Pediatric Primary Care Case Studies (51 page)

In addition, consider the possibility of sexual abuse when the child (Child Welfare Information Gateway, 2007):

•   Has difficulty walking or sitting

•   Suddenly refuses to change for gym or to participate in physical activities

•   Reports pain on urination, urethral discharge, or bleeding or genital bruising

•   If female, has atypical vaginal discharge, bleeding, genital bruising, or rashes

•   Demonstrates bizarre, sophisticated, or unusual sexual knowledge or behavior

•   Becomes pregnant or contracts a venereal disease, particularly if under age 14

•   Runs away and/or reports sexual abuse by a parent or another adult caregiver

The healthcare provider must always remember that such behavioral changes are not diagnostic per se of sexual abuse but are often indicative for further thorough investigation by a child abuse expert.

You ask questions that might pertain to Tommy’s issues, and Ms. Jenkins denies any such issues with Tommy.

Ms. Jenkins tells you at the end of the interview, “I love my boy, and now wonder if Roy molested him. That drawing of Tommy’s isn’t like him, and at first I just wanted to ignore the fact that something might have happened. I’ll do anything to protect my kids.” She then starts crying. You reply, “I’m glad that you are willing to put Tommy’s welfare as your first priority.”

What other questions do you need to ask Tommy?

You talk to Tommy in private. He is reluctant at first and you affirm to him that he has done nothing wrong and is not in trouble. You start off by asking about school, sports, and then ask him to tell you about his drawing. You ask him about the boy, and he says, “It’s me.” You ask him to tell you about the boy and the people in his picture. He looks down at the floor and says while pointing at the picture, “That’s my pee pee, where I go pee.” He then identifies Roy, his mother, and sister Lucy. You ask him to tell you about each one of them. He starts with his mother and then his sister; he describes their facial appearance and talks about them in a positive manner. He says nothing about Roy spontaneously, so you ask, “Tommy, who is this person (while pointing to the figure of the adult man).” He says “Roy” and again looks at the floor and avoids eye contact. You start by saying, “He’s a tall man. Tell me about your picture of Roy.” He says, “Roy scares me when he looks at me. I don’t like him. He’s got big hands and does bad things with them.” You reply, “Oh? Tell me about those bad things.” Tommy then continues and says, “Roy came into my bedroom while I was sleeping and pulled down my pjs (pajamas). I woke up, and he was rubbing my pee pee. I didn’t like it at all and told him to stop. Roy said, This is good for you. It’s our secret.’ ” Tommy pauses, so you ask, “What was he rubbing your pee pee with?” Tommy states, “His big hands.” You ask, “And then what happened?” “I told him to stop but he wouldn’t.” You say, “Oh, and then what happened?” Tommy stated, “He pulled down his pants and told me to kiss his pee pee. I said ‘no’ and started crying and wet my bed. Lucy woke up and Roy ran out of our room.” You end this discussion and ask, “Is there something more you think I should know?” Tommy says, “Roy smelled like beer.”

Based on what Tommy said, you have enough data to initiate a report. Tommy will be further examined and interviewed by child protective services and professionals who are expert in the field. Another approach to interviewing children about possible sexual abuse is to talk about “good” and “bad” touches that involve touching the child’s private parts. You would use this approach when talking with Lucy to see if she too was a victim.

Should the primary care provider interview the child about the abuse or let the experts do this?

Children who are sexually abused are often coerced by the abuser to “keep it a secret.” The child must be appropriately questioned without the parent or caregiver present to minimize emotional damage and maximize information retrieval. Although investigative interviews should be conducted by social workers or practitioners specifically trained in child abuse, this should not keep primary care providers from asking relevant questions to obtain a detailed pediatric history and a review of systems. A medical history, past incidents of abuse or suspicious injuries, and menstrual history should be documented (Kellogg & Committee, 2005). Line drawings, dolls, or other aids can be effective tools to help the child to talk about the abuse. It is important for the clinician to avoid leading and suggestive questions or showing strong emotions. Instead maintain a “tell-me-more” or “and-then-what-happened” approach. Document the questions asked and the child’s responses as well as his or her demeanor and emotional responses to questioning. Use quotation marks to document the child’s exact words and/or your questions. For example, Tommy said, “Roy came into my bedroom and pulled down my pajama pants. I [the HCP] replied, “And then what happened, Tommy?”

The general rule of thumb to remember is that children younger than 3 years of age are generally not interviewed (Kellogg, 2005). Tommy is 5 years old and should be interviewed, beginning by asking him to tell you about the people in his drawings.

What data do you want from the physical examination?

Physical Examination

If the routine physical examination of potentially sexually abused children cannot be conducted without additional physical or emotional trauma, the examination should be deferred to professionals from child protective services, who will schedule a detailed forensic examination with a health provider expert in the field of child sexual abuse. If the primary care provider is able to secure the child’s cooperation for a physical examination, he or she should conduct the examination mindful of the child’s developmental needs for sensitivity, particularly when inspecting the genital and rectal areas. Document all physical finding that are
obtained during the regular well or sick child examination. A total body assessment of the skin is important to document. In particular, you are looking for signs of physical abuse such as scarring, burns, or bruising that are suggestive of nonaccidental injury because of their pattern or placement on the body. Features of nonaccidental trauma include any injury that leaves a pattern consistent with an agent of injury (belt or bite marks, rope abrasions, or sock/glove injury pattern with a burn injury) or when the type or degree of injury is inconsistent with the child’s developmental capability.

Likewise, the rectal and genital/urinary system should be inspected as you would do for any child. Be sure to have a good light source. Look for any signs of bruising, tears, scars, discharge, or lesions. As is the case for all genital/ rectal examinations, inform the child of what you are doing. For the female who is not yet a teen, a frog leg position is the easiest for the child to assume. It allows the girl to comfortably spread her legs apart. With your gloved hand, gently spread the labia majora apart and conduct your inspection. A side-lying position with legs bent at the knees is easiest to inspect the rectal area.

If there has been genital contact by the perpetrator, it is important that forensic evidence, including labs and diagnostics, be collected within 24 to 72 hours after the sexual incident, but only by a forensic expert. This forensic exam will be arranged by child protective services (Kellogg & Committee, 2005). Such examiners frequently use a colposcope to magnify the genital and rectal areas, looking for signs of rectal or genital injuries such as tears, lacerations, abrasions, bruising, scars, scratches, atypical laxity of the anus, anal tags, hymenal trauma, or lesions (e.g., herpes or warts). The examiner will collect specimens for sexually transmitted infections, semen, and pubic hairs depending on the history and age of the child.

Tommy allows you to conduct a complete physical examination, including examining his genital and rectal areas. He doesn’t want his mother in the room when this is done. You explain to Tommy that you will need your medical assistant to be there to help you. (This is also done to provide a second person in the room who can verify what occurred during the examination if issues of inappropriate conduct by the provider arise.) Tommy says, “OK, she can be in the room.” You do your physical examination, which is essentially normal. You are careful to note, “No bruising, unusual scars, lesions, rashes, or abrasions on the skin or rectal/genital areas. His genital/rectal examination is normal with no anal laxity noted.”

Lack of physical findings of sexual abuse is common in young children because of the nature of the abuse (nontraumatic fondling), such as occurred with Tommy. Furthermore, delayed disclosure, quick healing times, and the fact that most sexual abuse of young children does not involve penetrating injury are points the HCP needs to remember (Brady & Dunn, 2009). At this point, no diagnostic laboratory testing for sexually transmitted diseases is needed.

Indicators of Potential Child Abuse in Children’s Drawings

When investigating possible abuse in children, art functions as a nonthreatening tool for communication between client and clinician (Stember, 1980). The size and placement of the figure(s) relative to the space available may be indicative of the child’s perception of self-importance. Also, many or few details, parts of the drawing emphasized or deemphasized (e.g., heavier or lighter or darker or fainter lines) can indicate how the child feels about him- or herself. The drawing being more advanced or immature than is appropriate for the child’s developmental age may be indicative of emotional disturbances. Tears and frowns on a child’s face are common indicators of sadness or depression. Smiles may be indicators of happiness, but also may be indicators of repression if inappropriate to the context of the scene. Huge circular mouths are often drawn when oral sex is involved. Similarly, Wohl and Kaufman (1985) suggested that hair is a common representation of masculinity, and that overemphasis on or omission of hair may represent feelings related to sensuality, or sexual anxiety, confusion, or inadequacy. Hands are the most frequently omitted human body part in drawings by persons experiencing significant emotional difficulties. Presumably, omission of hands reflects perceived lack of control.

The assumption underlying the use of art is that, because emotionally disturbed children are believed to reflect their problems in their drawings (Yates, Beutler, & Crago, 1985), the drawings of children who have been abused will differ from those of nonabused children. Free drawings, as well as the House-Tree-Person, Draw-A-Person, and Kinetic Family Drawings are used by psychologists in their assessment of a child who may have been abused. In free expression drawings, the child is asked to make a drawing about whatever he or she wants. The House-Tree-Person Test was originally developed by John Buck as an outgrowth of the Goodenough scale utilized to assess intellectual functioning. The child is asked to draw a house, a tree, and a person the best they can. The child’s figure gives some indication of how the child perceives himself or herself in the world (Burns & Kaufman, 1972). For the Goodenough-Harris Draw-A-Person Test, the child is asked to draw a man, a woman, and themselves on separate pieces of paper. Scoring scales are used to examine and score the child’s drawings (Harris, 1963). The Kinetic Family Drawings, developed in 1970 by Burns and Kaufman, requires the child to draw a picture of his or her entire family including themselves. The drawing is meant to elicit the child’s attitudes toward his or her family and the overall family dynamics (Burns and Kaufman).