Sexual Abuse/Assualt Definitions
Acute sexual abuse or assault is defined as:
-
Any sexual abuse or assault of
a child or adolescent that occurred less than 72
hours (3 days) before, with anal or genital skin
contact
-
Assault or abuse in a pubertal
female (has started menstrual cycle) within 120
hours (5 days) - if genital body fluid exchange may
have occurred
Non-acute sexual abuse or assault is defined
as:
Recommended Approach
-
All acute
child sexual abuse/assault cases need to be
transported to an appropriate sexual abuse/assault
evaluation center with experience in evaluating
sexually abused/assaulted children for an urgent
medical evaluation and possible forensic evidence
collection. Notify and coordinate with local law
enforcement for transport to appropriate facility.
-
Any non-acute
sexual abuse or assault that presents with any of
the following conditions should also be seen
urgently in an evaluation center.
Current serious anogenital
complaint – (e.g., pain, non-menstrual bleeding.
Itching or discharge don’t require urgent care)
Serious mental health problem
(e.g., suicidal, severely depressed or mentally
unstable). The evaluation should focus on the mental
health problem, not the examination for sexual abuse
Current serious anogenital
complaint – (e.g., pain, non-menstrual bleeding.
Itching or discharge don’t require urgent care)
-
All non-acute
sexual abuse/assault cases should be evaluated in
the most experienced, child friendly environment in
the community. Typically, this is the local Child
Advocacy Center. The timing for the evaluation
should be the next available appointment.
Indications for a medical evaluation of
non-acute sexual abuse/assault in children include:
-
An abnormal exam from an
outside institution
-
Disclosure of possible
perpetrator contact with child’s genital/anal area
and/or child contact with perpetrator’s genital/anal
area, including any contact by genitals, finger or
object
-
A report of genital discharge,
or prior bleeding or discomfort/pain following
possible abuse, even if that has since resolved. If
the child still has pain or bleeding, refer
immediately to the local sexual
assault center
-
A report of prior anal
bleeding or discomfort following possible abuse that
has since resolved. If the child still has pain or
bleeding, refer immediately to the
local sexual assault center
-
Parental concern
-
Any concern for injury raised
during a skilled interview
-
Another child in household
with a sexually transmitted infection
-
Another child in a child care
setting with a sexually transmitted infection – if
there is suspicion that abuse occurred in that
setting
-
A sibling with a report of
sexual abuse and possible contact with an alleged
perpetrator
Sexual abuse/assault cases that may not
need a medical exam after a forensic interview and
consultation with an experienced child abuse specialist
include:
-
Old history of fondling,
without pain or bleeding
-
A child living in the same
household as an alleged victim or perpetrator, if
that child has NO history suggestive of abuse, and
has provided a credible denial of abuse during a
structured forensic interview
-
Abusive acts that clearly do
not include physical contact (e.g., taking
pornographic photos/videos of child; having child
view pornographic photos/video; voyeurism)
Physical Abuse
A child’s medical and mental health
status is key to determining the need for emergency, urgent
or less urgent health care. In addition, there are forensic
considerations, as evidence may be lost (e.g., bruises
fade). The following is a guide to the timing of the
forensic medical evaluation.
The following conditions should be
evaluated immediately at the nearest ED:
-
Any child with a change in
mental status (e.g., not acting right)
-
Any child with a loss of
consciousness
-
Any signs of head trauma
including bruising, swelling, or redness on the
face, head or ear in a child under 1 year old with a
history suspicious for abuse, or no adequate
explanation for the injury
-
Any burn on a child less than
3 years of age
-
Broken bone (fracture) with
concerning or no explanation for injury
-
A child with abdominal pain,
abdominal bruising, or other reason to suspect
abdominal trauma (e.g., child severely beaten)
-
A child with a recent
ingestion of a toxic or illicit substance
The following conditions should be medically evaluated
urgently (within 12-24 hours), by a child
abuse specialist, if possible*:
-
Bruising in an infant who
cannot “cruise” (walk holding onto objects)
-
Any suspicious bruising on a
child who is less than three years old or
developmentally delayed
-
Small, localized burns
(cigarette, iron) that newly or recently occurred
The following conditions should be medically evaluated
non-urgently (within 24-48 hours) by a
child abuse specialist, if possible*:
-
Suspicious bruising in a child
over 3 years old and developmentally normal
-
Pattern bruise marks
-
Healing localized burns
(cigarette, iron)
*If unable to refer to child abuse specialist urgently,
photographs should be obtained and reviewed by child abuse
specialist.
In addition, consider evaluation by a child abuse specialist
for:
-
Follow-up of any child with an
inconclusive hospital evaluation for physical abuse
-
Siblings of a child who has
been physically abused, according to the following
guidelines:
-
Siblings under the age of 3
must receive a medical evaluation by a child abuse
specialist
-
Strongly consider requesting
skeletal survey For infants less than one year,
strongly consider head CT
-
Siblings 3-6 years
old—strongly consider medical evaluation by either
Child Abuse Pediatrician or child’s primary care
practitioner
-
Siblings 6-10 years
old—consider medical evaluation based on concerns
raised by child and/or caregivers, school, etc.
Child Neglect
There are many circumstances when the
assessment and management of child neglect can be enhanced
with medical consultation by a physician specialist in child
abuse and neglect.
While the concern with physical health may be a priority, expert consultation can also inform assessments where children’s mental health, dental health and development may be affected.
In general, such consultation is not urgent as neglect reflects patterns of inadequate care or children’s needs not being met over time. Nevertheless, it is helpful if the consultation is sought early during the assessment.
In most situations, a physical examination is not needed for the consultation.
The consultation will usually hinge on the availability of a comprehensive history and medical records, particularly from the child’s primary care provider. It may often be helpful if the consultant confers with the primary care provider.
The following are circumstances for which expert medical consultation is recommended:
CPS report for medical neglect (e.g., failure/delay to seek medical care, failure to adhere to recommendations for evaluation or treatment)
Neglect in children with chronic diseases or conditions
Neglect in children with disabilities or mental health problems
Supervisory neglect related to injuries, ingestions, fatalities
Failure to thrive, growth problems, severe obesity
Concerns of dental neglect
Concerns regarding hygiene, sanitation, lack of basic utilities (e.g., heat) that may affect children’s health