The training room at the new Grand County Emergency Medical Services building was packed last Thursday afternoon. First responders and multidisciplinary team members gathered to attend a training on pediatric forensic medical exams—what they are and when they’re called for—put on by the Grand County Children’s Justice Center.
Dr. Antoinette Laskey, pediatrician and chief of the Division of Child Protection and Family Health at the University of Utah, traveled to Moab to deliver the presentation explaining the signs that should prompt a forensic medical exam for a child who has suffered suspected abuse; who to contact to initiate the process; and what the exams involve.
Attendees included law enforcement from the Moab City Police Department, Grand County Sheriff’s Office, and Utah Highway Patrol; advocates from Seekhaven Family Crisis and Resource Center; medical and mental health care providers; and emergency medical technicians—all members of a support system who may encounter child victims of suspected physical or sexual abuse.
What is the Children’s Justice Center?
The Children’s Justice Center is part of a national network of support centers (called Children’s Advocacy Centers in most states) that works in coordination with the National Children’s Alliance, which was founded in 1988.
“Children’s Advocacy Centers coordinate the investigation, treatment, and prosecution of child abuse cases by utilizing multidisciplinary teams of professionals involved in child protective and victim advocacy services, law enforcement and prosecution, and physical and mental health,” according to a Department of Justice website.
The Grand County Children’s Justice Center opened in 2005, and is overseen by the county attorney’s office. This spring a new director took leadership of the CJC: Brooke DeGraw, who returned to Moab after 16 years away. She formerly served as the director of Seekhaven; she took on her new role in March.
“I host forensic interviews for kiddos that have suffered abuse,” DeGraw said, explaining the purpose of the CJC. Non-medical interviews are conducted by a trained staff person (either a law enforcement officer or Division of Child and Family Services representative) with a trauma-informed approach in a comfortable environment, and designed to collect all important information so that the child only has to give such an interview one time.
“Another big part of my job is, I host multidisciplinary meetings,” DeGraw added. That means coordinating representatives from different agencies involved in public health and safety, and making sure everyone is on the same page regarding case statuses and protocols.
Trainings like Thursday’s discussion on forensic medical exams help ensure multidisciplinary responders are working with the same information and protocols.
Forensic medical exams
Forensic medical examiners are trained to use a trauma-informed approach and to collect evidence in a way that’s most likely to preserve it. They’re also prepared to testify before a jury on their findings and the significance of those findings.
The primary objective of a forensic medical exam is to provide the patient with any needed medical care, whether that’s treatment for injuries or infections, pregnancy prevention, or therapy for trauma or mental health issues stemming from an abusive incident or situation. Collecting forensic evidence that can shed light on the incident, if possible, is another important objective.
Laskey’s direct, efficient delivery clearly outlined protocols and the reasoning behind them; she even found instances for humor, even though the subject was grim.
“I don’t treat adults; adults are gross,” she joked as she discussed how some procedures for examining specific injuries are different for minors than they are for adults.
Large bay doors on one side of the room opened to the bright blue skies and yellow leaves of fall while Laskey clicked through slides at the front of the room. She broke the presentation down into two categories: physical and sexual abuse.
In cases of sexual abuse, the timing of a forensic medical exam is crucial, both because prophylactic treatments are more effective the earlier they’re administered, and because the liklihood of collecting forensic evidence is highest within the first 24 hours after an incident has occurred. For pre-pubertal patients, an exam will be most effective within the first 72 hours; for post-pubertal patients, the window is 120 hours.
Prophylactics against HIV are most effective within 72 hours of exposure; medications preventing pregnancy are most effective within 120 hours. (These medications do not cause abortions, but rather prevent implantation.)
“The clock is working against us,” Laskey said.
However, even if the window for collecting forensic evidence is past—for example, even if a child waits months to disclose an incident—it’s still important to conduct an exam. Healthcare providers can still identify and treat STDs and also screen for mental health issues.
Laskey pointed out that an exam cannot confirm whether abuse did or did not occur. Even consensual sex between adults can leave injuries, she noted, and nonconsensual sex may leave no injuries. Injuries in soft tissues also heal very quickly, she said.
She debunked other myths about forensic exams of sexual abuse cases. They are not, she said, intrusive or invasive; they don’t use the same procedure conducted during a routine gynecological visit; the exam is not traumatizing for kids; it can’t prove or disprove that penetration has occurred; and the exam still has value even if it’s conducted a long time after the incident occurred. For non-acute exams (exams conducted beyond the time immediately after an incident), healthcare professionals can still look for indications of abuse, treat any infections if they’re present, screen for mental health issues and trauma, and provide reassurance and advice to patients and families.
In cases of physical abuse, there are different protocols depending on the age of the patient. For infants under 12 months, who are not yet ambulatory, signs of possible abuse are different than for toddlers, who often get into accidents on their own. Laskey described several “sentinel injuries” in infants that could indicate more serious problems.
Subconjunctival hemorrhages, or blood in the whites of the eyes, can be caused by squeezing injuries. These spots can appear in infants after a vaginal birth, but should go away within a few weeks.
Tears in the oral frenula (the skin beneath the tongue) are another troubling sign in nonambulatory patients. The injury could indicate that something was shoved in the patient’s mouth—even something as soft as a binky, Laskey said, can tear the frenula if shoved forcefully.
Bruises in the ears are another sentinel injury in infants. Ears are a protected area and unlikely to bruise unless someone deliberately twists, pinches, or otherwise injures them. Bruises anywhere on an infant’s body could indicate abuse or a bleeding disorder—either case could prove fatal if it’s not addressed.
Toddlers who can walk are more prone to accidents and bruises are not necessarily a cause for concern in that age group, but examiners should still be observant of the location and nature of bruises. Injuries on soft, usually protected areas of the body, or bruises that reveal a certain pattern, could be signs of abuse. For example, accidents are unlikely to cause bruises on the fleshy part of the cheeks.
“Bony prominences are more likely to have accidental injuries,” Laskey said.
School-aged children are easier to examine than infants or toddlers, Laskey said, because they can explain what happened. However, it can still be difficult to determine exactly what happened if different parties offer different explanations for an injury, or if narratives conflict with forensic evidence.
Responders who suspect the possibility of abuse can contact Daphne Solomon, the Children’s Justice Center Nurse Practitioner for Grand and San Juan Counties. Solomon is the only Nurse Practitioner in the area trained to conduct exams for acute sexual assault for patients aged 14 and under. If she’s unavailable to conduct an exam, she coordinates with other trained nurse practitioners to find a provider who can complete the exam quickly.
“In the past, when a child required a SANE exam, the family needed to travel to Primary Children’s Hospital or a neighboring state where the exam could be performed,” Solomon wrote in an email to the Moab Sun News.
A small group of nurses at Moab Regional Hospital are trained as Sexual Assault Nurse Examiners, or SANEs, but specific training is required to examine and treat patients under the age of 14.
A primary care physician can perform exams for past sexual abuse, but the Children’s Justice Center Nurse Practitioner has specific training that could help identify signs of abuse or other medical diagnoses unrelated to abuse.
Laskey said it’s better to conduct an exam that doesn’t raise concerns than to decide not to conduct an exam that could have exposed an abusive situation.
“We really want to have the opportunity to make a difference for a kid,” Laskey said.
DeGraw is in the process of applying for re-accreditation for the Grand County Children’s Justice Center. The National Children’s Alliance is the accrediting organization, and it uses ten standards to evaluate advocacy and justice centers. The standards are updated every five years and accredited centers are reviewed at that interval. DeGraw has submitted a required application, which is being reviewed by NCA staff; a site visit to the Grand County center is scheduled in the coming months.
The first standard is that a center must work with a multidisciplinary team including members from child protective service agencies, medical providers, victim advocates, prosecutors, and law enforcement. Other standards require that centers promote diversity, equity, and inclusion; that centers conduct forensic interviews in a legally sound and neutral, fact-finding manner; that centers provide or give referrals for victim support and advocacy; that they facilitate medical examinations when needed; that they provide or refer to mental health care; and that they have a formal process for case review and coordination.
Centers must have a case tracking system: the Grand County CJC tracks through a database run by the state, and through monthly multidisciplinary team meetings. The standards also require a legal entity to be responsible for a center’s program and fiscal operations—in Utah, the Attorney General’s office oversees CJCs in the state. The last standard is that a center must provide for child safety and protection.
“I’m knee-deep in it,” DeGraw said of the re-accreditation process.
The network of Children’s Justice and Children’s Advocacy centers was developed to help “connect all the dots,” DeGraw said, in cases of child abuse, providing a central resource for victims and families. The need for such an organization persists: the NCA’s statistics website says that between January and June of this year, CJCs in Utah served 2,419 children.