MEDICAL AND LEGAL EVIDENCE IN CHILD PROTECTION

Transcription

1 MEDICAL AND LEGAL EVIDENCE IN CHILD PROTECTION ASTRID HEPPENSTALL HEGER, M.D. Professor of Clinical Pediatrics Keck School of Medicine, and S. Mark Taper Family Advocacy Center 1721 Griffin Ave. Los Angeles, CA (323) Telephone (323) Facsimile State Bar of Texas SEX, DRUGS & SURVEILLANCE January 10-11, 2013 Houston CHAPTER 9.2

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3 TABLE OF CONTENTS POWER POINT PRESENTATION - MEDICAL AND LEGAL EVIDENCE IN CHILD PROTECTION... 1 ATTACHMENTS - PRESS MATERIALS i

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5 Medical and Legal Evidence in Child Protection Medical experts called to give evidence in court must know the scientific basis and published literature on which his/her statement and opinions are based The Rt Hon Baroness Butler Sloss GBE Medical and Legal Evidence in Child Protection Child Protection Evidence Base Evaluation of the Sexually Abused Child: Review and Update Astrid Heppenstall Heger, MD, Keck School of Medicine, 1

6 Question # 1 What have we learned about sexual abuse and normal anatomy through the use of standardized methods, language and photodocumentation??? Non Specific Findings Variations in Hymeneal Morphology Variations in Hymeneal Opening Size Bumps and Notches Peri hymeneal/peri urethral Bands Intra vaginal Findings Estrogenization Vascular Changes 2

7 Congenital Findings Peri urethral Support Bands Longitudinal Intravaginal Ridges Bumps and Tags Clefts: Ventral and Posterior Linea Vestubularis External Ridge Labial Adhesions Vascularity and erythema Hymeneal Opening Size Changes with: Age Development/Weight Position Traction Measurement Techniques Hand held Colposcope/with Caliber Computer Imaging 3

8 Comparison of Hymen Anatomy Pokorny 1987 McCa nn 1990 Berenson, Heger 1991 Gardner 1991 Berenson, Heger 1992 Heger 2000 Myhre 2003 Number * Median Age 66 Newborns Months Annular/Conc 27% 43% 73% 19% 22% 53% 6.7 entric Crescentric/ Posterior Rim 45% 44% 7% 62% 36% 29.2% 78.4 Sleeve-Like Redundant 20% 9% 14.9%** Transitional 6.2 Fimbriated 19% 33%.5 Septate 2% 1% 1% 2% Other or Unable to Determine 7% 9% < 1% 5/6.7%** * <% 7.2% * Using traction **includes fimbriated ***Remnant McCann 1990 NonSpecific Findings Berenson, Heger 1991 Gardner 1991 Berenson, Heger 1992* Heger 2000 Berenson Chacko 2000* Number Periurethral Bands 50.6/16% Frequent 19% 98% 91.8% 95% 2.3% Myhre 2003 Longitudinal Intravaginal Ridges 90.2% 56% 25% 93.8% 87% Hymenal Tag 24.4% 13% 2% 3% 3.4% 5% 0/ Hymenal Bump or Mound 33.8% <1% 11% 7% 34% 46% 23.4/ Linea Vestibularis 15.7% 23% 4% 19% 7% 2.2 Ventral Hymen Cleft/Notch at 12 Ventral Hymen Cleft/Notch 1.2% 24% 8% 79% Excluded 6.6% 3.3% 2% 8% 19% Excluded Failure of Fusion 0.6% External Ridge 86% 15% 8% 2.3 Erythema 56% 48.9% 37% Change in Vascularity 30.9% 44% 5% 37.4% 7% 10.3 Labial adhesions 38.9% 17% 15.6% 7% 7.7 Hymenal Notch/Cleft Posterior Hymenal Concavity Posterior 19%* 33%* 18.3% 3.5% * did not include fimbriated 5.8%** 29.5% Inc. in Notches Folded out *Fimbriated Hymen (3+Notchess-were excluded) **Angular Hymen 4

9 Non specific Anal Findings Reflex anal dilation; constant or intermittant Venous pooling or congestion Erythema Thickened folds; flattened folds Fissures Diastasis Ani (smooth area; dimple/depression) Perianal Tag Change in pigmentation Findings McCann, 1989 Berenson, 1993 Heger, 2000 Myhre, 2001 Number Anal Dilation 130/267 49% % 10.8% (18.8% KCP) Intermittant RAD 81/130 62% 2.2% (KCP) Venous Pooling/ Congestion 83/113 73% % 16.7% Thickened Folds 54.2% Irregular folds: 2.6% Anal Fissures 1 7% Diastasis Ani 21/81 26% 26% 81.3% 12.7% (KCP) Perianal Tag 18/164 11% % 6.6% Increased 74/251 30% 10% 78% pigmentation Flattened folds 43% Scar 4/240*** 0 0% 0 Erythema 68/168 41% 7% 9.5% Dimple/Depression 15/81 18% 11.2 and 19.5 (KCP) ** Not photographed Normal/Non specfic Perianal Findings 5

10 Question # 2: What should we expect when we are asked to evaluate a child for possible sexual abuse? Children referred for evaluation of Sexual Abuse Most research reports on findings in this group Findings are not tested against normal studies or healed studies Most errors made in this group because of template errors, i.e. notches, narrowing, thickening, concavities, hymenal openings etc. What would be a predictable percentage of abnormal medical examinations in children who disclose abuse? 6

11 Sexual Abuse Research: 25 years DATE Orr 1979 Cantwell1 983 Emans 1987 Hobbs 1987 Adams 1994 Kellogg 1998 Bowen 1999 Berenson 2000 Number Heger 2002 Ages <16 (9.2) <13 < 15 (5.6) <15 (8) <17 (9) < 14 (4.6) <18 7.1) <8 <1 4 (6.9; 5.5) % Abn. 23% 84%* 30% 83% M 58 % F 23% 15% (3% definitive) 8.3% 2.5% 4% Vagina 35% 84% 30% 58% 14% Same 8.3% 2.5% 6% F 1% M Anal n/a NA 83% M, 7% 0% n/a 1% 25% F Other 7% STI 6% Trauma 2.5% STI n/a 3.1% STI n/a n/a * Hymenal opening size only. Bowen and Aldous, 1999 History Normal Non- Specific 1 Specific 2 Definite 3 Other 4 Total Normal/non- Specific Definitive 49.5% 34% 12.8% 1.6% 2.1% 98.4% or Probable Suspicious 39.7% 54.8% 2.4% 0 3.2% 100% NoHistory 53.5% 35.2% 2.8% 0 8.5% 100% 1. Non specific:erythema, bumps, septa labial adhesions 2. Specific/suggestive: acute trauma, narrowing, angular deformities 3. Definite: Semen, STD s 4. Other: Medical conditions or accidental injuries 7

12 Berenson and Chacko, 2000 Hymenal findings: Abused N=192 Non-abused N=200 LIR 89% 87%.65 Periurethral baneds 94% 95%.83 Hymenal bands 55% 60%.31 Tags 3% 5%.29 Bumps 46% 46%.92 Notches* Superficial 7% 5%.52 Deep 1% 0.24 External Ridges 8% 8%.92 Vascular changes 8% 7%.70 Transections 1% 0.49 Perforation 1% 0.49 *Excluded notches in fimbriated hymens; see original 1992 article. P-value LAC+USC: Patterns of disclosure : Medical findings Total Sample N=2384 Disclosing Group N=1652 Non-disclosing Group N=732 Non-Disclosing Group Non-disclosing N=550 Medical only N=182 Normal examination % % % % % Abnormal Examination 88 4% 72 4% 16 2% 1 0.2% 15 8% Age of victim 6.6 years 7.6 years 4.4 years 4.4 years 4.4 years Gender: Girls % Boys % Girls % Boys % Girls % Boys % Girls % Boys % Girls % Boys 25 14% Age: 6.9 years 5.5 years 7.9 years 6.2 years 4.3 years 4.5 years 4.3 yrs 4.5 yrs 4.4 yrs 4.5 yrs 8

13 Severe and Non Severe forms of Abuse Abnormal Medical Findings in Disclosures Severe Abuse % of total Abnormal Examination % of severe abuse Non-severe Abuse % of total Abnormal Examination % of non-severe abuse Girls N= % 61 6% % 8 2% Boys N= % 2 1% 74 30% 1 1% Question # 3 What should we expect when a child presents with acute injuries??? How do these injuries Heal??? 9

14 Genital Trauma Accidental Trauma: Present because of the injury. Straddle injuries Penetrating trauma Sexual Assault: Present because of the history or injury May be free of trauma Penetration? Accidental Genital Trauma Straddle injuries Bruising of labia, peri urethral and perineum Often presents with posterior injuries May be penetrating and mimic sexual assault 10

15 Accidental Trauma: Review of Literature Reports N History Location Injury Healed? West, Straddle 1 uncertain 1 Stretch 3 penetrating Labia Labia Tear PF Inner labia Bruise Bruise Tear Bruise N/a Dowd, Straddle 3 With penetration Pierce, Straddle 5 Penetrating 3Stretch 2 Scratch 3 SA 79% labia 16% PF 7% vagina 2% hymen 66 Anterior 20 Posterior Penetrating Bond, Straddle Labia minora De San Lazaro 98 34% Posterior 1 Hymenal Minor Laceration/abr. Pen: Laceration Asymmetrical Lac/Abrasion Split of perineum Tears to vestibule and vagina Minor (anterior or lateral to the hymen P F and Perineum Abrasion to hymen 4 Straddle Sandal injury V ertical, linear, midline, may involve the perineum and PF Note: 5later disclosed SA Note: Accidental penetrating no PF damage PF not intact with SA NA Boos, 99 1 Straddle Labia Hymen Iqbql, % Straddle 23.5% Blunt \ 6% Penetrating 64% Labia 7./8% PF 8.4% Hymen Tear Hymen full laceration (6) And (8) Partial Tear All demonstrated lacerations with some requiring surgery Resolved 6 Trauma of Sexual Assault Examinations are usually normal Nature of abuse (fondling, simulated inter course, anal and oral penetration) Delay in reporting (trauma is healed) Estrogen is protective Protocols: Emergency: <72 hours Urgent:<Less than two weeks Scheduled: Over two weeks 11

16 Date Finkel, 89 McCann, 92 Heger, 03 Kellogg, 2004 McCann 07 Anderst, 09 Number 6 Prepubertal 3 Prepubertal 94 (prepubertal) 36 (Adolescent) 113 Prepubertal 506 Adolescent Accidental Self report penile genital NAT (Pregnant) unknown penetration Acute Healed 5 with superficial findings 1 Case deep laceration Reports of Ano Genital Injury 2 Deep lacerations ; 1 Partial TX See next slide 18 Hymenal lacerations Normal % 35/36 15 healed 87% (>10 X) Other 1 Hymen distorted and scars 2 Hymen Irregular, jagged border 22% with findings diagnostic of penetration 2/36 with evidence of penetration 3 persisted with transection 56 had positive exams 52 without history of consensual sexual activity LAC+USC Longitudinal Study 94 Cases of genital trauma followed to healing Accidental trauma 27 cases straddle and penetrating injuries Sexual Abuse: 19 Cases of anal trauma 48 Cases of sexual assault 12

17 Healing trauma: Location and type of injury : Heger 2003 Location of Acute Injury N Abrasion or Hematoma Nature of Acute Trauma Laceration or Tear Healed Trauma Vascular changes/ scars or transections, etc. Posterior Fourchette/ Fossa Navicularis healed as a vascular change Hymen healed as angularlity 35 Lacerations: Vascular changes: 12 Surgery: 10; 6=scars/4 vascular changes Labial fusion: 2 No changes :11 Abrasions: 1vascular change 25 Partial (8) Complete (17) Transections: (17) 6=surgically repaired/2 appeared normal 15=transections persisted unchanged 6 followed through puberty+unchanged Partial tear: (8): 5 healed with notching/narrowing Perihymenal tears healed with vascular changes Abrasions: normal Labia minora & majora Two lacerations initially healed with change in vascularity However over time all trauma to the labia healed completely Anus* * abrasions & tears 6 & 12 o clock changes in Anal tone 2 cases developed herpes 1 skin tag 2 cases with hyperpigmentation (one after surgery for CA) Longitudinal Study Conclusions: 1. Transections of the hymen do not heal without surgical repair. There were no transections associated with digital vaginal penetration. Surgical repair does improve appearance of intactness in the preadolescent through puberty. 2. Partial hymenal tears and abrasions heal with findings that are either normal or non-specific. 3. Most trauma heals quickly; victims need to be examined emergently by experts. 4. Anal trauma heals quickly and completely. 5. Sexual assault was associated with the most egregious injuries 6. Accidental trauma: hymenal trauma in 32%; posterior fourchette in over 50% of cases. 13

18 Post Traumatic Changes Sexual Assault with History of Penetration PRE PUBERTAL Usually normal (history) Transections to base of hymen Loss of hymen Usually 3 to 9 o clock Posterior Fourchette lacerations/abrasions Anal Trauma Possible: Heals quickly POST PUBERTAL Extra genital trauma Normal/No Transections Hematomas and transections...partial or to the Base (4 8 o clock) Posterior Fourchette laceration/abrasions Anal Trauma Possible: Heals quickly Question # 4: What factors must we take into account when we complete an evaluation of sexual abuse and prepare a complete report and diagnosis??? What next??? 14

19 Triage: Who is the abuser? Abuse vs. Assault Known abuser/incest Over long period of time Delayed disclosure Medical findings minimal if any Unknown assailant One time episode May involve physical violence Quicker disclosure Medical findings are more likely Sexual Abuse Indicators No Medical indicators at all Genital Injuries Bruising, scratches, bites STD s Blood Stains in underwear. Dysuria, urethral discharge Abdominal/Pelvic Pain History Behavior changes Domestic/family Violence Physical Abuse 15

20 Value to Process The Interview Used as the basis of diagnosis for legal purposes History from Law enforcement Establish Rapport Sexual history Medical history History of assault The Medical Evaluation Preliminary Information Documentation Clinical Laboratory Treatment Injuries Pregnancy prophylaxis STD prophylaxis Mental Health/advocacy 16

21 Hand held camera Colposcope 35 mm Video Telemedicine Peer review Digital camera Photodocumentation The Colposcope: Advantages Documentation Replaces need for Re examination Magnification Peer Review Video colposcopy Networks/Telemedicine Computer Technology 17

22 Forensic Documentation Clinical Photodocumentation Trauma Genital Extra genital History Laboratory Cultures: STD S DNA and Trace evidence. (most often in young children at the site of the assault) Summary: Interpret post pubertal findings with caution Sexual Assault after puberty can occur without injuries and may leave a normal appearing hymen after healing. Actual Vaginal Penetration (across the hymen) of the pre adolescent will leave diagnostic transections. Pre adolescent transections do not heal with a normal appearance unless repaired. Anal Trauma usually heals without scarring 18

23 SUMMARY Sexual assault is a dangerous diagnosis that needs to be done by experts. History most important Documentation and chain of evidence. Medical treatment: HIV, Hepatitis B, Pregnancy and other STD s Forensic experts testimony Mental health Woman s & Children s Emergency Room Mary; age 12: Diagnosis: 34 weeks pregnant Sexual assault by Stepfather Medical and forensic evaluation Coordination of pre-natal services Adoption Counseling DCFS report CVC B.G. Doe 5# 3 oz.s Jan.1, 2001 Support during delivery DNA analysis & coordination with LAPD Adoption VIP CMHC Home schooling Parenting Therapy Tutoring After-school program Family interventions 19

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25 The mission of the Violence Intervention Program (VIP), in East Los Angeles, is to treat and protect all victims of interpersonal and family violence through a multi-disciplinary public-private partnership with LAC+USC Medical Center that offers medical, forensic, mental health and advocacy services around-the-clock to victims of child abuse and neglect, domestic violence, sexual assault, elder abuse and dependent adult abuse, as well as foster care youth The Center for the Vulnerable Child (CVC) is established at LAC+USC Medical Center to provide forensic, medical and mental health care to child victims of abuse and neglect. In 2003, the CVC was named the Everychild Foundation Center for the Vulnerable Child in recognition of a generous gift from the Everychild Foundation The Sexual Assault Center (SAC) is created in response to frequent requests from law enforcement and the legal system to evaluate non-pediatric victims of sexual assault. Teens and adults are offered the same services that have been provided to children in a safe and less traumatizing environment than the emergency rooms at the general hospital The Violence Intervention Program (VIP) is formed to serve as the umbrella organization for the child abuse program, sexual assault center and all future programs A 24-Hour Domestic Violence Response Team begins providing round-the-clock crisis intervention and advocacy to victims of domestic violence who are seen at LAC+USC Medical Center including the emergency departments, helping them navigate through medical and legal issues, social services and helping them identify a safety plan for themselves and their children. The team also provides training to healthcare professionals and medical students in recognizing the signs of domestic violence The Adult Protection Team (APT) is launched as the first hospital-based multidisciplinary team in Los Angeles County that focuses on elder and dependent adult abuse by providing medical assessments and appropriate interventions for victims of abuse and neglect The VIP Community Mental Health Center, Inc. (VIP CMHC) is incorporated as an exempt 501(c)3 nonprofit organization, to provide child victims and non-offending family members with crisis intervention, clinical assessments, individual, family and group therapy, mentoring, tutoring, case management and advocacy. In 2005, the VIP CMHC added a prevention program for high-risk teens that works with partners in the community and the school systems to break the cycle of domestic violence and empower teens to be advocates for themselves and their peers VIP undertakes its first capital campaign to renovate a 1930s building owned by the County of Los Angeles adjacent to the Medical Center. With a generous gift from the S. Mark Taper Foundation, as well as many other benefactors, the Taper Family Advocacy Center is opened and becomes the home to the VIP 21

26 administrative offices and the VIP CMHC. The VIP CMHC is given room to serve more children and families as well as expand its services to include the onsite Sanders Family Education Center and the Nike Play Yard The Community-Based Assessment and Treatment Center (CATC) opens to provide ongoing medical services, case management, developmental assessments and mental health services to children in foster care. CATC was the first of the HUBs, a network of clinics throughout Los Angeles County aimed at better caring for child abuse victims and foster youth and providing them with consistent healthcare homes The Los Angeles County Elder Abuse Forensic Center (LACEAFC) launches as a multidisciplinary team of medical, mental health, social service, legal, and law enforcement professionals to protect vulnerable elders and dependent adults from abuse and neglect. The LACEAFC provides expert and comprehensive case examination, documentation, consultation and prosecution of elder and dependent adult abuse cases throughout Los Angeles County VIP opens The Santana House, a newly renovated building adjacent to the Taper Center to house the LACEAFC, additional VIP CMHC offices including an Occupational Therapy program, and the Santana House Youth Action Center, home to VIP s teen prevention and community outreach program After the successful renovation of a portion of the LAC+USC Medical Center Outpatient Department, VIP opens the Forensic Urgent Care Center, combining all VIP medical services in one holistic location. Medical and forensic services for children which were previously divided in two separate clinics are now brought together in one expanded, state-of-the-art space, the CATC-HUB, with triple the exam and consultation space, onsite offices for law enforcement, social services and crisis intervention. Immediately adjacent is the APT with more exam rooms to meet the growing population of elders and dependent adults in need of care In collaboration with several LA County departments, VIP opens the Children s Welcome Center (CWC), also known as the Children Awaiting Placement (CAP) center. With a generous gift from Cornelia Funke, as well as several other benefactors, the CWC provides children with a safe and comfortable space while they await placement into foster care. 22

27 L.A. NOW SOUTHERN CALIFORNIA -- THIS JUST IN Violence intervention program gets new home at hospital April 26, :59 pm Los Angeles County celebrated the grand opening Thursday of the home for the Violence Intervention Program, which treats victims of violence and abuse on the campus of the L.A. County/USC Medical Center. The program provides medical, forensic, mental health and social services to victims of child abuse, domestic violence, sexual assault and elder abuse. The newly renovated building brings together all of the services in one location and has more exam rooms and waiting room space. There are medical exam rooms, as well as offices for law enforcement personnel and staff from the Department of Children and Family Services. There is also a day care center, which Violence Intervention Program director Astrid Heger said she would like to use to keep youths for up to 23 hours while social workers find them help. The building, which displays paintings from local artists, is much different than the small office at the hospital where the program started, Heger said. She said her goal was to have a place where patients, many of them children, could feel comfortable and respected while they get the treatment they need. "They deserve to have a place where they feel safe," she said. -- Anna Gorman Photo: Los Angeles County/USC Medical Center. Credit: Brian Vander Brug / Los Angeles Times 23

28 New L.A. County center gives foster children a place to sleep After more than a decade of troubled youngsters spending the night in a high-rise's waiting room, the Children's Welcome Center offers a hot meal and a bed for every child. Dr. Astrid Heger, center, talks with children's fiction writer Cornelia Funke, right, who donated funds for the Children's Welcome Center, and county Supervisor Gloria Molina. (Al Seib / Los Angeles Times / November 8, 2012) By Garrett Therolf, Los Angeles Times November 9, 2012 Leaders of Los Angeles County's embattled child welfare system believe they have solved one of their most intractable problems finding a place for some of the most troubled foster children to lay down their heads at night. For more than a decade, thousands of children - unruly teenagers, premature infants and others have spent uneasy nights in a high-rise building's waiting room, cramped together without sufficient beds or food while social workers struggle to find them a place in foster care. For some children, it was their first introduction to the system after being removed from their families. For others, it was just another stop after a series of failed placements. Too many returned night after night when daytime searches for new homes yielded nothing. In May, Supervisor Gloria Molina called it the county's "dumping ground." A new center at Los Angeles County-USC Medical Center, however, promises to provide a comfortable space to spend the night and a stronger team to assess the children and more quickly find them suitable places to live. The so-called Children's Welcome Center offers a hot meal and a bed for every child, and it was built largely with private money from wealthy Angelenos concerned about the youth. Among the philanthropists were Cornelia Funke, the children's author and illustrationist sometimes called the J.K. Rowling of Germany. 24

29 Dr. Astrid Heger, a prominent advocate for abused children at the hospital, helped spearhead the project. She said the center would give each child a real bed and clean pajamas. No more would they sleep under paper blankets on a bare floor. About 700 children have already passed through the center. On a recent night, she said, "there were these kids gathered around the table in the kitchen eating a hot spaghetti meal, and we wept not just us but the guys from facilities management had tears in their eyes." Molina stitched dozens of quilts for the children with her East Los Angeles sewing circle. "This doesn't solve everything we are still looking for a place for children 11 years old and up but this is a big step in the right direction," Molina said. Many of the attendees at the grand opening Thursday said that the center was long overdue and that the delay had been worsened by state officials who repeatedly inspected the old facilty and declared it suitable in response to complaints by county social workers and others that periodically emerged in news reports for more than a decade. Last year, for instance, one of the social workers in the waiting room documented problems, and his statement was used by advocates in a complaint with the state. "In some cases, the treatment that these children receive comes very close to the child abuse from which they are escaping," said Lincoln Saul, the social worker. But a spokesman for California Department of Social Services Director Will Lightbourne said his department investigated the claims and found the waiting room lawful and suitable. Others told a different story. Molina's staff visited a chaotic scene, including a 9-month-old infant who had been present at a drug bust, three pregnant teenagers and recently released juvenile offenders who were getting little sleep while social workers frantically juggled a multitude of after-hours child abuse investigations. Drugs were sometimes used openly, they said. The county auditor-controller found that some employees in the waiting room had not received the criminal clearance required to work in such a facility. And there was poor record-keeping for the children's stays and numerous safety risks. Molina called state director Lightbourne's approval of the old facility "something one bureaucrat tells another bureaucrat. But I said from one mom to another mom that anyone could see that was not a healthy place for a child." garrett.therolf@latimes.com Copyright 2012, Los Angeles Times 25

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