It is hard to imagine that an estimated six million children are abused and neglected in the United States each year. These shocking statistics include different forms of maltreatment, ranging from physical, verbal, emotional and sexual abuse to physical neglect and medical neglect.
The Child Protection Program (CCP) at St. Louis Children's Hospital is a professional hospital-based program that provides clinical services and training. The program is staffed by pediatricians, pediatric nurse practitioners and licensed clinical social workers.
Jamie Kondis, MD, FAAP discusses the warning signs of child sexual abuse, as well as SLCH’s SAM (sexual abuse management) and SANE (sexual assault nurse examiner) clinics.
Selected Podcast
Sexual Abuse Management at St. Louis Children's Hospital
Featured Speaker:
Learn more about Jamie Kondis, MD
Jamie Kondis, MD
Jamie Kondis, MD, FAAP, is a Washington University emergency medicine physician at St. Louis Children’s Hospital.Learn more about Jamie Kondis, MD
Transcription:
Sexual Abuse Management at St. Louis Children's Hospital
Melanie Cole (Host): It's hard to imagine that an estimated 6 million children are abused and neglected in the United States each year. These shocking statistics include different forms of maltreatment ranging from physical, verbal, emotional and sexual abuse. My guest today is Dr. Jamie Kondis. She's a Washington University Emergency Medicine physician at St. Louis Children's Hospital. Welcome to the show, Dr. Kondis. How is sexual abuse identified? What are some of the warning signs for pediatricians that you want them to notice--some of the red flags?
Dr. Jamie Kondis (Guest): Hi. Thank you for having me here during April, which is Child Abuse Prevention Month. As you said, child sexual abuse is extremely common. We know that at least 1 in 4 females and at least 1 in 9 males will be sexual abused or assaulted sometime in their lifetime. So, it is definitely something that pediatricians need to be thinking about and it's something that a lot of pediatricians feel uncomfortable with because it is a difficult topic to broach with families. I think important things to remember are that most children will be sexually abused by someone that they know and trust. A lot of families will be thinking it's going to be a stranger; it's going to be someone kind of scary that they need to warn kids about but, actually, over 90% of the children who are sexually abused, are abused by someone that they know and trust like a family member or coach or teacher or close friend. So, just educating families to be really aware of who their children are spending time with and who they're around and educating parents to be talking to kids at a young age about their bodies, which parts of their bodies are private and that no one should be touching their private areas except when they're really young, a parent if they're helping them in the bath and then, obviously, a doctor can look in those areas if their parent is there, but just kind of doing that early education with kids about their bodies and their private areas so kids will be comfortable then, coming to their families and telling them if someone is unfortunately abusing them. So, that's one thing pediatricians can do at a young age is just kind of demystifying the private areas of the body and talking about them openly. A lot of families feel like they can't talk about the private areas. One of the things we always emphasize is calling body parts what they are--not making up funny names for them or shunning them, or anything like that because when kids are comfortable with those areas and they call them by their actual name instead of calling it your "bad spot" or something, calling it your vagina, your penis, then it doesn't make it seem weird to come talk to your family or your pediatrician if something's going on down there and pediatricians can emphasize healthy behaviors for families. Those are some of the things they can do. In terms of detecting sexual abuse in your patients, again, I think just having healthy conversations with kids from a young age and building rapport with them, because a lot of kids, their pediatrician is actually the first person that they disclose to, because a lot of kids will feel most comfortable with their pediatrician. Then, being aware of how to respond if a kid tells them something. Really, the best way to respond is just kind of listening, not asking a bunch of questions at first, just kind of listening and being understanding, and not acting shocked or scared, just kind of listening to the kid and what they're telling you, and then knowing how to report the concerns to the correct people. That's one thing that we can always help with. I get a lot of calls from pediatricians like "This patient has just told me this. Now what do I do?" and that's definitely something that our team can help with because it can be kind of scary if that happens. A lot of kids present with abnormal behaviors, so just be watching for those. Sometimes, they're presenting with extremely sexualized behaviors at a young age, abnormal knowledge of sexual contact that kids shouldn't have at a young age, or even just non-specific things like being really depressed all of a sudden or sometimes kids are suicidal or depressed because they're being abused. So, just kind of being aware of those behaviors and thinking about abuse as a possible reason.
Melanie: What are some long-term effects of sexual abuse on children?
Dr. Kondis: There are a lot of long-term effects, unfortunately. We know that children who are sexually abused have a higher rate of things like drug use and teen pregnancy. They also have much higher rates of mental health problems like depression and suicide attempts. So, one of the things that we actually do when we identify kids who are being abused is refer them to the Washington University Psychiatry who has the trauma response program which was started about seven years ago by Dr. Constantino and his social worker who provides the therapies, Jennifer Holzhauer. That's a program through Wash U. where kids who have experienced an acute trauma can then undergo a therapy intervention that is to prevent them from getting PTSD and then long-term effects from their abuse. It's actually very successful. Actually, anyone can refer to the Trauma Response Program. It doesn't have to go through us, so that information is on the Wash U. Child Psychiatry webpage of how to refer to that program. That's one thing to definitely keep in mind, is the mental health sequela. That's huge for kids who have been sexually abused. They have higher rates of other types of abuse, we know, when they're being sexually abused as well. So, one thing we always do when we're working kids up for sexual abuse is we think about physical abuse and neglect and other forms of abuse as well. But, yes, there are a lot of unfortunate really poor, long-term effects for kids, so we really try to get them referred to all different types of services when we detect abuse.
Melanie: So, tell us about your clinic, Dr. Kondis, and what services that you offer your patients for the SAM Clinic, the Sexual Abuse Management Clinic, and the Sexual Assault Nurse Examiner Clinics, the SANE Clinic.
Dr. Kondis: Yes. So, we have a couple different options here for kids who are being sexually abused. For kids who are acutely assaulted--and by acute, I mean the time frame is 72-hours or less. So, if you find out that your patient has been abused--something has just happened to them within the past three days--we recommend that those children come to our emergency department and see our SANE nurse practitioners. SANE stands for Sexual Assault Nurse Examiner, and it's a nurse or, in our case, a nurse practitioner, who has undergone some specialized training--really very intensive training--to become an expert at the care of an acutely sexual assaulted person. You can be an adult SANE or a pediatric SANE, which is what ours are. They have to take a course and do a lot of observed exams, and then they get certified. All of ours are board-certified by the International Association of Forensic Nursing. We are actual unique in the region because we are the only pediatric SANE program in all of our area of Missouri and Illinois--all of Missouri except for Kansas City--and all of Southern Illinois. So, we are kind of "it" for pediatric sexual assault high-level of care. What happens is when kids come and they come to the ED with an acute sexual assault, one of our SANE nurse practitioners is on call 24/7. They come immediately to the emergency department and they handle all of their care, and they're really, since they're such experts, it really goes very smoothly. Everything is very streamlined. They take a history from the patient and from the family, they do all of the evidence collection that is needed, they make the hotline report, and speak with law enforcement, anyone that's involved, and then they do the physical exam and provide prophylactic medications that these patients sometimes need, and then arrange all of their follow-up. So, it's really a very streamlined process for the patient. We've had this program in existence for nearly three years now. April 15th will be our third anniversary and we've noticed just a huge benefit since having the program in terms of the patients are seen much quicker, and they get out of the ED much quicker, which they obviously appreciate. We've noticed much better results with getting results from our evidence collection. We're having much better relationships with law enforcement and with prosecutors and everyone that we work with out in the community because we have this small, specialized team. So, that's a real service that we offer here that nobody else does. And then, for all of the patients that are not acute, where they don't need that evidence collection and those prophylactic medications, then we offer our SAM Clinic which, as you said, stands for “Sexual Abuse Management Clinic”. That is here at Children's Hospital where our clinic's space is on the 11th floor, and we handle a wide variety of patients there and that is staffed by our child abuse pediatricians and then one of our nurse practitioners, Kathleen Houston, who's also one of our SANE Nurse Practitioners. We can see kids Monday through Friday during normal clinic hours, and we see all of our acute sexual assault patients in follow-up in the SAM Clinic because they need some additional lab testing; they need some additional medication refills. That's also when we refer them, if we haven't already referred them in the ER, we make sure they're getting into the Trauma Response program. But, in addition to those patients, we also take referrals from all different places in the community. Pediatricians refer us patients if, for example, they are doing an exam in their office and they see a finding that they're not sure about and want a second opinion, they can send those patients to us. Or, we also get referrals from other community agencies, like the Child Advocacy Center, who does forensic interviews of patients. They may be interviewing a child about abuse and realize that that child never got a physical exam, so they'll send them to our clinic. And then, patients can also self-refer. They may be concerned about abuse, look up Children's Hospital on the internet, and see that we have a clinic, and they may call us. So, we get patients all different ways in our clinic. Generally, if it's something where they need to be seen kind of that same day, then we'll probably direct them to the Emergency Department just because that is the fastest way that they can be seen, but we can usually get patients into clinic like within the same week--usually pretty quickly. So, we definitely encourage pediatricians to call us, and that clinic number is 314-454-2879.
Melanie: Dr. Kondis, to wrap up, what do you want other pediatricians to know about sexual abuse and the importance of recognizing these signs and when to refer to a specialist?
Dr. Kondis: Yes. Well, I guess, obviously, thinking about it is the most important thing because I think you have to be thinking about it all the time because it's just something that is so common, but it's not going to be as obvious as a kid walking into your office with a broken leg or with a cold or something, you know? The signs can be a little more subtle. So, just to be thinking about it and then, I do know that a lot of pediatricians are uncomfortable with the subject of sexual abuse because it's not something that we do a really good job of training pediatricians about. So, you can be out in practice and not necessarily feel really comfortable with it like a lot of other things. So, definitely call us anytime. Either myself or Dr. Jamus, our Child Protection Program Medical Director, one of us is on call 24 hours a day, all the time, 365 days a year, so pediatricians with questions can always reach us through Children's Direct. We are always happy to discuss patients with you, even if it's not about someone that you necessarily think needs to come see us. If you just want to run something by us, we are really always happy to talk to them. And then, if they do have those patients where they think they need an exam, call our SAM clinic and we can definitely get them in. And then, if it's someone that you think needs to be seen right away, they can call us about those, too, and then we can get them into the ED and seen by our SANE program. So, we have so many different ways that we can see these patients but we are always here to discuss those cases with them.
Melanie: And, tell us about your team. Why is St. Louis Children's Hospital so great to work with?
Dr. Kondis: Well, so many reasons, really. I think we have an excellent team. We do have, as I said, two attending physicians, and then we have a Fellowship here, as well, so we have a Child Abuse Pediatric Fellow. We have our three nurse practitioners and one of them is on call all of the time for our SANE program, and then, they also do our clinic. We also have a nurse in our clinic who will be the one actually. Her name is Stacy. She would be the one actually taking your phone call, if you call clinic to schedule an appointment, and she is really excellent at getting our patients in and right away, and in for follow up. We also work really closely with our social workers, both our inpatient and our Emergency Department social workers. We meet every day to discuss the patients that we're going to be seeing--we meet as a team. We just have a lot of really great people here working on these patients. We have, really, I think, one of the largest teams definitely in our region, focused just on child abuse, so I think that's a real positive.
Melanie: Thank you so much for being with us today, Dr. Kondis. It's really such important information for listeners to hear. A physician can refer a patient by calling Children's Direct Physician Access Line at 1-800-678-HELP. That's 1-800-678-4357. You're listening to Radio Rounds with St. Louis Children's Hospital. For more information on resources available at St. Louis Children's Hospital, you can go to www.stlouischildrens.org. That's www.stlouischildrens.org. This is Melanie Cole. Thanks so much for listening.
Sexual Abuse Management at St. Louis Children's Hospital
Melanie Cole (Host): It's hard to imagine that an estimated 6 million children are abused and neglected in the United States each year. These shocking statistics include different forms of maltreatment ranging from physical, verbal, emotional and sexual abuse. My guest today is Dr. Jamie Kondis. She's a Washington University Emergency Medicine physician at St. Louis Children's Hospital. Welcome to the show, Dr. Kondis. How is sexual abuse identified? What are some of the warning signs for pediatricians that you want them to notice--some of the red flags?
Dr. Jamie Kondis (Guest): Hi. Thank you for having me here during April, which is Child Abuse Prevention Month. As you said, child sexual abuse is extremely common. We know that at least 1 in 4 females and at least 1 in 9 males will be sexual abused or assaulted sometime in their lifetime. So, it is definitely something that pediatricians need to be thinking about and it's something that a lot of pediatricians feel uncomfortable with because it is a difficult topic to broach with families. I think important things to remember are that most children will be sexually abused by someone that they know and trust. A lot of families will be thinking it's going to be a stranger; it's going to be someone kind of scary that they need to warn kids about but, actually, over 90% of the children who are sexually abused, are abused by someone that they know and trust like a family member or coach or teacher or close friend. So, just educating families to be really aware of who their children are spending time with and who they're around and educating parents to be talking to kids at a young age about their bodies, which parts of their bodies are private and that no one should be touching their private areas except when they're really young, a parent if they're helping them in the bath and then, obviously, a doctor can look in those areas if their parent is there, but just kind of doing that early education with kids about their bodies and their private areas so kids will be comfortable then, coming to their families and telling them if someone is unfortunately abusing them. So, that's one thing pediatricians can do at a young age is just kind of demystifying the private areas of the body and talking about them openly. A lot of families feel like they can't talk about the private areas. One of the things we always emphasize is calling body parts what they are--not making up funny names for them or shunning them, or anything like that because when kids are comfortable with those areas and they call them by their actual name instead of calling it your "bad spot" or something, calling it your vagina, your penis, then it doesn't make it seem weird to come talk to your family or your pediatrician if something's going on down there and pediatricians can emphasize healthy behaviors for families. Those are some of the things they can do. In terms of detecting sexual abuse in your patients, again, I think just having healthy conversations with kids from a young age and building rapport with them, because a lot of kids, their pediatrician is actually the first person that they disclose to, because a lot of kids will feel most comfortable with their pediatrician. Then, being aware of how to respond if a kid tells them something. Really, the best way to respond is just kind of listening, not asking a bunch of questions at first, just kind of listening and being understanding, and not acting shocked or scared, just kind of listening to the kid and what they're telling you, and then knowing how to report the concerns to the correct people. That's one thing that we can always help with. I get a lot of calls from pediatricians like "This patient has just told me this. Now what do I do?" and that's definitely something that our team can help with because it can be kind of scary if that happens. A lot of kids present with abnormal behaviors, so just be watching for those. Sometimes, they're presenting with extremely sexualized behaviors at a young age, abnormal knowledge of sexual contact that kids shouldn't have at a young age, or even just non-specific things like being really depressed all of a sudden or sometimes kids are suicidal or depressed because they're being abused. So, just kind of being aware of those behaviors and thinking about abuse as a possible reason.
Melanie: What are some long-term effects of sexual abuse on children?
Dr. Kondis: There are a lot of long-term effects, unfortunately. We know that children who are sexually abused have a higher rate of things like drug use and teen pregnancy. They also have much higher rates of mental health problems like depression and suicide attempts. So, one of the things that we actually do when we identify kids who are being abused is refer them to the Washington University Psychiatry who has the trauma response program which was started about seven years ago by Dr. Constantino and his social worker who provides the therapies, Jennifer Holzhauer. That's a program through Wash U. where kids who have experienced an acute trauma can then undergo a therapy intervention that is to prevent them from getting PTSD and then long-term effects from their abuse. It's actually very successful. Actually, anyone can refer to the Trauma Response Program. It doesn't have to go through us, so that information is on the Wash U. Child Psychiatry webpage of how to refer to that program. That's one thing to definitely keep in mind, is the mental health sequela. That's huge for kids who have been sexually abused. They have higher rates of other types of abuse, we know, when they're being sexually abused as well. So, one thing we always do when we're working kids up for sexual abuse is we think about physical abuse and neglect and other forms of abuse as well. But, yes, there are a lot of unfortunate really poor, long-term effects for kids, so we really try to get them referred to all different types of services when we detect abuse.
Melanie: So, tell us about your clinic, Dr. Kondis, and what services that you offer your patients for the SAM Clinic, the Sexual Abuse Management Clinic, and the Sexual Assault Nurse Examiner Clinics, the SANE Clinic.
Dr. Kondis: Yes. So, we have a couple different options here for kids who are being sexually abused. For kids who are acutely assaulted--and by acute, I mean the time frame is 72-hours or less. So, if you find out that your patient has been abused--something has just happened to them within the past three days--we recommend that those children come to our emergency department and see our SANE nurse practitioners. SANE stands for Sexual Assault Nurse Examiner, and it's a nurse or, in our case, a nurse practitioner, who has undergone some specialized training--really very intensive training--to become an expert at the care of an acutely sexual assaulted person. You can be an adult SANE or a pediatric SANE, which is what ours are. They have to take a course and do a lot of observed exams, and then they get certified. All of ours are board-certified by the International Association of Forensic Nursing. We are actual unique in the region because we are the only pediatric SANE program in all of our area of Missouri and Illinois--all of Missouri except for Kansas City--and all of Southern Illinois. So, we are kind of "it" for pediatric sexual assault high-level of care. What happens is when kids come and they come to the ED with an acute sexual assault, one of our SANE nurse practitioners is on call 24/7. They come immediately to the emergency department and they handle all of their care, and they're really, since they're such experts, it really goes very smoothly. Everything is very streamlined. They take a history from the patient and from the family, they do all of the evidence collection that is needed, they make the hotline report, and speak with law enforcement, anyone that's involved, and then they do the physical exam and provide prophylactic medications that these patients sometimes need, and then arrange all of their follow-up. So, it's really a very streamlined process for the patient. We've had this program in existence for nearly three years now. April 15th will be our third anniversary and we've noticed just a huge benefit since having the program in terms of the patients are seen much quicker, and they get out of the ED much quicker, which they obviously appreciate. We've noticed much better results with getting results from our evidence collection. We're having much better relationships with law enforcement and with prosecutors and everyone that we work with out in the community because we have this small, specialized team. So, that's a real service that we offer here that nobody else does. And then, for all of the patients that are not acute, where they don't need that evidence collection and those prophylactic medications, then we offer our SAM Clinic which, as you said, stands for “Sexual Abuse Management Clinic”. That is here at Children's Hospital where our clinic's space is on the 11th floor, and we handle a wide variety of patients there and that is staffed by our child abuse pediatricians and then one of our nurse practitioners, Kathleen Houston, who's also one of our SANE Nurse Practitioners. We can see kids Monday through Friday during normal clinic hours, and we see all of our acute sexual assault patients in follow-up in the SAM Clinic because they need some additional lab testing; they need some additional medication refills. That's also when we refer them, if we haven't already referred them in the ER, we make sure they're getting into the Trauma Response program. But, in addition to those patients, we also take referrals from all different places in the community. Pediatricians refer us patients if, for example, they are doing an exam in their office and they see a finding that they're not sure about and want a second opinion, they can send those patients to us. Or, we also get referrals from other community agencies, like the Child Advocacy Center, who does forensic interviews of patients. They may be interviewing a child about abuse and realize that that child never got a physical exam, so they'll send them to our clinic. And then, patients can also self-refer. They may be concerned about abuse, look up Children's Hospital on the internet, and see that we have a clinic, and they may call us. So, we get patients all different ways in our clinic. Generally, if it's something where they need to be seen kind of that same day, then we'll probably direct them to the Emergency Department just because that is the fastest way that they can be seen, but we can usually get patients into clinic like within the same week--usually pretty quickly. So, we definitely encourage pediatricians to call us, and that clinic number is 314-454-2879.
Melanie: Dr. Kondis, to wrap up, what do you want other pediatricians to know about sexual abuse and the importance of recognizing these signs and when to refer to a specialist?
Dr. Kondis: Yes. Well, I guess, obviously, thinking about it is the most important thing because I think you have to be thinking about it all the time because it's just something that is so common, but it's not going to be as obvious as a kid walking into your office with a broken leg or with a cold or something, you know? The signs can be a little more subtle. So, just to be thinking about it and then, I do know that a lot of pediatricians are uncomfortable with the subject of sexual abuse because it's not something that we do a really good job of training pediatricians about. So, you can be out in practice and not necessarily feel really comfortable with it like a lot of other things. So, definitely call us anytime. Either myself or Dr. Jamus, our Child Protection Program Medical Director, one of us is on call 24 hours a day, all the time, 365 days a year, so pediatricians with questions can always reach us through Children's Direct. We are always happy to discuss patients with you, even if it's not about someone that you necessarily think needs to come see us. If you just want to run something by us, we are really always happy to talk to them. And then, if they do have those patients where they think they need an exam, call our SAM clinic and we can definitely get them in. And then, if it's someone that you think needs to be seen right away, they can call us about those, too, and then we can get them into the ED and seen by our SANE program. So, we have so many different ways that we can see these patients but we are always here to discuss those cases with them.
Melanie: And, tell us about your team. Why is St. Louis Children's Hospital so great to work with?
Dr. Kondis: Well, so many reasons, really. I think we have an excellent team. We do have, as I said, two attending physicians, and then we have a Fellowship here, as well, so we have a Child Abuse Pediatric Fellow. We have our three nurse practitioners and one of them is on call all of the time for our SANE program, and then, they also do our clinic. We also have a nurse in our clinic who will be the one actually. Her name is Stacy. She would be the one actually taking your phone call, if you call clinic to schedule an appointment, and she is really excellent at getting our patients in and right away, and in for follow up. We also work really closely with our social workers, both our inpatient and our Emergency Department social workers. We meet every day to discuss the patients that we're going to be seeing--we meet as a team. We just have a lot of really great people here working on these patients. We have, really, I think, one of the largest teams definitely in our region, focused just on child abuse, so I think that's a real positive.
Melanie: Thank you so much for being with us today, Dr. Kondis. It's really such important information for listeners to hear. A physician can refer a patient by calling Children's Direct Physician Access Line at 1-800-678-HELP. That's 1-800-678-4357. You're listening to Radio Rounds with St. Louis Children's Hospital. For more information on resources available at St. Louis Children's Hospital, you can go to www.stlouischildrens.org. That's www.stlouischildrens.org. This is Melanie Cole. Thanks so much for listening.