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

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

3. Terminology Child Forensic Acute Chronic Sex Sexual Abuse
Medical terminology

4. 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

5. 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

6. 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

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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

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

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

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

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

19. 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

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

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

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

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

24. 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

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

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

27. 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

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

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

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

31. Paediatric Assessment-medical needs
Injuries
Pregnancy
Infection
Drugs
Analgesia
Advise

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

33. 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

34. 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

35. 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?

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

37. 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.

38. Questions ?