CHAPTER 127 ■ SEXUAL ASSAULT: CHILD AND ADOLESCENT JENNIFER MOLNAR, MEGAN SCHLUCKEBIER O’CONNELL, CYNTHIA MOLLEN, PHILIP SCRIBANO GOALS OF EMERGENCY CARE Treat life-threatening or limb-threatening injuries first, although the vast majority of sexually assaulted patients will not require such immediate intervention Determine best location and care team for the patient All patients presenting to the emergency department (ED) must have a medical screening examination and psychosocial evaluation to determine whether an emergency condition exists that requires further treatment If there is no urgency for evaluation of possible injury, forensic evidence collection, or acute or prophylaxis treatment, a complete and thorough examination can be scheduled for a later date with a child abuse subspecialist An emergency examination is indicated if the alleged assault occurred within the preceding 72 hours in postpubertal patients and within the preceding 24 to 72 hours in prepubertal patients, or if the patient has genital complaints or other symptoms requiring medical attention, or if the safety of the child is in question A coordinated, multidisciplinary team approach to the evaluation provides victims with access to comprehensive care, minimizes potential trauma, encourages the use of community resources, and may help facilitate legal investigation Comprehensive care includes history and physical examination, psychosocial screening, photo documentation of injury, forensic evidence collection, STI screening and prophylaxis (including HIV), pregnancy prophylaxis, crisis management, reporting to child protection services (CPS) and law enforcement, and ensuring medical as well as psychosocial follow-up care A successful sexual assault response team (SART) program requires ongoing team education, debriefing sessions, case review for quality review and improvement, and significant institutional resources OVERVIEW OF APPROACH Team Composition SART is a multidisciplinary team of specially trained professionals devoted to the care of pediatric victims of sexual assault Team composition includes, but is not limited to, members of the ED, general pediatrics, child abuse and HIV subspecialists, trauma surgery, social work, pharmacists, and child life specialists Collaboration between all team members is best accomplished by designating a team coordinator and a lead support person from each clinical area The multidisciplinary nature of the team allows for sharing of best practice and current evidence, provides a common mental model for patient care, organizes communication, supports important processes such as inhouse 24/7 coverage for victims of sexual assault, and provides a forum for continued quality improvement In settings where a dedicated SART is not available, a multidisciplinary team approach, based on available resources, is ideal Training Recruitment and initial and ongoing training of all team members (social work, child life specialists, nursing, medical) are critical steps in building an effective SART Identifying team members who have a passion for serving the special needs of this unique patient population adds to the success of the program Specialized training and simulation sessions prepare practitioners to respond to the acute sexual assault pediatric victim and include educational hours spent in didactics and mentored clinical experience In settings without a SART, attention to specific training, with ongoing review of cases and skills, remains essential Assessing and Maintaining Competency Ongoing updates, refresher workshops with simulation, and real-time feedback are critical to continued SART training Throughout the year, realtime chart reviews including photo documentation of each case allow for timely feedback and targeted education Debriefing immediately following an examination can promote communication and feedback within the team This is a highly important reflective activity which includes group reflection to improve future performance of care Monthly team meetings, quarterly skill-building sessions with simulations, literature review, and case review are essential to advancing clinical care for the pediatric sexual assault victim Strong partnerships with local law enforcement, child advocacy, rape crisis centers, and CPS include key stakeholders as part of the SART team ongoing education and collaboration Professional development is strongly encouraged Certification by the International Association of Forensic Nurses (IAFN) is recognized as validation of competency for sexual assault nurse examiners (SANE) with the designation SANE-A for adult/adolescent specialization or SANE-P for pediatric/adolescent specialization Membership to a local chapter of IAFN is also encouraged Finally, board certification in pediatric emergency medicine (EM) or child abuse pediatrics documents medical expertise Assessing and Maintaining Quality Technologic advances in photo documentation and the increasing reliance on telemedicine change rapidly; SART members must be informed and up to date on trends and new developments in the specialty Maintaining a database of all patients’ cases, performing group literature reviews, and meeting with key players within the local community allow the SART mission and performance to be enhanced through collaboration and advocacy across the community and its services Significant institutional support and strong leadership are required to put these processes into place KEY POINTS Timely care for the victim of sexual assault is crucial; this determines level and extent of care A multidisciplinary team approach is best; ongoing case review and targeted education provide opportunities for continued quality improvement Partnership with CPS, law enforcement, forensic crime laboratory, and community services including child advocacy centers, rape crisis centers, and other behavioral health agencies is important CLINICAL PEARLS AND PITFALLS First and foremost, assure that the child is provided optimal comfort during what can be an anxiety-provoking clinical encounter Efforts to gauge the child’s level of uneasiness prior to conducting the examination will guide the approach to the examination If a nonoffender caregiver is available, and is able to provide comfort and reassurance to the child, maintaining contact with that adult during the assessment can be very beneficial Second, prepare all necessary equipment, supplies and specimen and testing swabs and collection kits prior to positioning the child for the examination If a colposcope or some other related equipment for visualization and photo documentation is used for these examinations, allow the child to become acclimated with the equipment to alleviate anxiety Third, utilize child life specialists or other personnel to provide distraction techniques and additional comfort to support the child While the optimal examination position is a supine frog-leg position using stirrups on an examination table, for the younger child, positioning the child on the lap of a trusted caregiver facilitates cooperation with the examination Examination and photo documentation may be enhanced by placing a towel roll under the child’s sacral region to allow for best visualization while in the supine and frog-leg position Finally, a head-to-toe examination is conducted to look for signs of physical abuse or neglect Given the importance of the child’s cooperation to adequately visualize all of the genital structures, avoidance of any potentially noxious examination experiences (i.e., otoscopic examination) should be considered When obtaining specimens for testing and/or evidence collection, avoidance of any direct contact of the hymenal tissue reduces discomfort in the prepubertal patient The Children’s Hospital of Philadelphia Clinical Pathway ... SANE-P for pediatric/ adolescent specialization Membership to a local chapter of IAFN is also encouraged Finally, board certification in pediatric emergency medicine (EM) or child abuse pediatrics... trained professionals devoted to the care of pediatric victims of sexual assault Team composition includes, but is not limited to, members of the ED, general pediatrics, child abuse and HIV subspecialists,... simulations, literature review, and case review are essential to advancing clinical care for the pediatric sexual assault victim Strong partnerships with local law enforcement, child advocacy,