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Suspected Child Abuse Evaluation Protocol

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					                     Suspected Child Abuse Evaluation Protocol
                                       2008

                                                  Index
I. Goals and Objectives ………………………………………3

II. Definitions……………………………………………………3

  A.   Child
  B.   Child Abuse
  C.   Endangerment
  D.   Mandated reporters
  E.   Perpetrator
  F.   Serious Physical Injury
  G.   Serious Physical Neglect
  H.   Serious Mental Injury
  I.   Sexual Abuse or Exploitation

III. Directives………………………………………………….5

  A. Mandatory Reporting of Abuse

       1. Childline and Erie County Office of Children and Youth

       2. Law Enforcement Authorities

  B. Temporary Protective Custody

  C. Penalties for Failure to Report or to Refer Suspected Child Abuse

  D. Immunity from Liability.

IV. Referrals…………………………………………………..7

   A. Medical

   B. Counseling

   C. Victim Compensation Fund

   D. CAC

V. Screening for Suspected Child Abuse…………………8

    A. Red Flags



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B. Risk Factors

C. Interview

D. Physical Examination

E. Photography

F. Ancillary Testing

G. Additional Specimen Collection, Examination and Laboratory

    Testing for Suspected Sexual Abuse of Child

         1. Males and females

         2. Postpubescent Females

         3. Prepubescent Females

         4. Prepubescent Boys and Nonsexually active Adolescents.




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      Suspected Child Abuse Evaluation Protocol
I. Goals and Objectives
   The goal of this protocol is to ensure that the child is maintained in a safe environment and provided
   all necessary medical treatment.
   The objectives are to identify the child in need of protection, establish guidelines for the medical
   examination of a child suspected of being abused, and establish documented guidelines for
   assessment, intervention, and implementation of a referral process.

II. Definitions
   These definitions are intended as a guide. They are derived from Pennsylvania State Law and
   subject to periodic revision. Definitions vary by state. Please check state regulations for the
   complete definitions and the latest revisions.
      A. Child: In this protocol, a child is defined as a person less than 18 years old. This definition
      can be extended to include those individuals with a mental age less than 18.

      B. Child Abuse: Child abuse is defined as abuse occurring to a child and includes:

             any recent act or failure to act that causes nonaccidental serious physical injury;
             an act or failure to act that causes nonaccidental serious mental injury or sexual abuse or
              sexual exploitation;
             any recent act, failure to act or series of such acts or failures to act that creates an
              imminent risk of serious physical injury, sexual abuse or sexual exploitation; and/or
             serious physical neglect that endangers a child’s life or development or impairs a child’s
              functioning.

              Note: A child shall not be deemed to be physically or mentally abused for the sole reason
              that the child is, in good faith, being furnished treatment by spiritual means through
              prayer alone in accordance with the beliefs or practices of a recognized church or
              religious denomination. Also, a child shall not be deemed to be physically or mentally
              abused because of environmental factors beyond the control of the person responsible for
              the child’s welfare, such as inadequate housing, furnishings, income, clothing, and/or
              medical care.
      C. Endangerment: A parent, guardian, or other person supervising the welfare of a child under
      18 years old or a person that employs or supervises such a person commits an offense if he/she
      knowingly endangers the welfare of the child by violating a duty of care, protection, or support.
      The offense also includes circumstances where a parent, guardian, or other person supervising
      the welfare of a child under 18 years old or a person that employs or supervises such a person, in
      an official capacity, prevents or interferes with the making of a report of suspected child abuse.
      A person supervising the welfare of a child is defined as a person other than a parent or guardian
      who provides care, education, training, or control of a child.

      D. Mandated Reporter: A mandated reporter is a person who is required to report a suspicion
      of child abuse. This is a person who, in the course of employment, occupation or practice of a


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profession, comes into contact with children and has a reasonable suspicion of abuse or neglect,
whether it is through history or examination.

E. Perpetrator: In the judicial system, a perpetrator is defined as a person who has committed
abuse against a child. A person ten years and older can be charged with a crime. Children less
than ten are not generally charged with a crime due to culpability, but still require intervention
by Child Protective Services (CPS). Note: Child Protective Services (CPS) defines a perpetrator
as a person who has committed child abuse and is a parent, paramour of a parent, a person
responsible for the welfare of a child (including a person who provides mental health diagnosis
or treatment), or an individual, age 14 or older, residing in the same home as a child.

F. Serious Physical Injury: Injury is considered serious if it causes severe pain and/or
significant temporary or permanent impairment of physical functioning or is accompanied by
physical evidence of a continuous pattern of separate, unexplained injuries.

G. Serious Physical Neglect: This is a condition caused by the acts or omissions of a perpetrator that
endanger the child’s life or development, or impair the child’s functioning. This can be a result of
prolonged or repeated abandonment of a child not old enough to care for him/herself and includes a
willful or wanton failure to provide essentials of life by parents or person(s) responsible for the child’s
welfare who have the ability to provide those essentials.

H. Serious Mental Injury: This is a psychological condition as determined by a physician,
psychiatrist, or licensed psychologist that is primarily caused by the perpetrator by the acts or omissions,
including the refusal of appropriate treatment. This condition renders the child chronically and severely
anxious, agitated, depressed, socially withdrawn, psychotic, or in reasonable fear that his/her life and/or
safety is threatened. This condition may also seriously interfere with the child’s ability to accomplish age-
appropriate developmental milestones or school, peer, or community tasks.

I. Sexual Abuse or Exploitation:

    1. The employment, use, persuasion, inducement, enticement or coercion of a child
        to engage in or assist another individual to engage in sexually explicit conduct.
    2. The employment, use, persuasion, inducement, enticement or coercion of a child to engage in or
        assist another individual to engage in simulation of sexually explicit conduct for the purpose of
        producing visual depiction, including photographing, videotaping, computer depicting and
        filming.
    3. Any of the following offenses committed against a child:
        a. Rape; nonconsensual sexual intercourse
        b. Consensual sexual intercourse if the child is:
             less than 13 years old;
             less than 16 years old and has intercourse with someone 4 years or older;
             less than 18 years old and contracts a STD and/or becomes pregnant and the person
                 responsible is four or more years older than the child.

    Note: A 16-year old can legally consent to sexual relations; however, if a person is less than
    18 years old and becomes pregnant and/or contracts an STD, this is considered a form of
    physical abuse if the person responsible is four or more years older than the child.
    Contracting a STD or becoming pregnant changes the physical nature of the child’s body, so
    CPS considers pregnancy and STD’s a form of physical abuse. Childline needs to be
    notified.


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              c. Sexual assault (involuntary or voluntary deviate sexual intercourse):
                Sexual involvement, including the touching or exposing of the sexual or other intimate parts of
                  a person, for the purpose of arousing or gratifying sexual desire in either the perpetrator or
                  subject child.
              d. Aggravated indecent assault
              e. Molestation
              f. Incest:
                   Sexual intercourse with an ancestor or descendant, by blood or adoption,
                   brother or sister of the whole or half blood, aunt, uncle, nephew, or niece of
                   whole blood
              g. Indecent exposure
              h. Prostitution
              i. Sexual abuse
              j. Sexual exploitation
              k. Pornography-examples:
                      Obscene photographing, filming, or depiction of children for commercial purposes.
                      Obscene filming or photographing of children or showing of obscene films or
                      photographs to arouse or gratify sexual desire in the perpetrator, subject child, or viewing
                      audience.

III. Directives
   These directives are intended as a guide. They are derived from Pennsylvania State Law and subject
   to periodic revision. Directives may vary by state. Please check state regulations for revisions and
   state- specific mandates.
   A. Mandated Reporting

      Reports are made by mandated reporters to: 1) Childline, 2) Erie County Office of Children and Youth
      (OCY), and Law Enforcement Authorities, if appropriate. Note: The child does not have to “come before”
      the mandated reporter. The child does not have to describe the abuse to the reporter or even be directly
      evaluated by that person. Mandated reporters do not have to prove abuse or investigate a situation to
      ascertain a certain level of proof. Mandated reporters do have to contact the authorities whenever
      reasonable suspicion of child abuse exists whether the information is obtained directly from the child or
      from another individual whom to the best of the mandated reporter’s knowledge appears to be a
      reasonable reporter. When reasonable suspicion of abuse or neglect occurs, whether it is through the
      history or the examination, the person identifying or suspecting the abuse is legally required to contact the
      appropriate agencies as described below.
      The responsibility of the mandated reporter is to make authorities aware of a possible situation and the
      authorities to then investigate it to determine whether enough evidence exists to take action.


          1. Childline (State Agency) 1 800 932 0313 and Erie County OCY.

          Information that should be provided to Childline and OCY includes:

                        the name, age, address and phone number for the child;
                        the name, age, address and phone number of the parent, guardian, or
                  caretaker;
                        the nature and extent of the injury or illness;
                        the date of the onset of illness or when injury occurred;
                        the location of where the suspected abuse occurred, if known;
                        the name and address of the suspected perpetrator, if known;


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                       whether other siblings or persons are residing in the home with the child;
                       if any action has been taken, ie, police notified; admission to the hospital;
                       photographs; emergency custody; coroner notified; and
                       the reporting source’s name and phone contact number.

After a verbal report is given, a written report of suspected child abuse (CY47 Form) must be completed and
forwarded to OCY. (See Appendix 1) The above information is documented on the form and must be sent to
OCY within 48 hours of the verbal report. The original CY47 remains as part of the medical record and the
agency will receive a copy.
Note: If a child is brought to a health care facility with any severe injury, the Law Enforcement Agency in
the area in which the abuse may have occurred should be contacted (See below).

        2. Law Enforcement Authorities

In addition to reporting to Childline and OCY, if a child is brought to a health care facility with any of the
injuries listed below, the law enforcement agency in the area in which the abuse may have occurred should be
contacted. If a local Children’s Advocacy Center exists, the detective responsible for child abuse
investigations should also be contacted. Other suspected cases of abuse not on the list may be reported to law
enforcement at the discretion of the reporter.
In situations where the alleged abuse was committed by a person who does not meet the definition of
a perpetrator under the CPS, then Childline shall report immediately to the district attorney, the
district attorney’s designee, or other law enforcement official, in accordance with the county
protocols for investigative teams. (CPS definition: A perpetrator is defined as a person who has
committed child abuse and is a parent, paramour of a parent, individual, age 14 or older, residing in
the same home as a child, or a person responsible for the welfare of a child, including a person who
provides mental health diagnosis or treatment.)
                       severe physical abuse (assault and battery)
                       death
                       life-threatening injury or condition
                       multiple fracture sites
                       beating with an instrument or weapon
                       gunshot wound
                       stabbing
                       premeditated physical abuse or torture
                       multiple cigarette burns
                       immersion burns
                       mutilation
                       sadism
                       non-severe physical abuse, but history of sibling death due to child abuse
                       sexual abuse
                       deliberate poisoning


    B. Temporary Protective Custody

    The treating physician at a hospital and/or a police officer can detain a child without a court
    order. The law allows hospitals to detain children at their facility if they suspect the child has
    been or will be abused. This means the parent/caretaker is not able to remove the child from the
    hospital without the evaluation of the child by the OCY. The hospital is only allowed to detain



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     the child for a 24-hour period or when the OCY Services makes a decision to contact the court,
     whichever comes first.
     Once a court order is obtained for custody, the child can not be released from the health facility
     until cleared by the OCY. If the OCY Case Worker determines that the child must be placed in a
     setting outside of the home at the time of discharge, then the OCY Case Worker must obtain
     either a voluntary placement agreement by the parent or a court order to detain the child to the
     OCY custody. A copy of the agreement or the court order should be placed on the medical record
     at the time of discharge.

     If a report of suspected abuse has been filed to the OCY while the child was receiving treatment in the
     Emergency Department, but the child does not warrant a hospital admission, the child should not be
     discharged from the treating facility until a discharge destination has been determined by the OCY

     C. Penalties for Failure to Report or to Refer Suspected Child Abuse

     A person or official required to report a case of suspected child abuse or to make a referral to the
     appropriate authorities who willfully fail to do so commits a misdemeanor of the third degree for
     the first violation and a misdemeanor of the second degree for a second or subsequent violation.

     D. Immunity from Liability

     Any person, institution, school, facility or agency participating in good faith in making a report
     or testifying in any proceedings arising out of an instance of suspected child abuse pursuant to
     the act is immune from any liability, civil or criminal, for such actions.

IV Referrals

     A. Medical follow-up
         The child should receive appropriate referrals for medical follow-up, as needed. Depending on the
         discharge destination, case management may be needed to ensure the child is receiving appropriate
         treatment.
     B. Counseling
         Many areas have Children’s Advocacy Centers, Rape Crisis Service, Crime Victim’s Centers or other
         programs that will provide crisis and ongoing counseling and support for the child. With the legal
         guardian consent, the hospital social worker can make the appropriate referrals. If the center has a
         24/7 hotline, they may be able to assist immediately, if needed.
     C. Victim Compensation Funding
         An Attorney General, District Attorney’s Office, or Crime Victim Centers will be able to direct the
         family to the local organization that can assist them in completing an application for Victim
         Compensation Funds. If a crime has occurred and been reported to the police, these funds may cover
         some crime-related expenses, if insurance will not, ie, Emergency Department visit, follow-up care,
         counseling, etc.
      D. Children’s Advocacy Centers
         A Children’s Advocacy Center is an organization whose primary purpose is to provide a child-
         focused, facility-based program dedicated to coordinating a formalized multidisciplinary response to
         suspected child abuse.” The Centers will assist county agencies, investigative teams, and law
         enforcement by providing services such as forensic interviews, medical evaluations, therapeutic
         interventions, victim support and advocacy, team case reviews, and a system for tracking cases. The
         victim may be referred to the center for follow-up interviews, examinations and counseling services.


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Screening for Suspected Child Abuse
Often, a specific history of abuse or neglect will not be given on the child’s presentation for medical
treatment. Identification of abuse or neglect often depends on recognition of particular types of injuries
or complaints frequently seen with child abuse.

For Forensic Assessment Tool Click Here

A. Red Flags

              The child manifests a physical or mental injury not compatible with the history given, ie,
               fractured bone or intracranial injuries from a simple fall; immersion burn from child pulling
               hot liquid onto him/her self.
              The injury pattern is atypical for accidental injury, ie, bruises or burns shaped like objects
               that may have been used to inflict injury: hand print, teeth marks, belt, cigarette burns
               especially on palms, soles of feet, back of buttocks, immersion burns, on buttocks, and/or
               internal genital trauma.
              Injuries present are not those mentioned in the complaint, the complaint is irrelevant to the
               trauma detected upon physical examination.
              No explanation is given for the injury; more than one explanation is given; explanations are
               inconsistent.
              The explanation is not consistent with age or development of child. The history provided
               would have required behavior beyond a child’s developmental capability, ie, newborn
               rolling off a bed.
              Unreasonable or unexplainable delay occurred in seeking medical treatment for the child,
               even if a serious illness or injury is present.
              Child is brought in for treatment by someone other than the parent.
              Unable to locate parents, without appropriate explanation, ie, out of town.
              Parents affect is inappropriate to the child’s condition, ie, overprotective, overly concerned,
               totally unconcerned and unemotional about a serious injury.
              When questioned, parents are unreasonably defensive.
              Parents appear extremely hostile or withdrawn from the child.
              The child appears frightened or withdrawn from parent; the child may appear afraid to
               answer questions without direction from the parent.
              The child appears generally ill cared for.
              The child appears listless, unstimulated, and developmentally delayed.
              The child does not appear appropriately nourished.
              The child has history of frequent visits to Emergency Departments.
              The child has a history of repeated injuries or prior abuse.
              Evidence of hospital shopping or history of multiple medical providers exists.
              Consistent medical follow-up is lacking.
              Inadequate preventative care or lack of ordered follow-up care is evident.
              Recurrent vaginal infections in a child and/or genital injuries are present.
              Weight and length of child are specifically below normal for the age of the child (without
               medical explanation).
              Pain response is lessened, ie, femur fracture with no crying or fussing




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B. Risk factors:

       other violence or abuse in the home;
       substance abuse by a parent or caretaker;
       stressors, such as lack of money, loss of job, serious illness;
       lack of support systems;
       a history of abuse or neglect in the caretaker’s past;
       a large family, many children;
       mental health issues;
       single parent with a paramour as a caretaker;
       learning disabilities;
       unwanted pregnancy;
       poor parental supervision; and/or
       inappropriate corporal punishment in the home.

C. Physical Examination/Assessment

       A thorough examination should be performed on any child suspected of being abused or
        neglected.
       Note the child’s general condition.
       Determine the child’s weight and height. In the case of an infant or a child less than 2 ½ years
        old, record length and head circumference.
       Conduct a visual examination of the entire body.
       Note any bruises or markings by location, recording size, shape, and color.
       Examine the retina, ear drums and canal, oral cavity, genitalia, axilla, and soles of the feet for
        signs of occult trauma. Assess for absence of hair (alopecia).
       Palpate bones for tenderness and check joints for full range of motion.
       Examine the neck for ligature or choke marks, the chest for tenderness or deformity, and the
        abdomen and back for tenderness and bruising.
       Assess neurological status.
       Assess the developmental abilities.
       Note the behavior and emotional state of the child during the examination.




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    D. Interviewing:
In all cases, the following information should be obtained and carefully documented by a trained interviewer.
For a structured forensic interview technique click here


The interview process should be thorough, but nonthreatening. A primary concern should be the child’s physical
and emotional state. The interviewer should approach the child in a calm, friendly and unhurried manner. If
possible, the interview should be initiated with some general questions to help the interviewer ascertain the child’s
developmental age and to help the child feel comfortable with the interviewer. Examples of some questions
include, “What school do you go to? Do you have a nickname? How old are you?” Language should be simple
and appropriate to the developmental age of the child.
For a structured forensic interview technique click here
Ask one question at a time; don’t use sentences that have two or three questions in them. When possible, use
open-ended, nonleading questions. Move from gathering general to more specific information. If the child
becomes visibly anxious or withdraws, return to asking some rapport-building questions before requesting
additional information.
Examples
Open-ended                          Specific
What happened?                  vs. Did you fall out of a tree
Who else was there?             vs. Was your Mom there?
Where were you?                 vs. Where you home or next door?
Let the child know that your job is to help children feel better. Ask the child if he/she is worried or scared about
anything at this time; find out what that is. Address any concerns the child raises. If at all possible, interview the
child in private. Let the child know that you have to understand how the injury happened so that you can help fix
it. Tell them that sometimes children are afraid to tell how they got hurt because they think someone might be
mad. Ask if the child is afraid to tell you anything about what happened, find out why, and address the concern.

       If possible, interview caregivers, parents, and others separately
       Obtain the parent’s, caregiver’s, or other’s explanation of the cause of the injury or condition, including
        when and how it occurred, where it occurred, who was present, who was caring for the child at the time,
        when the person first became aware of the problem, and what the person did.
       Document by using the parent’s or caregiver’s own words.
       Clarify discrepancies or questions in a non-confrontational manner.
       Speak with the child in private, providing that the child is capable of giving a history. Obtain the child’s
        explanation of the injury or condition, including when and how it occurred, who was present, and where it
        occurred.
       Obtain an appropriate medical history (present, past, and family)




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E. Photography

If injuries or markings are visible on the child, photographs should be taken to document the injury. When
applicable, an informed consent for photographic evidence documentation of the injury should be obtained. The
type of photograph will depend on what equipment is available. Digital, 35mm, and Polaroid cameras are all
acceptable for photographic documentation. Digital and Polaroid are more convenient and easier to use for the
nonprofessional photographer.

       Each photograph should be labeled with the child’s name, date of the photograph, medical record number,
        the name of the person taking the photograph, and the body part.
       An identifying label that includes the name, date, and facility should be placed in the photograph with the
        child. Three different photographs should be taken to document each injury. These include:

            o    an overall photograph of the child that includes the face;
            o    a mid-range photograph showing the area of the injury; (This will orient the location of the injury.
                 For example, if a child has a bite mark on the left forearm, a photograph of the entire left arm and
                 shoulder should be taken. Make certain the injury is visible.) and
            o    a close-up photograph with the measuring device in place demonstrating length and width of
                 injury. If no measuring device is available, place a known object, such as a coin, next to the
                 injury. You can later assess the size of the coin compared with the size of the injury.
       The photographs/disc should be properly labeled, sealed in an envelope and stored per your facility’s
        policy. A locked evidence file specifically for record/photograph safe keeping is recommended.

F. Ancillary Testing

       Radiography

If a child less than 5 years old is suspected of being abused, a trauma survey or full body radiograph should be
considered. If a child is more than 5 years old, radiographs should be obtained if evidence of any bone tenderness
or limited ROM exists. If radiograph results are negative, repeating radiographs in two weeks to detect possible
calcification or subperiosteal bleeding may be warranted.

       Bone Scan
A bone scan should be considered in children less than 2 years old presenting with multiple bruises. A bone scan
may detect more recent trauma than a trauma survey and results can be used to complement findings on the the
bone films.

       Laboratory Testing
Depending on the findings, laboratory testing may be warranted. In children who fail to thrive and appear
malnourished, testing (below) is performed to assess their medical condition and to rule out any medical causes
for growth deficiencies.




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Appearance           Laboratory Tests                      Potential Diseases or conditions
                                                           (noninclusive)
Bruising                 Hemorrhagic Survey (below)
                            Complete blood count          Anemia, malignancy
                            Platelet count                Bone marrow disease, leukemia
                            Partial thromboplastin time   Clotting disorder
                            Prothrombin time              Clotting disorder
                            Bleeding time                 Bleeding disorder - indicates
                                                           how well platelets interact with
                                                           blood vessel walls to form
                                                           blood clots.
Bruising over back   Hemorrhagic Survey (above) and
or abdomen           Urinalysis                            Damaged kidney


Malnutrition and     CBC and differential                  Chronic bleeding, iron
failure to thrive                                          deficiency anemia, lead
                                                           toxicity, malignancy, and
                                                           infection
                     Urinalysis, urine culture             Kidney or bladder infection or
                                                           renal disease

                     Serum electrolytes                    Detects dehydration, acidosis
                     T4, TSH                               Hyperthyroidism,
                                                           hypothyroidism
                     PPD                                   Tuberculosis screening
                     Serum albumin, calcium, phosphorus,   Malnutrition, rickets, liver
                     liver function tests                  disease
                     Erythrocyte sedimentation rate        Chronic illness
                     Stool testing                         Intestinal problems.
                            Guaiac                        Occult blood
                            Culture                       Diarrhea, bacterial infection
                            Fat                           Malabsorption syndrome
                            Ova and parasites             Eggs, larvae, worms




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G. Additional Testing for Suspected Sexual Abuse of Child

       1. A Forensic Evidence Collection Kit
       This kit is used to collect specimens for evidentiary purposes in suspected rape. Instructions are present
       inside the kit for chain of evidence, collection of debris, foreign material, outer clothing, underwear, pubic
       hair combing, pulled pubic hair, pulled head hairs, known saliva samples, blood samples, vaginal, rectal,
       and oral swabs and smears for sperm and acid phosphatase, and documentation of medical history and
       assault information. The longer the time interval from the assault to the examination, the lesser the
       probabiltiy of any evidence being collectable. A maximum time interval post assault, usually 72 hours to
       96 hours, should be established. The forensic evidence kit should be utilized within this time frame.
       However, evidence may still be gathered by documenting any findings obtained during the medical
       examination (such as bruises or lacerations), photographs, and bite mark impressions (if appropriate). A
       genital/anal examination using the colposcope to document findings on a nonsexually active child or
       adolescent should be performed by someone trained to identify normal genital/anal antomy, as well as
       acute and chronic injury or abnormality.


       2. Colposcopic examination for suspected sexual abuse

       To evaluate for suspected sexual abuse, a detailed colposcopic examination should be performed by an
       experienced examiner. If the abuse was alleged to have occurred within 96 hours, swabs for possible
       semen samples should be obtained from the orifice that was allegedly penetrated. (A forensic evidence
       collection kit must be utilized.) During vaginal swabbing, the examiner should use care not touch the
       hymenal tissue on prepubescent children as this will cause discomfort.

       3. Laboratory Testing for Sexually Transmitted Disease (STD)
       Testing on children is performed on an individual basis, dependent on risk-historical information. Only
       about 5% of sexual abuse victims test positive for an STD. Many STD’s are asymptomatic; testing is
       usually performed to exclude a silent infection. Testing may also be considered when the health care
       provider is unable to obtain follow-up testing. Some examiners test all suspected abuse victims, whereas
       others test only those who are at a high risk of developing an infection, such as children with:
           o   a history of STD;
           o   a sibling or household contact diagnosed with a STD;
           o   history of prostitution;
           o   contact with a suspected perpetrator with a history of prostitution;
           o   prior sexual contact;
           o   abuse by multiple perpetrators or by a perpetrator with high risk behaviors;
           o   vaginal or urethral discharge;
           o   rectal pain or discharge;
           o   genital warts, ulcers, or sores;
           o   vaginal, rectal penetration or genital injury; and/or



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o   significant, high risk exposure to HIV. Pretest and posttest counseling is required in most areas.
    After counseling has been completed, an informed consent is obtained. The incidence of
    developing an HIV infection from a single episode of sexual abuse has proven to be very low.
    Recommendation of initiating HIV postexposure prophylaxis (PEP) may occur. This should be
    done as soon as possible after exposure, ideally within one hour and not more than 36 hours after
    exposure. Baseline blood work will need to be drawn before administration of the PEP.




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 Laboratory Procedures in Suspected Sexual Abuse (Selection dependent on risk-historical information)

Laboratory Procedures         Potential Diseases or   Specimen                   Comments
                              conditions              When cultures ordered
                              (noninclusive)          for gonorrhea or
                                                      chlamydia, GC transport
                                                      or pink chlamydia
                                                      transport media must be
                                                      used.
Males and Females
   HIV testing                AIDS                    Blood
   VDRL, RPR, FTA             Syphilis                Blood
   Hepatitis B                Hepatitis               Blood
   Pharyngeal culture for     Gonorrhea               Pharyngeal swab            Obtain in patients with a
   N.gonorrheae                                                                  positive history or high
                                                                                 suspicion of oral penetration.
                                                                                 Place in GC transport media
                                                                                 per lab instructions.
   Rectal cultures for        Gonorrhea and           Two rectal swabs           Sample anal crypts with a
   N.gonorrheae and           Chlamydia trachomatis                              swab. Avoid contamination
   Chlamydia trachomatis                                                         with fecal material. Place
                                                                                 one in GC transport and one
                                                                                 in chlamydia transport media
                                                                                 per lab instructions.
   Viral cultures and/or      Herpes simplex virus      Blister fluid from       A specimen from a skin
   skin scrapings for                                   lesion for viral         lesion (often a genital sore)
   herpetic genital lesions                             culture or PCR           is collected during the acute
                                                                                 phase (worst part) of an
                                                                                 outbreak and placed in a
                                                        Skin scrapings of
                                                                                 viral transport medium.
                                                        lesion for Tzanck test
                                                        Antibody tests           The specimen is collected by
                                                                                 scraping the suspected skin
                                                                                 lesion.
                              Human papillomavirus                               HPV: A genital examination
                              HPV                                                reveals flesh-colored to
                                                                                 white, flat or raised, single
                                                                                 or clustered lesions
                                                                                 anywhere on the genitalia.




                                                                                                             15
Postpubescence Females
   Cervical cultures       Gonorrhea and             Two cervical swabs         Place one in GC transport
   for N.gonorrheae and    Chlamydia trachomatis                                and one in chlamydia
   Chlamydia trachomatis                                                        transport media per lab
                                                                                instructions. If rapid results
                                                                                required, DNA probe with
                                                                                culture can be done.
                                                                                ( Not recommended in child
                                                                                abuse cases as false positives
                                                                                can occur in prepubescent
                                                                                children.)
   Wet Prep                Trichomonas, yeast,       Swab of vaginal vault or   Insert swab into ½ cc of
                           sperm                     walls                      saline. Transport
                                                                                immediately to lab.
   Gram Stains             Trichomonas, yeast,       Swab of vaginal vault or   Roll swab onto two slides.
                           sperm, presumptive        walls                      (Do not rub.)
                           gonorrhea , H.
                           vaginalis
   Pregnancy test          Pregnancy                 Blood or urine
Prepubescent Females
   Vaginal cultures for    Gonorrhea                 Two vaginal swabs          Place one in GC transport
   N.gonorrheae and        and Chlamydia                                        and one in chlamydia
   Chlamydia trachomatis   trachomatis                                          transport media per lab
                                                                                instructions. DO NOT
                                                                                ORDER DNA probes. False
                                                                                positives occur.
   Wet Prep                Trichomonas, yeast,       Swab of vaginal vault or   Insert swab into ½ cc of
                           sperm                     walls                      saline. Transport
                                                                                immediately to lab. Rare in
                                                                                prepubescent females.
   Gram Stains             Trichomonas, yeast,       Swab of vaginal vault or   Roll swab onto slides.
                           sperm, presumptive        walls                      (Do not rub.)
                           gonorrhea, H. vaginalis
Prepubescent and nonsexually active males
   Urethral culture for    Gonorrhea                 Urethral swab
   N.gonorrheae
   Urethral culture for    Chlamydia                 Urethral swab
   Chlamydia trachomatis




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4.Technique for collecting STD cultures

Place the child in supine, frog leg, or lithotomy position, depending on the child/adolescent’s physical
size.
Males and Females

Rectal specimens for gonorrhea and chlamydia: No lubricant should be used before STD testing or
evidence collection. Rectal specimens are best obtained with the patient in left lateral recumbent position.
Swabs for evidentiary purposes should be collected first. The culture swab (gonorrhea culture-charcoal
agar and chlamydia culture are obtained by inserting the swab into the anal canal to the rectal crypts
(approximately 1 ½ “). Place chlamydia culture in chlamydia transport media.

Endocervical swab for gonorrhea and chlamydia: Use one swab to remove exudate or mucus from
endocervix and discard this swab. Insert second swab until its tip is no longer visible; use firm rotating
pressure to obtain the specimen. Rotate the swab for 5-10 seconds and withdraw it without touching the
vaginal walls. Place only this second swab in the transport medium, snap off and seal tube with screw
cap. Label tube with patient’s name. Maintain specimen at room temperature or refrigerate.
DNA probes: The major disadvantage at the present time is that DNA probes cannot be done exclusively
if a child abuse case is involved. These cases must be detected with the microbiologic recovery of N.
gonorrheae organism from the clinical specimen.
Wet Mount for trichomonas and/or yeast: The vaginal vault and walls should be swabbed using one or
two swabs. If any fluid has pooled in other areas, these areas should be swabbed as well. The swabs
should then be placed in a tube containing 0.5 ml saline and examined within two hours of collection. The
sample should remain at room temperature.

Prepubescent females
Vaginal swab for chlamydia and gonorrhea: The specimens (vaginal as opposed to cervical) can also
be used for adolescent females who have not been previously sexually active and when the insertion of
the speculum to collect cervical cultures may cause undo stress and discomfort.
The cultures can be obtained by carefully swabbing the vaginal wall while paying attention to not touch
the hymenal tissue. Prepubescent hymenal tissue is very sensitive. The slightest touch may cause
discomfort.

Prepubescent boys and nonsexually active adolescents.

Urethral swab for gonorrhea and chlamydia: Urethral swabs should be taken only if the patient is
symptomatic for urethritis or has a penile discharge.The patient should not have urinated for 1 hour prior
to specimen collection. Remove pus or exudate. Insert a small swab with a wire shaft 2-4 cm into the
penis, gently rotate the swab to dislodge cells, then withdraw the swab. Place swab into transport
container, snap off, and seal. Label tube with patient’s name. Maintain specimen at room temperature or
refrigerate.




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