RECOGNIZING AND RESPONDING TO VICTIMS’ DISCLOSURES
It is difficult for young children to describe abuse. They may only disclose part of what happened, or they may make an indirect disclosure such as, “My stepdad keeps me up at night.” It is important not to rush the child and to listen to their concerns so that the child feels safe and supported. If a child discloses abuse, the following actions by the healthcare professional will help the child:
- Avoid denying what the child discloses.
- Provide safety and reassurance.
- Listen without making assumptions.
- Do not interrogate.
- Limit questioning to only four queries:
- What happened?
- When did it happen?
- Where did it happen?
- Who did it? (How do you know them?)
- Do not make promises.
- Document the child’s statements using exact quotes.
- Remain nonjudgmental and supportive.
- Understand the dynamics of abuse and neglect.
- Report suspicions to the authorities.
(Childhelp, 2021b)
Interviewing for Sexual Assault
If a child or adolescent discloses sexual abuse to a trusted adult, or there is cause for the adult to suspect sexual abuse, the adult should not question the child further. They should instead contact Child Protective Services or, if the child is in imminent danger, the police. These professionals have protocols in place to interview the child by a child interview specialist while police, prosecutors, and caseworkers observe.
Such forensic interviewers are trained to communicate in an age- and developmentally appropriate manner. Coordination of services with a child forensic interviewer is essential, with the expectation that one interview rather than several by different concerned parties reduces the chances of traumatizing the child further (US DOJ, 2015).
Management
A physically abused child will need to be screened for emergent needs. Once stability has been established, the child will need a history and physical. Child Protective Services should be informed when there is a suspicion of abuse and the child may need to be seen in an in-patient facility so that lab work and imaging can be done.
A child who has been sexually abused also must be evaluated for physical, mental, and psychosocial needs. Baseline testing is needed for sexually transmitted infections (STIs) for children of all ages. Pregnancy and empiric treatment for STIs may also be given to adolescent victims. STI prophylaxis and emergency contraception may be offered if the patient presents within 72 hours. Medication may include a regimen of nonoccupational post-exposure prophylaxis (nPEP). Evaluation at the earliest opportunity can be helpful to examine for anogenital injury and collect forensic evidence (CDC, 2021e).
Photographing Evidence
Whenever there are allegations of suspected child abuse or neglect, any records of physical findings may be used as evidence at a trial. Therefore, photos, diagrams, and accurate reporting of medical examination findings are invaluable. Such documentation should use language that is not open to misinterpretation.
If photographs will be needed, it is a good idea to inform the child or adolescent and encourage them to participate in the process. Photographs are another form of medical documentation that can provide objective, visual documentation of abuse. There should be a protocol for releasing the photos after a formal request, and a chain of custody may be necessary as well.
CASE
A mother brought her 12-year-old daughter, Chantal, to the emergency department. She said that her daughter had been complaining about painful urination and wanted to check if she might have a bladder infection. The triage nurse, Janelle, asked the mother, who appeared to be in the last trimester of pregnancy, to fill out some paperwork while she took the girl to the bathroom for a urine specimen.
Janelle noticed that the daughter appeared fearful and sat in silence while her mother did all of the talking. When they were alone behind closed doors, Janelle asked Chantal if there was anything that she wanted to talk about privately. Chantal responded by shaking her head no, but Janelle sensed that the girl was holding something back.
Haley was able to produce a clear, pale yellow urine specimen and then followed the nurse to an exam room. Janelle asked her if she had any pain when she urinated, and Chantal said yes. The nurse asked her if she had begun menstruating, and the child said she had not.
Janelle brought the mother into the exam room to wait with her daughter. After obtaining a brief history from the mother, the physician ordered a urinalysis. The urinalysis was negative. The doctor did an external genital exam that revealed numerous vesicular lesions on her labia. The child denied any sexual activity. The doctor cultured the lesions for herpes and asked the mother to step into his office to discuss his findings.
Once Janelle and Chantal were alone again in the room, the child burst into tears and told the nurse that her mother’s boyfriend had been rubbing his “private” on her and said that if she told anyone, her mother would go to jail. The nurse stopped questioning the child and reported her suspicion of child sexual abuse to the state child abuse hotline. The nurse knew that victims of child sexual abuse should only be minimally questioned until they can undergo a forensic interview.
On the following day, Chantal was interviewed by a child forensic interview specialist in a child-friendly advocacy center. She and her mother, who was also a victim of child sexual abuse, received counseling for over a year. Following an investigation by Child Protective Services, the mother’s boyfriend was eventually tried and convicted of sexual abuse.