Appendix 4. Customizing a Community Protocol

Communities starting from scratch in developing pediatric sexual abuse medical forensic exam protocols are encouraged to consider the recommendations in this national protocol in their entirety and tailor them to fit local needs, challenges, statutes, and policies. Communities that have existing protocols can consider whether any of the protocol recommendations or the tasks below could improve their response to prepubescent child sexual abuse or address gaps in services or interventions.

Contact staff at for technical assistance to help communities address questions that arise during the process of developing, implementing, refining, and enhancing pediatric exam protocols.

Tasks to Customize a Community Pediatric Exam Protocol

· Form a core planning team. This team should include representatives from core responding entities involved in the pediatric exam process in the community. (See A3. Coordinated Team Approach) Representatives should have authority to make policy decisions on behalf of their agencies. If there is already a multidisciplinary response team, it can serve as the core protocol planning team. Make sure your core team seeks input on exam process coordination issues from representatives from tribal lands or military installations within or neighboring the community, as well as institutions within the community that house prepubescent children or place them in housing. (See A2. Adapting Care for Each Child)

· Seek input from other responders to child sexual abuse. (See A3. Coordinated Team Approach) In addition to other professionals directly involved in comprehensive response, organizations serving specific child populations in the community should also be involved. (See A2. Adapting Care for Each Child) Their input regarding practices related to initial response and the exam process could be sought at least at two points. First, prior to protocol writing, solicit their thoughts about what is essential to include in the protocol and what areas of practice could be improved. Second, once the protocol is drafted, share it with them for their review and comment.

· Identify roles in planning. Early in the process, it is important to determine which entities and individuals will be responsible for coordinating overall protocol development planning and related research/information gathering, drafting the protocol, seeking approval for the protocol across entities, and periodically evaluating and updating the protocol.

· Assess needs. Before initiating policy changes, the planning team should assess the jurisdiction’s current response to child sexual abuse, with a focus on the exam process. (Contact staff at to discuss strategies for community assessment related to improving local response to child sexual abuse specifically around the exam process)

· Devise an action plan and create/revise the protocol. The planning team can take what it learns through needs assessments and translate it into an action plan for improving the exam process via the protocol. The plan should identify the steps that need to happen to finalize the protocol, who is responsible for coordinating or carrying out each action, possible resources, desired outcomes, and how the effectiveness of the action will be evaluated. As far as the specifics of identifying practices to include in the protocol and protocol writing, the team should consider (Littel, Malefyt, & Walker, 1998): What process will be used to facilitate decision making on (1) protocol development or revision, (2) protocol drafting and review by partners in response to child sexual abuse, and (3) adoption of the protocol by individual agencies/facilities or the community? How will protocol compliance be monitored and what mechanisms will be employed to solve problems that arise? The planning team should review the national protocol to determine what it wants to adapt for its protocol. It must consider jurisdictional statutes and policies and how to address community-specific needs and challenges. The action plan can be revisited periodically to assess progress and evaluate outcomes.[1]

· Distribute the protocol. The planning team should determine the most efficient method to disseminate the protocol to all professionals in the jurisdiction who are involved in the initial response to child sexual abuse and the exam process. The planning team needs an up-to-date contact list of these professionals, and it should agree upon a specific distribution plan. If electronic distribution is employed, make sure that professionals who do not have Internet access get a hard copy.

· Build the capacity of involved entities to implement the protocol. (See Littel, Malefyt, & Walker, 1998) A protocol’s effectiveness depends on individual agencies/facilities having adequate resources (e.g., funding, personnel, child-friendly approach, multi-language capacity, equipment, supervision, training, professional development opportunities, and community partnerships) to carry out their responsibilities and coordinate efforts with other involved responders. Agencies/facilities can assist one another in building individual and collective capacity to respond to child sexual abuse and participate in coordinated interventions.

· Promote accountability. To help with validating the protocol as a legitimate tool and promoting resource allocation to implement the protocol, consider asking responding agencies/facilities to supplement the protocol with interagency agreements or memorandums of understanding. Using the protocol as a basis, these agreements can outline roles and articulate how responders should work together to coordinate response. These documents should be jointly developed, agreed upon, and signed by agency/facility policymakers. They can be revised and signed on a periodic basis to ensure all agency personnel involved in the response are aware of protocol changes and reaffirm agency/facility commitment to carrying out agreements. Role checklists and performance outcome measures related to protocol practices for all team members can also be useful.

· Promote training. Agency/facility-specific, multidisciplinary, and cross-trainings are crucial components of protocol implementation. Involved responders must be informed of any changes in how they carry out agency/facility-specific responsibilities during the exam process and understand why these changes are needed. If they are being asked to coordinate their efforts formally with other entities, they must understand their role in coordination, the benefits of a collaborative response, the challenges such an effort involves, and ways to overcome challenges. (See A3. Coordinated Team Approach)

· Set up an evaluation system. The planning team should take the time to consider how to best compile data related to the pediatric exam process in order to evaluate effectiveness of response and make improvements to the protocol as needed.

· Revise the protocol periodically. Revisions may be based on feedback from responders and victims, evaluation recommendations, changes in laws, identification of new crime trends and prevention efforts, technology, research, and identification of new promising practices. The planning team should keep track of protocol areas needing improvement and meet periodically to discuss pertinent issues such as language to be used, how to resolve controversies, and, ultimately, to make needed changes.

[1] See for a child abuse protocol development resource for tribal communities from the Tribal Law and Policy Institute.