Reduction of distress in children undergoing sexual abuse medical examination

doi:10.1016/S0022-3476(98)70241-0

The Journal of Pediatrics

Volume 133, Issue 2, August 1998, Pages 296-299

https://doi.org/10.1016/S0022-3476(98)70241-0 Get rights and content

Abstract

A participant modeling film to reduce distress in children (5 to 13 years old) undergoing sexual abuse medical examination was tested. Twenty-one children viewing the participant modeling film reported less fear after film viewing and were behaviorally less distressed and more compliant, as rated by nurses and mothers, during gynecological examination than 21 children viewing a nonrelevant film. (J Pediatr 1998;133:296-9)

Section snippets

Methods

Institutional Review Board approval for this project was obtained from the State University of New York at Syracuse. Study participants were 42 children between 5 and 13 years of age who were scheduled for a genital examination because of suspected sexual abuse. Two additional subjects declined to participate, citing custody litigation issues.

At the clinic, informed consent was obtained from children and their parents or guardians. The children were randomly assigned to PMF (n = 21) or

Results

Descriptive statistics are presented in the Table.

Table. Descriptive statistics for dependent measures

Empty Cell	PMF			NRF
Empty Cell	Mean (SD)	Range	Possible range	Mean (SD)	Range	Possible range
HFRS before film	43.1 (13.2)	20-68	16-80	46.7 (10.8)	29-67	16-80
HFRS after film^*	37.4 (13.4)	16-66	16-80	48.1 (12.7)	23-71	16-80
HFRS after exam	36.1 (13.7)	16-66	16-80	43.8 (14.6)	24-45	16-80
HR before film	91.9 (12.8)	72-122	72-122	86.3 (15.1)	66-130	66-130
HR after film	85.8 (14.2)	51-120	51-120	85.3 (18.1)	56-138	56-138
HR after exam	88.8 (14.0)	64-122	64-122	86.0

Discussion

Children who viewed the PMF reported less fear after viewing and immediately before examination and exhibited significantly fewer distress behaviors during examination than children who viewed the NRF, even though all children received standard preparation. The fact that children in the PMF group were less distressed and more generally compliant during the examination is crucial. If children had reported decreased fearfulness but did not display less overt behavioral distress, the clinical

Acknowledgements

We thank the staff of the clinic who participated in this project: Ann Botash, MD, JoAnn Manual, MSW, Nancy Mitchell, RN, and Maureen O’Hara, RN.

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Cited by (15)

An Integrative Review of Literature Examining Psychometric Properties of Instruments Measuring Anxiety or Fear in Hospitalized Children
2012, Pain Management Nursing
Citation Excerpt :
Higher scores indicate higher levels of anxiety. The HFRS has been used in several studies with hospitalized children undergoing elective surgery (Lynch & Faust, 1998; Melamed & Siegel, 1975; Melamed, Meyer, Gee, & Soule, 1976; Melamed, Dearborn, & Hermecz, 1983; Peterson & Shigetomi, 1981; Pinto & Hollandsworth, 1989; Zabin & Melamed, 1980). Other studies have used this scale to compare the level of fear between children with chronic life-threatening illness and those with chronic nonlife-threatening conditions (Dolgin et al., 1990) and to measure children’s fear of a medical examination for sexual abuse (Lynch & Faust, 1998).
Anxiety and fear are among the most frequently reported emotional responses to hospitalization and are known to be contributing factors to pain and other negative patient outcomes. The first step in confronting unnecessary anxiety and fear is to identify valid and clinically feasible assessment instruments. The purpose of this paper is to review and evaluate instruments that measure children’s fear or anxiety associated with hospitalization or painful procedures. A search was conducted of published English-language literature from 1980 through 2010 with the use of Ovid Health and Psychosocial Instruments, Medline, Nursing/Academic Edition, Cinahl, and Google Scholar. Inclusion criteria specified that the self-report instrument: 1) was developed in English; 2) was developed for and/or widely used with hospitalized children or children undergoing medical procedures or treatment; and 3) had research evidence of psychometric properties from at least five different studies. A comprehensive review of the literature revealed only five fear or anxiety instruments with adequate testing for evaluation of reliability and validity. Although all instruments have beginning psychometric adequacy, no one tool stands out as superior to the others. Therefore, we recommend that researchers and clinicians exercise caution in choosing assessment instruments, balancing potential strengths with reported limitations. Using more than one tool (triangulating) may be one way to achieve more credible results. Knowledge of credible existing instruments alerts us to what is possible today and to the imperative for research that will improve communication with children tomorrow.
Multi-informant assessment of anxiety regarding ano-genital examinations for suspected child sexual abuse (CSA)
2010, Child Abuse and Neglect
Citation Excerpt :
In addition, some children exhibit anger, fear, oppositional behavior, and/or anxiety symptoms directly related to the medical examination (Berson, Herman-Giddens, & Frothingham, 1993); however, these responses may be due to previous, negative medical experiences rather than due to the emotional trauma of CSA (Lazebnik, Zimet, Ebert, Anglin, & Bunch, 1994). Last, even if children's anxiety can be reduced by a thoughtful approach to the examination, parental anxiety may persist (Lynch & Faust, 1998; Steward, Schmitz, Steward, Joye, & Reinhart, 1995) despite efforts to inform them of the examination process. In summary, children respond differently to the medical evaluation for CSA, and it remains unclear the extent to which anxiety is present during CSA examinations for children and adolescents.
Given the commonly held belief that physical examinations for child sexual abuse (CSA) are very distressing, our primary objective was to evaluate anxiety during these assessments using the Multidimensional Anxiety Score for Children (MASC-10). A second objective was to compare self-reported anxiety to parental report using the MASC-10 and to medical provider's rating of emotional distress using the Genital Examination Distress Scale (GEDS).
Child/parent dyads completed the MASC-10 prior to the evaluation and were retested at the completion of the medical exam. GEDS assessment occurred during the medical exam.
One hundred seventy-five subject dyads were enrolled and were predominantly female (77%), Caucasian (66%), accompanied by mother (90%), and receiving Medicaid (57%). A significant subgroup of children reported clinically significant levels of anxiety at the pre-examination assessment (17.1%) and post-examination assessment (15.4%). However, most subjects reported low anxiety at both pre- and post-examination assessments. Both child and parent report demonstrated less anxiety, on average, post-examination compared to pre-examination scores. Reduced anxiety was measured with a mean pre-T-score = 55.8 versus mean post-T-score = 53.1 (p < .001). Correlation coefficients for pre-T-scores and post-T-scores of child/parent dyad were 0.3257 (p < .0001) and 0.3403 (p < .0001). A small correlation was noted between child reported anxiety and medical provider observation using the GEDS for pre-exam (0.1904, p = .01), and post-exam (0.2090, p = .02).
Our research indicates that the majority of children are not severely anxious during medical evaluations for CSA. In addition, the MASC-10 shows promise as an instrument to assess anxiety from the ano-genital examination in CSA because it could be quickly completed by most patients and their parents, indicated a wide range of anxiety levels, and demonstrated some sensitivity to change. While parent report may identify some child anxiety, parent and provider report should not be substitutes for the self-report of children's anxiety during this medical evaluation.
A practical, quick, validated measure of anxiety can be used in the setting of CSA evaluations to identify anxiety in this population.
Comparison of examination methods used in the evaluation of prepubertal and pubertal female genitalia: A descriptive study
2008, Child Abuse and Neglect
Citation Excerpt :
One piece of missing data is the determination of the acceptance rate by the patients when this multimethod approach is employed (Overstolz & Baker-Gibbs, 2002). A number of studies have shown that the majority of females tolerate evaluations for possible sexual abuse with little or no negative psychological effect (De San Lazaro, 1995; Dubowitz, 1998; Gully, Britton, Hansen, Goodwell, & Nope 1999; Lazebnik Zimet, & Ebert 1994; Lynch & Faust, 1998; Palusci & Cyrus, 2001; Preskill & Preskill, 1984; Steward, Schmitz, Steward, & Joye 1995). Unfortunately, none of these studies have compared the patient's or the examiner's reaction when the prone, knee–chest position method was used.
To compare the effectiveness of three different examination methods in their ability to help the examiner detect both acute and non-acute genital injuries in prepubertal and pubertal girls suspected of having been sexually abused.
Forty-six prepubertal and 74 pubertal girls, whose ages ranged from 4 months to 18 years, were evaluated to determine the relative effectiveness of three different examination methods.
All the girls had sustained a recent genital injury from various causes. The mean time between an injury and the first examination was 24 h for the prepubertal girls and 27 h for the pubertal girls. The three “multimethod” examination approaches used were the supine labial separation method; the supine labial traction technique; and the prone knee–chest position. The supine labial separation method was useful in identifying an injury on the external portion of the genitalia in both groups of girls. Injuries within the vestibule, on the hymenal surface, or in the fossa navicularis required greater separation of the labia. This was accomplished through the use of either the supine labial traction technique or the prone knee–chest position. The prone knee–chest position was the most successful method for identifying hymenal lacerations in both groups of girls. Of the 10 hymenal lacerations detected in the prepubertal girls 20% were identified during the use of the supine labial separation method, 60% with the supine labial traction technique, and 100% with the prone knee–chest position approach. Of the 49 hymenal lacerations detected in the pubertal girls 24% were identified with the supine labial separation method, 65% with the supine labial traction technique, and 90% with the prone knee–chest position approach. The data from this study has shown that the results of a medical examination will vary by the method employed.
While no single technique detected all the injuries, the use of the multimethod examination approach did prove to be a valuable adjunct in the evaluation of both the prepubertal and the pubertal girl's genitalia, particularly in the identification of a hymenal laceration.
This approach uses three different examination methods: the supine labial separation method, the supine labial traction technique, and the prone knee–chest position. According to the results of this study, without the combined use of these three methods a significant number of injuries, particularly hymenal lacerations, could be missed in both the child and the adolescent.
Non-abused preschool children's perception of an anogenital examination
2007, Child Abuse and Neglect
Citation Excerpt :
About one third wrote positive comments on their questionnaire form, and these responses were valuable concerning what parents (and children) feel is important: the total environment designed to be familiar and comfortable for children. Reports from other studies support these findings: even sexually abused children do not find an AGE traumatic if the examination is conducted in a supportive atmosphere (Britton, 1998; De San Lazaro, 1995; Dubowitz, 1998; Gully et al., 1999; Lawson, 1990; Lazebnik et al., 1994; Lynch & Faust, 1998; Palusci & Cyrus, 2001; Saywitz et al., 1991; Steward et al., 1995; Waibel-Duncan, 2004; Waibel-Duncan & Sanger, 1999). Many parents appreciated how the AGE was made a natural part of the total examination, which is supported by other authors (Botash, 1997; Lentsch & Johnson, 2000).
An anogenital examination is usually part of the standard medical assessment in children evaluated for suspected sexual abuse, and the emotional impact on the child has been studied. The primary aim of this study was to assess non-abused preschool children's responses to an anogenital examination.
One hundred and fifty-eight children (119 girls), aged 5–6 years old, were recruited by self-selection from a town community in Norway. After a full medical “top-to-toe” examination, including an anogenital examination with use of a colposcope, the children were asked for their reactions to different parts of the examination. The instrument used was a Faces Rating Scale with five faces, ranging from smiling to crying. Parents and nurses also completed questionnaires regarding their perceptions of the children's reactions.
The results from the self-report scales showed that only 7.7% of the children rated the anogenital examination as somewhat negative, but the children rated the anogenital part of the examination as significantly more distressing than the examination of their ears and mouth. Microbiological swabbing from the anogenital area was most frequently mentioned as something the children disliked. Complementary data from the parents supported the children's responses regarding the anogenital part, but also emphasized the importance of good preparation and a “child-friendly” atmosphere when performing the examination.
Most preschool children, who have no history of sexual abuse do not find an anogenital examination traumatic if the examination is well planned and performed by experienced professionals in a supportive atmosphere.
Reaction to videocolposcopy in the assessment of child sexual abuse
2001, Child Abuse and Neglect
Objective: The purpose of this study was to clinically assess children’s reactions to videocolposcopy with real-time observation of magnified anogenital images (VCO), and to evaluate whether these reactions are affected by patient or other characteristics such as response to preparation, disclosure of child sexual abuse (CSA), or examination findings.
Method: Consecutive cases of children ages less than 18 years referred to a children’s hospital clinic for nonemergent evaluation of suspected CSA during 1997 through 1999 were studied. We noted the child’s response with clinical observation before and after videocolposcopy, and used the Genital Examination Distress Scale (GEDS) after evaluation. We compared these responses to patient gender, age, ethnicity, pubertal status, disclosure of child sexual abuse (CSA), and physical examination findings using univariate and regression analyses.
Results: Two hundred twenty-seven children (mean age 7.2 years, range 0–17) underwent videocolposcopy, of whom 55.1% disclosed sexual abuse and 17.2% had a positive examination. More than 80% were female, prepubertal, and non-Hispanic White. Most (85%) watched their examination on the monitor and were either cooperative or enthusiastic before and after videocolposcopy. Fewer very young children (ages 0–3 years) or female adolescents (13–17 years) watched the monitor. Summed GEDS scores were strongly correlated with observed responses after the procedure (p = .01), and children with CSA disclosure were three times more likely to watch the monitor and five times more likely than those without disclosure to have improved comfort. Other patient characteristics were not significantly associated with patient reaction to VCO.
Conclusions: Most children are interested in watching their anogenital examination using magnified real-time images obtained during videocolposcopy and tolerate the procedure well. The GEDS is highly correlated with subjective clinical observation. While some children may particularly benefit from participating in their examination by using VCO, long-term effects of the evaluation and any relationship of a child’s reaction to videocolposcopy with their history of sexual victimization remain to be established.
Objectif: Evaluer cliniquement les réactions des enfants à la videocolposcopie avec observation en temps réel des images anogénitales agrandies (VCO) et évaluer si ces réactions sont en relation avec d’autres éléments concernant le patient: réponse à la préparation, révélation de l’agression sexuelle (CSA) ou résultats de l’éxamen.
Méthode: On a étudié des séries de cas d’enfants de moins de 18 ans référés en consultation à un hopital pour une évaluation sans suite de suspicion de sévices sexuels. Nous avons noté la réaction de l’enfant avec l’observation clinique avant et après la videocolposcopie et nous avons utilisé la “Genital Examination Distress Scale (GEDS) après l’évaluation. Nous avons comparé ces réponses selon le sexe du patient, son âge, son appartenance ethnique, le stade de la puberté, la révélation de l’agression sexuelle (CSA) ainsi que les résultats de l’examen physique en utilisant l’analyze à une variable et par régression.
Résultats: 227 enfants (moyenne d’âge: 7.2 ans, intervalle: 0–17) ont subi une videocolposcopie, parmi lesquels 55.1% ont révélé une agression sexuelle et 17.2% ont présenté un examen positif. Plus de 80% étaient de sexe féminin, prépubères, et Blancs nonhispaniques. La plupart (85%) ont regardé leur examen sur le moniteur et se montrèrent coopérants ou enthousiastes avant ou après la videocolposcopie. Il y eut moins de très jeunes enfants (0–3 ans) ou d’adolescentes (13–17 ans) qui ont regardé le moniteur. Les scores cumulés étaient fortement corrélés avec les réponses observées après la procédure (p = 0.01) et les enfants avec dévoilement CSA étaient trois fois plus susceptibles de regarder le moniteur et cinq fois plus que ceux sans révélation à avoir éprouvé du soulagement. Les autres caractéristiques des patients n’étaient pas significativement associées avec la réaction du patient au VCO.
Conclusions: La plupart des enfants manifestent de l’intérêt à regarder leur examen ano-génital par videocolposcopie avec images agrandies et tolèrent bien la procédure. La GDES est en forte corrélation avec l’observation clinique subjective. Alors que certains enfants peuvent particulièrement tirer des bénéfices de leur participation à leur examen utilisant le VCO, il n’en reste pas moins à établir les effets à long terme de l’évaluation et toute relation entre la réaction de l’enfant à la videocolposcopie et son histoire en tant que victime.
Objetivo: Evaluar clı́nicamente las reacciones de los niños al videocolposcopio con observación en tiempo real de imágenes anogenitales y evaluar si estas reacciones están afectadas por las caracterı́sticas del paciente o por las respuestas a la preparación, la revelación del abuso sexual o los hallazgos del examen.
Método: Se trabajó con una serie de casos consecutivos de sujetos de menos de 18 años derivados al hospital clı́nico infantil para una evaluación no urgente de sospecha de abuso sexual infantil durante el periodo comprendido entre 1997 y 1999. Se registró la respuesta del niño a través de la observación clı́nica realizada antes y después del viedocolposcopio y se aplicó la Escala de Malestar por Examen Genital después de la evaluación. Se compararon estas respuestas en función del género, edad, raza, fase de la pubertad, revelación del abuso sexual infantil y hallazgos del examen fı́sico utilizando análisis univariados y de regresión.
Resultados: Un total de 227 niños con una media de edad de 7.2 años (rango 0–17) fueron evaluados con el videocolposcopio, de los cuales el 55.1% revelaron haber sido sexualmente abusados y el 17.2% tuvieron una evaluación positiva. Más del 80% fueron mujeres, prepúberes y de raza blanca no hispana. La mayorı́a (85%) vieron su examen en el monitor y fueron cooperativos y entusiastas antes y después del videocolposcopio. Pocos niños muy jóvenes (entre 0 y 3 años) o chicas adolescentes (entre 13 y 17 años) observaron el monitor. Las puntuaciones en la Escala de Malestar por Examen Genital estaban fuertemente correlacionadas con las respuestas observadas después del procedimiento. Los niños que habı́an revelado su abuso sexual observaban el monitor tres veces más que los que no lo habı́an revelado y mejoraron en su estado de bienestar cinco veces más. Otras caracterı́sticas del paciente no estuvieron significativamente asociadas con la reacción del paciente al videocolposcopio.
Conclusiones: La mayorı́a de los niños/as muestran interés por observar su examen anogenital utilizando imágenes ampliadas en tiempo real obtenidas durante el videocolposcopio y toleran bien el procedimiento. Las puntuaciones en la Escala de Malestar por Examen Genital están altamente correlacionadas con las observaciones clı́nicas subjetivas. A pesar de que parece que algunos niños/as pueden beneficiarse de manera especial en participar en su examen, quedan por establecer los efectos a largo plazo de la evaluación y cualquier relación de la reacción del niño al videocolposcopio con su historia de victimización sexual.
Disorders of sex development: Pediatric psychology and the genital exam
2017, Journal of Pediatric Psychology

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^☆: From the Center for Psychological Studies, Nova Southeastern University, Ft Lauderdale, Florida.

^☆☆: Supported in part by funding awarded to Dr Lynch from the State University of New York Health Science Center Foundation for the Children’s Miracle Network.

^★: Reprint requests: Jan Faust, PhD, Center for Psychological Studies, Nova Southeastern University, 3301 College Ave, Ft Lauderdale, FL 33314.

^★★: 0022-3476/98/$5.00 + 0 9/22/91961

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Reduction of distress in children undergoing sexual abuse medical examination☆,☆☆,★,★★

Abstract

Section snippets

Methods

Results

Discussion

Acknowledgements

Child Abuse Negl

Behav Ther

Preparing sexually abused girls for genital evaluation

Issues Compr Pediatr Nurs

Cognitive-behavioral and pharmacologic interventions for children’s distress during painful medical procedures

J Consult Clin Psychol

Effects of participant modeling on information acquisition and skill utilization

J Consult Clin Psychol

Same day surgery preparation: reduction of pediatric patient arousal and distress through participant modeling

J Consult Clin Psychol