Hello and welcome to the Learning Management System Training Pediatric Forensic Analysis Benefits of DNA Collection Beyond 24 Hours. And just a warning, this is a research presentation. It's a presentation that discusses a clinical research project. My name is Gail Horner. I am a forensic nursing specialist at the International Association of Forensic Nurses. I now get to support the practice of forensic nurses across the globe, which is really exciting. Prior to joining IFN, I worked as a pediatric pediatric nurse practitioner in the field of child abuse for over 25 years. I worked in a hospital-based child advocacy center and also as a member of the child abuse program at Nationwide Children's Hospital and also coordinated our pediatric sexual assault nurse examiner program in the emergency department. And the four people that are listed below are the members of the research team for this clinical research project. Katie and Jessica are both members of the pediatric SANE team at Nationwide Children's Hospital. Katie was formerly a nurse practitioner in the child abuse program, but is now with school-based health. And Jessica is a program manager at Nationwide Children's Hospital. Dr. Elizabeth Benzinger is the clinical director of the Ohio Bureau of Criminal Investigations Crime Lab in London, Ohio. And then Katherine is the research director at our child advocacy center, which is called the Center for Family Safety and Healing at Nationwide Children's Hospital. And I am not an academic by any means. I consider myself my entire career as a clinician. I was very lucky to work in a research-rich facility that supported research and the development of individuals, including nursing, in participating in research. So I certainly had assistance with research projects, but I would urge all of you clinicians, if you have a question, a clinical question that you are curious about, I would urge you to consider participating in clinical research. And you could certainly reach out to me for some pointers and maybe some how to get started with it. And then also look within your organization, within your hospital or your organization for resources. The authors, presenters, and planning committee for this educational offering have no relevant financial relationships to disclose. So for the next hour, we will describe forensic evidence findings in acute child sexual abuse after implementing a more inclusive protocol of indications for evidence collection. We will also describe factors associated with increased yield of identifiable foreign DNA and describe the literature related to forensic evidence findings in acute child sexual abuse. So we would all agree that child sexual abuse is a global pediatric healthcare problem and a human rights crisis. In the United States alone, when we think about the epidemiology of the problem of child sexual abuse, in the United States alone, according to the U.S. Department of Health and Human Services, in 2019 there were 61,000 victims of sexual abuse in the United States. And this number indicates cases of sexual abuse that were reported to Child Protective Services. Child Protective Services investigated and were able to substantiate. If you think globally, it is estimated that 5% of girls report sexual abuse before the age of 18. We know that these statistics are only the tip of the iceberg. Based on retrospective studies of adults, we know that one in five victims of child sexual abuse never disclose their victimization. And we also know that sexual abuse can result in significant lifelong consequences for its victims, lifelong physical and mental health consequences. We know that child abuse perpetrators often sexually abuse multiple victims and that they tend to not stop the victimization as they age. So given the number of children affected by sexual abuse and its potentially dire consequences, it is essential that children be protected from sexual abuse. Just to talk a little bit, just to give a little background on the problem that we were addressing in our research, our clinical research project. The American Academy of Pediatrics states that a child who discloses sexual abuse should be taken immediately to a medical facility for an examination and evidence collection if the latest incident of sexual abuse has occurred within 72 hours and there is a concern for exchange of bodily fluids. We know that the detection of perpetrator DNA from the clothing or the body of a child can improve prosecution of perpetrators. We also know that improved prosecution of sexual abuse perpetrators aids in the protection of children. Though the presence of forensic evidence aids in successful prosecution of sexual abuse, controversy remains regarding the timing and indications for collection of forensic evidence in child victims of sexual abuse or sexual assault. So we have controversy over the timing and indications. We have concern regarding the discomfort to the child that collecting a rape evidence kit can entail. Although we all know as clinicians that we've collected hundreds of rape evidence kits on children where they're not really uncomfortable. You can, you know, explain to the child what you're doing and show them and talk to them and it really doesn't have to be discomforting to the child. It can be a time-consuming process and the forensic analysis of evidence kits are, it is a costly process. So really we should not be collecting forensic evidence from children when there is no chance of recovery of any forensic evidence. So the purpose of our clinical study was to describe forensic evidence findings in acute child sexual abuse after implementing a more inclusive protocol and indications for collection of evidence in a pediatric emergency department. And we also wanted to identify factors associated with increased yield of identifiable foreign DNA. So the first step of this clinical research project and really any clinical research project is to conduct a review of literature because you want to see if your clinical question has already been answered in the literature and there may not be any reason to conduct your study. And you need to know what previous research on the topic has revealed because perhaps you have concerns that your study will reveal some additional information. So I'm going to talk a bit about how to conduct a review of literature and I want you to realize that my experience is all clinical. I am not an academic nor am I a medical librarian. So this is, this is, I'm telling you how a clinician can do a simple review of literature and you can use this to answer a variety of questions that you may have. So I would tell you to google pub pub space med and you will get to this link. And for this research project, think about what we're doing. So I would type in forensic evidence and we're talking about pediatrics. So let's see what we get when we type in the search words. So these are search words that you are typing in forensic evidence pediatric. And you'll see the first question or the first article doesn't really give us anything, nor the second, but we have a feeling that there really hasn't been any recent studies describing pediatric forensic evidence analysis. So we realize that we may need to kind of scroll down a bit into literature that it is a bit older. Here's a study that talks about a curriculum for child abuse, not exactly what we want to know as far as forensic evidence analysis. So we scroll down and now we're starting to see some articles that are talking about forensic, the analysis of forensic evidence from pediatric victims of sexual assault. We have this GRDET article from 2011. So nothing really since 2011. And then we scroll down and let's see what else we get. Again, we don't have any talking about forensic evidence analysis. Again, we don't have any talking about forensic evidence analysis. Here's an article in 2012 that talks about trace forensic evidence analysis. So that may be one that we want to look at. This Thackery article. Yes, that's definitely something we would want to look at. This Christian article. Yes. So again, and this Young article. And probably we don't want to go back any further than 2006. So that in a nutshell, and then what you would do is you type on, you click on the article, and then PubMed will take you to a screen where you can look at the abstract of the article to see if this is an article that you really want to pull to be able to include in your study, in your review of literature for your study. And this up here, you get all of the information that you need. We know that this article is in the archives of pediatric adolescent medicine. And many of you may be linked with a hospital library that would be able, that would enable you to obtain this article. And for others, there may be a fee. So again, it's best to link with perhaps a hospital or an academic, like a university library that would be able to assist you in actually obtaining these articles. And like I said, I am certainly not a academic. I am a clinician. And this is just the basics of how to conduct a lit search for a clinical problem. And I would urge you, if you have any questions, at the conclusion of this presentation, my email is there. You can certainly email me and I could assist you with a literature search if you have a particular clinical problem that you're looking at further exploring. Or certainly within IFN, the research committee would be a wonderful source of information for any clinician thinking about conducting a research study. The research committee could be a wonderful asset to assist you. And also within IFN, there's an open community for the research committee. If you truly have an interest in clinical research, I would urge you to reach out to that committee and join that committee. I had the blessing of working in an institution where I had research support in that I had linkage to a PhD, our research, Catherine Wolf, who's a wonderful person and a wonderful researcher. And she was able to assist me with data analysis. But again, I would urge you to reach out to the research committee and they could assist you. Or if you have any questions, really, at the end of this presentation, feel free to email me as well. So review of literature. So now I'll discuss the literature that I was able to retrieve when doing my lit search. So the American Academy of Pediatrics in 1999 stated that forensic evidence should be collected from the body and clothing of children when the latest incident of sexual abuse had occurred within 72 hours. And there was sexual contact. There was concern for sexual contact involving the exchange of bodily fluids. More recent studies, however, resulted in a softening of that recommendation. So the AAP in 2011 defers to the state recommendations for timing of forensic evidence collection. And again, they're saying evidence collection involving the exchange of bodily fluids. Interesting enough, bodily exchange of bodily fluids, it's never really defined in the literature. We would certainly think it would involve acts like genital-genital contact, anal-genital contact, oral-genital, oral-anal contact. But it's really never defined in the literature. The AAP in 2011 did state a caveat that some evidence supports limiting collection in pre-pubertal children to within 24 hours of the latest incident of sexual abuse. Adams in 2016, and Joyce Adams is kind of the guru of child sexual abuse. She's the individual that has developed the Adams criteria that we use for interpretation of anal-genital findings related to sexual abuse. So in 2016, Adams states sexual abuse that forensic evidence should be collected when there is concern of sexual abuse that may have resulted in the exchange of biologic material within 24 hours in pre-pubertal children and within 72 hours in adolescents. The problem is exchange of bodily fluids or biologic material is not really defined in the literature. And previous studies suggest that DNA can be recovered from sexual acts where one would not expect exchange of bodily fluids, such as genital fondling without digital genital penetration. And this was found in Christian as early as 2000 and Thackeray in 2011. So we may be missing opportunities for successful forensic evidence collection if we yield to the concept of collecting when we have a suspicion that there's an exchange of bodily fluids. So there is a dearth of forensic evidence yield from bodies of children when collected greater than 24 hours following sexual abuse. And first I'll talk about some early studies. Because certainly there has been a softening of that statement in later years, later research. Christian in 2000 looked at 273 children less than 10 years of age evaluated in an emergency department for concerns of acute sexual abuse. All children were examined within 44 hours of the sexual abuse. They all had forensic evidence kits collected. There was some form of evidence found in 25% of the children, 64% of that evidence. So the vast majority over two thirds or nearly two thirds was found on clothing and linen. No body swab was positive for semen after nine hours. Young in 2006 had similar results. Semen from bodies of pre-pubertal children was non-existent. And for adolescents, semen was recovered within 24 hours of sexual abuse. So these two early studies in 2000 and 2006, that's when the crime labs were testing for for fluids, for semen, amylase, or sperm. But then later studies in 2011, we have DNA amplification. So GRDET in 2011 looked at 277 children 13 years of age and younger. They all had forensic evidence kits collected. 80% had one or more positive laboratory screening tests for semen, sperm, or blood. 20% yielded identifiable DNA. Most were from children age 10 or older, but however, 14 kits from children less than age 10 yielded identifiable DNA. There were five positive body swabs on young children between seven and 95 hours after abuse. And GRDET stated that collection of evidence from the bodies of children should extend beyond 24 hours. And then Thackeray in 2011 looked at 388 children, less than 18 years of age, who were seen in a pediatric emergency department for concerns of acute sexual abuse. 25% of these children were positive for semen, amylase or blood. 16% of the kids yielded identifiable DNA. 20 were from the bodies of children less than 10 years of age. 17 were seen within 24 hours of abuse. However, there was one child who was positive for amylase on the thigh 54 hours after abuse. The Thackeray found that there was a poor correlation between child's disclosure and forensic evidence findings. And nine children yielded evidence findings with no history of acts where one would expect exchange of bodily fluids. So we see a big change from 2000 to 2011. And that is because there was the beginning, there was more sophisticated laboratory technology, the beginnings of DNA amplification were in use. And Christian in 2011 amended her statements from 2000 and states that due to advances in processes used by forensic crime labs and increased yield of forensic evidence, DNA amplification methods may increase evidence yield in child sexual abuse to more than 72 hours post abuse. So that concludes the review of literature and we'll get into actually the methods of our clinical study. So we received institutional review board approval from Nationwide Children's Hospital. We had a memorandum of understanding and approval by the Ohio Bureau of Criminal Investigation. We also had to obtain approval by the 36 different law enforcement agencies that were involved in the investigation because once, as we all know, once we as say nurses collect the evidence, the evidence kit then becomes the property of law enforcement. And so once the crime lab processes the forensic evidence kits, law enforcement really is the owner or they have jurisdiction over the results of the forensic analysis. So individual consent had to be obtained from all of the 36 law enforcement agencies involved. And then a retrospective review of medical and legal records was conducted for children from zero to 18 years of age on forensic evidence collected in the Pediatric Emergency Department from January 1st of 2016 to January of 2021. I'm sorry, to December 31st of 2017. And the legal records were collected on forensic evidence analysis completed by the Ohio DCI Crime Lab. Some of the rape evidence kits at Nationwide Children's Hospital are processed by the Columbus City Police Crime Lab. Those rape or forensic evidence kits were not included in this clinical study. So a retrospective chart review was conducted for patient and perpetrator demographics. Patient demographics like age, gender, perpetrator demographics like relationship to the child or were they an adult or a juvenile. History of sexual abuse or assault in the forensic interview. Sexual abuse chief complaint upon presentation to the Pediatric Emergency Department. History of sexual abuse given to the caregiver prior to arrival in the emergency department. Antigenical exam findings and sexually transmitted infections. The interview interval between sexual abuse and presentation to the Pediatric Emergency Department. And then a retrospective legal review was conducted for forensic, the results of the forensic evidence analysis completed by the Crime Lab. The medical examinations and forensic evidence collection were conducted by Pediatric Sexual Assault Nurse Examiners. All who had completed a 40 hour didactic training that was consistent with the IFN Sexual Assault Nurse Examiner Educational Guidelines. And evidence and exams were conducted in accordance with the Ohio Child and Adolescent Sexual Abuse Protocol of 2019. So indications for sexual abuse assault care in the Pediatric Emergency Department. So what children were seen in the, what criteria were used to determine what children would be seen in the Pediatric Emergency Department for a concern of sexual abuse? And this was according to current guidelines in 2016 and 17. A child less than 16 years of age presenting to the emergency department within 72 hours of the latest concern of sexual abuse. An adolescent 16 years or older presenting to the emergency department within 96 hours of the latest incident of sexual abuse. Child or adolescent giving history of genital to genital, anogenital, oral genital, oral anal or oral breast, digital genital, digital anal or fondling of the breast genitalia or anus. Unexplained acute, a child with an unexplained acute injury to the anus or genitals. If there was some reason to believe that acute sexual abuse occurred despite child unable to give history, it could have been something like a caregiver was concerned due to some behavior that a child had acutely began to exhibit perhaps after being with a certain individual. Or perhaps a child makes very vague statements to a caregiver about something that may have happened to them. A child or an adolescent who presented to the emergency department greater than 72 hours or 96 hours, depending on their age after the latest incident of sexual abuse who also had a related medical complaint such as vaginal pain, vaginal discharge, we would see them also in the emergency department. Or a pre-pubertal child known to have a sexually transmitted infection would be seen immediately in the emergency department. Children not meeting this criteria and yet there was a concern of sexual abuse which was typically a concern of sexual abuse out of the time window for the collection of forensic evidence was referred to our child advocacy center and seen within two or three days of presenting to the emergency department. This was, now we see the inclusive protocol for forensic evidence collection in the pediatric emergency department. So forensic evidence was collected for children between the ages of zero to 15 years who presented to the emergency department with a concern of sexual abuse occurring within 72 hours of the latest incident of abuse including genital to genital, anogenital, oral, genital or anal or breast contact, digital genital, digital anal, fondling the breast, genitalia and anus underclosing per child history to a caregiver or an adult prior to the presentation of the pediatric emergency department or during the forensic interview. So if a child is just talking, not just talking but talking about being touched on top of clothing and they're consistent with their statements of touching on top of clothing, we typically did not collect forensic evidence. And the same was true for adolescents age 16 or older with the same history as above. Forensic evidence was collected when there were other high risk, credible concerns even if a child was not giving history. And again, this was sometimes children exhibiting behaviors as I stated before, after being with a certain individual that perhaps there were concerns about had sexual abuse someone else or a child making vague statements to a caregiver. Forensic evidence was collected when pre-pubertal children presented to the emergency department with a positive result for a sexually transmitted infection. And that would be now if a child was giving history, was child was giving clear history of sexual abuse by father and that would have resulted in the sexually transmitted infection and they had not had contact with father for say like two weeks, we did not collect evidence in those situations. However, unfortunately, most of the pre-pubertal children presenting to the emergency department with positive SDI results tend to not be disclosing sexual abuse. So forensic evidence was collected. If there was an unexplained acute anal or genital injury or upon law enforcement request, we would collect forensic evidence. Exclusion criteria for evidence collection, the latest incident of sexual abuse was greater than 72 hours for children zero to 15 years of age and 96 hours for adolescents 16 years and above. And again, that was consistent with the standards of care per the Ohio protocol in 2016 and 2017. For children, we did not collect evidence when the child was engaging in sexualized behaviors or problematic sexualized behaviors where both children were under the age of 12 because under the age of 12, a child was not going to be prosecuted for the sexualized behavior. Child disclosure of sexual abuse made during the forensic interview was classified by the severity index for sexual behavior. Low severity, meaning low likelihood to have positive yield of forensic evidence. Fondling in a genital underclothes or overclothes without penetration. Fondling breasts over or underclothes. Exposure to pornography, exploitation, other sexually deviant behaviors, masturbation. Moderate severity, considered to be at moderate risk of yielding, moderate likelihood of yielding forensic evidence. Oral breast, oral genital, oral anal or digital genital or anal contact. High severity of sexual abuse, meaning high likelihood of yielding forensic evidence. Genital to genital and anal genital contact. The following definitions were used for purposes of this study. A relative perpetrator was defined as a father, stepfather, mother's boyfriend, grandfather, mother or other relative. A non-relative perpetrator was defined as an adult family friend, juvenile acquaintance or friend or an adult acquaintance. An unknown perpetrator was defined as there was concern of sexual abuse without an identified perpetrator, such as a child having a sexually transmitted infection or a genital injury or child exhibiting concerning behavior. And a stranger was defined as a stranger, someone the child and or the family had not previously met. Forensic analysis was conducted by the Ohio BCI Crime Lab. Forensic analysis methods were similar for all forensic evidence kits. A direct to DNA approach was utilized. Samples selected for DNA testing were ran without prior presumptive testing for bodily fluids. If the STR testing failed to produce an interpreter profile foreign to the patient, why STR testing for male DNA was performed. And the testing was completed partially based on information received from the submitting police agency. And then the sexual assault history form, the pediatric sexual assault nurse examiner completed and was placed in the forensic evidence kit. Data analysis. Data was stored in Excel spreadsheets. We were looking for dependent variables, specifically forensic evidence kit yield. The yield of identifiable foreign DNA from the bodies or children, bodies or clothing of children. And we wanted to look at what independent variables influenced the dependent variables. So we looked at, and this is just a partial list of what we looked at. We looked at demographics, child age, child janitor, perpetrator age, perpetrator relationship to the child, the history of abuse given in the forensic interview and the pediatric emergency department or to the caregiver prior to arrival in the ED. The interval between abuse and evidence collection. Frequencies were used for nominal level data. Logistic regression analysis was used to predict odds of finding at least one forensic result of foreign identifiable DNA. The nature and statistical significance of the relationship between the variables was defined by using P coefficients, odd ratios and the significance of walled statistics. So now let's take a look at the results from the clinical research study. Total of 306 children had forensic evidence kit collected between January 1st of 2016 and December 31st of 2017. That were analyzed by the Ohio BCI Crime Lab. So we took a look at their descriptive statistics. Over half or 59% of the children seen in the pediatric emergency department for sexual abuse concerns were 12 years of age or younger. 12 years of age is significant in Ohio in that 12 years of age or younger is below the legal age for any kind of sexual contact in the state of Ohio. Meaning if a 12-year-old and a 13-year-old would engage in some sort of sexual activity together, the 13-year-old could be charged with a crime against the 12-year-old. So that's kind of where you'll see, we describe information in detail for children 12 years and younger. And that's why we did that. Also 85% of the children in this study were female. Children in the study were sexually abused by a variety of perpetrators with more than half, 53% disclosing sexual abuse by a relative versus a little over a third, 35% disclosing sexual abuse by a known non-relative and another 7% disclosing sexual abuse by a stranger. Among children 12 years of age or younger, 73% were sexually abused by a relative, 18% by a known non-relative, 17% by a stranger and 13 children their perpetrator was unknown. Among children older than 12 years, less than a fourth, 23% were sexually abused by a relative, 58% by a known non-relative, 14% by a stranger and for five children older than the age of 12, their perpetrator was unknown. And if you'll see the interval from abuse, the majority of children were seen within 48 hours. Only 4.5% of the children were seen in the pediatric emergency department beyond in the 73 to 96 hour window and less than 1% were seen in the pediatric emergency department greater than 96 hours from the latest incident of sexual abuse. And if you look at acute findings on anogenital exam, only 11% of these children had any acute exam findings on exam, acute injury to the anus or the genitals on exam which is below the norm of 20 to 21%. 68% of children gave a history of sexual abuse in their forensic interview that was conducted in the pediatric emergency department. 18% of children gave no history of abuse in their forensic interview in the pediatric emergency department. And 13% had no forensic interview conducted. And that would have been because they were too young to be interviewed, they were developmentally too developmentally delayed to be interviewed, or perhaps they were, it was a very acute situation and they simply were not medically stable enough to be interviewed. Regarding their forensic interview disclosures, 62% disclosed sexual acts that were of high likelihood to yield forensic evidence, to yield identifiable foreign DNA, meaning they gave history of genital to genital or anal genital contact. Another 16% disclosed sexual acts of moderate likelihood. That would have been the oral genital, oral anal, oral breast, and digital anal or digital genital contact. And another 17% disclosed low likelihood. That would have been fondling of the breast, genitalia, and anus without penetration or exposure to pornography or other sexual deviant acts. Look down at the bottom of the slide at the total slide. 36% of the forensic evidence kits collected in this time period yielded identifiable foreign DNA from the clothing or bottom, or bodies from the children. This is much different than previous studies. When you consider Christian in 2000, 25% of the kits yielded forensic evidence and only 9% from body swabs. We had 25% of the children in the study had at least one positive body swab from which identifiable foreign DNA could be identified. Giardet, 20% identifiable DNA, and that wasn't all from the bodies. And Thackery, 16% identifiable DNA. You'll see, you'll also note that children zero to two years of age, none of those children, there were 26 of them, no positive forensic evidence kits from those children. However, certainly from all of the other age groups, we did. Factors associated with increased forensic yield of identifiable foreign DNA were explored. Increasing age of child victim was associated with increased likelihood of kit positivity for foreign DNA until age 16 years or older when positivity decreased slightly. No evidence kits, as I stated, collected from children zero to two years yielded foreign DNA. For every one year increase in child victim age, the odds ratio revealed a 12% increased likelihood of finding at least one foreign DNA profile. So certainly as children age, there was increased likelihood of identification of foreign DNA, but there was foreign DNA found in children from ages three to 18. So now let's take a closer look at positive kits in children ages 12 years of age or younger. And there were 34% of these kits were positive. So children ages three to five years of age, there were 14 positive kits, which was about 17% of the children between ages three to five years of age who had forensic evidence kits collected. And there were seven positive swabs collected from body sites in children six to eight years of age. Thirty-one or 32% of the kits were positive, and eight were positive from body sites. Children nine to 12 years of age, 33% of the kits were positive, and four swabs, four kits were positive from body sites. Time interval between sexual abuse and forensic evidence collection and identifiable foreign DNA yield was also examined. Evidence kits collected in the zero to 24 hours interval were significantly more likely to yield identifiable DNA than those collected in the 49 to 72 hour interval and the 73 to 96 hours interval. Only two kits were collected greater than 96 hours, and they yielded no identifiable foreign DNA. What's important about this study is that forensic evidence kits collected in the 25 to 48 hour interval from abuse were significantly more likely to yield identifiable foreign DNA than those collected in the 49 to 72 hour interval. So now we have that interval from abuse where we have increased likelihood of forensic evidence yield expanded out to 48 hours. And let's look at the interval from abuse at children 12 years of age or younger. So zero to 24 hours, children 12 years or younger, there were 14 positive kits, 7 from body sites. In the 25 to 48 hour interval, there were 20 positive kits, 11 from body sites. 49 to 72 hours, two positive kits, one from body sites. And 73 hours to 96 hours, one positive kit and none from body sites. However, like in the 49 to 72 hour interval, there was a four-year-old girl who gave no history of sexual abuse in her forensic interview. Her vaginal swab was positive for a foreign DNA profile that was identifiable. In the 73 to 96 hour, one child, six years old, gave no history of sexual abuse in the forensic interview, presented to the emergency department due to concerning statements to caregivers and there was some genital bleeding. There was a positive sample collected from that child's clothing. No child 12 years of age or younger had a positive sample collected from body sites in the 73 to 96 hour interval. The number of children having an acute anogenital injury or testing positive for sexually transmitted infection were too low to be able to describe statistical significance. But if you look at these numbers, I don't know, I think it would have played out. If you look at at least one positive with anogenital injury, 46% yes, 35% no. At least one positive, 30% yes, 22% in the kids with no anogenital injury. But again, the numbers, we only had 33% or 11%, so the numbers were just too low to be able to have any statistical significance. And when you look at sexually transmitted infections, certainly if we had had more, it looks like this would have played out even stronger. So 5% of our children had tested positive for sexually transmitted infection, it would have been chlamydia, gonorrhea, or trichomonas. And in the kids that tested positive, 60% had at least one positive, meaning either body or clothes. And negative for STIs, 35%. And at least one body positive in 53% of the children who tested positive for a sexually transmitted infection compared to 23% for children who tested negative for sexually transmitted infections. Then we also looked at forensic interview disclosures and the yield of identifiable foreign DNA. So 62% of the children disclosed high severity disclosures in their forensic interview, meaning they disclosed genital-to-genital contact or anal-genital contact. High severity disclosures in the forensic interview in the pediatric emergency department, those children were nearly four times more likely to yield positive foreign identifiable DNA than children with no disclosure or no interview that had been conducted. When we look at moderate severity disclosures, 31% of those children had forensic evidence kits that were positive for identifiable foreign DNA. Children who made low severity disclosures, 24% were positive for identifiable foreign DNA. And even children with no disclosure in their forensic interview or who did not have a forensic interview conducted in the pediatric emergency department, 17% of those children, their forensic evidence kit yielded identifiable foreign DNA. There was a three-year-old that made vague statements concerning for sexual abuse to her caregiver and in the forensic interview. She said, he'd do it to my butt. A positive body sample was collected from the thigh. There was a seven-year-old who disclosed fondling in a genital underclothes without any history of digital penetration and positive samples were collected from the vagina, anus, and thigh. The odds ratio between presenting pediatric emergency department sexual abuse concern and positive foreign DNA yield was also explored and no statistical significance was noted. And this is concerning because we use the presenting sexual abuse concern to kind of guide our plan of care. And I think it's interesting to note that for children who presented due to their sexual abuse being witnessed, six children were eight years of age or younger. There were 44% of these children had positive kits, 10 from body sites. Children that presented due to a physical concern noted by the caregiver, and again, seven children were aged 12 years or younger. 24% of the kits were positive, seven from body sites. Children who made concerning statements to their caregiver, and that's why they presented to the pediatric emergency department, 22 were aged 12 years or younger. There were 37% of those kits were positive, 42 from body sites. And behavioral or circumstantial concerns, 54 of these children were aged 12 years or younger. 37% of the kits were positive, 17 from body sites. We also looked at relationship of perpetrator to the child and yield for identifiable foreign DNA. Children sexually abused by an adult family friend were more likely to yield DNA than those sexually abused by a father. 161 children who were sexually abused by a relative perpetrator, and 23% of those children had positive forensic evidence kits. 127 children were sexually abused by a non-relative perpetrator, and 56% of those children had positive forensic evidence kits. 42 children, the father was the perpetrator, 12% had positive forensic evidence kits. Two of the children were 12 years of age or younger. A seven-year-old had a DNA profile of the father on her vaginal swab. A stranger was the sexual abuse perpetrator for 21 children, and 71% of these kits were positive. One children, age 12, had positive swabs from multiple body sites, positive for identifiable foreign DNA. So what does this study tell us? Well, first of all, the DNA yield in this study of 36% was significantly higher than previous studies, which is really a reflection of improved DNA amplification testing at crime labs. We also looked at factors associated with increased forensic yield of DNA. Unlike previous studies, this study revealed an expanded window of time since abuse associated with increased positive evidence yield. 25 to 48 hours since abuse had similar yield to 0 to 24 hours since abuse. Positive forensic evidence yield decreased to 16% in the 43 to 72-hour window, yet increased to 43% in the 43 to 96-hour window, but that was most likely reflective of older patient age and higher severity of sexual acts in the 73 to 96-hour window. All positive body swabs in the 73 to 96-hour interval were collected from adolescents 14 years or older, and they all gave history of genital-to-genital contact. Sexual abuse by a non-relative was most likely related to the child victim age, as the majority of children under 12 years of age were sexually abused by a relative, and over 12 years of age, they were sexually abused by a non-relative. We have to consider the presenting pediatric emergency department sexual abuse concern. That really is how we gauge our plan of care. There was no statistical effect upon positive foreign DNA yield, depending on the circumstances as to why the child presented. You know, and presenting concern often affects the decision regarding care, but we have to realize that this study and other studies have demonstrated that children presenting with somewhat circumstantial concerns may indeed have experienced sexual abuse, and failure to collect forensic evidence from these children can result in a loss of critical recoverable evidence. This study revealed certain factors associated with increased foreign DNA yield, and yet we know there are multiple outliers for each of the factors. When we consider children, increasing age of the child was certainly associated with increased DNA yield, and yet there were 33% of the positive kits were collected from children less than 13 years of age. 14 of the positive kits were collected in children aged three to five years of age, and seven were collected from body sites. The interval from abuse is expanded in this study to 48 hours, and with continued improvement of crime lab DNA amplification, perhaps that window can expand even further from abuse. And children who gave no disclosure or had no interview in the pediatric emergency department yielded 16 positive kits, outliers, multiple outliers for each factor that was associated with increased foreign DNA yield. This study had some limitations. There are several limitations that should be recognized when interpreting our data. First, this is a retrospective study, and variations in the quality and completeness of data collection exist, including recording of bathing following sexual abuse. Limitations in law enforcement jurisdictions' ability to share information regarding ongoing criminal investigations limited our ability to describe identifiable foreign DNA profiles as perpetrator DNA. Finally, Tanner staging and sexual maturity was not recorded, and positive forensic evidence yield in children 12 years of age or younger was described in detail due to the state law defining any sexual contact to be illegal. However, these children were most likely of various stages of Tanner stage development. So what does this mean for us in practice? We know that there are factors related to increased forensic evidence yield. We know that those can be identified. However, we cannot use them as tools to exclude the need to collect forensic evidence. DNA technology continues to advance, and continued review of clinical practices will be needed. If you have any questions, please shoot me an email, and I will be more than glad to answer your questions. Here's the references used for this presentation. This study has been accepted for publication in the Journal of Forensic Nursing, so look for it in 2022. And here are some additional references. And really, thank you for attending this educational session.

pediatric forensic analysis

DNA collection

Gail Horner

forensic nursing specialist

child sexual abuse

evidence collection

DNA yield

Pediatric Emergency Department

forensic interview disclosures

DNA technology

sexual abuse

forensic evidence

prosecuting perpetrators

victim age

time interval

forensic nursing