Paeds · child-safety-and-social-paediatrics
Trauma-informed examination and forensic documentation
Also known as Trauma-informed forensic medical examination · Forensic documentation in child maltreatment · Child protection medical examination · Medico-legal examination of the child · Trauma-informed paediatric assessment
A fellowship approach to performing a trauma-informed medical examination of a child who may have been maltreated and to documenting the findings so the record is contemporaneous, objective and court-admissible: setting the tempo and the environment, running a single trained forensic interview, conducting the consented and chaperoned examination, capturing photo-documentation, maintaining chain of custody, separating fact from opinion, and handing the whole bundle to the safeguarding and reporting systems that act on it.
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Target exams
Red flags
- A child who freezes, dissociates or becomes mute during examination — stop, slow down, and recognise the threat response rather than forcing the assessment
- An accompanying adult who refuses to leave, answers for the child, or controls the encounter — a controlling presence may be the perpetrator and must be separated before the interview
- An acute presentation inside the forensic window where the evidence kit is being missed or delayed in favour of a leisurely history
- Documentation written from memory hours later, or opinion blended into observed fact — both collapse under cross-examination
- A break in chain of custody for a forensic sample — the evidence is excluded before it reaches court
- A child examined repeatedly by different clinicians for the same allegation — each repeat is both a re-traumatisation and a contamination of the account
- Confidentiality promised to a child or family that mandatory reporting cannot honour
Life stages
Care settings
Clinical exam formats
Board mappings
- General and Community Paediatrics
- Child safety and maltreatment
- Current 2026 PREP curriculum — Learning Objective 2.3.1: Recognise and manage child abuse and neglect
- Current 2026 PREP curriculum — Learning Objective 2.3.2: Work effectively with child protection and interagency services
- Renewed curriculum for first-year trainees from 2027 — Learning goal 4: Safeguarding and child protection
- Emergency Medicine
- Clinical Applications — child protection and safeguarding
- Long Cases
- Short Cases
- Communication stations
- 2. Professional skills and knowledge: Safeguarding
- 9. Child protection and safeguarding
- 11. Adolescent health
- Foundation of Practice (FOP)
- Applied Knowledge in Practice (AKP)
- Safeguarding and child protection
- History
- Communication
- Clinical
- Development
- General Pediatrics Content Outline — Domain 8: Child Abuse and Neglect
- General Pediatrics EPA 8: Evaluate suspected child maltreatment
- Adolescent Medicine
- Patient Care 1: History and Physical Examination
- Patient Care 5: Patient Management
- Systems-Based Practice 2: Advocate for patients and populations
- Professionalism 1: Professional Behavior and Ethical Principles
- Advocate
- Professional
- Collaborator
- Pediatrics: Foundations EPA — Assessing suspected child maltreatment
Overview & Definition
A four-year-old boy is brought to the emergency department at midnight by a foster carer after he disclosed being hit. The triage nurse asks you what happens next. Your job at that moment is not to decide whether abuse occurred. Your job is to run a safe, staged assessment that protects the child, preserves any time-limited evidence, treats what can be treated, and produces a record that the child-protection and police systems can act on — all without making the child tell their story more times than is strictly necessary. [1] [5]
Trauma-informed examination is the application of trauma-informed care to the medical encounter with a child who may have been maltreated. The Substance Abuse and Mental Health Services Administration frames trauma-informed care around six principles — safety, trustworthiness and transparency, peer support, collaboration and mutuality, empowerment and choice, and awareness of cultural, historical and gender issues — and each one has a concrete operational meaning at the bedside. Safety means a quiet, private room and a calm, predictable examiner. Choice means telling the child they can stop the examination at any time. Transparency means explaining what you will do before you do it. [1] [2]
Forensic documentation is the second product of that encounter, and it is what separates a clinical visit from a medico-legal examination. The record must be contemporaneous, objective, and structured so that a court can read what was observed, what the child said in their own words, and what the clinician inferred — each clearly distinguished. A note written from memory hours later, or an opinion blended into a factual description, collapses under cross-examination and can cost a child their protection. [6] [7]
The single most important clinical rule is that re-traumatisation is itself a harm, and avoiding it is part of the treatment. A child who is examined repeatedly, questioned suggestively, or rushed through an unexplained procedure is not merely distressed in the moment — the encounter encodes as a further traumatic memory, fragments their recall, and worsens their long-term outcomes. Minimising the number of times the child must tell their story is therefore a clinical objective, not a courtesy. [1] [3]
References12ShowHide
- [1]Forkey H, Szilagyi M, Kelly ET, Duffee J Trauma-Informed Care. Pediatrics, 2021.PMID 34312292
- [2]Marsac ML, Kassam-Adams N, Hildenbrand AK, Nicholls E, Winston FK, Leff SS Implementing a Trauma-Informed Approach in Pediatric Health Care Networks. JAMA Pediatrics, 2016.PMID 26571032
- [3]Goldstein E, Chokshi B, Melendez-Torres GJ, Rios A, Jelley M, Lewis-O'Connor A Effectiveness of Trauma-Informed Care Implementation in Health Care Settings: Systematic Review of Reviews and Realist Synthesis. The Permanente Journal, 2024.PMID 38444328
- [4]Keeshin BR, Bryant BJ, Gargaro ER Emotional Dysregulation: A Trauma-Informed Approach. Child and Adolescent Psychiatric Clinics of North America, 2021.PMID 33743945
- [5]Adams JA, Kellogg ND, Farst KJ, Harper NS, Palusci VJ, Frasier LD Updated Guidelines for the Medical Assessment and Care of Children Who May Have Been Sexually Abused. Journal of Pediatric and Adolescent Gynecology, 2016.PMID 26220352
- [6]Lamb ME, Orbach Y, Hershkowitz I, Esplin PW, Horowitz D A structured forensic interview protocol improves the quality and informativeness of investigative interviews with children: a review of research using the NICHD Investigative Interview Protocol. Child Abuse & Neglect, 2007.PMID 18023872
- [7]Cross TP, Schmitt T Forensic medical results and law enforcement actions following sexual assault: A comparison of child, adolescent and adult cases. Child Abuse & Neglect, 2019.PMID 31075572
- [8]Feldman KW, Jenkins C, Laney T, Seidel K Toward instituting a chaperone policy in outpatient pediatric clinics. Child Abuse & Neglect, 2009.PMID 19818498
- [9]Berhane A, Hackell JM, Wallace S Use of Chaperones for the Pediatric and Adolescent Encounter: Policy Statement. Pediatrics, 2025.PMID 40383537
- [10]Brennan PA The medical and ethical aspects of photography in the sexual assault examination: why does it offend? Journal of Clinical Forensic Medicine, 2006.PMID 16571379
- [11]Lahoti SL, McClain N, Girardet R, McNeese M, Cheung K Evaluating the child for sexual abuse. American Family Physician, 2001.PMID 11261865
- [12]Demers LA, Wright NM, Kopstick AJ, Niehaus CE, Hall TA, Williams CN Is Pediatric Intensive Care Trauma-Informed? A Review of Principles and Evidence. Children (Basel), 2022.PMID 36291511