Trauma-informed examination and forensic documentation — formative SAQs

SAQ 1 — The non-acute assessment and the trauma-informed encounter (10 marks)

A six-year-old girl is referred to your outpatient clinic after a tentative disclosure to her teacher two months ago that her mother's partner "hurts her". She is quiet, avoids eye contact, and clings to her maternal grandmother, who is supportive. The school has already spoken to her three times. ^[1]

Questions

1. Outline how you would conduct this assessment, including the environment, who takes the history, and the order of the examination. (4 marks) ^{[1] [3]}
2. During the examination the child becomes mute and still. Describe the correct interpretation and your immediate response. (3 marks) ^[1]
3. State your documentation and disposition obligations after the assessment, including the meaning of a normal examination. (3 marks) ^{[2] [4]}

Model answer

Conduct of the assessment (4). Treat this as a non-acute, elective assessment: there is no forensic window, no kit, and no urgency. Provide a quiet, private, child-friendly room with a competent examiner and a chaperone, and minimise waiting. The history is taken once, by a trained forensic interviewer using a structured protocol such as the NICHD protocol; because the child has already been interviewed three times, the clinician listens and documents rather than re-questioning, since repeated and suggestive questioning contaminates the account and distresses her. State the limits of confidentiality, including mandatory reporting, before any history is taken. Conduct a general examination for growth, skin, and signs of other maltreatment, then a focused examination only if indicated and only at the child's pace. ^{[1] [3]}

Interpreting and responding to the freeze (3). The child has gone still, silent and apparently compliant — this is a freeze response, a threat response driven by amygdala activation and prefrontal suppression, not cooperation. Misreading it as "fine" and proceeding re-traumatises her. The correct response is to slow down, name what you see gently ("you've gone very quiet — we can stop if you need to"), give a genuine exit, and restore her sense of agency before continuing or deferring. ^[1]

Documentation and disposition (3). Write the record contemporaneously: the verbatim history in her own words, observed findings on body diagrams, and clinical opinion clearly separated from fact. A normal examination does not exclude abuse — most confirmed cases have normal or non-specific findings — so the disclosure and context carry the diagnosis and the report follows from that. Make a mandatory child-protection report on reasonable belief, agree a safety plan so she does not return to the alleged perpetrator, refer for trauma-focused therapy, and arrange a two-week and a two-to-three-month review that repeats serology where indicated and confirms the safety plan is working. ^{[2] [4]}