The history gathered in examinations of children who've experienced sexual abuse remains the most crucial part of the exam. For this reason, we wanted to provide students with examples of history-taking techniques. Some of the examples are opportunities to identify ways to improve your own history-taking skills, others to identify issues to consider related to developmentally appropriate communication with kids. The examples we use here do not indicate the only way to obtain histories from children, but rather some examples. Examinations may differ from program to program and community to community. You may note, for instance, that Kim asks a parent about the military. That may seem out of context, but it isn't for her community. What is not seen here is formal forensic interviewing. Forensic interviewing requires additional, very specific training, and is generally outside the role of the sexual assault nurse examiner. Hi, I'm Kim Nash, and I'm a forensic nurse. Today we're going to be recording a video for you about child history-taking. We have several forensic nurses who are trained forensic nurses and do conduct child exams on a regular basis. We're going to be talking to some of our children. The nurses didn't talk to their own kids. This is my friend Dylan. I didn't know her before tonight, and she's one of the kids that I talked to. I want you to know that these interactions were unscripted. Kids were not given the questions beforehand, and the nurses went in with just a very rough outline, so they really tried to naturally show you how they would speak to kids in a clinic setting. I want you to note the rapport building that you see. I want you to think about things that you really like and the things that you think would work for you, as well as the things that you think you might do different. This is also important to know. We're not teaching forensic interviews. I want you to really understand that, rather, we're showing healthcare providers who are obtaining a history from a child patient for the purposes of determining a plan of care, as well as diagnosis and treatment. So hopefully the following video clips will be helpful for you in your journey to learning how to do these exams. When child sexual abuse is being considered, the examiner should complete a detailed history with the presenting caregiver or adult who's bringing the child in. Unless the child is nonverbal, the history given by the caregiver should be gathered separately from the child. This also allows opportunity to explain the exam and what the findings will or will not show, dispelling any myths the caregiver may have about what conclusions can be reached following the exam. The history obtained from the caregiver should always include the medical and surgical history of the child, any and all medication the child takes, their immunization status, any over-the-counter medication the child takes, any allergies the child has, and issues the child has or may have had with their urinary tract, diarrhea, or constipation, as well as what, if any, treatment for those issues the child may have received. Alright, Yolanda, I know that we met briefly in the other room, but I just wanted to talk to you alone, away from your daughter Isabel, so that we could talk freely and not influence her with anything that we're saying. So I'm really glad that you brought her in today, I know this is a really stressful time. So I want to introduce myself again, my name's Kim, I'm a forensic nurse here at the hospital. All that means is that I'm a registered nurse, just like the other nurses here at the hospital, but I have some additional education and training that allows me to take care of patients that we either know or we suspect have been hurt by someone else. So that could be sexual assault, domestic violence, child abuse, elder abuse, human trafficking, those types of issues. So my job really is to address the medical side of things. I work closely with community partners like law enforcement, the prosecutor's office, the attorney's office, and advocacy, but today my sole focus is on your family's needs and your daughter's health. I am employed by the hospital, not law enforcement, and I just want you to know that that's going to be my sole focus today. So that's my role, I'm going to be doing an exam with your daughter, as long as it's okay with you and it's okay with her, where we're going to talk first, I'm going to ask her a lot of questions, and then I'm going to do a medical assessment. What I mean by that is I'm going to do a head-to-toe exam, no different than at the pediatrician's office where I'm looking in her ears, listening to her heart, pressing on her tummy, but I will do a more detailed genital and anal exam depending on the history that you give me about what brought you here today, and if she's able to give me any history. Remind me, she's eight, is that right? So an eight-year-old, she may feel comfortable to tell me something, but developmentally talking about sex and these issues is difficult for an eight-year-old because they're starting to understand those concepts, but they don't truly understand them like you or I do. So sometimes eight-year-olds will be very open with me, other times it's very difficult getting them to talk about things. So we'll see, but I will be looking at her genital area and I will be looking at her anal area. What parents are very concerned about when they bring little girls in is anything going to be going into her genitals, and because she has not started having periods yet and she's not become an adolescent yet, we will not be doing an exam like you or I would get as adult females, so we won't be doing a speculum exam. I will be using some different positions to put her in to look at all of her genital and anal area, but I won't be putting anything inside of her. Okay? I just wanted to give that information to you up front. The other thing is that I would like to utilize photography, so pictures, with her exam today, meaning if I find any body surface injury, bruises, cuts, scrapes, or abrasions during her head to toe, we like to take a picture of that with our digital camera, with your consent and with her consent. That does become a part of her medical record. I only take those body surface photos if I find injury. However, during the genital and the anal exam, we do like to take photos of those exams, those body parts, whether there's injury there or not, and those pictures do become a part of her medical record, and they're very helpful for a variety of reasons. They can help us if I do find injury, it can help us if we have to bring her back and do follow-up exams, it can help us if we find disease, if we need to bring her back and see the progression of that disease healing, but most cases there isn't disease in an 8-year-old and there isn't injury. Even when we know that something sexual has happened and a penetration has occurred, most often there isn't injury. However, it can be helpful to have those photographs in the file for medical reasons. It may be useful in an investigation and prosecution, and it may not be. The other thing that we do use photographs for sometimes is teaching, so when we're teaching new nurses who are coming into this role or new physicians who are coming into this role, those photographs may be used for educational purposes. With all of that being said, if those photos become a part of her medical record and that medical record is subpoenaed for use in an investigation or a prosecution, which we never know if that's going to happen, but if that happens, those photographs are a part of what goes with that medical record. So some parents find photography very beneficial and they sign a consent for it, others are not comfortable with it, and whatever you decide for your daughter and her exam, I will support. Okay. We'll go over the consents later on, I just wanted to bring that up so you have a little bit of time to think about it. The other thing I like to tell parents up front is that oftentimes they bring particularly young girls in and they think that our exam is going to be able to tell them a penetration occurred, and my exam is not going to be able to tell us that. A lot of parents come in thinking about this myth that something's popped, like popping the cherry with first penetration, have you heard that term before? I only use it because a lot of parents do. There is a structure around the vaginal opening on all females called the hymen, and it's a piece of tissue, and before a young girl hits puberty, it's very thin and translucent and vascular looking, can be very sticky and sometimes it looks like it's covering the vaginal opening, but there is an opening there. What I'll tell parents oftentimes is, let's say your daughter hit puberty and started having periods and she was a virgin, she'd never had sex before, if there was a membrane covering that vaginal opening, there'd be no way for the blood to get out. So there is an opening. What changes when you hit puberty is a female's body starts producing estrogen, and that estrogen changes the appearance of that structure called the hymen, and it changes from looking very thin and translucent to looking more fluffy and pink, almost like something's popped it and it's opened up and it looks more like a hair scrunchie around the vaginal opening. Nothing's popped it, nothing's punctured it, it's just the effects of estrogen. So I'd wish that I could do a simple exam and tell you if penetration has occurred, but the reality is I can't tell you that, my exam can't show that, but it can tell us is there injury and is there disease, and even more important than either one of those things, because she's eight, no matter what happened, it's going to be really important that she hears the message from me that there's nothing wrong with her body and that nobody will ever be able to look at her genitals and tell that this happened to her. So hearing that from a medical professional is very therapeutic, even for a child. So we want to make sure she hears that message from me, which she absolutely will. So talk to me a little bit about her medical history, is she a pretty healthy young lady? Yes, she's never had any issues. Any surgeries? No. Any broken bones? She had a broken arm when she was like five, she was playing on the trampoline. Trampoline, those are trampolines. Do you have a pediatrician? We do. Who's that? Dr. Johnson. Is she up to date on her immunizations? She is. Okay, good. And then I get a little bit of a social history from you, so where does she live? Does she live in a house? A house. Who lives in the house? Me, her dad, our dog, and herself. And her, okay. And is the home, and this is a question that I ask every parent that I come in contact with, not just you, it's part of our screening process, is there any violence in your home? By that I mean is there any physical violence between you and your husband? No. Okay, no physical violence. What about sexual violence? Does he ever force you to have sex when you don't want to? No. Okay, no sexual violence. And any verbal abuse, where he uses words to hurt your feelings? No. Okay. And any financial violence, where he holds money for groceries or clothes or healthcare? No. Okay, alright, good. I'm glad. And then, any drugs or alcohol problems in the home? No. Okay. And are you employed? I am. And what do you do for a living? I do billing. Okay. And is dad employed? Yeah. And what does he do? He does haircuts. Haircuts, alright, great. And any military, and are you or have you been involved in the military? Yeah. Same thing with your husband. So no military history. Alright, perfect. And do you have any friends or family in the area? Yeah, most of our family lives here. We have, like, my mom. Okay. So when going through a really difficult situation like this, I like to just make sure that you feel that you have social support, like family or friends who are going to back you up and be there for you. Yeah. Okay, good. I'm glad. Alright, so now I'm going to ask you just a little bit about the event that brings you here today. I know you told me a little bit about it in the other room, that you were concerned something had happened, but you weren't exactly sure. What made you concerned that something sexual might have happened to your daughter? And what were kind of the red flags that made you think, I need to bring her to the hospital to be seen? Well, last night when we were having dinner, she had mentioned to me about her uncle, which would be my brother. Okay. And she had just said that she had something to tell me, but she just wasn't 100% comfortable. Okay. So I kind of tried to figure out a little bit, but she wasn't really telling me. I asked if it was something to do with private parts, or him touching, or something like that, and she just kind of broke down and started crying, and I didn't know what else to do. So when I spoke to my family, their advice was to bring her in. Okay. Alright, good. I think you did a great job. I'm really glad you're here today, and I think that we can get you on the path to getting you some help and figuring out what's going on. Have you talked to law enforcement yet? Not yet. Okay. So I'm usually very upfront with my families. I'm not going to do anything without you knowing about it. Here in Colorado, we have a law. If we have a suspicion as healthcare providers, we don't need to know for certain, but if we have a suspicion that something might have happened to a child, we have an obligation to report. So I will be reporting this to law enforcement and to the Department of Human Services. I would like to do it here today so that I can kind of help you with that process. Okay. Typically what happens is law enforcement will send a patrol officer out and ask you some questions and write up a preliminary report, and then that gets sent on to detectives who are a little bit more educated and knowledgeable in this area about investigation. What may or may not happen, it's out of my hands, but what I typically do see happen is because of her age, they may schedule what's called a forensic interview. And that's where law enforcement will ask questions about what happened to her. It's typically done in a small room very similar to this, where it's videotaped, and she understands that it's being videotaped. And they ask her questions and try it. That will help with their investigation. So because of that, it's going to be important that I just ask very broad questions. I'm not going to ask specific questions of her today. We'll just see if she tells me something. If she doesn't, that's fine. I can still do my exam without her having told me anything. If she can give me some details, it absolutely helps me with my medical exam, but it's not a necessary part for me to proceed with the exam. Because of the possibility of a forensic interview, when you go home with her tonight, if you can tell your husband this as well and any other family members who know what's going on, it's important that you not let this uncle know what's going on in case law enforcement wants to have a different kind of angle with their investigation. But most important is going to be that you don't ask her questions. However, if she does come to you and tells you something, it'll be really important just to write down what she says, have kind of a poker face where you don't get upset or shocked, and just listen and make sure that you give her the messages that it's not her fault and you believe her. So that'll be kind of the most important thing right now. So now that I've talked to you and gotten a little bit more background, I am going to bring Isabel back to the exam room, and I'm going to talk to her alone. I'm going to ask her some questions. I start out with just how old she is and where she goes to school, who's in the house, and then I ask her to tell me kind of what she shared with you. So I'm going to talk to her, then I do my head-to-toe exam. If she wants you in during the exam, I'll bring you in. If she doesn't, then I'll just proceed and have the two of us. I will be trying to collect some evidence and some swabs, and I'll walk her through that. Nothing that I'm going to do is going to hurt her. And if she says, no, I don't want you to do that, then I don't do it. If she says that she doesn't want you in the room initially and then changes her mind, I will absolutely stop the exam and bring you in. Is there anything I didn't ask you that you think I should know? No, I think you pretty much covered everything. Okay, and I just threw a lot of information at you very quickly. Do you have any questions for me? No, I think, I mean, you answered most of it, just do you know how long the process takes? Yeah, I try to go depending on what the child, you know, pace they need to go at, which usually kids move through pretty quickly. Okay, so I anticipate being back here about 45 minutes with her. However, don't get panicked if it takes a little bit longer. Sometimes kids want to take a potty break or they want to stop and turn the TV on, or, you know, they might need some distraction where we play a game or something just to make them comfortable. Sometimes even I'll take kids for a walk in our hospital to go look at the fish if they're getting uncomfortable, something like that. So if it takes a little bit longer, don't get panicked. We'll come get you as soon as we're done. Okay. All right, thank you. Because all children are different in the way they progress from stage to stage, it's important to recognize that gathering a history from children is a very fluid thing. It's not black and white, and it cannot be made black and white. What we can do is suggest some generalizations that often apply when it comes to gathering histories from children. These are suggestions that may help you in your history taking, but be open because children are unique and frequently change the playing field for us. Generally speaking, taking a specific history from children under 4 years old is not recommended in these cases. If spontaneous information is disclosed by the child during the exam and the child is verbal enough to allow the examiner to ask follow-up questions, great. But specific targeted information regarding sexual abuse should not be asked of very young children due to their cognitive and verbal skills level. Some of you may be thinking, well, I know very verbal 3-year-olds, and yes, that's true. But again, these are generalizations, not hard and fast rules. When the examiner is getting a history from the child, whenever possible, it's helpful to have just the child in with the examiner. There are many times when the child may be hesitant to say something in front of a parent or caregiver for fear of their reaction, or the child discloses something that the parent wasn't prepared for, and the parent begins crying, which shuts the child down. Allowing for an independent history taking decreases the likelihood of these types of situations. It's appropriate and beneficial to explain this to the caregiver, along with the fact that the child will not be examined without either a parent, caregiver, or chaperone in the room. Oftentimes, this is the anxiety the parent has, the examination, not the history taking. Of course, there are times when the parent refuses to allow the history taking without them present, and we discussed how to handle these situations in the class, so I would refer you back to that for more information. And examiners want to avoid the use of leading questions whenever possible and take a more open approach to their history gathering. Use the child's language, not your own. Find out what the child calls their body parts, so when you're talking, you understand them, and they understand you. Again, more examples of appropriate language were given in the class. It's very important that examiners be familiar with appropriate developmental milestones in children of different stages, as well as typical levels of communication. Children are not young adults, and it cannot be assumed that they understand the language we typically use to communicate when we're speaking with adults. Additionally, the examiner needs to spend a few minutes building some rapport with the child. Typically, this is done by getting to know the child in the initial stages of history taking, by asking questions about the child's life. This can include whatever the examiner and child are comfortable with, family, pets, school, etc. It can be equally helpful to utilize a developmental screening tool to judge whether the child is on target for achieving milestones or identifying areas of possible deficiency. And of course, discovering what the child knows about body parts, beginning with general things even young kids know, like belly button and nose, fingers and toes, to more complex parts like elbows, knees, shoulders, and then finally reviewing breasts, genitalia, and bottoms, so the examiner uses the same language as the child. Let's watch Kim talk to Leo, who's a four-year-old boy. Leo's mom is a forensic nurse, so it's not surprising he's accurate with his genital anatomy. You should go ahead and hop up on that chair for me. Do you remember what my name is? No? My name is Nurse Kim. It's nice to meet you again. Nice to meet you. What's your name? Leo. Leo. Is that what you like to be called? Excellent. Leo, it's my job today to ask you some questions and then look at your body. Is it okay if I ask you questions and write the answers down? Is that all right? All right, so your name is Leo. Leo, how old are you? Four. Four years old. And do you go to school? You do? How many days a week do you go to school? Every day or just some days? One day. One day. Excellent. One day. All right. And what is your favorite thing to do at school? Learn. Learn. I like learning too. What is it at school that you do not like? Is there anything about school you do not like? No? You like everything? That's amazing. All right, so talk to me about where you live. Where do you live? I don't remember. Okay, well that is a good thing to bring up because I'm going to ask you questions and it's really important if you don't know the answer to tell me, I don't know that, I'm a nurse, Kim. So if you don't know the answer to one of my questions, that is okay. I ask lots of kids questions and lots of times they don't know the answer. That's totally normal. So all right, you don't know. Do you know who lives in your house with you? My mama. Mama, who else? Your brother. Your sister. She was in Denver. Right now? Right now. Okay, well lucky her. I love Denver. That's a lot of people in Denver. Lucky Denver. All right, so mama, brother, and sister live in your house. Who else lives in your house? Oh, Papa. All right, Papa. Anybody else? Me. Oh, you live in your house. All right, and Leo lives there. Anybody else? Nope. All right, so what is your favorite thing about your house and being at home? Sleeping. Sleeping. What is it? Is there anything about your house and being at home that you do not like? Doing chores. Doing chores. All right, excellent. Doing chores. All right, so the next thing I would like to do is ask you if you know what a nurse is. What does a nurse do? What is a nurse's job? Do some nurses do surgery? Well, I'm a nurse and would you like to know what my job is? What my job is today? Today my job is to ask Leo questions, write the answers down, and to look at Leo's body and make sure he is safe and healthy. So that's going to be my job today. All right, so one of the things that's going to help me is we're going to do some activities. And the first thing I'm going to have you do is I'm going to have you stand up and I'm going to push this chair away. So go ahead and stand up for me. Stand right here. I'm going to push this chair away. You stand right here. And I'm wondering, are you able to stand on one foot? Oh, very good. Can you do the other one? Now, I'm going to have you stand on one foot and I'm going to count and see if you can do it for six seconds. You ready? One, two, three, four, five, six. Good job. All right, can you hop on one foot? Oh, very good. Can you hop on the other foot? Let me see if you're as good on that. Oh, excellent. Excellent. All right. Now, I'm going to ask you, do you know what the word opposite means? Down and up. Those are two opposites. Very good. What is the opposite of tall? Small. What is the opposite of big? What is the opposite of big? I say, this apple's very big, but this apple's very... What is the opposite of big? Very good, Leo. You are so smart. All right, so now go ahead and stand up for me. I'm going to bring this chair back so we're nice and close. Go ahead and hop up there and sit down and make yourself comfortable. And I'm going to do a little game called the body game. And I'm going to see if you know what body parts are called. Okay? So I'm going to point at different body parts of me and you tell me what those parts are. What is this? Nose. A nose. What are these things here that I... Ears. Yes. This is a hard one. A lot of kids can't get this. What's this right here? Is this part of my face? Chin. Chin. Very good. What are these things I'm wiggling at you? Ears. Yes. This is a hard one, too. What's making my arm bend? Elbow. Elbow. You are smart. What's this thing in my shoe? What's in my shoe? Your feet. Yes, my feet. Very good. What is the part on a boy where the potty comes out? What do you call that part? Where the potty comes out? What is the part on Leo where he goes potty? What's that part called? Where the potty comes out. Pee. Where the pee comes out. What do you call that? Penis. Very, very good. What is the part where the poop comes out? Bottom. And what is the part on a girl where the pee comes out? Vagina. Vagina. So if I say penis, you know what I'm talking about. Or if I say bottom, you know what I'm talking about. Or if I say vagina, you know what I'm talking about. Right? Very good. I am impressed. You are one smart dude. Now, I'm curious. Do you know why you're at the doctor's office today? Do you know why you're at the hospital seeing a nurse? Yes. And do you know that it's my job to look at your body? And I'm going to look at all of those parts. I'm going to look at your nose, and I'm going to look at your elbow, and I'm going to look at your fingers, and I'm going to look at your feet, and your legs, and your penis, and your bottom to make sure that all of those parts are healthy. Okay. Is there anything about your body or your health that I didn't ask you that you think is really important for your nurse to know? You didn't ask me about the lungs. I did not ask you about your lungs. How are your lungs doing today, Leo? Good. They are? Good. Good, good. Alright, so I'm almost done with my questions because I see somebody's getting a little bit antsy. Are you got the wiggle worms in you? Oh, okay, good. Well, you sit however you want. So here is one of my last questions. Oh, is anything hurting you today? Is any part of your body hurting you today? No. No. Okay, good. Good, good, good. What if I get this there? Oh, yeah. If you pick at it, it hurts. Does it hurt right now when you're knocking it? Oh, good. But if you pick at it, it hurts. What is that? Show me that again. A scratch. It is a scratch. How did you get that scratch? Tell me about that. I don't know. You don't know? I see. You don't know how you got that scratch. Well, if you remember, will you tell me? If you remember, will you tell me? I don't. Okay. Alright. Alright. Anything else? Any other ouchies on your body you think your nurse should look at? Yardie height. Let me see that. What is that? We don't know what that is. May I see it again? When did you notice that? How long has it been there? That's hard to say, isn't it? I don't know. Well, here's a question. Let me see it again. Does it hurt? No. Okay. Does it itch? No. No. Alright. Alright. So, we've got a scratch and we've got this on your arm. Anything else we should look at? Any other ouchies that you think your nurse should know about? Alright. Well, I'll be on the lookout. When I'm looking at your body, I'll be on the lookout for other ouchies, okay? How about we go and get your mom now so that she can be in here when I listen to your lungs, and I look in your ears and your eyes, and I look at your penis and your bottom. Should we go get your mom? So, she's here with us? No? You want it just to be me and you? Okay. It can be just me and you, but if at any point you want your mom, I want you to tell me, because what you want and you feeling safe, it's really important. So, if you want your mom at any time, you say, Hey, Nurse Kim, I think I would like my mom now, and we will go get her, okay? Can I go to the bathroom? You may go to the bathroom. Let's go do that. Lots of times we see new examiners using words they're used to using with adults, but may not have the same meaning or point of reference for a child. One of those words is the word safe. Oftentimes, clinicians ask adult patients if they're safe at home as a screening mechanism to identify possible domestic violence victims. Honestly, this is too vague a question for most adults to understand, and it's a question we don't typically recommend. That said, examiners continue to use the term. If this is a term you typically use in your clinical setting, when it comes to kids, you really need to check the meaning of the word with them. In this next clip, you'll see the forensic nurse, Christina, ask a child what safe means to her, which is an excellent approach should you use this term. Younger children may say they don't know, which helps the examiner to understand they can't use that word in their history-taking. So let's take a look. All right, Abigail, we're going to come in here, and we're going to sit right here. Just right there. Okay. And I'm going to ask you a couple questions, okay? Now, if you need your mom, your mom's right outside that door, so you just tell me, and we can grab her, okay? If you feel uncomfortable or you get scared or need your mom, okay? All right, so how old are you? Seven. Seven. What grade are you going into? Second. Second grade? Ooh, do you know who your teacher is yet? No? What school do you go to? CMU. Oh, nice. Do you have a lot of friends? Yeah. Yeah? Do you have a best friend? Yeah. Yeah? What's her name or his name? Is it a boy or a girl? Girl. Girl? What's her name? Joyce. Joyce? Oh, how long have you known her? I don't know. Did you know her before? Mm-hmm. Yeah? Okay. So who do you live with at home? My mom and my dad, two brothers. Ooh, two brothers. And two dogs. And two dogs? What are your dogs named? Kaya and Rosie. Ooh, what kind of dogs are they? Do you know? No? Do you get along with your brothers? Only one. Only one of them? Are they older or younger? Both. Both? So one's older? Do you get along with your older brother? Yeah. Yeah? Do you get along with your younger brother? No? Do you fight? Yeah. That's how brothers are sometimes, huh? All right, so I'm going to ask you to do some silly things. And this is just so we can see what you know, okay? The first thing is, and it's kind of silly, I know you know how to do it, but we just have to ask you, okay? Can you hop on one foot? Ooh, very good. You know how to skip? I know there's not much room here. And I'm going to ask you some other silly things. I'm going to ask you your body parts, okay? So I just need you to tell me what you call them, okay? And we ask every kid that comes in here the same questions, okay? And that's just so when I look at you, I'm going to look at you from head to toe, and I'm going to make sure you're healthy, okay? So what is this? An ear. What is this? A nose. What is this? A tummy. What is this? A butt. Okay. What are these things? Boots. Okay. And what is that called, where you go bathroom? Private. Private, very good. Well, you passed my test, A+. So do you know why you're here today? No. No? Do you know where you're at? Where are you? Which is building hall. Well, I'm a nurse, and I'm going to look at you to make sure you're healthy, okay? All right. So just a couple more things. Do you know what it means to feel safe? If I say, do you feel safe? Yeah. What does that mean? If you're scared, that means you're not safe. Very good. So if I ask you, do you feel safe at home, what would you say? Yes. Very good. Okay. All right, well, I'm going to have you pick a gown. What's your favorite color? Blue. Blue? What do you want to be when you grow up? Something that takes care of animals. Oh, very good. A veterinarian? All right, well, I'm going to have you pick a gown, and you can pick any color you want, and then we'll get to your exam, okay? And like I said, I'm just going to look at your body to make sure you're healthy. And if you want your mom in here, we can grab your mom, okay? In the next clip, Christina also makes sure to clarify what safe means with Lucas. In addition, though, note that Lucas is uncomfortable discussing private body part names with Christina. He knows what they're called, but at his age he's not comfortable talking about that to a grown-up he's just met. The key to what Christina does is they agree on a term they'll use when they are discussing his genitalia during the exam. Hi, Lucas. I'm Christina, one of the nurses here. And we have your mom's outside, so if you need her we can always grab her, okay? Okay. Okay, and I'm just going to ask you a few questions. Is that okay? Okay. Okay. First, can you tell me how old you are? I am 10. 10? And what school do you go to? Colorado State University. Nice. And what grade are you going into? Fifth. When does school start? Do you know? Three weeks. Three weeks? Oh, my gosh, that's soon. Have you done your school shopping? No. No? All right. Do you have a lot of friends at school? A couple of friends. Yeah? Any best friends? No, I like them. Good. And they're nice? Yep. Good. All right, and who do you live with? My mom, my dad, my sister, my brother, and my daddy. All right. What's your cat's name? Austin. Austin. Where did you get that name from? Well, we got it from the Humane Society, and that's what they gave us. Oh, nice. And do you get along with your brother and sister? Mostly. Are they younger or older? Younger. Younger? Okay. Now, I'm going to ask you a question, and do you know what it means when I say, do you feel safe at home? It means sort of that if I like being at home, I might prefer to be at home. Very good. Do you feel safe at home? Yeah. Yeah? Good. Okay, and then I'm going to ask you some silly questions. Now, I know you know the answers to these, but we ask every kid that comes in here these questions just so we know that you know the answer. Okay? All right. And there is no right or wrong answer. Everybody has different ones. I hear everything. So, what is this? Your ears. What's this? Your nose. What is this? Your scalp. What's this? Your legs. Okay. What are these things? Your feet. You don't have to answer it, but it's important because if we do, when I look at you, I'm going to look all over your body on these body parts. So, if I say a name, I want you to make sure that you know what I'm talking about. Okay. Okay? I know the name. Okay. What do you call them? And there is no right or wrong answer. I've heard all kinds of crazy things. Yes, very good. And then what do you call where you go bathroom from? Do I really? I don't want to answer. You don't want to answer? Okay. What about if we make a name up so that way if we're doing your exam and I have a question, what name do you want to make up for that? That's not a good idea. All right. How about, um, um, um, I can't think of one. You can't think of one. Do you call it your privates? How about privates? Sure. Okay. We can call it that, okay? All right. So, what I'm going to do is I'm going to look at you from head to toe, okay? We're going to look at all those parts that we talked about just to make sure you're healthy and that everything's okay, okay? And if I do anything where you feel uncomfortable or you want me to stop, you just tell me stop, okay? And do you want your mom in the room when we do this exam? Okay. Whatever you feel more comfortable with, okay? Okay. All right. I'm going to have you go grab a gown. You can pick any color you want. What's your favorite color? Green or blue. Green or blue? I think we have that, okay? When you, the examiner, sit down for your history taking, introduce or reintroduce yourself to the child. Let them know what they can call you and ask what you should call them. Then explain your role in terms the child can understand. If when you're talking to the child something needs clarification, seek clarification. You'll see Kim do this with Dylan in the next clip to clarify precisely what is happening at school. Give kids some control, being careful not to give away all of your control. Simple things like choosing the color of the gown can achieve this principle. And then finally, whenever possible, position yourself below the level of the child. This helps the child feel more comfortable by not having to look up to and feel unnecessarily intimidated by the grown-up. Hey, Dylan. Come on in and have a seat here in our exam room. Now, I know I met you briefly in the other room with your parents. I'm wondering if you remember what my name is. It's hard, isn't it? You've met a lot of people today. My name is Kim. You can call me Nurse Kim. Now, I see here that your name is Dylan. Is that what you like to be called? Yes. So it's okay if I call you Dylan? All right, Dylan. Well, my job today is to do two things with you. One is to ask you a lot of questions and write your answers down, and the other is we're going to do an exam on your body. Make sure that you're healthy. So those are our two things today. Your mom and dad are in the other room waiting, and they know that we're in here. They know that I'm going to be asking you questions. And when we get done and we get to the part where I'm going to listen to your lungs and look in your ears and look at your body, if you would like them to come back in, they can come back in. Or if you would like it just to be me and you, that's okay too. So you get to make those decisions a little later on. First off, I'd like to ask you some questions, and I'm going to write the answers down because it's really important that I write down your answers so that I can remember what you told me. So you like to be called Dylan. And how old are you, Dylan? I'm 8. You're 8 years old. Do you go to school? Yes. What school do you go to? I go to Odyssey now. Oh, very nice. And what grade are you in? Third. Third grade. Third grade was my favorite. I remember my teacher, Mrs. Blake. I liked third grade because we got to learn multiplication and we learned cursive. I liked that. What do you like about school? I like to do science because I can learn about weather and do experiments. Really? So you're a science girl. That's exciting. Do you want to do something with science when you get older? Yes, I want to make a lot of different drinks and stuff. Really? With different ingredients. Like a mixologist? That would be awesome. Very, very cool. So tell me, what is one of your favorite things about school? My favorite things about school is that I can meet new friends and do a lot of stuff. Good. Do you have nice friends at school? Mm-hmm. Do you have any people who aren't nice to you at school? A couple people, but I'm one. I'm moving schools. Okay. So I can get away from them. I don't like hearing that some people aren't nice to other people. It makes my heart sad. When you say that some people aren't nice to you, are those people kids your age or are they adults? Kids. Other kids. All right. Did you tell somebody about that? Yes. I told the teacher and my teacher said to stay away from them. Oh, I'm glad that you told the teacher. That's good. So you like science. It's your favorite thing at school. You don't like it when people aren't nice to you at school. Is there anything else about school that you don't like? No. Okay, good. So talk to me about where you live. Do you live in a house or an apartment? I live in a house. A house. But I live in two houses because my mom and dad are divorced. Okay. Well, do you know that with my job being a nurse who sees kids, I talk to a lot of kids and most kids live in more than one house these days. So that is a really normal thing. So let's talk about both houses. Which one would you like to start with? I would like to start with my dad's house. Your dad's house. So tell me who lives in your dad's house. My dad's house, my stepmom, my dad, my sister sometimes, and my two stepbrothers. Okay. And so while we're on your dad's house, do you feel safe at your dad's house? Yes. Yes. What is your favorite thing about your dad's house? That I have a friend that's backyard is facing us so I can hop the fence and play with them. That's amazing. That's very cool. What is your not favorite thing about your dad's house? That I have to switch over a lot and I don't get to see the people there a lot. Okay. Is there anything about your dad's house I didn't ask that you think I should know? No. Okay. So let's talk. Is the other house your mom's house? Yes. Okay. So tell me about your mom's house. Me, my sister, and my mom all live there. There's just three people living in there. And sometimes my mom's partner comes over a lot. She lives in an apartment. And she used to live with us. Now she's just living in an apartment. And the favorite thing we like to do at our mom's house is do barbecues. Barbecues. Do you feel safe when you're at your mom's house? Yes. Okay. What is your not favorite thing about your mom's house? That I don't really have that many friends by my mom's house. I only have one. Okay. Alright. Alright. So when you're at your dad's house, if there was something that was really upsetting you or making you sad or bothering you or making you angry, who is the safe adult in your dad's house that you would talk to? My stepmom because I always knew I could always come to her. And the cool thing is that she's my BFF. She is? That is pretty cool. That's amazing. Have you ever told her that? Yes. Yes. I bet that makes her happy. So when you're at your mom's house, if you needed an adult to talk to because something was making you angry or sad or scaring you, who is the person you would talk to at your mom's house? My mom. Okay. Good. Good, good, good. You're doing great. You are doing great. Alright. So you have already, I usually ask kids your age, 8-year-olds, about friends and adults in their home. You've already answered a lot of my questions. So now I'm going to ask you a couple other things. Do you know what a nurse does? Do you know what my job as a nurse is? To help the doctors take care of patients and stuff? We do. We do. And so like I told you in the beginning, part of my job today is going to be talking to you and then looking at your body and making sure that you're safe. So one question that I think is really important that I ask all kids is, is there anything in your body that is hurting you today? Um, no. No? Okay, good. Good. I'm very glad. The other thing that I do is I do a little quiz or a test with the kids. And I don't really like calling it a test because the thing is there's not right or wrong answers. I point to different body parts on me and on you, and I have you tell me what you call those body parts. And the reason is, is that kids come in here, and they might call different body parts different things. So you might call this a nose, and the next kid I see might call it a schnoz. So my purpose is I want to make sure that I know what you call your body parts so that I can say the same words when we know what we're talking about. Okay? I'm going to point to some body parts and you tell me what you call those body parts. So let's start with this one. A nose. That's right. And what are these things on the side of my head? Ears. That's right. What is this thing here? A chin. That's right. What are these things that we're going to get you? Um, fingers. That's right. What is this thing that makes my arm bend? Elbow. That's right. What is this thing that makes my leg bend? Knee. That's right. What are these things in my shoes? Feet. Very good. What is this part on a girl where the potty comes out? A pee-pee. A pee-pee. What is that part on a boy where the potty comes out? Well, I didn't really feel comfortable saying the actual word, so I came up with a different word called a peanut. A peanut. All right. So if I say pee-pee, you know I'm talking about a girl's area, and if I say peanut, you know I'm talking about a boy's name, or a boy's part down there. All right. So pee-pee and peanut. What is this part that we're sitting on where the poop comes out? A butt. A butt. And do you have a different name for boys and girls? No. A boy, this could be a butt on a boy or a butt on a girl. Excellent. All right. So pee-pee, peanut, and butt. Very good. So it's helpful when the child is old enough to begin very broadly with a question such as do you know why you're here today, or do you know why your mom and dad brought you here today? Nothing about the question suggests the examiner is leading the child to talk about sexual abuse. When Dylan makes a disclosure, you'll notice Kim asks if this happened one time or more than one time. This is a much better approach than asking how many times did this happen, because children may not have an accurate sense of numbers or even timing as to when it occurred. It's very important to ask what it felt like. Did it hurt? Did the child notice anything like blood, or did it hurt to pee or poop afterward? And while you don't see Kim go into this during the video, for a child Dylan's age who disclosed, it would be totally appropriate and acceptable to ask her direct follow-up questions like did the babysitter put his mouth on your body anywhere? If so, where? Did the babysitter put his peanut anywhere else, your mouth, your bottom? These follow-up direct questions allow you to discover what other possible locations of evidence there might be and what other health risks should be considered in the treatment plan. And because Dylan does not know when this occurred, it's appropriate to ask mom and dad when the last contact with the babysitter was in order to attempt to establish the viability of the evidence collection. The next question that I have for you is I'm just curious if you know why your mom and your dad brought you here today. Because I told her about my babysitter. Okay. What did you tell her about your babysitter? That he was doing weird things to me. That he was doing weird things to you. And what were those weird things? Can you explain that to me? He was putting his peanut in my pee pee. Did this happen one time or more than one time? Just one time. Just one time. Okay. Now, this is kind of a hard question. Do you know when that happened? No. Okay. Did he say anything to you when that happened? No. Okay. And how did that feel? Did it hurt or did it not hurt? Because sometimes it doesn't hurt. It hurt. It hurt. Okay. And when that happened, did you notice anything afterwards like anything like that would indicate you were hurt? No. Okay. So no blood or anything like that. Okay. Alright. So, Dylan, you just did a really good job answering my questions. Is there anything that you think I should know about as your nurse that I didn't ask? No. No? Okay. Do you have any questions for me? Yeah. Alright. So what we're going to do is we're going to take a minute. I'm going to let you go pick out a gown because I need you to take your clothes off so that I can look at all of your body. But I want you to feel comfortable, too. So I'm going to give you like a little robe, a little gown to put on, and I'll let you pick that out. The other thing I want you to think about is when we get to the part where I'm looking at all of your body, things like your ears and listening to your heart and looking at your peepee and your butt, do you want that just to be me and you or would you like your mom or your dad to come in? Just me and you. Just me and you. Alright. I think that sounds perfect. Let's just do it me and you as long as you understand that at any time if you think, I changed my mind, I want my mom or I want my dad in here, you say, Nurse Kim, I changed my mind. Because what's really important is that you feel safe and comfortable. We will stop and bring them in. Okay. Okay. Alright. Thanks, Dylan. Let's go find you a gown. Okay. While Kim gives Dylan the option of having a parent in with her during the exam and while Dylan chose to just have Kim, it's critical that examiners understand the chaperone should be present during the exam of the child. If not a non-offending parent, then another member of the staff or community advocacy. But the examiner should not conduct the general exam without some type of chaperone for the safety of the child as well as the examiner. Another important aspect of the exam is the review of systems you do prior to the general exam. This allows for the rapport building with the examiner and it helps the child to understand you're interested in their entire body, not just their genitalia. In the same regard, if you see an injury on the child's body, ask them about what happened or ask their caregiver in an effort to understand what might be abuse-related and what is not abuse-related. Now let's watch Kim prepare Dylan for the exam itself. We will not show an examination, but rather just preparing the child. Alright, Dylan. Now that I have you in the room, I'm going to do what we talked about, which is look at your body. We'll look from the top of your head down to your toes and check everything out, okay? The first thing that I'd like to do is listen to your heart. Is that alright with you? You know what this is called? I've got no idea. It's called a stethoscope, and it helps me listen to your heart. I put it right here. And it helps me hear your heart, and you have a very nice, healthy, strong heartbeat. Have you ever heard your heart beat? You want to try it? So put these in your ears for me. And you're going to listen for a thump, thump, very low sound. You hear it? Can you hear mine? Hear it? Kind of cool, huh? Now I'm going to have you turn around and turn your back to me. I'm going to listen to your lungs, and I'm going to have you take a big breath in and out like this. Do it again. Good, and again. Good, and I'm going to have you scoot your bottom down that way, and I'm going to have you lay down so I can listen to your tummy. So go ahead and lay down. I'm just going to listen to your tummy. And you can breathe normally. Very good. Go ahead and sit up again. This is my light, and it helps me see lots of things. The first thing I'm going to do is look at your eyes. So I'm going to have you turn your face towards me, and I'm going to have you keep your eyes on my nose. So I'm going to shine the light in your eyes, but don't look at the light. Keep looking at my nose. Very good, and again. Very good, and then point your nose up just a little bit, and open your mouth really wide and stick your tongue out at me and say, Very good. Does your throat hurt at all? Okay, good. Very good. Very good. Now I'm going to look in your ears, so I'm going to have you look that way. I'm going to look in your ears. Oh, perfect. Perfect, perfect. Now turn your head like this. Oh, perfect. You've done this before, haven't you? Perfect. Very, very good. Now I asked you this before, and I just want to ask again. Is there any part of your body that hurts today? No. That's really good. I see you've got a little ouchie on your chin. What happened to your chin? I burned myself on a marshmallow stick when we were camping. On a marshmallow stick? Well, if you're going to get a burn, that's a pretty good way to do it. When did that happen? I don't know, a couple weeks ago. A couple weeks ago? All right, does it still hurt? It looks like it's healing really nice. Isn't it amazing how our bodies will heal themselves? It's pretty cool, isn't it? All right, the next thing that I'm going to do is put these gloves on. Have you seen doctors and nurses put gloves on before? Yeah. Why do we wear gloves? So you guys don't get the germs and stuff. Yeah, they're so that I don't get germs from you, but they're really so that I don't give you germs either. It goes both ways. What I like to do when I put gloves on, you're a little bit older, but some of the younger kids, they will scare to my gloves sometimes. So I like to do this with kids. I want you to touch them, feel them. So see, they're nice and soft. They don't hurt at all. I just want you to know anytime I'm touching your body with my gloves, it just feels like this. Do you want a pair of gloves? Do you want a pair of gloves? Should we get you a pair? All right. Stick your other hand. Do this one. Do that and then stick that. There you go. Very good. Now I think high five is in order. Very good. All right, so one of the things that I'm going to be doing when I look at your pee-pee and your butt and some of the other parts of your body is I'm going to be doing something that I call swabs, and I wanted to show you what these swabs look like. So these are my swabs. Now, some kids get scared when they see these swabs because they think of throat cultures. Have you ever had a throat culture where somebody sticks the swabs in the back of your throat and it makes you go, your head like that? Well, I'm not doing that today. I'm not doing that. So if I'm going to swab inside your mouth, I'm just going to be swabbing around where your teeth and your tongue are. I'm not going to be going all the way back in your throat. But these are my swabs, and they just look like really long Q-tips. Do you know what Q-tips are? So go ahead and take one of those. And when I say swab, what I usually do is it means tickle. So I'm going to tickle parts of your body with my swab like this. Will you do it to me? It doesn't hurt, does it? How would you describe that? Kind of a tickle? A rub or a tickle? So that's what I do. Do you want to keep holding that? Okay. So you hold that. So the next thing I'm going to have you do is get in a position so that I can look at your pee-pee. And there's two different ways that I'm going to look at your pee-pee. The first one is with you laying on your back, and that's the easiest one. My biggest question for you is do you like frogs or butterflies better? Butterflies. Butterflies, all right. So I'm going to have you sit like a butterfly. And what I'm going to have you do is bring your bottom. You're going to be facing me, and I'm going to be sitting on my stool here. And you're going to bring your bottom about right here. And then you're going to lay back on your back. So go ahead and lay back. And if at any point you can see me, you can always see me, you can always see what I'm doing. And we're going to make your knees and your legs look like butterfly wings. And the way that we're going to do that is I'm going to have you put the bottom of your feet together and let those knees go out just like this. Now, sometimes kids sit with butterfly wings closed, and that doesn't help me see what I need to see. So what I really need is nice, big, open butterfly wings like that, okay? And then what you're going to feel me do is you're going to feel me touching right here, and you're going to feel me touching here and here. And I'm going to do separation and traction, which is just opening things up like this, okay? All right? All right, good job. So go ahead and sit up. The next position that I'm going to put you in is something called knee-chest position. And this one is a little bit harder of a position to get into, but I think it's kind of cool because it reminds me a little bit of the way a dog or a kitty cat would sit. So do you have a dog or a kitty cat at home that you have? Remind me. I have two dogs at my dad's house, one dog at my mom's house, and one cat at my mom's house. Oh, perfect. So you know a lot about cats and dogs. So let's talk about a cat first. When you think about a cat at Halloween, their back is arched like this, right, like this way, up and down like this. So I want a kitty cat that's going to be scratching their back. So the first thing we do to get in the kitty cat position is I'm going to have you turn around and sit on your hands and knees. There you go. And I'm going to have you, I know this is going to be weird, but you need to scoot back a little bit closer towards me. Oh, that's perfect. That is absolutely perfect right there. So I'm going to have you sit on your hands and your knees like a kitty cat. And what you're going to do is you're going to come forward. You're coming like right on there. And you're going to make your legs nice and tall. So you're going to stand up with tall legs, and then you're going to spread your knees. All right, so your knees need to go open. And then what I need is I need you to raise your bottom up and make this part of your leg tall. That is perfect. See how this leg is tall here? So you're going to stay on your knees with your knees apart, and you're going to bring your butt towards your nurse, almost like you're going to toot on her. If you do, it's okay. I've had kids toot on me before, and it doesn't bother me. So the next thing we're going to do, this is perfect, with tall legs and knees wide apart. The next thing we're going to do is you're going to take your chest and your forehead and touch them to the bed. Now, you can turn and look this way so you're not facing the bed. You can turn your head that way. So bring your forehead and your chest, keeping this tall. That is perfect. Have you done this before? Oh, my gosh, perfect. Now you're going to point this bottom at your nurse, and you're going to keep those tall, and you're going to feel my hands on your bottom first so that I can look at your butt. And then you're going to feel my hands on the same spot down here on your pee-pee, okay? All right, that is perfect. It's fair to say that while 98% of the time kids are totally compliant with the exam, there are kids who are not having any part of it. This happened during the videotaping as well. So in keeping with real world, we wanted to show you what this can look like. Here it is. Miss Lucy. Oh, my gosh. You're good. There you go, lovey. Do you want to stay in the room? That would be fun too. Do you want me to stay in the room, Lucy? Would it be nice for you if Tia sat in the corner? If I sat right there and you could see me, and I'll smile at you and blow your kisses? Can I watch? You need to help Lucy feel comfortable. Hey, Lucy, do you want to pick one of these up? Should we film this? Do you want it? Of course I do. Oh, I like your sandals, Miss Lucy. I know which one Lucy would like. Let me see if it'll look. It could be orange. Some girls like orange. Okay, I can't do it. Can you do it? Or yellow, and I have a green one or a blue one. Would you like one of my pinwheels? We hope these examples will be helpful to you in your practice.

history taking

children

sexual abuse

rapport building

safety

age-appropriate language

open-ended questions

medical information

examination process

consent