Caring for young adolescent sexual abuse victims in a hospital-based children's advocacy center

Black Moms Matter: A Qualitative Approach to Understanding Barriers to Service Utilization at a Children's Advocacy Center Following Childhood Abuse

Black families are significantly less likely to receive evidence-based trauma treatment services; however, little is known about factors impacting engagement, particularly at Children's Advocacy Centers (CACs). The goal of this study is to better understand barriers and facilitators of service utilization for Black caregivers of CAC referred youth. Participants (n = 15) were randomly selected Black maternal caregivers (ages 26-42) recruited from a pool of individuals who were referred to receive CAC services. Black maternal caregivers reported barriers to accessing services at CACs including a lack of assistance and information in the referral and onboarding process, transportation issues, childcare, employment hours, system mistrust, stigma associated with the service system, and outside stressors such as stressors related to parenting. Maternal caregivers also shared suggestions for improving services at CACs including increasing the length, breadth, and clarity of investigations conducted by child protection services and law enforcement (LE) agencies, providing case management services, and having more diverse staff and discussing racial stressors. We conclude by identifying specific barriers to the initiation and engagement in services for Black families, and we provide suggestions for CACs seeking to improve engagement of Black families referred for trauma-related mental health services.

Outcomes and outputs affiliated with Children's Advocacy Centers in the United States: A scoping review

BACKGROUND

The Children's Advocacy Center (CAC) model is the predominant multidisciplinary model that responds to child sexual abuse (CSA) in the United States (US). While the CAC model has made important contributions in case coordination and referrals for specialty services, little is known about child- or family-oriented outcomes.

OBJECTIVE

Explore the trends and gaps involving outcome and output measures affiliated with CACs in the US.

PARTICIPANTS & SETTING

A scoping review of the literature was conducted on English language articles published between 1985-2019 that involved CACs and children less than 18 years of age.

METHODS

An electronic database search using the terms "Children's Advocacy Center(s)," "Child Advocacy Center(s)," and "CAC(s)" identified titles and abstracts. Data from articles selected for full text review were evaluated by a multidisciplinary team using a mixed methods approach.

RESULTS

Measures of CAC impact frequently focus on service and programmatic outputs with person-centered outcomes left often reported. The most prevalent output measures related to case prosecution and forensic interviews. Person-centered outcomes most commonly emphasized child mental health and caregiver satisfaction. The majority of articles were limited by weak or unspecified study designs.

CONCLUSION

The current literature on CACs suggests that while they are successful in coordinating services and facilitating referrals, little is known about how engagement with CACs impacts short- and long-term outcomes for children and families. Further research beyond cross sectional or quasi-experimental designs is necessary to better understand how variability in CAC structure, function, and resources can be optimized to meet the needs of the diverse communities that they serve. This is especially salient given the national dissemination of the CAC model. Without such additional studies, knowledge will remain limited regarding the enduring impacts of CACs on the lives of those impacted by CSA.

Worker Perceptions of the Multi-Agency Investigation & Support Team (MIST): A Process Evaluation of a Cross-Agency Response to Severe Child Abuse

The Multi-agency Investigation & Support Team (MIST) was a new approach to abuse investigations that aimed to minimize the distress and uncertainty experienced by children and non-abusive caregivers in dealing with the many agencies typically involved in a case post-disclosure, while also attempting to improve the accessibility of supportive and therapeutic services. As part of a broader evaluation, this study examined worker perceptions early in the implementation of this new approach. Thirty-three (33) interviews were conducted with workers affected by this new pilot. The interviews identified almost exclusively positive perceptions of the changes relative to practice as usual, particularly in terms of improvements to collaboration and communication across agencies, and the benefits of providing support alongside the investigation process. Some areas of difficulty and areas for improvement were identified, particularly the need for stronger governance of the cross-agency protocol and improved connection to some of the groups involved in the response that were not co-located. The study suggests professionals working in the MIST model consider the model beneficial to the quality of the response to severe child abuse while highlighting that the process of change into this new way of working was challenging at times.

The identification and treatment of mental health and substance misuse problems in sexual assault services: A systematic review

BACKGROUND

Specialist sexual assault services, which collect forensic evidence and offer holistic healthcare to people following sexual assault, have been established internationally. In England, these services are called sexual assault referral centres (SARCs). Mental health and substance misuse problems are common among SARC attendees, but little is known about how SARCs should address these needs. This review aims to seek and synthesise evidence regarding approaches to identification and support for mental health and substance misuse problems in SARCs and corresponding services internationally; empirical evidence regarding effective service models; and stakeholders' views and policy recommendations about optimal SARC practice.

METHODS

A systematic review was undertaken. PsycINFO, MEDLINE, IBSS and CINAHL were searched from 1975 to August 2018. A web-based search up to December 2018 was also conducted to identify government and expert guidelines on SARCs. Quality assessment and narrative synthesis were conducted.

RESULTS

We included 107 papers. We found that identification based on clinical judgement, supportive counselling and referral to other services without active follow-up were the most common approaches. Evaluations of interventions for post-rape psychopathology in attendees of sexual assault services provided mixed evidence of moderate quality. Very little evidence was found regarding interventions or support for substance misuse. Stakeholders emphasised the importance of accessibility, flexibility, continuity of care, in-house psychological support, staff trained in mental health as well as specialist support for LGBT groups and people with learning difficulties. Guidelines suggested that SARCs should assess for mental health and substance misuse and provide in-house emotional support, but the extent and nature of support were not clarified. Both stakeholders and guidelines recommended close partnership between sexual assault services and local counselling services.

CONCLUSIONS

This review suggests that there is big variation in the mental health and substance misuse provision both across and within different sexual assault service models. We found no robust evidence about how sexual assault services can achieve good mental health and substance misuse outcomes for service users. Clearer guidance for service planners and commissioners, informed by robust evidence about optimal service organisations and pathways, is required. PROSPERO registration number: CRD42018119706.

Better Together? A Review of Evidence for Multi-Disciplinary Teams Responding to Physical and Sexual Child Abuse

Multi-Disciplinary teams (MDTs) have often been presented as the key to dealing with a number of intractable problems associated with responding to allegations of physical and sexual child abuse. While these approaches have proliferated internationally, researchers have complained of the lack of a specific evidence base identifying the processes and structures supporting multi-disciplinary work and how these contribute to high-level outcomes. This systematic search of the literature aims to synthesize the existing state of knowledge on the effectiveness of MDTs. This review found that overall there is reasonable evidence to support the idea that MDTs are effective in improving criminal justice and mental health responses compared to standard agency practices. The next step toward developing a viable evidence base to inform these types of approaches seems to be to more clearly identify the mechanisms associated with effective MDTs in order to better inform how they are planned and implemented.

Toward evidence-based anti-human trafficking policy: a rapid review of CSE rehabilitation and evaluation of Indian legislation

This paper (a) examines the evidence base around rehabilitation of victims of trafficking for commercial sexual exploitation (CSE), (b) identifies the extent that India's proposed 2016 Trafficking of Persons (Prevention, Protection, and Rehabilitation) Bill reflects scientific and experiential evidence, and (c) discusses how gaps in the proposed bill can be informed by evidence. A rapid review of empirical studies on policies and interventions addressing rehabilitation of CSE victims was conducted. Although evidence is lacking, research suggests that cross-sectoral collaboration, training and monitoring law enforcement, psychotherapeutic interventions and care provided by short-term shelters, reintegration, and recognizing victims' rights improve the success of rehabilitative efforts. The proposed legislation does not sufficiently reflect evidence around successful rehabilitation efforts and suggests that implementing the bill as it currently stands would change little of the existing structures to support victims in receiving adequate services or successfully reintegrating into society.

A national survey of characteristics of child advocacy centers in the United States: Do the flagship models match those in broader practice?

Child Advocacy Centers (CAC) emphasize developing effective cross-agency collaborations between workers involved in serious abuse investigations to foster improvements in agency outcomes, and to minimize distress, confusion and uncertainty for children and families. This study examined the characteristics of CACs, whether models in practice match the predominant model presented in the research literature. Directors of CACs in the United States that were members of the National Children's Alliance (NCA) mailing list (n=361) completed an online survey in 2016. While some core characteristics were ubiquitous across CACs, the data suggests that different types of CACs exist defined by characteristics that are not prescribed under NCA principles, but which are arguably relevant to the quality of the response. From the results of a cluster analysis, the researchers propose a typology of CACs that reflects the development and integration of centers: (a) core CAC services (i.e. interviewing & cross-agency case review); (b) an aggregator of external services, and (c) a more centralized full-service CAC. Further research is needed to understand how these variations may impact practice and outcomes; this is particularly important considering many CACs do not match the full-service models most commonly examined in the research literature, which limits the degree to which these findings apply to CACs generally. This article proposes further research framed by the need to better understand how different parts of the response impact on outcomes for children and families affected by abuse.

Evaluating Nurse Practitioners Perceived Knowledge, Competence, and Comfort Level in Caring for the Sexually Abused Child

OBJECTIVE

The purpose of this project was to evaluate nurse practitioners' (NPs') current approach and self-reported competence in the care of the sexually abused child in the primary care setting.

METHODS

A 50-question survey was distributed to 5,734 NPs who were members of a state nursing organization and nursing alumni. Inclusion criteria included NPs caring for pediatric patients in a primary care setting in New York State.

RESULTS

A total of N = 325 responses were obtained, and 110 participants met the inclusion criteria. Very few NPs felt competent to perform a medical forensic examination on a sexually abused child (25.5%), and even fewer felt competent to render a definitive opinion on sexual abuse (17.3%) or to testify in court (12.7%). Most NPs felt the need for more training on child sexual abuse (78.2%). Most would prefer to refer children who are suspected of sexual abuse to an expert (77.3%), but very few (19.1%) are being referred to a local resource, like a Child Advocacy Center when a parent calls the office with a concern.

CONCLUSION

More research is needed to evaluate clinical practices regarding child sexual abuse. NPs see value in pursuing specialist referrals for child sexual abuse but do not have access to the appropriate resources or are unaware of the availability within their community.

PRACTICE IMPLICATIONS

NPs should be aware of their own limitations and seek out education to improve their knowledge and skills. Forensic nurses are ideally situated to provide education on the available resources and the recommended clinical guidelines for referral.

Provider ambivalence about using forensic medical evaluation to respond to child abuse: A content and discourse analysis

Forensic medical evaluation rates for child abuse victims in Texas are low relative to national rates. In exploring reasons, researchers collected quantitative and qualitative interview and focus group data from multidisciplinary child abuse response team members across the state. This paper presents results of a secondary analysis of (N=19) health care providers' interview and focus group transcripts, looking specifically at experiences with conducting forensic evaluations - thoughts, struggles, and ethical issues. The analysis was conducted from a critical realist perspective using content and discourse analysis. A theme of ambivalence was identified and explored. Three discursive themes were identified: ambivalence about the legal role, the health care role, and about unintended outcomes of evaluations. Extra-discursive elements related to the physical body, resource distribution, and funding policy were examined for their interaction with discursive patterns. Implications of findings include addressing issues in the current approach to responding to child abuse (e.g., uniting around common definitions of abuse; refining parameters for when FME is helpful; shoring up material resources for the abuse response infrastructure) and considering modification of providers' roles and activities relative to forensic work (e.g., deploying providers for prevention activities versus reactive activities).

Evidence for the Efficacy of the Child Advocacy Center Model: A Systematic Review

The Child Advocacy Center (CAC) model has been presented as the solution to many of the problems inherent in responses by authorities to child sexual abuse. The lack of referral to therapeutic services and support, procedurally flawed and potentially traumatic investigation practices, and conflict between the different statutory agencies involved are all thought to contribute to low conviction rates for abuse and poor outcomes for children. The CAC model aims to address these problems through a combination of multidisciplinary teams, joint investigations, and services, all provided in a single child friendly environment. Using a systematic search strategy, this research aimed to identify and review all studies that have evaluated the effectiveness of the approach as a whole, recognizing that a separate evidence base exists for parts of the approach (e.g., victim advocacy and therapeutic responses). The review found that while the criminal justice outcomes of the model have been well studied, there was a lack of research on the effect of the model on child and family outcomes. Although some modest outcomes were clear, the lack of empirical research, and overreliance on measuring program outputs, rather than outcomes, suggests that some clarification of the goals of the CAC model is needed.

Pattern and medical care of child victims of sexual abuse in Ekiti, south-western Nigeria

BACKGROUND

Child sexual assault (CSA) is a global health problem which affects many children and is often under-reported in developing countries. Data on CSA are few in these countries.

AIMS AND OBJECTIVES

This study aimed to review the pattern and medical care of victims of CSA in a tertiary hospital over a 39-month period.

METHODS

This is a retrospective, descriptive study. Case files of 28 cases of CSA were retrieved from those of 6535 patients seen in the paediatric out-patient department of Ekiti State University Teaching Hospital between 1 January 2010 and 31 March 2013.

RESULTS

Victims of CSA accounted for 0.43% of new patients seen during the period under review with a yearly increase over that time. Victims were all female with a median age of 11.5 years and the age range was 4-17. They all had genito-urinary findings and 3.6% had an anal tear. The assailants were all male, mostly adults. A school-teacher and school-friends were the perpetrators in 3.6% and 10.8% of cases, respectively. All were screened for HIV, but only 60.7% were screened for hepatitis B and C. Only 60.7% received HIV post-exposure prophylaxis and none was given prophylaxis against viral hepatitis B and C. Of those eligible for post-exposure emergency contraception, only 43.8% received it. Antibiotics and analgesics were routinely given in 89.3% cases. Only one of the patients attended for follow-up. None had repeat serological screening tests. The police were involved in 60.7% of cases but there was no prosecution.

CONCLUSION

Perpetrators of CSA are protean and, in the study area, there are gross inadequacies in the care provided for victims. Standard treatment protocols and additional training for health-care providers involved in the management of CSA victims are required.

Pediatric sexual assault nurse examiner care: trace forensic evidence, ano-genital injury, and judicial outcomes

INTRODUCTION

Although pediatric sexual assault nurse examiners (P-SANEs) have been providing care for over two decades there remain major gaps in the literature describing the quality of P-SANE care and legal outcomes associated with their cases. The purpose of this study was to compare quality indicators of care in a pediatric emergency department (PED) before and after the implementation of a P-SANE program described in terms of trace forensic evidence yield, identification of perpetrator DNA, and judicial outcomes in pediatric acute sexual assault.

METHOD

A retrospective review of medical and legal records of all patients presenting to the PED at Nationwide Children's Hospital with concerns of acute sexual abuse/assault requiring forensic evidence collection from 1/1/04 to 12/31/07 was conducted.

FINDINGS

Detection and documentation of ano-genital injury, evaluation and documentation of pregnancy status, and testing for N. gonorrhea and C. trachomatis was significantly improved since implementation of the P-SANE Program compared to the historical control.

DISCUSSION

The addition of a P-SANE to the emergency department (ED) provider team improved the quality of care to child/adolescent victims of acute sexual abuse/assault.

Development of a screening tool for pediatric sexual assault may reduce emergency-department visits

OBJECTIVE

To define the characteristics of a novel screening tool used to identify which prepubertal children should potentially receive an initial evaluation for alleged sexual assault in a nonemergent setting.

METHODS

Electronic medical records were retrospectively reviewed from 2007 to 2008. Visits with a chief complaint or diagnosis of alleged sexual assault for patients aged 12 years or younger were identified. Complete records, those with no evaluation before pediatric emergency-department arrival, and those with child advocacy center follow-up were included. Records were reviewed to answer the following: (1) Did the incident occur in the past 72 hours, and was there oral or genital to genital/anal contact? (2) Was genital or rectal pain, bleeding, discharge, or injury present? (3) Was there concern for the child's safety? (4) Was an unrelated emergency medical condition present? An affirmative response to any of the questions was considered a positive screen (warranting immediate evaluation); all others were considered negative screens. Those who had positive physical examination findings of anogenital trauma or infection, a change in custody, or an emergency medical condition were defined as high risk (having a positive outcome).

RESULTS

A total of 163 cases met study criteria; 90 of 163 (55%) patients had positive screens and 73 of 163 (45%) had negative screens. No patients with negative screens were classified as high risk. The screening tool has sensitivity of 100% (95% confidence interval: 93.5-100.0).

CONCLUSIONS

This screening tool may be effective for determining which children do not require emergency-department evaluation for alleged sexual assault.

Suspect confession of child sexual abuse to investigators

Increasing the number of suspects who give true confessions of sexual abuse serves justice and reduces the burden of the criminal justice process on child victims. With data from four communities, this study examined confession rates and predictors of confession of child sexual abuse over the course of criminal investigations (final N = 282). Overall, 30% of suspects confessed partially or fully to the crime. This rate was consistent across the communities and is very similar to the rates of suspect confession of child sexual abuse found by previous research, although lower than that from a study focused on a community with a vigorous practice of polygraph testing. In a multivariate analysis, confession was more likely when suspects were younger and when more evidence of abuse was available, particularly child disclosure and corroborative evidence. These results suggest the difficulty of obtaining confession but also the value of methods that facilitate child disclosure and seek corroborative evidence, for increasing the odds of confession.

A meta-analysis of the effects of psychotherapy with sexually abused children and adolescents

This paper presents a meta-analysis of the psychotherapy treatment outcome studies for sexually abused children and adolescents. There were 39 studies included, most of which aimed to treat the psychological effects of childhood sexual abuse. Separate meta-analyses were conducted according to study design and outcome domain, in keeping with meta-analytic conventions. However, given heterogeneity across studies and the need for sufficient n in each category for meaningful moderator analyses, the study designs were pooled into a repeated measures meta-analysis. There were large effect sizes for global outcomes (g=1.37) and PTSD/trauma outcomes (g=1.12). More moderate effect sizes were evident for internalizing symptoms (g=0.74), self-appraisal (g=0.63), externalizing symptoms (g=0.52), and sexualized behavior (g=0.49), while small effects were found for measures of coping/functioning (g=0.44), caregiver outcomes (g=0.43), and social skills/competence (g=0.38). Effects were maintained at follow-up more than six months after treatment for some outcome domains but not others. Studies represented diverse treatment approaches, and most treatments were effective in symptom reduction. Presence of probable moderators of treatment outcome varied across symptom domains, reflecting importance of targeting therapy to individual needs.