biological father: He told me if I told anybody that he would go back to jail. I would never see him again, and we would be homeless again..he called it the father-daughter secret and told me that all father s and daughter s do this, it is special

32 I wanted to tell but HPI: 12 year old female with a CC: pelvic pain and vaginal bleeding. Reports that she has been experiencing pain in her private area and heavy bleeding with her periods for 5 months. She has gone to her school nurse x3 and her pediatrician x2 for this. She was told that her symptoms were normal and given a Rx for Naproxen. PE: General: Pale, diaphoretic and dyspneic VS: BP 66/40 P 166 RR 36 T 97.2 SaO2 98% Abd: Soft, lower abdominal tenderness GU: Severe active vaginal bleeding Labs: Hgb 5.2 gm/dl Plan: OR for diagnostic exam under anesthesia, repair of extensive vaginal lacerations PICU Multiple blood transfusions I wanted to tell someone but I was afraid that he would hurt me even more and that no one would believe me anyway

Signs and Symptoms of Potential Sexual Abuse Younger Children Compulsive masturbation Excessive curiosity about sex Sexual acting out with

33 Signs and Symptoms of Potential Sexual Abuse Younger Children Compulsive masturbation Excessive curiosity about sex Sexual acting out with peers Becoming seductive Bet wetting, soiling Altered sleep patterns Learning problems Separation anxiety Fears and Phobias Somatic complaints

Seductive behavior Aggression towards peers Failing grades

34 Signs and Symptoms of Potential Sexual Abuse Pre-Puberty and Teenage Years Sexual inference in art work Excessive bathing Seductive behavior Aggression towards peers Failing grades Depression/suicide attempts ETOH or drug abuse Early marriage Pregnancy

Sample interview questions: Do you know why you are here today? Has something happened to you? Is there someone that is concerned about you? Has someone touched you in a way that bothered you?

35 Sample interview questions: Do you know why you are here today? Has something happened to you? Is there someone that is concerned about you? Has someone touched you in a way that bothered you? When did this happen? How many times? What did he or she touch you with? Have you told anyone? Let the child know that they did the right thing Emphasize that they are not at fault and did nothing wrong THIS MAY BE THE MOST IMPORTANT MESSAGE THE CHILD WILL HEAR

36 Physical Exam Timing? Emergent: Acute medical concerns (e.g., bleeding, pain) Need for evidentiary exam (within 72 hours) Need for emergency contraception Need for PEP for STI s including HIV Human trafficking Urgent: - Reported sexual abuse within the previous 2 weeks without emergent needs Non-urgent: Disclosure of abuse abuse by child, sexualized behaviors, family concern but contact occurred more than 2 weeks ago and without emergent needs

THE PHYSICAL EXAM Can promote the child s healing reassure that they are normal Head to toe exam assess for all types of abuse and neglect Explain, answer questions, address

37 THE PHYSICAL EXAM Can promote the child s healing reassure that they are normal Head to toe exam assess for all types of abuse and neglect Explain, answer questions, address specific needs and concerns Document verbatim spontaneous statements made during exam Familiarity with genital and anal anatomy Use accurate and precise language Use diagrams and picture

38 Ecchymosis in various stages of healing

39 Examination of the Female Genitalia In general, exam is limited to inspection of external areas Speculum ONLY in prepubescent girls with concerns for bleeding, mass or foreign body, or sexually active postpubescent girls NEVER force any part of the exam Remember that abused children are already experienced the abuse of authority and control Sedation ONLY with concerns for significant anogenital bleeding or injury, or foreign body

40 What am I looking at? Mons pubis Labia majora and minora Clitoral hood and clitoris Urethra and periurethral structures Perineum Posterior fourchette Fossa navicularis Hymen Vaginal vestibule

41 Examination Positions and Techniques Supine Frog-leg Allows for visualization of the labia, ease of labial separation and traction techniques Confirm abnormalities in the prone-knee chest position

42 Labial Separation

43 Labial Traction Allows for view of the hymen, vaginal opening and posterior fourchette

44 Prone Knee-Chest Position Allows for confirmation of hymenal findings, and visualization of anus, surrounding tissues, and rectal cavity during relaxation

45 Hymnology 101 Recessed structure that sits at the entrance to the vagina in all children Imperforate Hymen rare Appearance changes under the influence of estrogen Assessment includes: shape, size, signs of trauma or scar tissue Do not describe a hymen as intact Crescentic Hymen

46 Description of the Hymen Document the genital structure assessment and findings using the clock face analogy

47 Annular Hymen

48 Septate Hymen

49 Redundant Hymen

50 Cresentic Hymen Supine Position Knee-Chest Position

51 IMPORTANT PHYSICAL FINDINGS Discharge or lesions Lacerations, Abrasions or Bleeding Ecchymosis Posterior (inferior) hymenal ring abnormalities External Anal Exam abnormalities Confirm findings in knee-chest position

52 Documentation Use standard terminology and descriptive language Classification of injury Site Size (measure) Shape Surrounding tissue Color Age Borders, Depth Pattern Use quotations Use body diagrams/maps and photo documentation

53 Sexually Transmitted Infections Prevalence is low in prepubertal children(<5%) STI s in children strongly suggests sexual abuse Consider perinatal transmission Consider the need for testing on a case-by-case basis Penetration Abused by a stranger Abused by someone at high risk/known for STI Person in the household with a STI High rate of STIs in community Signs or symptoms of STI Prior STI Caregiver request for testing

STI Testing Gonorrhea and Chlamydia Prepubescent females urine NAAT, follow-up positives with a culture **NO DNA Gen probe Males Culture Oropharyngeal

54 STI Testing Gonorrhea and Chlamydia Prepubescent females urine NAAT, follow-up positives with a culture **NO DNA Gen probe Males Culture Oropharyngeal and anal culture (do not test for oropharyngeal Chlamydia) T vaginalis Wet mount HSV Culture or PCR Type-specific serology Syphilis Serology HIV Serology?PEP

55 Clinical Practice Guideline Defer STI treatment until after initial tests are conducted and any positive results are confirmed with follow-up tests CDC, 2015

CC: 2 yo with bruises and vaginal bleeding. Mother reports that she observed bleeding in diaper when changing her prior to coming to the ED tonight. No prior history.

56 CC: 2 yo with bruises and vaginal bleeding. Mother reports that she observed bleeding in diaper when changing her prior to coming to the ED tonight. No prior history. PMH: Denies Immunizations: UTD Social History: GOK She must have fallen off her toy. She s a climber.. PE: VSS. Cries when approached. Bruising on face, left supraclavicular area, and bilateral anterior inner thighs. Genital exam..

57 Genital exam Genital bleeding, transection of the hymen and laceration of the fossa navicularis and posterior fourchette

58 13 month old with CC: cries when she urinates

59 A interprofessional approach is mandatory for the safety and protection of children Medical providers Nursing Law enforcement Social Work Child Protection Services Victim Advocacy Follow-up in a Child Advocacy Center

60 Final clinical pearl: There is evidence that physicians miss opportunities for early identification and intervention. This is especially true for infants and toddlers who are at the highest risk of life-threatening and fatal injury at the hands of their caregivers Keep your index of suspicion high for the safety and protection of children. Bruises heal. but the pain lasts forever. AAP Clinical Report, 2015

61 Thank you for your attention! And Thank you for caring!

62 References Barlow, S., Freeborn, D., Cole, B., & Williams, M. (2012). Advanced practice nurse barriers to reporting child maltreatment. American Professional Society on the Abuse of Children, 24, Chadwick, D. L., Castillo, E.M., Kuelbs, C., Cox, S. A., & Lindsay, S.P. (2010). Missed and missing cases of abusive injuries: The magnitude and the measurement of the problem. Child Abuse & Neglect, 34, Jordan, K., MacKay, P., Woods, S. (2016). Child maltreatment: Optimizing recognition and reporting by school nurses. NASN School Nurse. Epub, In press. Jordan, K. & Nadler, M. (2014). Children at Risk of Maltreatment: Identification and early intervention in the emergency department Advanced Emergency Nursing Journal, 36, Louwers, E. C., Affourtit, M. J., Moll, H. A., dekoning, H. J., & Korfage, I. J. (2010). Screening for child abuse at emergency department: A systematic review. Archives of Disease in Childhood, 95, Menoch, M., Zimmerman, S., Garcia-Filion, P., & Bulloch, B. (2011). Child abuse education an objective evaluation of resident and attending physician knowledge. Pediatric Emergency Care, 27, U.S. Department of Health and Human Services. Administration for Children and Families. (2016). Child Maltreatment NPSS ASHEVILLE, NC

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