BY: ANGELA LISBURG, MS, RN, FNP-C
Jon Lezinsky
Imagine, for a moment, finding courage. Finding courage to tell someone about something happening to you; something bad, maybe something so terrible that you feel embarrassed and ashamed about it and are afraid no one will believe you. Maybe you believe that it's your fault. Maybe the person who did this to you threatened you and told you never to tell, and you are so frightened about what might happen next.
Then imagine that the person you told believes you and tells you they know just the right people to talk to about this.
Imagine your courage continuing as you go to a safe place, where there are people who continue to believe you, and they will help you and your family through the entire process of your healing. This safe place is a Child Advocacy Center, and South Dakota has five. In Pierre, South Dakota, Avera St. Mary's Hospital houses the Central South Dakota Child Assessment Center, a nonprofit agency that is an accredited Child Advocacy Center.
According to the South Dakota Children's 2015 report prepared by the Child Welfare League of America, South Dakota had 15,679 total referrals for child abuse and neglect. Of those, 2,676 reports were referred for investigation and 984 were substantiated. Of the children substantiated as victims, 91.8 percent were neglected, 14.3 percent were physically abused and 5.3 percent were sexually abused.
Child abuse occurs at every socioeconomic level, across ethnic and cultural lines, within all religions and at all levels of education. According to national statistics, a report of child abuse is made every 10 seconds. So when the worst of the worst may be happening to children in our communities, people must recognize the appropriate response.
HISTORY
The definition of "appropriate response" has changed over the years. Ten or 20 years ago, if a child disclosed abuse, he or she might have to talk about it to several different people at several different places, telling the details over and over again — a process that in itself was traumatizing. Different people asked different questions, sometimes in a leading manner or in ways that were not age-appropriate, resulting in cases against abusers that could fall apart easily. Mental health services for traumatized children were few and far between. It was difficult for children to heal and recover from what they had experienced or witnessed.
Decades of research have documented the short- and long-term harm of maltreatment to children's cognitive, social-emotional and physical development. Over time, it was recognized that child abuse and neglect are multifaceted community problems. Children need appropriate medical care, mental health services and support through the entire investigative and prosecutorial processes. No single agency, individual or discipline had the resources to serve all the needs of child victims and their family members.
In the mid-1980s, former U.S. Congressman Robert E. "Bud" Cramer saw that there needed to be a better system to help abused children, and the Child Advocacy Center model was created in his home state of Alabama. Simply put, the goal was to make services for children like a one-stop shop.
THE MODEL
The Child Advocacy Center model involves several strategies to make the current best practices in care accessible for children and their families. First of all, the Child Advocacy Center model provides services in a child-focused facility using a neutral approach.
As a child abuse medical provider, I believe neutrality is of utmost importance, because every child that comes into our care at the Child Advocacy Center has not necessarily been abused or neglected. Reports of abuse can turn out to be false. Physical symptoms can mimic signs of abuse. Taking a neutral approach assists in determining, as well as ruling out, child abuse and neglect. We need to be able to advocate for the child by advocating for the truth.
Second, in the Child Advocacy Center model, a professional specifically trained in child linguistics, child development and child-interviewing techniques conducts a child's forensic interview. The trained interviewer usually is alone with the child in a room, but investigative and treatment professionals involved in the case watch the forensic interview through closed-circuit television, two-way mirrors with audio or other observational methods.
The goal is to limit the number of times a child has to talk about what happened to him or her, because the fewer times a child has to disclose information, the less additional trauma is created. At a certain point, the interviewer steps out of the room to consult with the observers — who might include representatives from Child Protective Services, law enforcement and a child abuse medical provider — in case they have additional questions.
Directly after the interview, the child receives a comprehensive head-to-toe physical exam from a medical provider with specialized training in child physical abuse, child sexual abuse and neglect. Child abuse medical providers also have specific education regarding digital photography, forensic evidence collection and colposcopy (specific imaging for magnification of the external genital exam), if required.
The child is asked for his or her permission at each step in the physical examination, and if the child chooses, a non-offending guardian may be present for it. Treatment is provided to children as needed; and the best part of my job is reassuring children that their bodies will be OK.
Studies have shown that medical providers with training and experience in assessing child sexual abuse provide higher quality and more consistent decisions than do providers with less experience in such cases.
In addition, the Child Advocacy Center model involves providing services that are culturally competent and appropriate regarding ethnicity, age, gender identification and disabilities. Child victim support and advocacy is provided throughout the investigation and any subsequent legal proceedings. In addition, the child and non-offending caregivers are connected with specialized trauma-focused therapy.
TEAM APPROACH
The Child Advocacy Center model introduced the multidisciplinary team approach to these cases, bringing together agencies with the most expertise in the areas of child abuse and neglect. The multidisciplinary team approach means that professionals are involved from start to finish on these cases and collaborate to promote the best services for the child. The multidisciplinary teams usually involve members of law enforcement, Child Protection Services, prosecution, victim advocates, medical professionals, mental health professionals and the Child Advocacy Center. Not only do the multidisciplinary team members meet for assessment and decision-making on these cases, the team also meets monthly to review child cases, discussing the strengths, potential need for response improvement, and best practices. The combined knowledge of those from different disciplines results in a more complete understanding of the child's case and provides a family-focused response. Statistics show that an increased number of prosecutions result from the existence of a coordinated advocacy program.
Fortunately, nearly every day in South Dakota, Avera is able to support children who allegedly have been abused. The Central South Dakota Child Assessment Center is a nonprofit agency within Avera St. Mary's Hospital in Pierre, South Dakota. Though the Child Advocacy Center is supported with grant funding, Avera St. Mary's Hospital provides space as well as administrative oversight to the program.
The Central South Dakota Child Assessment Center has been recognized as a hospital department since 2006. This Child Advocacy Center also receives community support as a partner agency to Capital Area United Way. With the support of Avera St. Mary's Hospital and the community, all children are served regardless of their ability to pay. Holding national accreditation with the National Children's Alliance as a Child Advocacy Center, Central South Dakota Child Assessment Center is designed as a safe and welcoming place for children to be heard.
The center is a child-focused, community-oriented facility in which multidisciplinary team members collaborate in child abuse investigations. Working with five multidisciplinary teams in the region (two county and three federal), Central South Dakota Child Assessment Center brings together entire teams of professionals to better serve children of suspected abuse. The collaborating teams may include representatives from law enforcement agencies (including local law enforcement, the Division of Criminal Investigation, tribal law enforcement, Bureau of Indian Affairs and Federal Bureau of Investigation), Department of Social Services Child Protection Services and tribal Child Protection Services, medical providers, prosecutors (state and federal), mental health professionals and victim advocates. They work together to ensure that the physical and emotional needs of child victims are fully met through evidenced-based practices.
Central South Dakota Child Assessment Center serves 24 counties covering an area of 32,336 square miles and a population of approximately 127,757. Within this region, the center serves four of the poorest counties in the United States, with per capita income of less than $10,000. Though Central South Dakota Child Assessment Center serves clientele of every ethnicity, approximately 65 percent of children evaluated are American Indian.
National statistics from the U.S. Census Bureau have indicated that 27 percent of American Indian and Alaska Native families with children live in poverty. Research also suggests that domestic violence exposure is high for these children relative to that of their non-Native peers. Specific research on American Indian children from Alaska and South Dakota provides evidence of the highest rates of maltreatment in the United States (99.9/1000 and 61.2/1000, respectively). This is significant to Central South Dakota Child Assessment Center, as they receive referrals from the Cheyenne River Sioux Tribe, Crow Creek Sioux Tribe, Lower Brule Sioux Tribe, Rosebud Sioux Tribe and Standing Rock Sioux Tribe.
There is a correlation, in all ethnicities, with poverty and intimate partner violence. According to the American Academy of Pediatrics, the co-occurrence of child abuse and intimate partner violence is well documented, and research has indicated that 30 percent to 60 percent of families in which either child maltreatment or intimate partner violence is occurring also has another form of violence being perpetrated.
In fact, intimate partner violence has been identified as a leading precursor of child maltreatment. There are profound and often lifelong effects on children who are exposed to such violence. They fail to thrive physically, psychologically and emotionally; and the effects may continue far into adulthood.
If suspected child abuse and neglect is reported, children discovered in these cases are connected to the appropriate investigative agency and the investigative agency connects the child to a Child Advocacy Center. Children, ages 0-18 years of age, may be referred to Central South Dakota Child Assessment Center by law enforcement or Child Protection Services. Referrals are most often for cases of child physical abuse, child sexual abuse, neglect, child emotional abuse, drug endangerment or witness to violence. Adults with cognitive disabilities may also be served by Central South Dakota Child Assessment Center. In 2015, 252 children received medical evaluations at Central South Dakota Child Assessment Center. Since its inception, well over 2,000 children have received services.
Central South Dakota Child Assessment Center assures that the child's needs come first. These littlest victims of crime, and their non-offending family members, are coming forward to tell their stories and seek help. It is the mission of Central South Dakota Child Assessment Center, in partnership with Avera, to allow these children to be understood and the healing process to begin.
ANGELA LISBURG is a child abuse medical provider and coordinator of the Central South Dakota Child Assessment Center, a department of Avera St. Mary's Hospital, Pierre, South Dakota.
RESOURCES
Child Welfare League of America, "South Dakota's Children 2015." www.cwla.org/wp-content/uploads/2015/06/2015-State-Fact-Sheet-South-Dakota.pdf.
Michelle C. Sarche and Paul Spicer, "Poverty and Health Disparities for American Indian and Alaska Native Children," Annals of the New York Academy of Sciences 1136 (June 2008): 126-36.
Jonathan D. Thackeray et al., "Intimate Partner Violence: The Role of the Pediatrician," Pediatrics, 125, no. 5 (May 2010). http://pediatrics.aappublications.org/content/125/5/1094.full.
Wendy Walsh et al., "Which Sexual Abuse Victims Receive a Forensic Medical Examination? The Impact of Children's Advocacy Centers," Child Abuse & Neglect 31, (2007): 1053-68.
David Wood, "Effect of Child and Family Poverty on Child Health in the United States," Pediatrics 112, issue supplement 3 (September 2003): 707-11.