Physical Examination : Considerations
Telemedicine for child abuse evaluations
Exchanging medical information via electronic communications from one site to another to improve patient health has been used by many clinical sites. The “live encounter” with the patient occurs at one site, using video conferencing software while a “remote” site offers expertise from a child abuse medical professional. There are many potential benefits to this use of telemedicine, particularly in resource limited areas. The use of telemedicine for remote examinations, such as where the patient is at home and the provider is at a clinical site, requires careful consideration of potential challenges. These may include:
- Safety and confidentiality issues, such as when a suspected perpetrator may also be in the home
- Gaining the trust of a patient in a situation where there is not a face-to-face opportunity to discuss the use of photographs, for example, may be challenging.
- Limited ability to examine the patient virtually
- Technology challenges (user or connection issues)
In all forms of telemedicine, as in direct patient contact, attention to trauma informed principles should be a priority.
Consent and assent
In most circumstances, the parent of a minor is responsible for giving consent for the examination and medical treatment. However, in some instances, a minor may consent to his or her own treatment, provided that the minor is able to understand the risks, benefits, and potential alternatives for treatment, that is, deemed capable of meaningful decision-making. When consent is provided by a parent or legally responsible caregiver, the agreement of a child to participate in the examination and collection of evidence, or “assent,“ is an important moral consideration in the examination of children of all ages. Decision-making involving the health care of older children and adolescents should include, to the greatest extent feasible, the assent of the patient as well as the participation of the parents and medical provider (Spriggs 2023).
The age of consent varies based on state laws. In New York State a guide for consent for medical care for those under age 18 is available here: https://ocfs.ny.gov/programs/youth/rhy/assets/docs/Medical-Consent-Youth-Under-18-Experiencing-Homelessness.pdf
State laws for minors’ consent for routine medical care are available on this site: https://schoolhouseconnection.org/article/state-laws-on-minor-consent-for-routine-medical-care
Personnel During the Examination
To minimize further trauma, the child or adolescent should be asked their preference for including a parent, guardian or other familiar, supportive and trusted adult in the examination room. Limiting the number of people to as few as possible during the physical examination and evidence collection process is recommended. The examining medical professional, a support person and/or a nurse may offer a comfortable examination environment. Law enforcement or child protective agency representatives or others involved in the investigation should never be in attendance. Under no circumstances should the examination be held in the presence of a parent or guardian suspected of perpetrating the abuse. The child/adolescent is usually given a choice regarding the presence of parents or other support person(s). However, before being given that choice, the examining medical professional needs to decide whether the presence of a caregiver during the medical examination is desirable. Ideally, the parent or guardian should be supportive of the child/adolescent and help decrease anxiety. There are, however, certain situations when the presence of the caregiver may create a negative environment. These situations include:
- When the parent is distraught or disbelieving and their behavior may have a negative effect on the child/adolescent
- When a parent is acting to censor information the child/adolescent may provide
- When a history of sexual abuse in the parent may trigger emotions in the parent that may affect the child/adolescent's behavior
Preparing the child/adolescent for the examination
Preparing the child/adolescent for the physical examination helps reduce anxiety and minimizes trauma. It also enhances your ability to perform a comprehensive examination. Make an effort to increase the child/adolescent's sense of control and suggest relevant coping strategies. In addition, throughout the exam, reassure the child/adolescent about the healing of any injuries.
Preparation Tips
- Assess the child/adolescent's level of fearfulness before the exam. This information will be helpful in determining appropriate preparation strategies.
- Be aware of fears specific to age or developmental level and be familiar with some management techniques.
- Allow the child/adolescent as much control as possible during all phases of the exam.
- Ascertain the child/adolescent's understanding about the reasons for the exam as well as what he/she thinks will happen during the exam. Explain the exam in child-friendly language that uses developmentally appropriate words. Remember that children often interpret statements very literally.
- Use visual methods with younger children to demonstrate the exam procedures. Allow the child to play the role of the medical provider. This may provide the child with a sense of control and mastery over the situation while allowing emotional distance.
- Allow children and adolescents to choose whether they would like a parent or caregiver present during the examination. To prevent placing unnecessary pressure on the child/adolescent, avoid asking him/her to decide in front of that adult.
- Be careful about physical boundaries. Avoid touching the child/adolescent except for examination purposes and explain all physical touching as much as possible
- Consider using relaxation techniques when children and adolescents show the ability to understand the use of these methods. (e.g., progressive muscle relaxation, controlled breathing exercises, guided imagery).
- If the parent/caregiver is present during the exam, assign that person a specific role or task to perform. This will diminish anxiety and will likely decrease the child/adolescent's fear as well.
- Avoid the use of medical restraints or force of any kind during the examination. If the child/adolescent refuses an examination, the medical provider and parent/caregiver should consider rescheduling the examination to a later date. A rescheduled examination might best occur after the child is able to process their emotional trauma through therapy and develop coping skills for the examination.
- In every case, the medical and emotional needs of the child/adolescent should come before the legal needs.
Sedation and Anesthesia
The use of sedation for the examination of a sexually abused child is generally not necessary nor recommended. The use of sedative medications should be restricted to situations where suspected major injuries require assessment or surgical repair. These include large lacerations, active bleeding, and evidence of internal bleeding. In rare cases when a child/adolescent is too frightened to cooperate despite preparation and relaxation techniques and the exam is urgent due to medical needs, sedation or anesthesia may be indicated. The potential negative emotional effects of performing an examination while the child is asleep must be considered.
If sedation or anesthesia must be used, carefully explain the procedures to the child/adolescent and parent or caregiver and obtain consent. Reassure the child/adolescent that he/she will be protected while sedated. Sedatives and anesthesia may result in a relaxation of the anal sphincter and perineal muscles, thus significantly affecting the physical findings.
