Medical evaluation of ALL violence against children PROMISE Brussels, 2107 RESMIYE ORAL, MD UNIVERSITY OF IOWA resmiye-oral@uiowa.edu

Medical standard Child’s medical history Family medical history Vital signs (… growth parameters) Head to toe physical exam Differential diagnosis Diagnostic work-up Medical Forensic Final diagnosis for treatment plan

Physical, emotional, social, relational Emotional abuse Physical abuse Sexual abuse Neglect Well-being (Family centered)

Medical standard Child’s medical history and family medical history may help providers provide family centered holistic care to all family members Two generational psychosocial, trauma/resilience assessment (family well-being evaluation) Mental health problems in the family Clues to emotional violence against child may be observed

Medical standard Child’s medical history and family medical history may help providers provide family centered holistic care to all family members Developmental milestones Missing preventive care (vaccines, lead level…) Potential genetic disorders Was ADHD diagnosis correctly established? Risk factors for all forms of violence to child Plan for referral for services for both generations

Medical standard Vitals: Potential medical conditions (high BP, high HR…) Growth charts Weight: Nutritional neglect Head circumference: Intracranial issues Body length: Endocrine problems

Medical standard Head to toe physical exam Genital exam Beyond genitalia Thorough skin exam (Oral-dental/breasts/ medial thighs/behind ears/neck/scalp) Signs of medical illness or inflicted injuries may be caught

Physical exam To identify all treatable conditions child may have Injuries, Sexually transmitted infections Growth, developmental delay Other medical conditions To update missing preventive care Reassurance of child and family…

Medical exam in Barnahus Injuries in covered areas of body Oral/dental/breast/skin injuries may be related to sexual and non-sexual violence Corroborating findings with forensic interview Evidence collection can be done less traumatically during physical exam Physical abuse, emotional abuse, dental neglect, nutritional neglect can be uncovered

Kalamaki sunset

Do they make sense together? Caretaker/Child HISTORY DEVELOPMENT/AGE MECHANISM, EXTENT Any history of trauma should be compatible with the developmental level of the child or other children involved, and the type, mechanism, and extent of injury. Child Injury

Medical standard Differential diagnosis Diagnostic work-up Medical/Accidental Forensic Diagnostic work-up Medical (relevant labs) Forensic (Evidence collection, STI screening)

Medical standard Final diagnosis for treatment plan: Complete vaccines High lead level: refer to hospital, DPH Start iron for iron deficiency anemia Refer to dentist (no dental care with decayed teeth) Refer to developmental pediatrician

Kalamaki, Turkey

Medical standard Final steps for forensic assessment: Send forensic evidence kit material to forensic lab Assault occurred within last 72 hours No need for STIs : Hx credible, no physical contact, no ejaculation history, no genital discharge, abdominal pain… Skeletal survey (infant <24 m/o, non-sexual physical abuse findings) …

REGIONAL ORGANIZATION Hospital Based CPT + Barnahus Local governments Local governments Forensic Medicine Inst. Forensic Medicine Inst. Schools Schools Dept. of Public Health Dept. of Public Health Prosecution Law enforcement Bars Child Protection Services Prosecution Law enforcement Bars Child Protection Services Child Death Review Teams Child Death Review Teams

MANAGEMENT of CHILD ABUSE & NEGLECT Hospital (Diagnostic evaluation) Child Protective Services Police Department/Gendarmerie District Prosecutor Courts Hospital (Treatment) Hospital (Diagnostic evaluation) Child Protective Services Police Department/Gendarmerie District Prosecutor Courts Hospital (Treatment) When an allegedly abused child enters the child protection system, the child and the family may get involved with various agencies and various units of each agency from a medical facility to court system over a certain period of time that may span months to years.

Child Protection Program=Barnahus Severe Physical Abuse Criminal neglect, etc Acute Sexual Assault Sexual abuse Barnahus/Child Advocacy Center Sexual Abuse Child witnesses of crime Physical Abuse CAC/Barnahus Sexual Abuse Child witnesses of crime Physical Abuse Child Protection Program Severe Physical Abuse Criminal neglect, etc Acute Sexual Assault Sexual abuse Child Protection Program Severe Physical Abuse Criminal neglect, etc Acute Sexual Assault Sexual abuse Child Advocacy Center (CAC) may be established in a hospital, in an INML office, or within the premises of any CPS related governmental or non-governmental agency depending on the local resources and leadership. Most CACs focus on addressing

all child victims of violence… Police forces Child protection services This is the Only we way We may serve all child victims of violence… Barnahus Hospital CPP prevention prosecution

Thank you, Questions, comments… Resmiye-oral@uiowa.edu