A3. Coordinated Team Approach

These recommendations are for communities to facilitate a coordinated team approach to response to prepubescent child sexual abuse during the exam process.

Promote multidisciplinary coordination during the exam process, within a community and/or across jurisdictions as applicable in a case. The medical forensic examination in its entirety addresses the health needs of child sexual abuse victims AND is a potential evidentiary source for investigative agencies. The medical history, exam findings (written and photo-documentation), and forensic samples if collected during the examination can supplement other evidence and information gathered by investigators. Coordination across responding entities can help ensure that medical forensic care is a component of the initial response to child victims, along with protection, access to other community resources, and support to minimize trauma. Coordination and communication among initial responders can also enhance documentation and evidence collected during medical forensic care as well as information gathered during forensic interviews,[1] which can aid law enforcement and child protective services in investigating these cases and keeping children safe, and support prosecutors in holding perpetrators accountable for their behavior.

Use multidisciplinary response teams to foster coordination and communication among responding agencies/facilities in a community in prepubescent child sexual abuse cases. Teams should include multijurisdictional representation if cases typically involve responding entities from more than one jurisdictionA team structure provides a mechanism to link key entities involved in the response during the exam process and allow them to consistently coordinate interventions whenever there is a report of child sexual abuse It also helps them communicate about and stay abreast of what is happening in individual cases. The team structure can be a quality assurance tool, promoting regular meetings of responders, case reviews, responder education, activities to prevent vicarious trauma of responders, and evaluation of team effectiveness. Jurisdictions vary in the extent and formality of team coordination, as well as in specific team purposes (e.g., to provide coordination around victim care and protection, investigative activities, and/or comprehensive response). In many jurisdictions, multidisciplinary teams and team coordination protocols are statutorily mandated in child abuse and neglect cases.[2] Often, children’s advocacy centers assist in the coordination of these teams (see below). A spirit of cooperation, information sharing, and case coordination are a few benefits of these multidisciplinary response teams (Knapp, 2014). Such benefits can lead to better case outcomes and greater child and family satisfaction with interventions than seen with community response to child abuse that is not coordinated across disciplines or jurisdictions if applicable in a case.[3]


Identify core responding sectors and their roles during the exam process, in cases of prepubescent child sexual abuse. Note that if a CHILDREN’S ADVOCACY CENTER exists in a community, it may coordinate a multidisciplinary, multijurisdictional response.

For the list below, be aware: it does not include comprehensive interventions beyond the exam process; it is limited to key broad roles of core responders in individual cases; and responders’ roles/tasks may differ based on jurisdictional and agency/facility policies and case circumstances. See the various protocol chapters for further discussion on response components and the infrastructure needed to support an effective response.


Key Broad Roles: Exam Process

(Roles may vary in specific cases and based on jurisdictional and agency/facility policies)


· Tailor response to the developmental level of each child as well as the cultural and linguistic needs of the child and caregiver.

· Arrange for language assistance and other accommodations as needed in a case.

· Offer crisis intervention and support for the child and caregiver as early as possible.

· Offer the child and caregiver information to facilitate informed decision making throughout.

· Coordinate/communicate with other involved responders.

· Inquire about safety at each contact with the child and caregiver: provide immediate assistance as needed and connect them to resources for safety planning assistance.

· Adhere to jurisdictional laws on victim’s rights.



Initial response: child’s entry into health care system

· Assess the child for acute medical needs, stabilize, and treat.

· Determine the urgency of care needed and arrange for acute/nonacute medical forensic care.

· Mandatorily report the abuse as per jurisdictional law and facility policy.

· If the child has urgent safety needs at the health care facility, immediately involve law enforcement/child protective services and follow facility procedures.

Conduct acute/nonacute examinations:

· Obtain/document the medical history.

· Perform the physical and anogenital examination and document findings.

· Collect, dry, package, label, seal, and securely handle forensic specimens.

· Evaluate and treat injuries.

· Evaluate for STDs, including HIV, and provide care.

· Collect samples for toxicology analysis.

· Plan for discharge and follow-up care (medical, safety, mental health, victim services, investigation, etc.).



(see definition

in Glossary)

Initial contact with the child and caregiver:

· Offer crisis intervention, support, information, and safety planning to the child and family.

· Explain victim rights to the child and family, review community response procedures and options, answer their questions, and provide referrals.

· Support the child and caregiver in voicing their concerns.

· Advocate for the child’s self-identified needs to be addressed with a coordinated, developmentally, culturally, and linguistically appropriate response.

· Accompany the child/caregiver during the examination.

· Mandatorily report the abuse as per jurisdictional law (if identified as a mandatory reporter).

· Explain longer-term advocacy services available to aid in addressing child and family needs related to the abuse (e.g., ongoing support, safety planning, counseling/referrals, culturally specific services, legal and medical systems advocacy, and service coordination).



(local, state,

territorial, tribal,

military, federal)

Timely response to reports:

· Respond to 911 calls and referrals from child protective services.

· Determine basic facts of the reported incident, if the child is in imminent danger, need for immediate medical attention, and case jurisdiction (avoid delaying response to the child if delays exist in determining jurisdiction).

· Work with child protective services as needed to provide child protection.

· Facilitate access to an initial medical assessment and medical forensic examination (arranging transportation as needed).

· Coordinate crime scene processing.

· When contacted by the exam site to pick up forensic evidence, retrieve evidence and deliver to designated labs/law enforcement storage facility.

· Conduct/arrange the preliminary interview of the child/forensic interview, preferably by someone trained to interview child sexual assault victims, either before or after the medical forensic examination, in conjunction with child protective services as applicable to the case.




(county, state,

territorial, tribal,


Timely response to reports:

· Assess the child’s immediate safety.

· Make referrals to the appropriate law enforcement agency and coordinate multi-agency response based on circumstances of report and initial assessment of child safety.

· Facilitate access to an initial medical assessment and medical forensic examination (arrange transportation as needed).

· Conduct/arrange the preliminary interview, preferably by someone trained to interview child sexual assault victims, of the child/forensic interview either before or after the medical forensic examination, in conjunction with law enforcement as applicable to the case.


NOTE: The core responders below typically have more of an advisory rather than a direct role during the exam process.



Key Broad Roles: Exam Process


(county, state,

territorial, tribal, military, federal)

Be available to consult with first responders to answer questions that arise and to request additional information as necessary to aid in case prosecution.



(state, territorial, federal, private)

Be available to consult with criminal investigators and pediatric examiners to answer questions to assist in identification, collection, and processing of forensic evidence.


See www.SAFEta.org for details on the range and roles of professionals involved in the exam process, as well as in a more comprehensive response.

Clarity of core responders’ roles during the exam process can help increase their collaboration in individual cases and reduce conflicts surrounding issues such as reporting, victim protection, health care, safety planning, victim services, and investigation.

Encourage the development and use of children’s advocacy centers to facilitate coordination of multidisciplinary response teams. Children’s advocacy centers have been established in many jurisdictions to facilitate team coordination in child abuse and neglect cases, with the goals of child safety, trauma-informed care, justice, and healing. These centers are child-friendly facilities in which the team—typically comprised of law enforcement, child protective services, prosecutors, medical professionals, mental health providers, and victim advocates—coordinates the investigation, prosecution, child protection, and treatment of child abuse. In addition to brokering coordination among responders in individual cases, many children’s advocacy centers offer a location to provide services under one roof, such as forensic interviews, medical forensic examinations, victim advocacy, and mental health treatment. Children’s advocacy centers can be developed to serve a community or a region (e.g., in a rural or sparsely populated area), and involve representatives from a single jurisdiction or multiple jurisdictions.[4]

Multidisciplinary response teams are encouraged to include community-based sexual assault victim advocacy programs on their teams, as well as seek their input when developing team response protocols. Involvement of these programs in coordinated response team efforts helps ensure that children and families have a continuous source of victim-centered, trauma-informed support during and beyond their interactions with the health care system and criminal justice and child protection systems. Most community-based sexual assault victim advocacy programs have crisis intervention and support services available 24 hours a day, every day of the year. They can also address children’s support needs as they mature into adolescents and adults. These programs are often experienced in systems advocacy around sexual victimization issues, which could be an asset to team sustainability. If a community-based sexual assault victim advocacy program serves child victims, advocates should be trained in working with children and their caregivers. If it does not serve children, it may still offer support services for caregivers.

As mentioned earlier, if a community-based sexual assault victim advocacy program exists in a community but is not yet involved in the exam process in these cases, teams are urged to partner with these programs to engage advocates in this process and build their capacity to do this work.

Promote partnerships between children’s advocacy centers and community-based sexual assault programs,[5] as well as with other entities that have a victim advocacy role during the exam process and beyond. Together, they can coordinate resources and determine the spectrum of victim services they can provide to children, caregivers, and families to strengthen the community response in individual cases.

See www.SAFEta.org for additional resources on multidisciplinary teams to respond to child sexual abuse cases, children’s advocacy centers, and community-based sexual assault victim advocacy programs.[6] Staff at SAFEta.org are also available to answer specific questions related to establishing these entities.

Develop a diverse team representative of the community that can address the varied needs of children and caregivers in specific cases and support all aspects of response during the exam process. The use of a tiered team structure can be helpful to identify the range of responders who might potentially be involved in the exam process and indicate at what point they may be activated. For example, the first tier should encompass core responding sectors in a community that typically might be drawn into a sexual abuse case during the exam process—including but not limited to health care, victim advocacy, law enforcement, child protective services, prosecution, and forensic sciences (note that, during the exam process, prosecution and forensic sciences usually have advisory rather than direct roles).[7] If a children’s advocacy center exists in a community, it may play a central role in coordinating a multidisciplinary response. Subsequent tiers can include other professionals and entities whose participation might be requested by core responders during the exam process to address child, family, or case needs. Examples include but are not limited to mental health providers,[8] specialized investigative teams dealing with sex trafficking or drug endangerment, legal assistance services, such as civil attorneys and victim rights attorneys, financial assistance programs, and providers serving specific populations (e.g., local programs for persons who are Deaf and hard of hearing, or for individuals from specific cultural, racial, or ethnic communities).

An additional group to consider is the personal support persons whose presence children and/or caregivers may request during the exam process, beyond family members or friends (e.g., a religious/spiritual support person, a school guidance counselor or favorite teacher, or a culturally specific support person such as a mentor from a local ethnic community center). While personal support persons are unique to a case and typically not response team members, teams should recognize their utility in helping children and caregivers who request them to positively cope with the exam process. (See B5. Medical History and B7. Examination for more explanation on personal support persons and the need to educate them on the scope and limitations of their role)

Communities and teams of all types can create tiered team structures tailored to their teams’ purposes and requirements (e.g., jurisdictional legislation may mandate that, minimally, certain agencies participate), available resources, and the needs of children and families.

Include a trained pediatric examiner as a core team responder.[9] The examiner may be a physician, advanced practice provider (e.g., advanced practice nurse or physician’s assistant), or registered nurse. The team should be aware of qualifications for pediatric examiners from various disciplines in their jurisdiction and seek qualified personnel. The team can reach out to health care providers in the community who serve children, as well as organizations such as the American Academy of Pediatrics (AAP), the NCA, and the IAFN to search for candidates.[10] (See A4a. Pediatric Examiners)

Ensure that all team members are aware that they may be called to be involved in a coordinated response in these cases, including and beyond the exam process as determined by a community, and be willing to respond. To foster collaboration, core responders and/or team coordinators such as staff from children’s advocacy centers are encouraged to reach out and engage other potential team members. They should work with potential team members to overcome any hesitation they may have regarding their involvement.  

Outline responding entities’ team roles and responsibilities in written agreements, such as an interagency memorandum of understanding (MOU) or memorandum of agreement (MOA). Such agreements may address the exam process only or speak to a more comprehensive response, highlighting the terms of the response protocol. These agreements should help clarify for all responders: their roles on the team; team confidentiality issues and requirements (see A5b. Confidentiality and Release of Information); how to contact and interact with each other as needed in a case; and the need to respect one another’s contributions to the team, even if their roles might sometimes conflict. Agreements should be signed by leadership of each entity involved and be revised and renewed on a periodic basis. (See Appendix 4. Customizing a Community Protocol)


Many potential challenges exist to creating functional multidisciplinary and multi-jurisdictional response protocols and teams, including ones stemming from scarce resources, lack of expertise, and conflicts among entities. Contact staff at SAFEta.org for input on overcoming specific challenges, offer ideas for engaging responding entities, and provide examples of written agreements among team members.

Employ team features that strengthen the team’s capacity to protect prepubescent child victims, address their health care needs, and gather forensic evidence during the exam process. Note that many of the features described below also support a comprehensive response and promote team quality assurance. Team features that apply to direct response should be incorporated into the response protocol.

Recommended Features of Multidisciplinary Response Teams

  • Ensures mechanisms are in place to activate core responders . Policies and procedures for activating core responders should take into account that children “enter the response system” at different points. (See B2. Initial Response and B3. Entry into the Health Care System) Educate first responders about their roles in triggering team action. Note that if there is a children’s advocacy center, it may play a central role in activating the team response.
  • Ensures policies and procedures are in place for core responders to identify if there is a need for additional providers and entities to be involved during the exam process, and then request their involvement . To the extent possible, these “additional” responders should be informed of such policies and procedures in advance and be willing to carry out assigned roles.
  • Publicizes team response procedures to community professionals who have frequent contact with prepubescent children and their families (e.g., health care providers serving children, hospital emergency department staff, staff from youth organizations, school personnel, contractors and volunteers, child care providers, personnel serving children with disabilities and those who are Deaf, faith community leaders, mental health and social service providers, and staff from youth residential programs and emergency shelters). Also publicize team services broadly to the public, encouraging reporting of child sexual abuse.[11]
  • Maintains a protocol for information sharing that speaks to the extent of information sharing possible among various team members in individual cases, according to applicable laws and agency/facility policies. As mentioned above, a written agreement among team members should address team confidentiality issues and requirements.
  • Operates on a 24/7 basis to respond to reports of sexual abuse, assess and address safety issues, medically assess children to determine urgency of care needed, conduct acute examinations, make referrals for nonacute examinations, and provide support to children and families. To address acute and nonacute exam needs, a need for flexibility exists in program coverage; no one discipline should define service hours and options for the team. If a children’s advocacy center’s medical clinic performs both nonacute and acute examinations, but is open only at certain times (e.g., 9 a.m. to 5 p.m. during weekdays), the community still needs 24/7 coverage for acute cases.
  • Requires a health care provider to medically screen each child to determine the urgency of care needed and what type of medical forensic examination is appropriate . (See B3. Entry into the Health Care System) Law enforcement agencies, child protection services, and other first responders should have procedures to connect the child on a 24/7 basis to a health care provider for this purpose. (See B2. Initial Response)
  • Documents the team’s response in each case . Not only does documentation lend itself to team accountability, it serves as a tool for case review and assessment of next steps in a case. Statutorily mandated multidisciplinary response teams are often required to retain such documentation. When documenting response, maintain the privacy of the child’s personal information to the extent possible, as per applicable laws (See A5b. Confidentiality and Release of Information).
  • Meets regularly (regularly is locally defined) for two distinct purposes, in acute and nonacute cases. The first reason is for case review—discussion and information sharing among the team on active cases, including the investigation, case status and service provision, potential challenges, and next steps. Core responders should participate in case review meetings. Pediatric examiners should be included even though they also participate in medical peer review. (See A4a. Pediatric Examiners) Additional responders who were involved in specific cases might also be invited to participate; their participation may depend on whether it is appropriate for them to have access to child-specific information shared at case review meetings. Secondly, the team can utilize meetings of members to maintain and enhance the quality of the team. This task involves addressing system issues, such as revising procedures in response to agency/facility and statutory changes and scientific or technological advances. It also involves facilitating the team’s continuing education All team members could be invited to meetings addressing systemic issues.
  • Facilitates team communications related to specific cases . Much can happen in a case in the short-term after a report is made. Mechanisms should be in place to assemble involved team members sooner than a scheduled case review meeting, if needed, to debrief, troubleshoot, and discuss next steps.
  • Plans in advance to respond in varying circumstances . (See A2. Adapting Care for Each Child) For example, it would be useful for agencies/facilities that comprise the team to have incremental goals for building multiple language service capacity to be inclusive of all child populations. It might be helpful to create a coordinated system for relaying information in individual cases about the need for language services and accommodations, so that needed services and accommodations can be arranged prior to the child and caregiver seeing the next responder. Organizations that serve specific populations in the community can be sought out as potential resources to aid children and families requesting culturally-specific support. The team can establish procedures for coordinating with other specialized investigative teams as needed in a case, such as child endangerment and sex trafficking task forces. The team should have a standard approach to initially assess safety for children in various situations. It should consider how to coordinate a response when child sexual abuse is reported in institutional settings or has occurred on a military installation, as well as multijurisdictional coordination needs. The team should stress to its members the expectation that relevant responders in a case should be prepared and available to testify in court if subpoenaed.
  • Seeks feedback from team responders and other community professionals involved in a case (e.g., who referred children to the team or interacted with children after the exam process). Use this feedback, gathered post-examination, to improve team coordination and interventions in the future. Input could be sought via participation in team meetings or other forums, with care taken to maintain confidentiality of victims’ personally identifying information within the team. Also, obtain post-examination feedback from children and caregivers about exam process experiences.
  • Addresses vicarious trauma[12] among team members via discipline-specific support and team infrastructure and policies . The support that team members and involved agencies/facilities can offer to one another can be instrumental in reducing the impact of vicarious trauma. Formal and informal venues can be used to facilitate discussions among responders about self-care and working together to prevent and cope with secondary trauma. Critical incident stress debriefings might be useful in individual cases.[13]
  • Encourages education for team members . Consider discipline-specific training that advances responder skills and emphasizes a team approach, multidisciplinary training, cross-training between disciplines, and informal educational opportunities. Multidisciplinary trainings and cross-trainings can build knowledge of the nature and dynamics of sexual abuse; describe the team response process, explaining roles and challenges facing each discipline; review mandatory reporting obligations and report writing; emphasize a child-focused, victim-centered, trauma-informed approach; promote culturally and linguistically appropriate care; stress the need for a prompt examination and ongoing safety planning; provide expert witness training; describe related policies, protocols, agreements, and forms; build understanding of needs and challenges in response to child sexual abuse in specific populations; and provide a forum for staff from different agencies/facilities to build relationships, identify common goals, and ask questions.
  • Strategizes how to offer training for team members in rural, remote, poor, and other communities that lack the needed resources and/or expertise . Jurisdictions may want to consider forming specialized training teams that can offer multidisciplinary training consistent with cutting-edge practices in child sexual abuse cases. These teams can work with local responders to ensure that the training sessions they offer address unique community needs and challenges (e.g., safety challenges and resources unique to a tribal community). They can also determine the best method to train responders—in some instances, use of online, live webinars and video conferences, online interactive training modules, and other distance learning tools might be useful.
  • Plans team activities, communications, and materials so that they are accessible to all its members . For example, team meetings and trainings should be held at accessible locations. Members who are Deaf or hard of hearing may require sign language interpretation.

See www.safeta.org for resources related to building community capacity to implement the above features of multidisciplinary teams to respond to prepubescent child sexual abuse cases. Staff from Kidsta.org are also available for consultation on community-specific issues.


Consider unique coordination issues when child sexual abuse occurs in institutional settings, tribal lands, or military installations. The following section is meant simply to further teams’ thinking about customizing coordinated response for these settings and communities. It is not meant to be an inclusive listing of all coordination or responder training issues relevant to these settings and communities.

Institutional Settings

  • Multidisciplinary response teams should collaborate with institutions in their community that either house prepubescent children or place them in homes (e.g., residential programs, shelters, detention facilities, boarding schools, and foster care), with the goal of ensuring that children in these systems receive adequate and coordinated interventions in the event that they are sexually abused.
  • Although these institutions may have their own protocols and services to respond to child sexual abuse (including requirements of oversight agencies or as prescribed by legislation[14] ) and mechanisms to investigate sexual abuse as a violation of institutional policies, the community justice system is ultimately responsible for criminal justice and child protection remedies for children in these settings. Community resources may be needed to care for victims in these settings.
  • Agreement between the team and an institution can help extend the team’s protocols and resources to children in the institution and build upon institutional capacities to address needs of child victims in a timely and appropriate manner. In addition to team training on response protocols specific to an institutional setting, protocols between an institution and community responders should be incorporated into institutional policy and relevant staff training.
  • The team can plan with an institution regarding how children, caregivers, staff, and others within the institution should make a report and seek help for sexually abused children; how to facilitate communication between the institution and the team when there is a report; who must be notified regarding a report; what consent for care is needed and how to obtain it; and how to coordinate each step of response. Variations in response must be considered when suspected perpetrators are institutional personnel or foster home providers. Children need to be placed in alternative housing if their safety in an institutional setting or foster home cannot be secured.
  • For acute and nonacute medical forensic care, the team must consider how children and first responders in an institution access pediatric examiners and the logistics of arranging such care when conducted at a community-based health care facility versus within the institution. Examples of logistical issues include transportation of the child to/from the exam site and child accompaniment by staff and/or caregivers during transportation and the examination.

American Indian Tribes and Alaska Native Villages

  • American Indian tribes and Alaska Native villages, as sovereign nations, may have their own laws and regulations. They may also have law enforcement agencies, child protective services/social services, prosecution offices, courts, advocacy programs, health care systems, and other services to address child sexual abuse.
  • When child sexual abuse takes place on tribal land, one or more governments (tribal, federal, or state) may be able to take action in response.[15] A tribal criminal justice system, if it has jurisdiction in a case, may investigate and prosecute the case concurrently with another government’s investigation and prosecution.[16]
  • A tribe may have its own multidisciplinary response team or a team may be in place to promote multidisciplinary coordination within and across jurisdictions among entities in the response to child sexual abuse on tribal lands, the investigation and prosecution of these cases, and the care of victims. [17] Jurisdiction-specific roles and coordination tasks must be delineated to prevent confusion when intervening in individual cases and to ensure that the collective response is streamlined and effective. Coordination is crucial to enable victims to access the full range of resources these jurisdictions collectively offer. Multijurisdictional partnerships are needed to move towards a system that provides evidence-informed services for children and families.
  • Protocols should standardize activation of responding entities across jurisdictions, according to agreed-upon procedures, to allow for quick determination of jurisdiction in a case and how to assist each child.
  • Nontribal responders that serve child sexual abuse victims from tribal communities should be familiar with procedures for coordinating initial interventions with tribal entities, including ensuring children have timely access to the medical forensic examination. Ideally, they should also have training on working with tribal communities.
  • Multijurisdictional coordination plans should address distribution and disposition[18] of forensic evidence collection kits used in prepubescent child sexual abuse cases; related health care and forensic specimen preservation; transfer of forensic evidence to the appropriate investigative agency, crime lab, or designated evidence storage facility; exam payment to the facilities and examiners; and family reimbursement for medical costs incurred (as allowable).[19]

Military Installations (drawn from militaryonesource.mil)[20]

  • Child abuse reports relating to victims with parents or guardians who are military members can be made either to appropriate child protective service agency or the installation family advocacy program. When suspected abuse is reported, a team will assess the safety and welfare of the child. If child protective service team members learn the call involves a military family and a memorandum of understanding is in place, they should contact the installation family advocacy program.
  • Child abuse and neglect are defined in the military as injury, maltreatment, or neglect to a child that harms or threatens the child’s welfare. The family advocacy program will become involved when one of the parties is a military member or, in some cases, a DoD civilian serving at an overseas installation. The family advocacy program will also intervene when a dependent military child is alleged to be the victim of abuse and neglect while in the care of a DoD-sanctioned family child care provider or installation facility, such as a child development center, school, or youth program.
  • When the family advocacy program receives a call concerning the safety and welfare of a child, it ensures that everyone who is capable of protecting the safety and wellbeing of the child—the active-duty member’s commander, law enforcement, the medical treatment facility, and child protective services—is aware of the risk and protective factors that are impacting the family. These community members often work as a team to ensure that children are protected, the parents receive appropriate intervention, and the family receives the services they need to be able to form more healthy relationships.
  • If child protective services determines that abuse or neglect did occur, the civilian family court system will become involved. Sometimes, the judge will appoint a guardian ad litemto represent the child’s interests. This attorney will review all available information and evidence from law enforcement, the family advocacy program, and child protective services, and make recommendations to the court based on what he or she believes is in the child’s best interest.
  • For the medical forensic examination, child sexual abuse cases are referred to local civilian medical experts when no trained military pediatric medical forensic examiner is available to the military installation. (K. Robinson, personal communications, May 28, 2015).
  • Multidisciplinary response teams from local communities that surround military installations should develop procedures in conjunction with family advocacy programs for coordinating interventions and services for children in sexual abuse cases who are military dependents based at these installations. Written agreements should be developed and signed by all involved entities to clarify roles and responsibilities. Providers near military installations should reach out to the family advocacy program on the installation to determine the best way to collaborate.


Contact staff at safeta.org for input on overcoming specific coordination challenges in responding to child sexual abuse in institutional settings, tribal communities, or military installations.

 Table of Contents A4. Health Care Infrastructure

[1] See B5. Medical History for a discussion of the difference between the medical history and forensic interviewing.

[2] See ndaa.org/wp-content/uploads/MDT-draft-for-MAB_-01052015-last.pdf for a National District Attorneys Association’s 2015 review of state, federal, and territorial legislation sanctioning use of multidisciplinary response teams for child abuse and neglect investigations. In addition to prosecution-based multidisciplinary teams, multidisciplinary child protection teams are legislated in many jurisdictions. Child protection teams focus on the protection of children who are victims of abuse or neglect from additional maltreatment. Child protection often involves civil action, while prosecution is a criminal justice issue (Center for Child Abuse and Neglect, 2000). Applicable criminal and civil justice actions should be considered in each case, and actions taken should be coordinated to the extent appropriate.

[3] For a bibliography of articles on multidisciplinary teams and collaboration in community response to child abuse, see the National CAC Calio library. Of related interest are studies by Campbell et al. (2011), Campbell et al. (2012), Campbell et al. (2013), and Greeson and Campbell (2013, 2015) that explore the effectiveness of sexual assault response teams (SARTs). While this body of research mainly focuses on adult and adolescent victims, it has some applicability for coordinated team response in prepubescent child sexual abuse cases.

[4] See ww.ndaa.org/pdf/Update%20Vol24_No2.pdf for a resource on children’s advocacy centers in Indian Country.

[5] Cruising into Collaboration: Developing Strong Relationships between Rape Crisis and Children’s Advocacy Centers at www.nsvrc.org/sites/default/files/nsac-2014-handouts-cruising-into-collaboration-developing-strong-relationships-between-sa-programs-child-advocacy-centers.pdf provides an example of one community’s partnerships in this area.

[6] Note a few key resources: The National Children’s Alliance (NCA) at www.nationalchildrensalliance.org/ offers information on and a directory of children’s advocacy centers, as well as accreditation to centers that adhere to its member standards. Technical assistance and training providers for multidisciplinary investigative teams in child abuse and neglect cases and children’s advocacy centers include: Northeast Regional Children’s Advocacy Center at www.nrcac.org; Southern Regional Children’s Advocacy Center at www.nationalcac.org; Midwest Regional Children’s Advocacy Center at www.mrcac.org; and Western Regional Children’s Advocacy Center at www.westernregionalcac.org. See www.justice.gov/ovw/local-resources for links to state, territorial, and tribal sexual assault coalitions.

[7] Note, however, that some communities, especially those with children’s advocacy centers, may consider prosecutors to be direct rather than advisory core responders during the exam process.

[8] Note, however, that some communities, especially those with children’s advocacy centers, may consider mental health providers as part of the core responder team.

[9] See Canaff (2004) for key reasons that pediatric examiners are critical team members.

[10] For example, the IAFN website offers a mechanism to search for SANE programs by location at www.forensicnurses.org/search/custom.asp?id=2100.

[11] Note that B2. Initial Response speaks to initial response to reports or suspicions of child sexual abuse, prior to the children’s entry into the health care system. B3. Entry into the Health Care System includes procedures targeting initial responding primary care providers and emergency department clinicians.

[12] Vicarious trauma means the cumulative effect of witnessing the suffering of others over time—the term refers to the negative changes to an individual’s physical, psychological, and spiritual health (RSP & NSVRC, 2013). The NSVRC and IAFN (2014) at www.nsvrc.org/sites/default/files/nsvrc-publications_sane-mobile-app_resources-vicarious-trauma.pdf offer a related clinician discussion and resources. NSVRC and RSP (2013) offer another resource for ideas for building trauma-informed programs that support the self-care of those doing this work at www.nsvrc.org/sites/default/files/publications_nsvrc_guides_building-cultures-of-care.pdf.

[13] Critical incident stress debriefing is a proactive intervention involving a group discussion about a distressing critical incident. Based on core principles of crisis intervention, it is designed to mitigate the impact of a critical incident and to assist the persons in recovery from the stress associated with the event. Ideally it is conducted between 24 and 72 hours after the incident. (The explanation was drawn from Critical Incident Stress Management International (2015) at www.criticalincidentstress.com/what_is_cism_.)

[14] For children in all types of residential facilities (Brown, 2008): States are primarily responsible for ensuring the wellbeing of children in facilities and setting standards that certain facilities must meet to obtain and maintain an operating license. Federal agencies also set requirements for children’s wellbeing that states uphold in exchange for receiving federal funds—such as those administered by the U.S. Department of Health and Human Services to support state systems of care for child welfare, mental health, and substance abuse; by U.S. DOJ for state juvenile justice systems (implementing PREA); and by the U.S. Department of Education for state education systems. If patterns of child abuse and neglect are identified and found to violate the civil rights of children in certain facilities that are operated or substantially sponsored by state and local governments, the federal Civil Rights of Institutionalized Persons Act can authorize the U.S. Attorney General to conduct investigations and bring actions against state and local governments. Federal oversight authority does not extend to private facilities that serve only children placed/funded by caregivers or other private entities.

[15] Determining the appropriate jurisdiction can be very difficult and confusing.  For a summary of which government entity has jurisdiction under different scenarios, see  the United States. Attorneys’ Criminal Resource Manual, Section 689 available at www.justice.gov/usam/criminal-resource-manual-689-jurisdictional-summary

[16] Sekaquaptewa, Bubar, and Cook (2008) offer a discussion of factors that tribes should consider when making the decision to prosecute a tribally defined child sex crime case concurrent with a federal prosecution of the same case (where an Indian is the suspected perpetrator). See Chapter 8 at www.tribal-institute.org/download/CCC_February_2009.pdf.

[17] For example, Peterman (2010) indicated that depending upon the tribe, a federal multidisciplinary team that has jurisdiction in child sexual abuse cases on a specific reservation usually includes but is not limited to representatives from the following agencies: United States Attorney’s Office; FBI (victim-witness specialist and special agent); Bureau of Indian Affairs, Office of Law Enforcement Services (victim-witness specialist and special agent); the tribal police department; Indian Health Service; nurse midwife program; mental health services; tribal child welfare; tribal attorney general’s office, state child protection, and tribal victim services. The multidisciplinary team model has been invaluable in Indian Country primarily because of the distance between most U.S. Attorney’s offices and the reservations for which they are responsible (a 100-mile trip between sites is not unusual). See www.justice.gov/sites/default/files/usao/legacy/2010/07/26/usab5804.pdf.

[18] Disposition refers to the ongoing process of determining what to do with evidence in a case (Technical Working Group on Biological Evidence Preservation, 2013).

[19] For a resource for building tribal-state relations, see Child Welfare Information Gateway (2012c).

[20] For more information, see Military OneSource (n.d.) at www.militaryonesource.mil/health-and-wellness/family-violence?content_id=282305