Sexual Abuse- Paediatric Assessment Dr Arlene Boroda Consultant Paediatrician 15 October 2008

Introduction Name Qualifications Present employment Experience (Previous relevant jobs) (Special interest) (Training) (Cases seen)

Terminology Child Forensic Acute Chronic Sex Sexual Abuse Medical terminology

CSA Definition ‘Sexual abuse involves forcing or enticing a child or a young person to take part in sexual activities, including prostitution, whether or not the child is aware of what is happening. The activities may involve physical contact, including penetrative (e.g. rape, buggery or oral sex) or non-contact activities, such as…looking at, or the production of pornographic material or watching sexual activities, or encouraging children to behave in sexually inappropriate ways.’ Working Together to Safeguard Children HM Gov 2006

References Children Act HMSO1989, revised 2004 Framework for Assessment of Children in Need and their Families DOH1999 What to do if you are worried that a child is being Abused DOH 2003 Working together to Safeguard Children HMGov2006 Child Protection Companion RCPCH 2006 Responsibilities of Doctors in Child Protection cases with Regard to Confidentiality RCPCH 2004 Guidance of Paediatric Forensic Examinations in relation to possible CSA RCPCH and FFLM 2007 The physical signs of child sexual abuse: An evidence- based review and guidance for best practice RCPCH 2008 GMC 0-18 Guidance for all doctors 2007 London Child Protection Procedures 2007

Comprehensive paediatric assessment Strategy Discussion Parents Police Health Referral process Education Social Care Comprehensive paediatric assessment Strategy Discussion Definite or possible abuse Immediate Management Joint Paediatric Forensic Exam Specialist Exam Admit to ward if necessary Legal Action Ongoing Management-Nominated Consultant Paediatrician (Hospital/Community) Social care Case Conference Medical Care

Framework for the Assessment of Children in need and their Families DOH (2000)

Ideal Assessment- Best Practice Holistic Done once-well planned ASAP after referral Parents informed before “Paediatric friendly” environment Combined with ABE Consent of child & parent Parent present Comprehensive Standardised proforma Forensics considered S.T.D.s considered Pregnancy considered Patient led Follow-up considered Doctors appropriately trained Multi-agency Joint examination

Consent Co-operation, confidence Child Parental responsibility Care Order- Court Court Order Gillick competent child- <16 years Maturity, depends on what is involved, complexity of decision

Consent Except in an emergency, where the patient has the capacity to give consent you should obtain written consent in cases where providing clinical care is not the primary purpose of the examination or investigation and /or where there may be significant consequences for the parents…social or personal life GMC: Seeking patient’s consent: the ethical considerations 1998

Paediatric Assessment- Equipment Environment: Child Friendly Room – private, quiet, warm, safe, well lit, clean NHS file / original notes Proforma, body maps Growth charts Doctors bag – stethoscope, B.P E.N.T.set, Developmental assessment kit Scale, Tape measure Time Light + video photo documentation = Colposcope Telephone

Paediatric Assessment- Examiners Guidance of Paediatric Forensic Examinations in relation to possible CSA RCPCH and FFLM 2007 A single doctor can conduct a paediatric forensic exam provided he/she has all the necessary skills (complementary skills) The examining doctor must ensure they are familiar with the evidence-based guidance regarding the interpretation of signs

Paediatric Assessment- Examiners Guidance of Paediatric Forensic Examinations in relation to possible CSA RCPCH and FFLM 2007 Competence and confidence- Examination Forensic Sampling Photodocumentation Evidence base Note keeping Reports Communication with outside agencies Presenting evidence in Court

Documentation Notes- contemporaneous, detailed, accurate, legible, safe, accessible, scientific, simple, signed Body maps Drawings Pictures- videos: “It is essential that high quality photos are obtained, if not, document reasons” Reports, correspondence

History of Abuse Obtain info from social worker or police officer: What Where When How Who If

Assault Last incident- time Assailant details- relationship, numbers, race, gender Abuse-slap / punch/ burn/ tied up/ beaten/ scratched/ gagged Weapons Threats Protection-gloves, condom..

Assault Oral/vaginal/anal/ intercourse Protection- condom Lubricant used Other sexual activity Substances-drugs, alcohol, solvents

Assault Since assault- Washed/ bathed/showered Changed clothes/napkin/sanitary wear Defaecated/ urinated Changed- outer clothes/ under clothes

Paediatric Assessment- Introduction PROFORMA Introduce yourself Explain why child is here Confirm language is understood Explain what will happen/ Confirm leaflet has been read Give child chance to ask questions and express choices and control Consent

Paediatric Assessment- History May be from parent/ carer/ child Holistic Detailed Carers Family tree Home Education CHRONOLOGY

Paediatric Assessment- History Birth Growth Development Immunisations Learning Special needs Health contacts- -Past -Admissions Medication

Paediatric Assessment- History Behaviour and emotional problems: Sleep Mood Nightmares Anger/depression Appetite DSH Continence- wetting/soiling

Paediatric Assessment- History of Symptoms Pain Bleeding Swelling Bruising Injuries Abdominal pain Admissions Conditions-past, present

Paediatric Assessment- History in postpubertal females: Menarche LMP Sanitary wear- ST/Tampons History in sexually active: Last Sex –date, time, person Types of sex Protection used

Paediatric Assessment- Examination Informed consent Examiner- gender, expertise Chaperone Facilities Privacy Photodocumentation Forensic sampling STI screen Pregnancy test

Paediatric Assessment- Examination Comprehensive Top to toe Growth Vital signs Holistic Detailed Initial and follow-up

Paediatric Assessment- Ano-genital Examination Indications: Child abuse Neurological problems Dysfunctional family, looked after child Very resistant incontinence Discharge on underwear or clothes Previous ano-genital surgery Day-time dribbling of urine Contact with a known sex offender Sibling of an index case General Anaesthetic- for a genital or a foreign body

Male Genitalia Penis- foreskin, shaft, glans Testes Anus Pre and post pubertal

Female Genitalia Breasts Axillae Pubic Hair Intimate examination Anus Pre-and post-pubertal

Paediatric Assessment- Forensic Samples Chain of evidence Body Hair Nails Fluids Clothes and underclothes Genitalia

Paediatric Assessment-medical needs Injuries Pregnancy Infection Drugs Analgesia Advise

Paediatric Assessment- Further needs Tests- radiological, haematological, forensic. Notes / Documentation Reports / Statement Meetings Liaison Follow-up

Paediatric Assessment- Follow-up Appropriate medical advice Counselling Follow-up / re-examination-review/ healing of injuries Photography of injuries Specialised forensic tests e.g. odontology Specialised medical tests e.g. skeletal survey, fundoscopy, other. Liaison

Paediatric Follow-up PSYCHOLOGICAL / Emotional Pregnancy Infections including S.T.Ds,PEP Injuries Complications Immunisations Growth Further history- medical records; hospital, G.P. CHRONOLOGY Development Educational Social TEST RESULTS Reassurance / Questions

Interpretation of Signs Consistent with the History Position Appearance Age/development Questions: How common is the sign/symptom in normal/non-abused children? Is child abuse a likely cause? What is the mechanism of causation?

Summary Any case can go to court/ not Work in a team Work within competencies and guidance Review/discuss/ reflect Learning is lifelong

Duties in Child Protection Where professionals are undertaking child protection work, their first duty is to the child(ren) concerned. As far as parents are concerned, professionals should act in good faith, exercising reasonable skill and care.

Questions ?