Identifying Competence in the Context of the Pediatric Anogenital Exam

Journal of Child and Adolescent Psychiatric Nursing, Jan-Mar 2004 by Waibel-Duncan, Mary Katherine

PROBLEM. Appraisals of and concerns about the pediatrie anogenital exam in order to promote a better understanding of predisposing factors that may underlie some people's adjustment to these exceptional circumstances.

METHODS. Thirty-three girls ages 8-15 and 82 adult guardians rated their acute exam appraisals and concerns using a 5-point Likert-type scale. Data were collected immediately after the anogenital exam at a pediatrie outpatient clinic specializing in medical evaluations following allegations of child sexual abuse.

FINDINGS. Participants reported relatively low levels of acute exam concerns as well as relatively high appraisals of the exam's importance and desirability, their ability to emotionally tolerate the exam, and optimism regarding the event's potential amelioration.

CONCLUSIONS. Data suggested the presence of specific competencies that may be instrumental in safeguarding children's and adult guardians' psychological well-being in the context of the pediatrie anogenital exam.

Search terms: Appraisals, child sexual abuse, competence, medical fears, pediatric anogenital exam

Without a doubt, child sexual abuse (CSA) and its associated Stressors-the disclosure process, forensic interview(s), medical evaluation(s), and court appearance(s)-have the potential for profoundly disrupting children's and adult guardians' psychological well-being. With few exceptions, the available research has focused on inventorying children's and adult guardians' abuse-related symptoms and signs of maladjustment while paying relatively little attention to areas of competence that may limit the nature and intensity of potential psychological damage.

Consistent with an emerging trend in the broader fields of clinical and pediatrie psychology, professionals involved in cases of child maltreatment have begun to shift their assessment strategies and intervention goals from identifying symptoms and palliating distress to recognizing resilience and promoting psychological adjustment (DePanfilis & Wilson, 1996). More specifically, Briere's (1992) treatment philosophy for working with adult survivors of CSA has proposed that "the goal of therapy is less the survivor's recovery than his or her continued growth and development-an approach that utilizes the survivor's already existing skills to move beyond his or her current level of adaptive functioning" (p. 82).

The pediatric anogenital exam may provide one of the first opportunities to deliver such therapeutic benefit to both children and their supportive adult guardians. Clinical observations and empirical findings have suggested that the majority of children and adults negotiate the demands of this medical procedure relatively well (see Britton, 1998 for a review). The present study systematically explores individuals' acute exam-related cognitive activity (i.e., concerns and appraisals) in order to begin identifying predisposing factors that may underlie their healthy resolutions to the examination.

Theoretical Framework for Understanding Individuals' Intrapersonal Examination Experience

The potential usefulness of Smith and Lazarus' (1990, 1993) cognitive appraisal theory as a guide for exploring individuals' exam experiences has been described and empirically tested elsewhere (Waibel-Duncan & Sandier, 2001, 2002). Briefly, Smith and Lazarus differentiate between primary appraisals ("What's at stake?") and secondary appraisals ("What can I do about it?"). Primary appraisal components include motivational relevance ("How important is the event?") and motivational congruence ("How desirable is the event?"). High primary appraisals correspond to events that are perceived as stressful and are likely to engender a greater emotional investment. secondary appraisal components include appraisals of problem-focused coping potential ("To what extent can I alter the current situation to make it more consistent with my goals, values, or commitments?"), emotion-focused coping potential ("To what extent can I emotionally tolerate the current situation?"), and future expectancy ("What is the current situation's potential for amelioration?"). According to the appraisal model, these appraisal components combine in theory-specific ways to elicit appraisal themes of challenge, threat, or loss/helplessness.

Prior research on individuals' pre-exam cognitive activity (Waibel-Duncan & Sandier, 2001) suggested that participants from the present study would report a relatively high emotional investment in the exam, confidence in their ability to cope with and adjust to the exam, optimism for a positive outcome, and perceptions of the exam as a challenge. Prior research on individuals' anticipatory exam worries (Waibel-Duncan, 2001) also suggested that the majority of the current study's participants would report relatively mild concerns about specific aspects of the acute medical encounter.

Wolin and Wolin's (1996) resiliency model was used as a framework for interpreting data on participants' exam-related cognitive activity. The Wolins' model describes seven independent strengths-independence, insight, initiative, relationships, morality, creativity, and humor-and emphasizes their contributions to individuals' capacity for self-repair and growth. Data were expected to show indirect evidence of at least four areas of competence: insight, independence, initiative, and the ability to form relationships. According to the model, insight refers to the ability to accurately probe the meaning and significance of potentially stressful events. Independence refers to the ability to psychologically distance oneself from aversive situations by creating safe and appropriate physical or psychological boundaries. Initiative refers to the ability to assert oneself in order to master controllable aspects of the environment in pursuit of selfdetermination and self-preservation. Finally, individuals' ability to form and maintain relationships suggests their skill at identifying and attracting trustworthy and potentially helpful adults who may be able to minimize the maximum amount of harm in the context of unpleasant circumstances.