1. Medical evaluation of ALL violence against children
PROMISE
Brussels, 2107
RESMIYE ORAL, MD
UNIVERSITY OF IOWA

3. 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

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

5. 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

6. 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

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

8. 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

12. 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…

14. 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

16. Kalamaki sunset

20. 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

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

22. 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

23. Kalamaki, Turkey

24. 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) …

25. 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

26. 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.

27. 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

28. 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

29. Thank you, Questions, comments…