Transcript Sexual Abuse- Paediatric Assessment

Sexual AbusePaediatric Assessment
Dr Arlene Boroda
Consultant Paediatrician
15 October 2008
Introduction
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Name
Qualifications
Present employment
Experience (Previous relevant jobs)
(Special interest)
(Training)
(Cases seen)
Terminology
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Child
Forensic
Acute
Chronic
Sex
Sexual Abuse
Medical terminology
CSA Definition
• ‘Sexual abuse involves forcing or enticing a child
or a young person to take part in sexual
activities, including prostitution, whether or not
the child is aware of what is happening. The
activities may involve physical contact,
including penetrative (e.g. rape, buggery or
oral sex) or non-contact activities, such
as…looking at, or the production of
pornographic material or watching sexual
activities, or encouraging children to behave in
sexually inappropriate ways.’
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Working Together to Safeguard Children HM Gov 2006
References
• Children Act HMSO1989, revised 2004
• Framework for Assessment of Children in Need and their
Families DOH1999
• What to do if you are worried that a child is being Abused
DOH 2003
• Working together to Safeguard Children HMGov2006
• Child Protection Companion RCPCH 2006
• Responsibilities of Doctors in Child Protection cases with
Regard to Confidentiality RCPCH 2004
• Guidance of Paediatric Forensic Examinations in relation
to possible CSA RCPCH and FFLM 2007
• The physical signs of child sexual abuse: An evidencebased review and guidance for best practice RCPCH 2008
• GMC 0-18 Guidance for all doctors 2007
• London Child Protection Procedures
2007
Parents
Police
Health
Education
Referral process
Social Care
Strategy Discussion
Comprehensive paediatric assessment
Definite or possible abuse
Immediate Management
Joint Paediatric Forensic Exam
Specialist Exam
Admit to ward if necessary
Legal Action
Ongoing Management-Nominated Consultant
Paediatrician (Hospital/Community)
Medical Care
Social care
Case Conference
Framework for the Assessment of
Children in need and their Families DOH
(2000)
Ideal Assessment- Best Practice
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Holistic
Done once-well planned
ASAP after referral
Parents informed before
“Paediatric friendly”
environment
Combined with ABE
Consent of child &
parent
Parent present
Comprehensive
Standardised proforma
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Forensics considered
S.T.D.s considered
Pregnancy considered
Patient led
Follow-up considered
Doctors appropriately
trained
• Multi-agency
• Joint examination
Consent
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Co-operation, confidence
Child
Parental responsibility
Care Order- Court
Court Order
Gillick competent child<16 years
Maturity, depends on what is involved,
complexity of decision
Consent
• Except in an emergency, where the patient has the
capacity to give consent you should obtain written
consent in cases where providing clinical care is not the
primary purpose of the examination or investigation and
/or where there may be significant consequences for the
parents…social or personal life
GMC:
Seeking patient’s consent: the ethical considerations
1998
Paediatric AssessmentEquipment
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Environment: Child Friendly
Room – private, quiet, warm, safe, well lit, clean
NHS file / original notes
Proforma, body maps
Growth charts
Doctors bag – stethoscope, B.P
E.N.T.set, Developmental assessment kit
Scale, Tape measure
Time
Light + video photo documentation = Colposcope
Telephone
Paediatric AssessmentExaminers
Guidance of Paediatric Forensic Examinations in relation to possible CSA
RCPCH and FFLM 2007
• A single doctor can conduct a paediatric
forensic exam provided he/she has all the
necessary skills (complementary skills)
• The examining doctor must ensure they
are familiar with the evidence-based
guidance regarding the interpretation of
signs
Paediatric AssessmentExaminers
Guidance of Paediatric Forensic Examinations in relation to possible CSA
RCPCH and FFLM 2007
Competence and confidence• Examination
• Forensic Sampling
• Photodocumentation
• Evidence base
• Note keeping
• Reports
• Communication with outside agencies
• Presenting evidence in Court
Documentation
• Notes- contemporaneous, detailed,
accurate, legible, safe, accessible,
scientific, simple, signed
• Body maps
• Drawings
• Pictures- videos: “It is essential that high
quality photos are obtained, if not,
document reasons”
• Reports, correspondence
History of Abuse
• Obtain info from social worker or police
officer:
• What
• Where
• When
• How
• Who
• If
Assault
• Last incident- time
• Assailant details- relationship, numbers,
race, gender
• Abuse-slap / punch/ burn/ tied up/ beaten/
scratched/ gagged
• Weapons
• Threats
• Protection-gloves, condom..
Assault
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Oral/vaginal/anal/ intercourse
Protection- condom
Lubricant used
Other sexual activity
Substances-drugs, alcohol, solvents
Assault
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Since assaultWashed/ bathed/showered
Changed clothes/napkin/sanitary wear
Defaecated/ urinated
Changed- outer clothes/ under clothes
Paediatric AssessmentIntroduction
• PROFORMA
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Introduce yourself
Explain why child is here
Confirm language is understood
Explain what will happen/
Confirm leaflet has been read
Give child chance to ask questions and express
choices and control
• Consent
Paediatric AssessmentHistory
• May be from parent/ carer/ child
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Holistic
Detailed
Carers
Family tree
Home
Education
• CHRONOLOGY
Paediatric AssessmentHistory
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Birth
Growth
Development
Immunisations
Learning
Special needs
Health contacts-Past
-Admissions
• Medication
Paediatric AssessmentHistory
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Behaviour and emotional problems:
Sleep
Mood
Nightmares
Anger/depression
Appetite
Mood
DSH
Continence- wetting/soiling
Paediatric AssessmentHistory of Symptoms
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Pain
Bleeding
Swelling
Bruising
Injuries
Abdominal pain
Admissions
Conditions-past, present
Paediatric AssessmentHistory in postpubertal females:
• Menarche
• LMP
• Sanitary wear- ST/Tampons
History in sexually active:
• Last Sex –date, time, person
• Types of sex
• Protection used
Paediatric AssessmentExamination
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Informed consent
Examiner- gender, expertise
Chaperone
Facilities
Privacy
Photodocumentation
Forensic sampling
STI screen
Pregnancy test
Paediatric AssessmentExamination
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Comprehensive
Top to toe
Growth
Vital signs
Holistic
Detailed
Initial and follow-up
Paediatric AssessmentAno-genital Examination
Indications:
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Child abuse
Neurological problems
Dysfunctional family, looked after child
Very resistant incontinence
Discharge on underwear or clothes
Previous ano-genital surgery
Day-time dribbling of urine
Contact with a known sex offender
Sibling of an index case
General Anaesthetic- for a genital or a foreign body
Male Genitalia
• Penis- foreskin, shaft, glans
• Testes
• Anus
• Pre and post pubertal
Female Genitalia
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Breasts
Axillae
Pubic Hair
Intimate examination
Anus
Pre-and post-pubertal
Paediatric AssessmentForensic Samples
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Chain of evidence
Body
Hair
Nails
Fluids
Clothes and underclothes
Genitalia
Paediatric Assessment-medical
needs
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Injuries
Pregnancy
Infection
Drugs
Analgesia
Advise
Paediatric AssessmentFurther needs
• Tests- radiological, haematological, forensic.
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Notes / Documentation
Reports / Statement
Meetings
Liaison
Follow-up
Paediatric AssessmentFollow-up
• Appropriate medical advice
• Counselling
• Follow-up / re-examination-review/ healing
of injuries
• Photography of injuries
• Specialised forensic tests e.g. odontology
• Specialised medical tests e.g. skeletal
survey, fundoscopy, other.
• Liaison
Paediatric Follow-up
• PSYCHOLOGICAL /
Emotional
• Pregnancy
• Infections including
S.T.Ds,PEP
• Injuries
• Complications
• Immunisations
• Growth
• Further history- medical
records; hospital, G.P.
• CHRONOLOGY
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Development
Educational
Social
TEST RESULTS
• Reassurance /
Questions
Interpretation of Signs
Consistent with the
• History
• Position
• Appearance
• Age/development
• Questions:
• How common is the sign/symptom in normal/non-abused
children?
• Is child abuse a likely cause?
• What is the mechanism of causation?
Summary
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Any case can go to court/ not
Work in a team
Work within competencies and guidance
Review/discuss/ reflect
Learning is lifelong
Duties in Child Protection
• Where professionals are undertaking child
protection work, their first duty is to the
child(ren) concerned.
• As far as parents are concerned,
professionals should act in good faith,
exercising reasonable skill and care.
Questions
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