Program Profile: Children’s Advocacy Center Model

This program is a multidisciplinary, victim-focused approach designed to improve forensic interviewing and the continuity of care for youth who are victims of sexual abuse and assault. The program is rated Effective. The program showed a statistically significant increase in the receipt of physical health examinations and counseling referrals for treatment group youth, compared with youth in the community comparison group.

An Effective rating implies that implementing the program is likely to result in the intended outcome(s).

Program Goals/Target Population

The Children’s Advocacy Center (CAC) Model is a multidisciplinary, victim-focused program that delivers comprehensive, culturally competent care to diagnose and provide treatment for all types of child maltreatment cases, including physical neglect and abuse, incest, and extrafamilial sexual abuse (Edinburgh et al. 2008; OJJDP N.d.). The CAC model is designed to improve the overall forensic interviewing process and physical and mental health treatment for youth who have reported experiencing sexual abuse. The forensic interview typically consists of a structured conversation between the victim of sexual assault and a criminal investigator or forensic interview specialist, to elicit a detailed account of the victim’s experience. However, the traditional method of interviewing sexually abused or assaulted youth has also been criticized for being unnecessarily stressful and traumatic (Cross et al. 2007). One problem is the lack of coordination between agencies, which often leads to the victims being interviewed too many times and thus retraumatizing them. In addition, the lack of coordination often results in more stressful interview environments, such as in a police station, where the youth may believe they are in trouble (Cross et al. 2007).

Overall, the goal of the CAC model is to improve the delivery of care to youth victims of sexual abuse and assault, coordinate multiple investigations of the abuse and assault though an objective and nonrepetitive process, and reduce the harmful effects of sexual abuse and assault on youth and their families through an inclusive service center that emphasizes a child-focused approach (Wolfteich et al. 2007).

Services Provided

The CAC model includes the provision of services (which may vary from site to site) that coordinate with local child-friendly facilities to enable professionals from victim advocacy and child protective services, law enforcement and prosecution, and the medical and mental health fields to work together to investigate, prosecute, and treat child abuse. The team approach improves interagency communication, increases the effectiveness of the investigation and prosecution, and results in fewer interviews with and less trauma for the victim (OJJDP 2020). CAC models can be implemented in a variety of private, child-friendly locations to create less stressful interview environments, such as independent centers, prosecutor’s offices with separate entrances specifically for CAC-involved youth, or hospitals (Cross et al., 2007).

Hospital-based CAC patients receive comprehensive health care assessments, which involve the collection of information about the abuse, past medical history, a history from the adolescent’s perspective (which is videotaped), a complete physical exam, and treatment for prior abuse. If the abuse occurred within the previous 72 hours, CACs provide treatment for the injuries, collect forensic evidence (such as DNA), treat sexually transmitted infections (STIs), and assess victims for acute psychological trauma. Additionally, hospital-based CACs provide counseling referrals to child abuse victims based on the results of these health assessments.

Hospital-based CAC patients are examined using video colposcopy, as opposed to visual examinations, which are then reviewed by pediatricians with expertise in sexual abuse (rather than by nurses who are Sexual Assault Nurse Examiners, nurse practitioners, family physicians, pediatricians, emergency physicians, or internists). Experts in child sexual assault are considered to be less likely to misinterpret normal findings, compared with physicians who do not have specific experience in the area (Edinburgh et al. 2008).

Key Personnel

A multidisciplinary team is a common element of CACs. The hospital-based model is implemented by a team of pediatricians, nurse practitioners, nurses, and psychologists who provide forensic examinations, diagnoses, treatment, and ongoing therapeutic interventions and follow up.

Study 1

Edinburgh and colleagues (2008) used a retrospective, matched case-comparison quasi-experimental research design to determine whether there were differences in health care assessments and treatment received by adolescent victims referred to a hospital-based Child Advocacy Center (CAC), compared with adolescent victims who received treatment by community providers. This study took place in an urban county, where CAC adolescents were retrospectively matched and selected based on evidence of their abuse submitted for criminal charges within the same court system. Patient chart information, retrieved from the submitted court records, was used to collect information for the study and match patients to the index (treatment) cases and community cases groups.

Cases were matched on the victims’ gender and age within 9 months, type of assault (single or multiple persons committing the offense), and the adult or juvenile status of the person perpetrating the offense. When the age of the person perpetrating the offense was unknown, juveniles were matched within 3 years of age, but adults were matched as closely as possible (49.6 percent matched within 1 year, and 80.9 percent matched within 4 years). There were 52 CAC cases that were not matched; and when there was more than one match to the treatment CAC group, then one community case was randomly selected among those. A comparison was conducted that compared the 128 CAC matched cases with the 52 CAC unmatched cases; there were no statistically significant differences in demographic characteristics, type and severity of abuse, likelihood of physical examination, treatment, or legal outcomes.

The treatment group comprised consecutive patients between the ages of 10 to 15, who were diagnosed with extrafamilial sexual abuse between January 1998 and December 2003, at a hospital-based CAC. Patients in the treatment group were 78.1 percent female with an average age of 12.7 years. Adolescents in the CAC treatment group experienced family problems that included a history of domestic violence (35.9 percent) and a history of child protective services (CPS) involvement (26 percent). Almost 80 percent of victims delayed their disclosure (after 72 hours) of abuse. Individuals perpetrating the offense had an average age of 23.3 years. Approximately 84 percent of adolescent victims were abused by a single person, 11.7 percent were abused by multiple individuals, and 4.7 percent had “Too many to count.” More than half of the adolescents, 62.5 percent, were abused sexually by penile-vaginal/anal penetration. The treatment group received comprehensive health care assessments, which included obtaining information about the abuse, past medical history, a history from the adolescent’s perspective, a complete physical exam, and treatment for prior abuse, which were reviewed by an expert pediatrician in sexual abuse.

The comparison group of 128 community cases were selected using the same process as the treatment group. The comparison group was not referred to a CAC for sexual abuse and assault. Investigations were conducted by police elsewhere in the community using non-CAC care providers, including Sexual Assault Nurse Examiners (SANE) nurses, nurse practitioners, family physicians, pediatricians, emergency physicians, and internists, who performed visual examinations (Edinburgh et al. 2008). Patients in the comparison group were 78.1 percent female with an average age of 12.8 years. Adolescents in the comparison group experienced family problems that included a history of domestic violence (44 percent) and a history of CPS involvement (23 percent). There were 74.4 percent of victims who delayed their disclosure of abuse. Those committing the offense had an average age of 23.6 years. Almost 86 percent of adolescents were abused by a single person, 11.7 were abused by multiple individuals, and 2.3 percent had “Too many to count.” More than half of the adolescents, 64.5 percent, were abused sexually by penile-vaginal/anal penetration.

Outcomes of interest included whether victims received a physical exam and were referred for counseling. Whether the victim received a physical exam was measured by examining clients’ records to see if any of the following exams were administrated: 1) an ano-genital exam for injury (which was recorded if patient records indicated penile-anal or penile-genital penetration had occurred), 2) a Sexually Transmitted Infection (STI) or prophylaxis and pregnancy test (for girls), or 3) the Bureau of Criminal Apprehension’s DNA evidence kit was performed by staff when an assault occurred within 72 hours and included penile contact. Whether the victim was referred for counseling was measured by the patient’s chart information indicating if a counseling referral was made during the health assessment. To evaluate these differences between the CAC treatment group and comparison group, logistic regression was used. The study authors did not conduct subgroup analyses.

There are generally nine core implementation components of Child Advocacy Centers (CACs), including 1) a child-friendly facility; 2) a multidisciplinary team (including a designated legal team responsible for program and fiscal operations); 3) an investigative child interview conducted in an objective, nonrepetitive manner; 4) a medical examination of the child; 5) provision of mental health services; 6) victim advocacy and support; 7) case review; 8) case tracking; and 9) an organizational structure with culturally competent policies and practices (Jackson 2004; OJJDP N.d.). Additional methods to promote these components are codified as accreditation standards by the National Children’s Alliance (NCA), the member organization for CACs (Cross et al. 2007; Wolfteich et al. 2007).

Furthermore, there are four regional CACs (Northeast Regional, Southern Regional, Midwest Regional, and Western Regional) that provide consultation and training and technical assistance services to develop and strengthen pre-existing local centers. Training and technical assistance is personalized to the specific needs of the region and helps local centers develop comprehensive, multidisciplinary responses to meet the needs of child victims and their families (OJJDP 2020). Regional centers work collaboratively with the NCA, which provides national leadership and advocacy for local centers. In addition, the NCA provides training, technical assistance, and networking opportunities to communities that are planning, establishing, or improving local centers (OJJDP N.d.).

These sources were used in the development of the program profile:

These sources were used in the development of the program profile: