Child Sexual Abuse Triage : Referral to a Child Abuse Expert

Making a Referral to a CAC

The New York State (NYS) Office of Children and Family Services (OCFS) supports a Child Advocacy Center (CAC) model that provides a coordinated and evidence-based approach to help children who have experienced suspected abuse. This county-based model brings together trained professionals and community resources, including law enforcement, prosecution, child protective services, medical providers, mental health therapists and victim advocates, to create a multidisciplinary team (MDT). The MDT's goal is to minimize the effects of child abuse trauma by making children and their families feel safe and supported through coordination of care, evidence collection, investigations, intervention and treatment.

The components of this model include:

Referral

Law enforcement, child protective services, medical providers and others refer a child to the CAC.

Interview

A trained forensic interviewer meets with the child in a child-friendly space at the CAC to ask questions in a way that doesn't retraumatize the child. The family/victim advocate meets with the caregiver to discuss any needs that the family may have and how to receive services and help.

Decision-making

Based on the forensic interview, the MDT makes decisions together about how to best help the child/family, including investigation, treatment, intervention and prosecution.

Follow-up

CAC MDT members continue to follow up with the caregiver and child, providing support and advocacy services throughout the investigation and possible court proceedings.

The Thought Process When Considering a Referral

• Limited timeframe for forensic evidence collection
• Safety of the child
• Local resources and costs to the patient and family
• Trauma informed care needs
• Patient factors such as vital signs and emotional state.

Making a Referral to a Child Abuse Expert

In general, to maximize the medical, legal, and protective outcomes for children and adolescents in abuse situations, professionals who have not received appropriate training should not perform evaluations. If you have questions regarding your role in the acute medical management of a particular child/adolescent, contact a child advocacy center for guidance. 

If you refer a child/adolescent to a CAC as a mandated reporter, you remain responsible for reporting your suspicions of abuse. Report the suspected sexual abuse to the proper authorities and then refer the medically stable child/adolescent to one of these centers. 

If the child/adolescent lives in a geographic area where there is no specialized center, a decision must be made based on local availability of medical care. In most cases, the most appropriate site for the medically stable child/adolescent is the primary care office. The value of good medical records and the availability of a past medical and family history cannot be overstated. However, the Emergency Department may offer the most appropriate services and have access to resources, such as an on-call service for Sexual Assault Forensic Examiners, for forensic evidence collection, photographs, pregnancy prevention, or prophylactic STI and treatment of incurred injuries.

Suggested Communication to the Child Abuse Expert

When referring a child to the child abuse expert, it is important to share objective information as clearly as possible. Describe your initial assessment that determined the need for the referral by providing the details listed in the box below:

Additional Considerations for Hospitals

• If your hospital has a child abuse team, consider consultation based on your hospital policies.
• If your hospital does not have a child abuse team, consider a report to child protective services and referral to a child abuse expert. An evaluation by a clinical child abuse expert may mitigate bias and unnecessary investigations.
• Algorithm

Additional Considerations for CACs

• CACs should promote a patient-centered approach to medical services, including preference for where the patient obtains medical care. Maintaining a neutral approach to appropriate medical services preserves a healthcare-focused approach.
• Healthcare providers require specific training and ongoing professional development in child abuse pediatrics. Except in rare cases, the diagnosis of child abuse should ultimately be reviewed by advanced medical consultants, as described by the NCA Med-Appendix 2 https://www.nationalchildrensalliance.org/wp-content/uploads/2021/10/2023-RedBook-v5B-t-Final-Web.pdf
• Peer review is supportive of diagnostic accuracy in the evaluation of suspected child sexual abuse victims.
• The medical director/medical team should have in place a policy to review cases referred to the child advocacy center and discuss the need for medical evaluations. 
• Determining the need for medical evaluations and potential triage to the emergency department should be a collaborative decision based on necessity and involve the medical team of the designated child advocacy center.
• Given the limited availability of medical providers in the field of child abuse pediatrics, widespread adoption of telehealth should be considered to facilitate medical examinations at child advocacy centers. Telehealth may support the goal of evaluation of all child sexual abuse cases by a child sexual abuse expert.
• In addition to children presenting with concerns regarding child sexual abuse, children presenting with concerns of physical abuse should be provided medical evaluation by someone trained in child abuse medicine.
• Communication amongst investigative professionals, advocates at the CAC, the hospital emergency department, and primary care provider is a critical component of the referral and triage process and appropriate medical care.
• Algorithm