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A Role for the Nurse Practitioner
J Pediatr Adolesc Gynecol (2001) 14:101-102
Perspectives on Pediatric and Adolescent Gynecology from the Allied Health Professional Angela Nicoletti, MS, RN, C WHNP Department of Obstetrics and Gynecology, Brigham & Women’s Hospital, Boston, Massachusetts
A Role for the Nurse Practitioner Ms. Ferro is a pediatric nurse practitioner (PNP) in collaborative practice with a pediatrician. In addition to seeing patients for well-child visits and for some sick visits, she routinely sees the prepubertal females for education about body changes and preparation for menarche. This visit also establishes a relationship that will facilitate gynecological care in adolescence. She is seeing one of their patients, Alyssa, for the second time this year. Alyssa is almost 11 years old and has begun developing breast buds, which foreshadow the onset of menarche. At her first visit with Ms. Ferro 6 months ago, Alyssa was a little shy but inquisitive and made good eye contact. She liked school and got good grades. Today’s appointment was made because there have been some disturbing changes in Alyssa’s behavior since that last appointment. She has made several visits to the school nurse’s office with complaints of abdominal pain for which no physical basis has been found. Her mother reports that Alyssa has had problems sleeping and that her school work has deteriorated. Her teachers have noted changes in her behavior also. Normally friendly, she has lately been withdrawn and less participatory in class. Clearly Alyssa is a changed young lady for reasons yet to be determined. It is suspected something has or is happening in Alyssa’s life that is deeply disturbing, though she has denied problems. Over the course of two visits, Ms. Ferro gently draws out information about Alyssa’s school life, her friends, her home life, and family. During the second visit, Ms. Ferro probes a little more into family dynamics. Alyssa is the oldest of three children. Her parents have been divorced for four years. Her father lives in another state and she wishes she could see him more often. Last year her mother remarried. Her stepfather is “OK”, she says in a small voice looking downward. Do you like him?, Ms. Ferro asks. “No”, she says softly and starts to cry. With some gentle probing, a © 2001 North American Society for Pediatric and Adolescent Gynecology Published by Elsevier Science Inc.
disclosure of sexual abuse is elicited. He has been doing “bad things” to her and she is afraid to tell her mother. Not an unusual scenario for childhood sexual abuse. Perpetrators are usually people that children depend on for financial, physical, emotional, or religious support. For a variety of reasons, children are often afraid to tell anyone. They may be afraid for their own safety or the safety of someone close to them. The pre-adolescent and adolescent may be fearful of not being believed. Often they are told that “no one will believe you.” In my practice, it is not unusual for a teen who gives a history of past sexual abuse to say that her mother did not believe her when she disclosed it. The behavioral problems reported in sexually abused children are similar to those reported by other children who have had very stressful experiences. They may include sleep problems, nightmares, enuresis, encopresis, phobias, depression, and withdrawal. In older children, one may see conduct disorders, truancy, substance abuse, early initiation of sexual activity, running away, and suicide attempts. According to the guidelines prepared by the Committee on Child Abuse and Neglect of the American Academy of Pediatrics, a report to the child protection agency may or may not be indicated in the case of suspicious behavioral changes without a disclosure of abuse. However, the child should be closely followed and referred for mental health counselling. Behavioral signs that are more specific for sexual abuse, such as sexually precocious play, perpetration of sexual acts against others, and acting out abusive situations should be reported to the child protection agency even if there is no disclosure of sexual abuse. Medical complaints are often nonspecific. They may include unexplained rectal or genital pain, recurrent urinary tract infections, and vaginitis. Close medical follow-up is indicated in the absence of a disclosure of sexual abuse. Strong indicators of sexual abuse such as unexplained rectal or genital trauma, unexpected pregnancy or the 1083-3188/01/$20.00 PII S1083-3188(01)00083-3
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Nicoletti: A Role for the Nurse Practitioner
presence of a sexually transmitted disease (STD) should be reported to the child protection agency even if there is no disclosure of sexual abuse. When sexual abuse is disclosed in the medical setting, the primary responsibility of the health care provider is to protect the child. In Alyssa’s case, it is not clear what her mother’s response will be or if she will be able to protect her child; therefore, a report was made to the child protection agency before discussing the issue with her mother and before allowing her to leave the office. A medical examination is necessary when sexual abuse is suspected or reported. The child should be interviewed alone. The purpose of the examination is to assess and treat any medical problems resulting from the abuse. It is not to confirm or negate the accusation. It is important to the child’s emotional and physical healing to know there is no permanent damage, that injuries heal, and that the abuse is not their fault. With care and sensitivity to the child’s needs, the medical examination can be done without further traumatizing the child; an adequate examination by a qualified person is essential. An already traumatized child should certainly not be subjected to multiple examinations. Ms. Ferro’s position in the pediatric office is 24 hours a week. For 16 hours per week she works in a pediatric emergency room and has become certified as a sexual abuse nurse examiner (SANE). This certification includes training in appropriate exam techniques and collection of evidence, in precise medical documentation, and court testimony. As a SANE certified nurse, she is well-qualified to perform the medical examination on Alyssa. A paramount concern in the examination for child sexual abuse is to put the child at ease. Ms. Ferro described to Alyssa what the exam would include and that it would not hurt. While Alyssa was still fully clothed, Ms. Ferro had her assume the positions necessary to do the exam—the supine frog-leg position for the vaginal exam and the supine position with her knees pulled to her chest for the exam of the anal area.
Alyssa was able to see the equipment necessary for the exam—the colposcope for magnification and pictures and a miniswab for cultures. A speculum exam is not necessary, especially in a pre-pubertal child. Distractions during the exam are recommended and vary depending on the age of the child. Alyssa chose to use a radio head set, which the PNP often uses to distract teens who are uneasy about their pelvic exams. Alyssa’s anogenital exam was normal as is the usual case in sexually abused girls. Alyssa’s disclosure seemed not to include vaginal penetration but did include anal entry. The elasticity of rectal tissue, however, reduces the possibility of positive finding in most instances of rectal assault. Vaginal and rectal cultures for gonorrhea and chlamydia were negative. Rapid diagnostic tests lack specificity and for this reason are not accepted as legal proof in court. Opinion varies as to the extent of STD testing in the pre-pubertal child because of the low yield and high cost. Alyssa’s mother did believe her and was devastated to learn that her new husband had been abusing her daughter. Alyssa and her mother were referred for family and individual counselling to reduce the emotional sequelae that are often seen in victims of sexual abuse. Loss of trust and self-esteem and confusion about appropriate expressions of affection and intimacy are common. Depression, eating disorders, substance abuse, early initiation of sexual activity, and early childbearing in teens and adults suggests the possibility of a history of sexual abuse and should be explored. Health care providers are mandated by federal law to report any suspected cases of child abuse to the state child protection agency and or to law enforcement officials. Proof of the abuse is not necessary, only reasonable suspicion. The consequences of such trauma often result in unhappy maladjusted adults. The health care system has an obligation to be alert for the signs of possible abuse and to act on those suspicions so that appropriate interventions can be initiated as soon as possible.
Perspectives on Pediatric and Adolescent Gynecology from the Allied Health Professional Angela Nicoletti, MS, RN, C WHNP Department of Obstetrics and Gynecology, Brigham & Women’s Hospital, Boston, Massachusetts
A Role for the Nurse Practitioner Ms. Ferro is a pediatric nurse practitioner (PNP) in collaborative practice with a pediatrician. In addition to seeing patients for well-child visits and for some sick visits, she routinely sees the prepubertal females for education about body changes and preparation for menarche. This visit also establishes a relationship that will facilitate gynecological care in adolescence. She is seeing one of their patients, Alyssa, for the second time this year. Alyssa is almost 11 years old and has begun developing breast buds, which foreshadow the onset of menarche. At her first visit with Ms. Ferro 6 months ago, Alyssa was a little shy but inquisitive and made good eye contact. She liked school and got good grades. Today’s appointment was made because there have been some disturbing changes in Alyssa’s behavior since that last appointment. She has made several visits to the school nurse’s office with complaints of abdominal pain for which no physical basis has been found. Her mother reports that Alyssa has had problems sleeping and that her school work has deteriorated. Her teachers have noted changes in her behavior also. Normally friendly, she has lately been withdrawn and less participatory in class. Clearly Alyssa is a changed young lady for reasons yet to be determined. It is suspected something has or is happening in Alyssa’s life that is deeply disturbing, though she has denied problems. Over the course of two visits, Ms. Ferro gently draws out information about Alyssa’s school life, her friends, her home life, and family. During the second visit, Ms. Ferro probes a little more into family dynamics. Alyssa is the oldest of three children. Her parents have been divorced for four years. Her father lives in another state and she wishes she could see him more often. Last year her mother remarried. Her stepfather is “OK”, she says in a small voice looking downward. Do you like him?, Ms. Ferro asks. “No”, she says softly and starts to cry. With some gentle probing, a © 2001 North American Society for Pediatric and Adolescent Gynecology Published by Elsevier Science Inc.
disclosure of sexual abuse is elicited. He has been doing “bad things” to her and she is afraid to tell her mother. Not an unusual scenario for childhood sexual abuse. Perpetrators are usually people that children depend on for financial, physical, emotional, or religious support. For a variety of reasons, children are often afraid to tell anyone. They may be afraid for their own safety or the safety of someone close to them. The pre-adolescent and adolescent may be fearful of not being believed. Often they are told that “no one will believe you.” In my practice, it is not unusual for a teen who gives a history of past sexual abuse to say that her mother did not believe her when she disclosed it. The behavioral problems reported in sexually abused children are similar to those reported by other children who have had very stressful experiences. They may include sleep problems, nightmares, enuresis, encopresis, phobias, depression, and withdrawal. In older children, one may see conduct disorders, truancy, substance abuse, early initiation of sexual activity, running away, and suicide attempts. According to the guidelines prepared by the Committee on Child Abuse and Neglect of the American Academy of Pediatrics, a report to the child protection agency may or may not be indicated in the case of suspicious behavioral changes without a disclosure of abuse. However, the child should be closely followed and referred for mental health counselling. Behavioral signs that are more specific for sexual abuse, such as sexually precocious play, perpetration of sexual acts against others, and acting out abusive situations should be reported to the child protection agency even if there is no disclosure of sexual abuse. Medical complaints are often nonspecific. They may include unexplained rectal or genital pain, recurrent urinary tract infections, and vaginitis. Close medical follow-up is indicated in the absence of a disclosure of sexual abuse. Strong indicators of sexual abuse such as unexplained rectal or genital trauma, unexpected pregnancy or the 1083-3188/01/$20.00 PII S1083-3188(01)00083-3
102
Nicoletti: A Role for the Nurse Practitioner
presence of a sexually transmitted disease (STD) should be reported to the child protection agency even if there is no disclosure of sexual abuse. When sexual abuse is disclosed in the medical setting, the primary responsibility of the health care provider is to protect the child. In Alyssa’s case, it is not clear what her mother’s response will be or if she will be able to protect her child; therefore, a report was made to the child protection agency before discussing the issue with her mother and before allowing her to leave the office. A medical examination is necessary when sexual abuse is suspected or reported. The child should be interviewed alone. The purpose of the examination is to assess and treat any medical problems resulting from the abuse. It is not to confirm or negate the accusation. It is important to the child’s emotional and physical healing to know there is no permanent damage, that injuries heal, and that the abuse is not their fault. With care and sensitivity to the child’s needs, the medical examination can be done without further traumatizing the child; an adequate examination by a qualified person is essential. An already traumatized child should certainly not be subjected to multiple examinations. Ms. Ferro’s position in the pediatric office is 24 hours a week. For 16 hours per week she works in a pediatric emergency room and has become certified as a sexual abuse nurse examiner (SANE). This certification includes training in appropriate exam techniques and collection of evidence, in precise medical documentation, and court testimony. As a SANE certified nurse, she is well-qualified to perform the medical examination on Alyssa. A paramount concern in the examination for child sexual abuse is to put the child at ease. Ms. Ferro described to Alyssa what the exam would include and that it would not hurt. While Alyssa was still fully clothed, Ms. Ferro had her assume the positions necessary to do the exam—the supine frog-leg position for the vaginal exam and the supine position with her knees pulled to her chest for the exam of the anal area.
Alyssa was able to see the equipment necessary for the exam—the colposcope for magnification and pictures and a miniswab for cultures. A speculum exam is not necessary, especially in a pre-pubertal child. Distractions during the exam are recommended and vary depending on the age of the child. Alyssa chose to use a radio head set, which the PNP often uses to distract teens who are uneasy about their pelvic exams. Alyssa’s anogenital exam was normal as is the usual case in sexually abused girls. Alyssa’s disclosure seemed not to include vaginal penetration but did include anal entry. The elasticity of rectal tissue, however, reduces the possibility of positive finding in most instances of rectal assault. Vaginal and rectal cultures for gonorrhea and chlamydia were negative. Rapid diagnostic tests lack specificity and for this reason are not accepted as legal proof in court. Opinion varies as to the extent of STD testing in the pre-pubertal child because of the low yield and high cost. Alyssa’s mother did believe her and was devastated to learn that her new husband had been abusing her daughter. Alyssa and her mother were referred for family and individual counselling to reduce the emotional sequelae that are often seen in victims of sexual abuse. Loss of trust and self-esteem and confusion about appropriate expressions of affection and intimacy are common. Depression, eating disorders, substance abuse, early initiation of sexual activity, and early childbearing in teens and adults suggests the possibility of a history of sexual abuse and should be explored. Health care providers are mandated by federal law to report any suspected cases of child abuse to the state child protection agency and or to law enforcement officials. Proof of the abuse is not necessary, only reasonable suspicion. The consequences of such trauma often result in unhappy maladjusted adults. The health care system has an obligation to be alert for the signs of possible abuse and to act on those suspicions so that appropriate interventions can be initiated as soon as possible.