Sexual Assault Examinations in a Pediatric Emergency Setting

ACLP Bulletin | Fall 2018 | VOL. 36 NO. 4

Janine Patton, MS, CCLS
Texas Children's Hospital, Houston, TX

A child life specialist is asked to wear many different hats during each patient interaction,but none more so than during a sexual assault exam (SAE). Most often, SAEs take place in the Emergency Department (ED) of a hospital that has staff trained to complete the exam. In an SAE, a child life specialist serves as a playmate, a teacher, an advocate, a confidant, and a resource, often at the same time.

An SAE begins with an interview, where the child life specialist spends time normalizing the environment with the child while the caregiver speaks with the staff. This is also an opportunity for the child life specialist to asses the patient’scoping style while developing a relationship that will help better support the child during the exam. Building rapport in this less stressful environment before moving to the exam room can be especially helpful for patients of the opposite gender. After transitioning to the exam room, the steps of the procedure can be discussed with the patient. It is during this portion where preparation materials and intentional language choices can be extremely beneficial. Discussing the steps of the procedure in the abstract may be sufficient for older or more developmentally mature patients, but younger patients may require images or sensory preparation, such as feeling the soft texture of the swabs firsthand prior to beginning the exam.

During the exam, the child life specialist will need to switch hats more frequently, explaining the steps as a teacher, providing distraction as a playmate, and validating the stresses and fears as a trusted adult, while advocating for breaks or alterations to the plan of care as necessary. In such a dynamic environment, the child life specialist must stay alert, frequently reassessing the patient’s coping and adjusting supportive strategies as needed. Does the patient benefit from playing games on the iPad? Or is the patient too focused on the exam that deep breathing and conversation are more appropriate? Each patient is different, and therefore the assessment and available resources must be varied. Nevertheless, the mere presence of child life often improves the atmosphere surrounding the exam, creating a calming and supportive environment for the patient and caregiver alike. While it can be emotionally taxing on all parties involved, the role of a child life specialist is invaluable to an SAE for any patient, regardless of age or gender. Furthermore, child life presence during an exam tends to provide comfort not only to the patient and family, but to the staff as well, allowing them to focus on the technical aspects of the exam while knowing that the child life specialist is informing the patient and enhancing their coping during an emotional experience.

Every SAE is a bit different, but most tend to follow a similar sequence. First, the child is asked to change into a hospital gown. Depending on the situation, the child’s clothing maybe collected for evidence. Often, the nurse or doctor will obtain swabs of the inside of the child’s cheeks. Next, the child will sit on the bed, close to the edge and assume a “froglegs” or “butterfly legs” position, where the bottoms of the feet are touching each other and the legs are bowed outward.When the positioning is correct, the nurse or doctor can take images of the vaginal or penile area as well as use swabs to collect specimens that may be used for forensic evidence and STD/STI testing. For the rectal portion of the exam, the child will often be asked to turn onto the stomach and prop up on the knees while leaning on the elbows. This allows the buttocks to be inclined, again allowing for photos and swabs to be completed. In certain cases, blood work is also obtained for additional testing. Lastly, the child may be asked to take medications if any preventative or symptom treatment is needed from the assault. During the exam, many patients benefit from a combination of alternative focus and step-by-step instructions, which provide simultaneous education and support. It is helpful to create a coping plan prior to the exam, but it is also necessary to continually reassess that plan throughout the interaction in the event that adjustments need to be made to enhance the child’s coping once the exam has begun.

While it can be emotionally taxing on all parties involved, the role of a child life specialist is invaluable to an SAE for any patient, regardless of age or gender. Furthermore, child life presence during an exam tends to provide comfort not only to the patient and family, but to the staff as well, allowing them to focus on the technical aspects of the exam while knowing that the child life specialist is informing the patient and enhancing their coping during an emotional experience.

Preparation Materials

Preparation materials have a multitude of benefits for SAEs. Depending on the hospital, child life services may not be available at all hours in the ED, and child life specialists from other units may be supporting children through these exams. For those not accustomed to SAEs, it can be a challenging task to prepare and support a patient and family, and having preparation materials ready to go can ease the way. Utilizing a preparation book provides the child life specialist with soft and honest language regarding the exam, easing the pressure to find the words to prepare the patient for an exam. Additionally, preparation materials can include photos of the room where the exam will be completed, the positions that the patient will be asked to assume, and the swabs or other items that will be used to collect evidence. If time allows and it is appropriate for the patient, a child life specialist can utilize a doll or stuffed animal to help demonstrate the positions and swabbing or can practice the positions with the patient in non-threatening environment. Furthermore, preparation materials can empower staff members outside of child life to provide preparation during hours when no child life services may be present. Similar to times when a non-ED child life specialist is covering the unit, these staff members may find the preparation materials to be a reassurance of using the “right” words when talking with patients and can create a more open and conversational environment. Ultimately, preparation materials open the opportunity for the patient to feel more comfortable asking questions and seeking information related to the exam.

Possible items to include:

Photos of the room (if different from patient’s current room on the unit)
Photos of the camera that will be used for documentation
Photos of the positions children will be asked to assume for exam
Photos and explanation of swabs/evidence collection
Photos of lab draw equipment (if needed)
Sensory items (swabs, gloves, etc.)
A list of common terms that the patient may encounter
Examples of safe, soft, and honest language regarding the exam

Intentional Language Choices

As child life specialists, we know that language choice can be critical to the success or failure of an interaction. SAEs are no different in that utilizing safe and honest language can help develop a trusting relationship in a highly sensitive exam. Based on the age of the patient, different word choices may be appropriate. First, it is important to learn how the patient refers to his or her private area. Using familiar terminology can aid in rapport building as well as returning some control to the patient during the exam. Additionally, identifying the patient’s level of understanding of the purpose of the exam can lead to different word selection. For instance,a toddler likely will not understand “evidence collection,” so comparing oral swabs to teeth-brushing can help normalize that aspect for the patient. It can also be helpful to familiarize the child with terminology that they may overhear from conversations that staff are having with the caregiver,including but not limited to: case number, CPS, evidence,forensics, and investigation.

Utilizing a Separate Area for the Exam

Depending on the layout of the ED, conducting the exam in a space other than the patient’s room may not be feasible.However, this accommodation follows the same mentality of having a “procedure room” on an inpatient unit. Utilizing a separate area to complete the exam can help reinforce that the exam is to help keep the patient safe, and that it is only permissible for an adult to be looking at the child’s private area because it is a medical professional who is helping to reinforce that safety. Furthermore, because of the sensitivity of the exam, utilizing a designated room allows the patient’s room on the unit to continue to remain normalized with play or activities. The equipment needed to complete the exam can remain in the designated room and can reaffirm for the patient that once he or she leaves the room, the exam is actually completed. Should the facility not have an available separate space to conduct the exam, the child life specialist can advocate for the equipment to all enter and exit the room at the same time, along with the necessary staff members, in order to help the child distinguish when the exam is beginning and when it is completed.

Forensic Nursing/Sexual Assault Nurse Examiner

Some institutions utilize trained sexual assault nurse examiners (SANEs), registered nurses who are specifically trained to complete sexual assault/rape kits for pediatric victims in a way that fosters an empathetic and caring environment.While this specific role may not be available at every hospital,incorporating professional development opportunities to provide more education to staff members working with these patients can greatly increase the positive outcomes related to the exam.

Children’s Assessment Centers

Many hospitals have specific departments, centers, or external organizations that work to provide follow-up and additional services to patients and their families who complete an SAE. These centers, which may have different names in different locations, provide follow-up checks for patients who may have experienced injuries related to their assault.They also complete additional interviews and can connect families to resources and services for additional coping support as they move forward. These professionals are well trained in working with sensitive and emotional situations,providing empathy and support to families every day.

Research and Professional Development

There is a variety of research available surrounding pediatric SAEs. Several research studies and presentations can be found on the accompanying Specialized Resource article,which can be accessed and shared for further learning opportunities. In addition, valuable resources for children and their families are detailed in this article.

Conclusion

Ultimately, the services and resources that are appropriate for victims of sexual assault will vary from one patient to the next. Additionally, each hospital may approach the exams in a different logistical manner, including the use of a SANE or a designated SAE room. Nevertheless, it is important to note the crucial role that child life can play in creating a more psychosocially supportive environment for a child and family after such a traumatic event as a sexual assault.

Sexual Assault Specialized Resources

Resources for parents/caregivers, patients, and child life specialists/healthcare providers, please see Sexual Assault Specialized Resources.

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