Consent
In most circumstances, the parent of a minor gives consent for the medical treatment.
However, in some instances, a minor is able to consent to his or her own treatment,
provided that the minor is able to understand the risks, benefits, and potential
alternatives for treatment. 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.
Personnel During the Examination
As few people as possible should be present during the physical examination and evidence collection process. The examining medical provider, a support person and/or a nurse should be the attending personnel. Law enforcement or child protective agency representatives or others involved in the investigation should not 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, you need 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 be detrimental to the examination. These situations include:
When the parent is distraught or disbelieving and this 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
If you decide that the parent should not be present, a member of the medical team should take the child/adolescent to a private area, provide support and comfort, and explain why the examination is being conducted and what it will include.
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 dolls or other 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. In order 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.
Consider using relaxation techniques with older children and adolescents. (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 the ramifications of this refusal. If there is suspicion of injury or infection and the child/adolescent is too frightened or unwilling to cooperate, consider anesthesia.
In every case, the medical and emotional needs of the child/adolescent should come before the legal needs.
Sedation and Anesthesia
It is unusual to use sedation or anesthesia for the examination. The use of medication should
be restricted to situations where suspected major injuries require assessment or surgical
repair. These include: large lacerations; active bleeding; evidence of internal bleeding, such
as dried blood on the perineum; generalized bruising; or extreme tenderness. In addition,
developmentally delayed children/adolescents may require anesthesia. In rare cases when a
child/adolescent is too frightened to cooperate despite preparation and relaxation techniques
and the exam is urgent, sedation or anesthesia may be indicated. However, consider the
negative emotional effects of "putting the child to sleep" on a victim who has been
drugged during abuse.
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. The type of sedative used will depend on hospital practice and policy.
