Gail Hornor

Child sexual abuse: Consequences and implications

Sexual abuse is a problem of epidemic proportions in the United States. Given the sheer numbers of sexually abused children, it is vital for pediatric nurse practitioners to understand both short-term and long-term consequences of sexual abuse. Understanding consequences of sexual abuse can assist the pediatric nurse practitioner in anticipating the physical and mental health needs of patients and also may assist in the identification of sexual abuse victims. Sexual abuse typically does not occur in isolation. Implications for practice will be discussed.

Sexual behavior in children: Normal or not?

Sexual abuse is a problem of epidemic proportions in the United States. Given the scope of the problem of sexual abuse and the amount of media attention it receives, it is not unusual for parents or caretakers who witness a child exhibiting sexual behavior to become alarmed. Primary care providers, including pediatric nurse practitioners, may be the first professional parents contact with concerns regarding a childs sexual behavior. It is imperative that primary care providers understand childhood sexuality and respond appropriately when confronted with child sexual behaviors in their practice. Although the literature includes little research on the subject of normal child sexual development, certain guidelines have been identified to describe normal child sexual behaviors and those of concern. Case studies illustrate the response of two primary care providers when they are confronted with sexual behaviors in their patients. Implications for practice are discussed, with examples and guidelines provided for primary care providers to use when evaluating sexual behavior in their pediatric patients.

Forensic Evidence Collection and DNA Identification in Acute Child Sexual Assault

OBJECTIVE: To describe forensic evidence findings and reevaluate previous recommendations with respect to timing of evidence collection in acute child sexual assault and to identify factors associated with yield of DNA. METHODS: This was a retrospective review of medical and legal records of patients aged 0 to 20 years who required forensic evidence collection. RESULTS: Ninety-seven of 388 (25%) processed evidence-collection kits were positive and 63 (65%) of them produced identifiable DNA. There were 20 positive samples obtained from children younger than 10 years; 17 of these samples were obtained from children seen within 24 hours of the assault. Three children had positive body samples beyond 24 hours after the assault, including 1 child positive for salivary amylase in the underwear and on the thighs 54 hours after the assault. DNA was found in 11 children aged younger than 10 years, including the child seen 54 hours after the assault. Collection of evidence within 24 hours of the assault was identified as an independent predictor of DNA detection. CONCLUSIONS: Identifiable DNA was collected from a childs body despite cases in which: evidence collection was performed >24 hours beyond the assault; the child had a normal/nonacute anogenital examination; there was no reported history of ejaculation; and the victim had bathed and/or changed clothes before evidence collection. Failure to conduct evidence collection on prepubertal children beyond 24 hours after the assault will result in rare missed opportunities to identify forensic evidence, including identification of DNA.

Common Conditions That Mimic Findings of Sexual Abuse

Sexual abuse is a problem of epidemic proportions in our society. Given the prevalence of sexual abuse, it is vital for medical providers, including pediatric nurse practitioners, to recognize sexual abuse in their patients and respond appropriately. Failing to recognize sexual abuse can leave children at risk for continued abuse and potentially lead to the sexual abuse of additional children. Serious ramifications also can arise when sexual abuse is diagnosed erroneously. Children can be removed from their homes and placed in foster care. An innocent person can be prosecuted. It is important for pediatric nurse practitioners to understand that the majority of children who are sexually abused will have a normal or nonspecific ano-genital examination. However, physical findings of sexual abuse are noted in approximately 4% of children who give a history of sexual abuse. Certain clinical findings can mimic sexual abuse. This article will discuss some of the more common findings mistaken for sexual abuse and assist the pediatric nurse practitioner in correctly recognizing these findings and responding appropriately.

Medical Evaluation for Child Physical Abuse: What the PNP Needs to Know

Sexual abuse is a problem of epidemic proportions. Pediatric nurse practitioners (PNPs) will most likely encounter sexually abused children in their practice, both those who have been previously diagnosed and others who are undiagnosed and require identification by the PNP. This continuing education article will discuss the medical evaluation of children with concerns of suspected sexual abuse. Acute and non-acute sexual abuse/assault examinations will be discussed. Physical findings and sexually transmitted infections concerning for sexual abuse/assault will also be discussed.

Child Maltreatment: Screening and Anticipatory Guidance

Child maltreatment is a problem of epidemic proportions in the United States. Given the numbers of children affected by child maltreatment and the dire consequences that can develop, prompt identification of child maltreatment is crucial. Despite support of the implementation and development of protocols for child maltreatment screening by professional organizations such as the National Association of Pediatric Nurse Practitioners and American Academy of Pediatrics, little is available in the literature regarding the screening practices of pediatric nurse practitioners and other pediatric health care providers. This Continuing Education article will help pediatric nurse practitioners incorporate this vital screening intervention into their practice. Practical examples of when and how to incorporate screening questions and anticipatory guidance for discipline practices, crying, intimate partner violence (domestic violence), physical abuse, and sexual abuse will be discussed.

Emotional response to the ano-genital examination of suspected sexual abuse

Introduction: Concerns have arisen among professionals working with children regarding potential emotional distress as a result of the ano‐genital examination for suspected child sexual abuse. The purpose of this study was to describe and compare childrens anxiety immediately preceding and immediately following the medical assessment of suspected child sexual abuse, including the ano‐genital exam, and to examine demographic characteristics of those children reporting clinically significant anxiety. Method: In this descriptive study, children between the ages of 8 to 18 years of age requiring an ano‐genital examination for concerns of suspected sexual abuse presenting to the Child Assessment Center of the Center for Child and Family Advocacy at Nationwide Childrens Hospital were asked to participate. The Multidimensional Anxiety Scale for Children (MASC‐10) was utilized in the study. The MASC‐10 was completed by the child before and after the physical exam for suspected sexual abuse. Results: Although most (86%) children gave history of sexual abuse during their forensic interview, the majority (83%) of children in this study did not report clinically significant anxiety before or after the child sexual abuse examination. Children reporting clinically significant anxiety were more likely to have a significant cognitive disability, give history of more invasive forms of sexual abuse, have a chronic medical diagnosis, have a prior mental health diagnosis, have an ano‐genital exam requiring anal or genital cultures, and lack private/public medical insurance. Discussion: A brief assessment of child demographics should be solicited prior to exam. Children sharing demographic characteristics listed above may benefit from interventions to decrease anxiety regardless of provider ability to detect anxiety.

Childhood trauma exposure and toxic stress: what the PNP needs to know.

Trauma exposure in childhood is a major public health problem that can result in lifelong mental and physical health consequences. Pediatric nurse practitioners must improve their skills in the identification of trauma exposure in children and their interventions with these children. This continuing education article will describe childhood trauma exposure (adverse childhood experiences) and toxic stress and their effects on the developing brain and body. Adverse childhood experiences include a unique set of trauma exposures. The adverse childhood experiences or trauma discussed in this continuing education offering will include childhood exposure to emotional abuse, physical abuse, sexual abuse, emotional neglect, physical neglect, domestic violence, household substance abuse, household mental illness, parental separation or divorce, and a criminal household member. Thorough and efficient methods of screening for trauma exposure will be discussed. Appropriate intervention after identification of trauma exposure will be explored.

Child neglect: Assessment and intervention

Neglect is often a neglected form of child maltreatment even though it is the most common and deadliest form of child maltreatment. Pediatric nurse practitioners (PNPs) will most likely encounter neglected children in their practice. It is crucial that PNPs recognize child neglect in a timely manner and intervene appropriately. This continuing education article will help PNPs understand and respond to child neglect. Neglect will be defined and risk factors will be discussed. Children who are neglected can experience serious and lifelong consequences. The medical assessment and plan of care for children with concerns of suspected neglect will be discussed.

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 Childrens 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.