A1. Principles of Care



While these recommendations are primarily for health care providers involved in caring for prepubescent child sexual abuse victims, they should be considered by all professionals who have a role in the initial response to child sexual abuse. Implementation of these principles requires collaboration across involved disciplines and entities.

Provide interventions that are child-focused, victim-centered, and trauma-informed. These terms are explained below as they are used in the protocol:

  • CHILD-FOCUSED: An approach to care that is developmentally, linguistically, and culturally appropriate for prepubescent children; designed with their needs, abilities, and best interests in mind; and intended to reduce potentially traumatic effects of the exam process.
  • VICTIM-CENTERED: An approach to care that is grounded in an awareness of and commitment to addressing the needs of victims of sexual abuse during the exam process. It is informed by the victim’s circumstance (See A2. Adapting Care for Each Child). A victim-centered approach recognizes that victims deserve timely, compassionate, respectful, and appropriate care to promote their healing, as well as information to support their decision making. This approach encourages choice for victims whenever possible, as fitting their developmental level and applicable laws. Medical personnel may refer to victim-centered care as patient-centered care.
  • TRAUMA-INFORMED: An approach to care that seeks to support the healing and growth of children who have experienced sexual abuse, while avoiding their retraumatization (National Sexual Assault Coalition Resource Sharing Project [RSP] & NSVRC, 2013).[1] A trauma-informed approach considers and evaluates all interventions in light of a basic understanding of the role that violence plays in the lives of victims (Harris & Fallot, 2001), as well as integrates an understanding of the child’s history and the context of their experience (RSP & NSVRC, 2013).[2] It recognizes the effects that trauma can have on children’s behavior, coping strategies, relationships, and ability to interact with health care providers, law enforcement, and other professionals.

In addition to interventions directed at victims, a child-focused, victim-centered, trauma-informed approach to prepubescent child sexual abuse also seeks to assist caregivers in developing strategies and skills to protect, reassure, and support child victims, as well as cope with their own distress.[3] Community interventions that build upon children’s strengths, along with a protective, reassuring, and supportive response by caregivers, can help lessen the abuse’s negative impact on children (WCSAP, 2009, 2015a).


In each case, responders need to assess the child’s developmental level and communication skills as these factors can impact the nature of their interactions. (See A2. Adapting Care for Each Child) Especially with younger children, caregivers play a primary role in providing and receiving information during the exam process. In the protocol, note the need for this assessment whenever the phrases “child and caregiver” is used in the context of communicating information to them or decision making.

Uphold guiding principles of care. Below are seven principles and key actions that responders can take to support child-focused, victim-centered, trauma-informed care for prepubescent children who disclose sexual abuse or are suspected of being sexually abused (adapted in part from Day & Pierce-Weeks, 2013; United Nations High Commissioner for Refugees, 1995).

 

Guiding Principles of Care for Prepubescent Children

 

Principle 1: Provide children with timely access to examinations, trained examiners, and quality care.

 

Principle 2: Secure the physical and emotional safety of children.

 

Principle 3: Recognize each child has unique capacities and strengths to heal.

 

Principle 4: Offer comfort, encouragement, and support.

 

Principle 5: Provide information about the exam process and links to resources to further address needs.

 

Principle 6: Involve children in decision making, to the extent possible.

 

Principle 7: Ensure appropriate confidentiality.

 

 

Guiding Principles of Care — Prepubescent Children

Principle 1: Provide children with timely access to examinations, trained examiners, and quality care.
  • Offer every child who discloses sexual abuse or is suspected of being sexually abused a medical forensic examination. However, children should never be forced to undergo the examination.
  • Offer all children high-quality medical forensic care, regardless of factors such as ethnicity, race, language, religion, sex, sexual orientation, gender identity, ability/disability, or financial situation.[4] A child’s unique needs and circumstances should influence nuances of care (See A2. Adapting Care for Each Child ).
  • Ensure that examinations are conducted by medical providers who are trained to conduct the pediatric sexual abuse medical forensic examination (See A4a. Pediatric Examiners).
  • Consider child sexual abuse a priority at health care facilities. Promptly evaluate children to treat serious injuries and determine the urgency of medical forensic care needed. Seek assistance to address immediate safety concerns and provide emotional support. An appropriately timed medical forensic examination should follow. Understand that a disclosure or suspicion of sexual abuse, even if delayed, may be an emergency for the child and family (See B3. Entry into the Health Care System).
  • Focus on care of the whole child—she/he is more than a victim of sexual abuse.
  • Maintain the priority of the health of children over the collection of forensic evidence.

 

Principle 2: Secure the physical and emotional safety of children.
  • Evaluate the consequences of actions during the exam process with children and caregivers. The least harmful course of action for the child is always preferred.
  • Be cognizant of safety risks facing children during the exam process and have mechanisms in place to address imminent risk of danger. For example, if the accompanying caregiver is suspected of perpetrating the sexual abuse, convey this urgent concern to law enforcement and child protective services, and follow health care facility policy on responding to this situation. Do not conduct a forensic examination of the suspected perpetrator at the same time and location as the child examination (although it might be feasible for another examiner to conduct the suspect examination in another facility location). Avoid actions that might overwhelm or frighten the child, such as placing her/him in a noisy room with many unfamiliar people and no personal support person.
  • Encourage communication, information sharing as allowed by applicable laws, and collaboration among responders to identify and address safety concerns in a timely and appropriate manner. Connect children and caregivers to resources for post-exam safety planning assistance (e.g., child protective services and victim advocacy services).

 

Principle 3: Recognize each child has unique capacities and strengths to heal.
  • Identify and build upon the strengths of the child and the family as a part of the healing process.
  • Use a person-first approach to care that places the focus on the child first—her/his experiences, safety and wellbeing, needs, and reactions. When working with children with disabilities, utilize the same person-first approach to ensure that the focus is not placed on the child’s disability status.
  • Encourage factors that promote children’s resiliency. Resiliency is the ability to thrive and grow during and following an adverse experience (NSVRC, 2013; Steele & Malchiodi, 2011). Resliency results from individual characteristics and coping mechanisms (innate and acquired) and protective factors in a child’s ecology, which the child uses to defend her/himself against violations of her/his rights and cope with and recover from adversity (IRC, 2012). On the family level, examples of protective factors include involvement on the part of caregivers, family cohesion, adequate housing, and stable and adequate family income (IRC, 2012). Examples of protective factors at the community level include involvement in community life, peer acceptance, supportive mentors, and access to quality schools and health care (IRC, 2012).

 

Principle 4: Offer comfort, encouragement, and support.
  • Seek training on how to respond in a child-focused, victim-centered, trauma-informed way to disclosures of sexual abuse from children.[5] The impact of adult reactions to such disclosures on children’s psychological health can be profound—negative reactions can traumatize children; whereas calm and supportive reactions can foster feelings of safety and acceptance (IRC, 2012). Understand that a lack of a disclosure or a recantation on a child’s part does not necessarily mean the sexual abuse did not occur. Also, educate caregivers about this fact.
  • Seek training on how to guide caregivers to be supportive and reassuring to their children in the aftermath of sexual abuse. For instance, caregivers may benefit from discussions with responders about what is helpful to say and do to comfort the child and what they should avoid saying, what to tell their other children about the abuse, and how to handle it when other children are angry when the abused child is “getting all the attention.” Responders can also model appropriate behavior for caregivers to use with child victims. Modeling may be particularly effective when it is delivered by pediatric health care providers, as caregivers may consider the providers to be experts in the health of children.
  • Offer children crisis intervention, support, and victim advocacy as early as possible. Also, offer these services to caregivers to help them cope with their reactions to the abuse, reduce their stress, and aid them in supporting the child.
  • Afford children as much privacy at the health care facility as possible. For example, if possible, do not leave children and caregivers in the facility’s main waiting area prior to care. Throughout the examination, limit exposure of the child’s body to the area being examined.
  • Consider the child’s comfort throughout the exam process. For example, reduce wait time as much as possible. Offer developmentally appropriate toys, stuffed animals and dolls, books (in languages/formats they can understand), and electronic devices to occupy them while waiting for the examination. Consider how to enhance comfort via the physical environment (e.g., comfortable furniture, low lighting at least prior to the examination, and calming pictures on the walls that children can focus on during the examination). Consider additional measures that can be taken by responders to increase comfort. For instance, for a child who is thirsty during an acute examination, make collection of oral samples a priority so the child is able to drink as soon as possible. If nonacute medical forensic care is needed, schedule it at a time that works best with the child’s routine (e.g., not at her/his bedtime). Before discharge, provide the opportunity for the child to wash, brush his/her teeth, have a snack, and change clothes. Offer replacement clothing if clothing was taken as forensic evidence.
  • Provide accommodations and other modifications in care so that the exam process is welcoming to and inclusive of the needs of children and caregivers (e.g., providing language interpreters as necessary, describing the exam room and what is happening for someone who is blind, accommodating requests for responders of a specific gender or culture, if possible, etc.). (See A2. Adapting Care for Each Child)
  • Recognize that the exam process may take longer with some children. Avoid rushing to finish. Rushing may not only distress children, it can lead to gaps in the collection of information, forensic specimens, and documentation.
  • Recognize in some instances that a caregiver may be more upset than the child during the exam process and need support to stay calm around the child. Victim advocates can be helpful in providing such support. [6]

 

Principle 5: Provide information about the exam process and links to resources to further address needs.
  • Offer verbal information to children and caregivers during the exam process, tailored to developmental level and linguistic capacity. Before or at discharge, provide a packet of written information summarizing what was said or referred to during the exam process. Topics to cover minimally include:
    • What will happen during the examination (overall and for each procedure);
    • Exam finding results, including that it is “normal to be normal” and follow-up care instructions/appointments;
    • Sexual abuse dynamics, related laws, the range of victim reactions and concerns of children and caregivers, and the process of healing from sexual abuse;
    • Safety planning;
    • Costs families will be expected to cover for the examination and other related medical care, what the jurisdiction will cover, and their options for financial assistance in covering these expenses;
    • Resources available in the community to address post-exam needs related to the sexual abuse, such as victim services, mental health counseling, and crime victims’ compensation programs;
    • Criminal justice and child protection investigative processes, as applicable; and
    • Contact information for involved responders.
  • Recognize that most children and caregivers have little knowledge about the exam process and sexual abuse. Provide them a balance of information and appropriately time its delivery—the goal is to help them be more prepared rather than overwhelmed.
  • Encourage questions from children and caregivers about the information provided. If they have questions post-exam, be clear to whom they should direct questions regarding specific topics.
  • Tailor referrals to the needs of children and caregivers (e.g., seek mental health providers who can speak the same language as the child, have expertise in child sexual abuse issues, and experience addressing other issues of the child that may impact counseling effectiveness, such as those related to race, ethnicity, religious affiliation, sexual orientation, gender identity, disability, and/or living in an institutional setting). Avoid generic referrals when specialization is more fitting. Respect child and caregiver decisions to prioritize or decline referred services. For example, a mother may decline counseling for herself because she is more concerned about getting financial aid to cover medical costs and deflect wages lost while attending medical appointments with her child.
  • Help children and families in accessing resources. For example, rather than just providing referrals, connect them with service providers, and help schedule appointments and coordinate transportation to/from services.
  • Be aware of the best ways to connect victims with services in your community. In some communities, one referral to victim advocacy services or a child advocacy center is sometimes all a health care provider needs to do to ensure children and caregivers are assisted in coordinating all other necessary services.

 

Principle 6: Involve children in decision making, to the extent possible. (See B1. Consent to Care)
  • Inform children what their options are throughout the exam process. Encourage related questions.
  • Give children control during the examination whenever possible (e.g., seek their permission to proceed with exam steps, let them choose which color of gown to wear and whether to have a support person in the exam room, and ask for their input on where to position that person in the room). However, recognize their capacity to make decisions depends in part on their developmental level and applicable laws. [7]
  • Honor children’s right to decline all or part of the medical forensic examination (with the exception of emergent/urgent medical care and treatment), even if the parent/guardian consents.
  • Recognize children may need time and support to overcome hesitation to allow exam procedures. Some may benefit from more explanation (e.g., an older child may feel more comfortable agreeing to the examination if he/she is provided with a description of equipment that will be used and can see it in advance). It is also helpful to explain in advance to children and caregivers if they will be left alone for periods of time (e.g., while waiting for a specialist consultation) and the anticipated time frame so as to avoid increasing anxiety.
  • Talk directly to children (as is developmentally appropriate) rather than talking about them to caregivers.
  • Interact with children in a transparent and respectful manner. For example, if a child’s wishes (e.g., for an examiner of a specific gender) are not able to be followed, explain the reasons why.

 

Principle 7: Ensure appropriate confidentiality. (See A5b. Confidentiality and Release of Information)
  • Inform children and caregivers of mandatory reporting requirements. Provide examples of what needs to be reported, why, and reporter responsibilities. (See A5a. Reporting)
  • Ensure children’s medical records are securely stored and carefully controlled by the health care facility, as per applicable laws and policies. Release records only according to applicable jurisdictional laws and facility policies.
  • Recognize children and caregivers may have confidentiality concerns (e.g., that others will find out that the child contracted a STD from the sexual abuse). Explain that they will receive medical results from the examination, but typically will not have access to the investigative report until after the case is closed. Explain what will be shared with the investigative team, what communications the team will likely have with them, and measures that will be taken to protect the child’s personal information outside of the team. Be open to discussing how they can talk to their families about sensitive topics or what to do to cope if certain information becomes public.

 

In addition to the specific references to other protocol chapters, the above principles of care are woven throughout all the chapters of this protocol.

 

See www.SAFEta.org for resources to help communities incorporate the above principles of care into their response to prepubescent child sexual abuse. Also, see resource examples referenced in the protocol.

 

Provide prepubescent child victims and their families with timely access to victim advocacy services during the exam process. This access is important to upholding the above principles of care in individual cases. Victim advocates typically function to aid victims and their families in getting help to cope with the impact of sexual victimization in their lives and to promote healing. They may also encourage coordination and collaboration among responders so that interventions are child-focused, trauma-informed, and victim-centered. Victim advocates who serve prepubescent child sexual abuse victims and their caregivers should receive specialized training for working with these populations.

 

In many jurisdictions, advocates who serve child sexual abuse victims and their families (via community-based sexual assault victim advocacy programs, children’s advocacy centers, criminal justice system victim-witness offices at the local, state, territorial, tribal, and federal levels,[8] military family advocacy programs, tribal social services, and others) may be available to assist children and/or caregivers during the exam process. Some, community-based sexual assault victim advocacy programs in particular, offer children and/or caregivers accompaniment during the examination, providing crisis intervention, emotional support, help in voicing their concerns, short-term safety planning, information, and/or referrals. Outside of the exam process, victim advocacy programs may offer assistance with longer-term safety planning, counseling/referrals to counselors, support groups for nonoffending caregivers, assistance with applications for victim compensation programs, and accompaniment during related medical appointments and legal proceedings. In communities where community-based sexual assault victim advocacy programs exist but are not involved in the exam process in prepubescent child sexual abuse cases, responding entities are urged to partner with them to engage advocates in this process (See A3. Coordinated Team Approach).

 

In jurisdictions where victim advocacy programs are not available to provide children and/or caregivers services in these cases, exam facility staff (e.g., child life specialists,[9] social workers, chaplains, and/or behavioral health staff) may be enlisted to provide them with support during the exam process. Like advocates, facility staff that provide such support should receive specialized training to prepare them to address the support needs of child sexual abuse victims and their caregivers.

 

See www.SAFEta.org for links to resources for victim advocacy programs for working with child sexual abuse victims and their caregivers. Also check out resources from sexual assault coalitions (go to www.justice.gov/ovw/local-resources for links to state, territorial, and tribal coalitions) and the Office of Juvenile Justice and Delinquency Prevention’s (OJJDP) regional children’s advocacy centers (go to www.ojjdp.gov/Programs/ProgSummary.asp?pi=30 for links to the Northeast, Southern, Midwest

and Western regional children’s advocacy centers).


 Table of Contents A2. Adapting Care for Each Child

[1] Trauma begins when the experience overwhelms normal coping mechanisms; in response to the traumatic event, the child may have a range of physical and psychological reactions (RSP & NSVRC, 2013). Retraumatization can occur when environmental cues related to the trauma (e.g., sound or smell) trigger a fight, flight, or freeze response (Proffitt, 2010).

[2] See RSP and NSVRC (2013) at www.nsvrc.org/sites/default/files/publications_nsvrc_guides_building-cultures-of-care.pdf for more on trauma-informed care. This resource offers an ecological model of trauma that illustrates how a child’s reaction to sexual abuse is influenced by circumstances surrounding the abuse and the child’s life experiences. The attributes of the community to which the child belongs also can influence how she/he is affected by the abuse. Implementing trauma-informed care involves striving to understand victims within their familial, social, and community context and experience (Proffitt, 2010; RSP & NSVRC, 2013). Core principles of trauma-informed care include (Proffitt, 2010; RSP & NSVRC, 2013): physical and emotional safety of victims; trust (with providers striving to maximize their trustworthiness to victims, make clear tasks, seek consent, maintain appropriate boundaries, etc.), choice (supporting victims’ choices and control during the healing process); collaboration between victims and those providing care; empowerment (identifying the child’s strengths and prioritizing building skills that promote healing and growth); and cultural competency (ensuring cultural applicability of care and options, as well as sensitivity to the role of culture in the child’s experience and decision making).

[3] Examples of related resources: Yamamoto (2015) at www.nsvrc.org/sites/default/files/publications_nsvrc_guides_the-advocates-guide-working-with-parents-of-children-who-have-been-sexually-assaulted.pdf offers an advocate guide for working with caregivers of child victims. It includes parent tip sheets. The National Child Traumatic Stress Network (2009) at www.nctsn.org/sites/default/files/assets/pdfs/caring_for_kids.pdf offers a guide on what caregivers of sexually abused children need to know. WCSAP offers a parent survivor brochure at www.wcsap.org/parent-survivors. Caregiver resources are also offered at www.nctsn.org/resources/audiences/parents-caregivers (National Child Traumatic Stress Network) and www.stopitnow.org/ohc-content/resources-for-parents-of-survivors (Stop it NOW!).

[4] Federal law prohibits recipients of federal financial assistance from discriminating based upon a person’s membership in a protected class. Protections vary by statute, but generally speaking, recipients must comply with the prohibition against race, color, and national origin discrimination contained in Title VI of the Civil Rights Act (Title VI) of 1964, as amended, 42 U.S.C. § 2000d; the prohibition against disability discrimination contained in Section 504 of the Rehabilitation Act (Section 504) of 1973, as amended, 29 U.S.C. § 794; the prohibition against age discrimination contained in the Age Discrimination Act (Age Act) of 1975, as amended, 42 U.S.C. § 6102; and the prohibition against sex discrimination in education programs contained in Title IX of the Education Amendments (Title IX) of 1972, as amended, 20 U.S.C. § 1681. Certain funding statutes also contain prohibitions on discrimination, and recipients of funds made available under those statutes must comply with requirements of those statutes. Recipients of funds made available under the Omnibus Crime Control and Safe Streets Act (Safe Streets Act) of 1968, as amended, 42 U.S.C. § 3789d(c); the Juvenile Justice and Delinquency Prevention Act (JJDPA) of 1974, as amended, 42 U.S.C. § 5672(b); and the Victims of Crime Act (VOCA) of 1984, as amended, 42 U.S.C. § 10604(e) are prohibited from discriminating on the basis of race, color, national origin, religion or sex. Recipients of funds under the VAWA of 1994, as amended, 42 U.S.C. § 13925(b)(13), are prohibited from discriminating on the basis of race, color, national origin, religion, sex, disability, sexual orientation, or gender identity. 

[5] See NSVRC (2014) for Bringing Hope: Responding to Disclosures of Child Sexual Abuse (online course).

[6] Rheingold et al. (2013) found that child and caregiver understanding of the examination and caregiver response to the disclosure of sexual abuse were associated with caregiver and child anxiety. In addition to providing information about the examination to reduce their distress and providing advocate support during the exam process, caregivers who experience high levels of anxiety can be referred to advocacy programs for individual and group support services, as well as for mental health counseling.

[7] All states and the District of Columbia allow minors 12 and above to consent to certain health care services without permission of parents/guardians—see www.guttmacher.org/statecenter/spibs/spib_OMCL.pdf (Guttmacher Institute, 2015) for examples. Some may also allow minors to seek or receive these services without parental/guardian notification. However, in most jurisdictions, prepubescent children do not have these rights. Responders should become familiar with the applicable related laws of their jurisdiction.

[8] Note that criminal justice system-based advocates/victim service providers, such as those in law enforcement or prosecution offices, generally cannot offer confidential services, while community-based advocates/victim service providers generally provide confidential services (to the extent permissible by jurisdictional law and their program policies).

[9] Child life specialists are professionals trained in child development who help children cope with the stress and uncertainty of illness, injury, disability, and hospitalization. They most commonly work in hospital pediatric programs. (This explanation was drawn from Child Life Council (n.d.).)