B2. Initial Response

These recommendations are for those involved in initial response to prepubescent child sexual abuse cases prior to a child’s entry into the health care system (which is addressed in B3. Entry into the Health Care System). Emergency medical service/paramedic providers are included in this chapter as pre-health care setting initial responders.

Build consensus among entities involved in prepubescent child sexual abuse cases in a community (the multidisciplinary response team) regarding discipline-specific and coordination procedures for initial response. (See A3. Coordinated Team Approach) Procedures should address all sexual abuse cases, regardless of when the incident occurred; Procedures should facilitate timely identification of and response to children’s immediate safety and health needs, and the needs of case investigation as applicable. Responders who are not from an agency designated to receive mandatory reports should know how to make a report, what to do if there are concerns of imminent danger, and how to facilitate the child’s health care. [1]

The multidisciplinary response team should ensure that first responders are educated on procedures for initial response. Examples of first responders include child protective service hotline or intake workers, 911 dispatchers, law enforcement representatives (e.g., patrol officers), emergency medical service (EMS)/paramedic providers, and advocates who answer sexual assault crisis hotlines. These persons serve on the “front line” and may be involved in these cases prior to specialized personnel, units, or teams. Note that communities differ in, if, and how they use specialized personnel. (Be aware that other health care providers beyond EMS/paramedics are also first responders, but are addressed in B3. Entry into the Health Care System)

Tribal communities, military installations, and institutional settings and systems that house or care for prepubescent children may have their own procedures for handling sexual abuse disclosures and their own first responders (e.g., tribal law enforcement, child protective services/social services, victim advocates, and military installation police and family advocacy program staff). Multidisciplinary response teams from surrounding communities, as well as federal child abuse multidisciplinary teams, are encouraged to work with such entities to ensure that initial response procedures are coordinated with jurisdictional response or across jurisdictions, to the extent necessary. (See A3. Coordinated Team Approach)

Identify populations in the community from a specific culture (e.g., new immigrants, or groups that have historically been marginalized) for which it may be useful for the response team to identify professionals who are part of or provide services to that group and are willing to assist with the initial response. For example, faith leaders may be willing to act as liaisons between first responders and families in their congregation. Sometimes, but not always, children and families will be open to interventions when they have the support of someone from their own culture (but do not assume this is what they want—ask them). Ideally, such outreach should occur as part of a team’s planned efforts to build its capacity to serve all members of the community, rather than immediately prior to interventions in an individual case. Professionals identified to assist in initial response to victims from specific populations should be informed that they may be called on for this reason, educated on appropriate response to child sexual abuse, and confirm their willingness to act in this capacity. (See A3. Coordinated Team Approach)

Make sure the public knows what to do when a disclosure or a suspicion of child sexual abuse occurs. Citizens and all professionals in a community who interact with prepubescent children and their families should be educated on who is mandated to report child abuse and neglect, who can voluntarily report, and who to contact to report. Inform the public how entities involved in the local response to child sexual abuse work together to intervene in these cases. (See A5a. Reporting)

Recognize key elements of the initial multidisciplinary team response that may occur prior to the child’s entry into the health care system, as described below. (See Appendix 6. Initial Response Algorithm) These are general elements of response—responders should follow their jurisdictional and agency policies. Note that “team response” does not mean all responders will be involved in every case; rather, they may be called to respond, depending upon case needs.

*Key* Elements of the Initial Multidisciplinary *Team Response***
Report of disclosure or suspicion should trigger the multidisciplinary response team. The team should: · *Communicate among responders* to ensure timely, coordinated action, as needed, in a specific case. · *Tailor the response to accommodate the needs of the child* *and the caregiver/family* (e.g., developmental level, abilities, linguistic needs, health conditions, housing status, and culture, to the extent possible). Response should be child-focused, victim-centered, and trauma-informed. (See A1. Principles of Care and A2. Adapting Care for Each Child ) · Note that, *if a children’s advocacy center exists in a community*, center staff may play a central coordinating role for the multidisciplinary response team during the initial response.
If child protective services, law enforcement, or 911 is the first responder: · *Assess immediate* *safety needs* of the child, others at scene, and others where the child or suspected perpetrator(s) lives/or those with whom the suspect may come in contact. If in imminent danger, 911 should be immediately involved. · *Assess the child’s need for* *emergency medical care. If at the child’s location, administer necessary first aid. As needed, request EMS/paramedic assistance. With recent sexual abuse, take precautions to prevent the loss of forensic evidence on the child’s body or clothing to the extent possible while treating acute injuries. · Explain to the child and caregiver: Mandatory reporting, the next steps in the response, the importance of medical forensic care, and the availability of support and advocacy. · Seek basic information from the child and caregiver* regarding the abuse reported to ascertain a time frame and the nature of the abuse, and, as applicable, to apprehend the suspect and facilitate crime scene preservation. (Note: this limited fact-finding is not the investigative/forensic interview, which may occur before or after the medical forensic examination) · *Arrange an* *initial health care assessment* to provide the child emergency medical treatment (if applicable) and/or determine the urgency of medical forensic care needed (acute or nonacute). A health care professional should determine the urgency of medical forensic care. (See B3. Entry into the Health Care System ) First responders should understand that a child’s health must be assessed even if law enforcement or child protective services perceive that the child’s body or clothing contains no forensic evidence. First responders should be familiar with health care facilities that perform initial assessments (some jurisdictions designate them; others do not), and facilities that conduct prepubescent sexual abuse medical forensic examinations (many jurisdictions have designated facilities for medical forensic care). For each exam site, first responders should know whether the site offers acute and/or nonacute care, hours of operation, and staffing. If an exam facility is closed or the pediatric examiner is unavailable at one site, they should know the next closest, appropriate exam site. · Follow jurisdictional policies for *alerting the health care facility* of the pending arrival of a child sexual abuse patient. If it is a designated exam facility, check that a pediatric examiner is available. · *Transport the child and caregiver to ensure timely arrival at the appropriate health care facility* (e.g., via EMS, law enforcement, or child protective services), and to maximize preservation of forensic evidence on the child’s body and clothing. Transportation should be offered in both acute and nonacute cases. o Note that, if the facility where the initial medical assessment has been performed differs from the exam site, the child and caregiver may also need to be transported to the exam site. o Note that children with disabilities may have specialized transportation needs and use assistive devices (e.g., motorized wheelchairs and telecommunication equipment) and/or service animals (e.g., guide dogs and hearing-assistance dogs) that need to be transported to the exam site. Do not touch assistive devices or service animals without the child’s permission. · *Facilitate preservation of crime scene and forensic evidence, as applicable. If forensic evidence may be collected during the medical forensic examination: o Explain to the child and caregiver the need to preserve forensic evidence on the child’s body and clothing to the best of their ability until it can be collected at the health care facility (e.g., ideally, the child should not wash, change clothes, urinate, defecate, drink, eat, brush hair or teeth, or rinse the mouth) and that clothing may be taken as evidence. Instruct the caregiver to bring a clean change of clothes for the child to the exam facility. If the child changed clothes since the abuse, collect the clothing worn during and immediately after the abuse. Other items that potentially contain forensic evidence (e.g., jewelry worn during the abuse, towels and blankets that were used after the abuse, and soiled diapers or underwear) should also be collected. Follow jurisdictional/agency policies for retrieval of clothing/crime scene items so that forensic evidence is not inadvertently destroyed or contaminated and chain of custody of evidence is maintained. o Note that a child who uses assistive devices and/or service animals generally cannot go without them, as the child often views them as an extension of her/himself. If considered to be potential forensic evidence in a case, they should not be taken away from the child. Rather, during the medical forensic examination, the pediatric examiner can swab and photograph these devices or animals with the same intent and process as used to collect and photo-document forensic evidence from the child’s body. o Take precautions to avoid damaging forensic evidence while interacting with the child, at the crime scene, and when transporting the child and any assistance devices or service animals to the health care facility.. Wear gloves, and avoid the transfer of responder DNA to the child (via sweat, saliva from coughing, etc), or disrupting the crime scene.[2] o EMS/paramedic providers who transport the child to the health care facility should follow jurisdictional/agency policy for collecting and packaging linens used and provide them to the health care provider or law enforcement personnel (if at the health care facility). o For recent sexual abuse cases in which alcohol or drugs is disclosed or suspected, if the child needs to urinate or vomit prior to arrival at the health care facility, these fluids should be collected and packaged as per jurisdictional/agency policy. Also, collect and package containers that may have been used to drug a child. · Follow jurisdictional policies for activating an advocate* (as available) to support the child and family.
If an advocacy or victim service agency is the first responder: · *Make a child sexual abuse report and communicate any urgent safety concerns* to the appropriate agencies, as required by jurisdictional/agency policies. · *Offer assistance to children and caregivers* *during the initial response*, specific to the services offered by the agency: e.g., support and crisis intervention; basic information on sexual abuse, victim reactions, medical forensic care and other aspects of community response; assistance contacting responders; safety planning; medical accompaniment during the examination, and legal accompaniment.

Key Elements of the Initial Multidisciplinary Team Response

Report of disclosure or suspicion should trigger the multidisciplinary response team. The team should:

· Communicate among responders to ensure timely, coordinated action, as needed, in a specific case.

· Tailor the response to accommodate the needs of the child and the caregiver/family (e.g., developmental level, abilities, linguistic needs, health conditions, housing status, and culture, to the extent possible). Response should be child-focused, victim-centered, and trauma-informed. (See A1. Principles of Care and A2. Adapting Care for Each Child )

· Note that, if a children’s advocacy center exists in a community, center staff may play a central coordinating role for the multidisciplinary response team during the initial response.

If child protective services, law enforcement, or 911 is the first responder:

· Assess immediate safety needs of the child, others at scene, and others where the child or suspected perpetrator(s) lives/or those with whom the suspect may come in contact. If in imminent danger, 911 should be immediately involved.

· Assess the child’s need for emergency medical care. If at the child’s location, administer necessary first aid. As needed, request EMS/paramedic assistance. With recent sexual abuse, take precautions to prevent the loss of forensic evidence on the child’s body or clothing to the extent possible while treating acute injuries.

· Explain to the child and caregiver: Mandatory reporting, the next steps in the response, the importance of medical forensic care, and the availability of support and advocacy.

· Seek basic information from the child and caregiver regarding the abuse reported to ascertain a time frame and the nature of the abuse, and, as applicable, to apprehend the suspect and facilitate crime scene preservation. (Note: this limited fact-finding is not the investigative/forensic interview, which may occur before or after the medical forensic examination)

· Arrange an initial health care assessment to provide the child emergency medical treatment (if applicable) and/or determine the urgency of medical forensic care needed (acute or nonacute). A health care professional should determine the urgency of medical forensic care. (See B3. Entry into the Health Care System ) First responders should understand that a child’s health must be assessed even if law enforcement or child protective services perceive that the child’s body or clothing contains no forensic evidence. First responders should be familiar with health care facilities that perform initial assessments (some jurisdictions designate them; others do not), and facilities that conduct prepubescent sexual abuse medical forensic examinations (many jurisdictions have designated facilities for medical forensic care). For each exam site, first responders should know whether the site offers acute and/or nonacute care, hours of operation, and staffing. If an exam facility is closed or the pediatric examiner is unavailable at one site, they should know the next closest, appropriate exam site.

· Follow jurisdictional policies for alerting the health care facility of the pending arrival of a child sexual abuse patient. If it is a designated exam facility, check that a pediatric examiner is available.

· Transport the child and caregiver to ensure timely arrival at the appropriate health care facility (e.g., via EMS, law enforcement, or child protective services), and to maximize preservation of forensic evidence on the child’s body and clothing. Transportation should be offered in both acute and nonacute cases.

o Note that, if the facility where the initial medical assessment has been performed differs from the exam site, the child and caregiver may also need to be transported to the exam site.

o Note that children with disabilities may have specialized transportation needs and use assistive devices (e.g., motorized wheelchairs and telecommunication equipment) and/or service animals (e.g., guide dogs and hearing-assistance dogs) that need to be transported to the exam site. Do not touch assistive devices or service animals without the child’s permission.

· Facilitate preservation of crime scene and forensic evidence, as applicable. If forensic evidence may be collected during the medical forensic examination:

o Explain to the child and caregiver the need to preserve forensic evidence on the child’s body and clothing to the best of their ability until it can be collected at the health care facility (e.g., ideally, the child should not wash, change clothes, urinate, defecate, drink, eat, brush hair or teeth, or rinse the mouth) and that clothing may be taken as evidence. Instruct the caregiver to bring a clean change of clothes for the child to the exam facility. If the child changed clothes since the abuse, collect the clothing worn during and immediately after the abuse. Other items that potentially contain forensic evidence (e.g., jewelry worn during the abuse, towels and blankets that were used after the abuse, and soiled diapers or underwear) should also be collected. Follow jurisdictional/agency policies for retrieval of clothing/crime scene items so that forensic evidence is not inadvertently destroyed or contaminated and chain of custody of evidence is maintained.

o Note that a child who uses assistive devices and/or service animals generally cannot go without them, as the child often views them as an extension of her/himself. If considered to be potential forensic evidence in a case, they should not be taken away from the child. Rather, during the medical forensic examination, the pediatric examiner can swab and photograph these devices or animals with the same intent and process as used to collect and photo-document forensic evidence from the child’s body.

o Take precautions to avoid damaging forensic evidence while interacting with the child, at the crime scene, and when transporting the child and any assistance devices or service animals to the health care facility.. Wear gloves, and avoid the transfer of responder DNA to the child (via sweat, saliva from coughing, etc), or disrupting the crime scene.[2]

o EMS/paramedic providers who transport the child to the health care facility should follow jurisdictional/agency policy for collecting and packaging linens used and provide them to the health care provider or law enforcement personnel (if at the health care facility).

o For recent sexual abuse cases in which alcohol or drugs is disclosed or suspected, if the child needs to urinate or vomit prior to arrival at the health care facility, these fluids should be collected and packaged as per jurisdictional/agency policy. Also, collect and package containers that may have been used to drug a child.

· Follow jurisdictional policies for activating an advocate (as available) to support the child and family.

If an advocacy or victim service agency is the first responder:

· Make a child sexual abuse report and communicate any urgent safety concerns to the appropriate agencies, as required by jurisdictional/agency policies.

· Offer assistance to children and caregivers during the initial response, specific to the services offered by the agency: e.g., support and crisis intervention; basic information on sexual abuse, victim reactions, medical forensic care and other aspects of community response; assistance contacting responders; safety planning; medical accompaniment during the examination, and legal accompaniment.

Table of Contents

B3. Entry into the Health Care System

[1] As noted in A5a. Reporting, VAWA confidentiality provisions include a requirement that VAWA grantees who are not mandated reporters of child abuse and neglect under their jurisdictional laws may only report abuse and/or neglect if the victim consents. However, if there exists an imminent risk of harm to a child, the grantee program should follow its program policies for accessing emergency assistance. The grantee program can also help connect the child with health care services, if given permission.

[2] Chen and Steer (2012).