Investigating Child
Sexual Abuse
Christine E. Barron, MD
Assistant Professor, Pediatrics
Warren Alpert Medical School
at Brown University
Objectives
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National Data
Physical Examination
“Red Flag” Behaviors
Disclosures and Forensic Interviewing
Multidisciplinary Team
Prevention
2008 National Data


~ 3.3 million reports involving ~6 million
children
772,000 children were found to be victims of
maltreatment
70%
 15%
 <10%
 <10%

Neglect
Physical Abuse
Sexual Abuse
Psychological maltreatment

Child Maltreatment 2008
Sexual abuse is common
National survey of US adults
 Childhood sexual abuse reported by
 27% of women
 16% of men1



Each year ~1% of children are victims of
CSA
Adolescents: highest rates for sexual assaults
1Finkelhor
et al. Child Abuse & Neglect 1990;14:19-28.
Risk Factors
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CSA occurs across all socioecomonic and ethnic
groups
Race and ethnicity have NOT been identified as
risk factors
Disabilities are a risk factor
Family Constellations

Putnam. J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 42:3, MARCH 2003
Myths of Sexual Abuse
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Perpetrators are strangers
Perpetrators who touch boys don’t touch girls
Children tell about the abuse immediately
Children tell fantasies
Any child victim with penetration will have an
abnormal examination
Disclosures in custody issues are all false
allegations
Pedophiles
Can have normal peer sexual relationships
 Can be sexually oriented only to children
 Can be abuse reactive



Child-on-Child
Often someone family knows
Sexual abuse – RI laws
Age
<=13
<=13
14
15
16
17
>=18
Unable to consent
Child molestation
14
15
16
17
>=18
Mark Massi
Third degree
Consensual
sex
Physical Examinations

Evaluations for the
Diagnosis & Treatment
of Child Sexual Abuse
American Academy of Pediatrics

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Developmentally appropriate interview
Complete examination to include growth,
development, social, and emotional state
Directed genital examination for specific signs
or physical indicators
Laboratory evaluation, cultures for STI’s -- as
indicated by history or physical

Culture versus NAAT testing
Physical Examination
Provides reassurance
 Examine for treatable conditions, STIs
 Collect legal evidence
 Chronic sequelae
 Assists in the protection of the child
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Triage
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Nonurgent (within few weeks)
Urgent (within a few days)
 Vaginal discharge, odor, possible pregnancy
Emergent (within 24 hours)
 Vaginal, rectal bleeding
 Psychological crisis
 Safety concerns
 Forensic Evidence Collection
Examination

When possible examinations should be
completed by specially trained physicians to
ensure that the examination is not more
traumatizing then the incidences of abuse.
General Physical Examination
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Head to toe physical examination
Attention to:
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Abdominal Exam
Skin- appropriate UV light source
 Bruising
 Ligature/control marks
Oral
 Sign of penetration
 Sexually transmitted diseases
Physical Examination Genitals

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Completed in a non-traumatic manner
External inspection

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A speculum is infrequently used in adolescents and
rarely used in pre-pubertal children
Colposcope
Tool for magnification and photo-documentation
 Does not see what is not there

Estrogen Effect on Hymen
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Circulating maternal hormones causes
estrogenization of hymen
Hormonal influences decrease in childhood
Hormonal influences become obvious once
again during puberty
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Estrogen- Thickened, redundant and pale.
Physical Signs and Symptoms
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Bruises, scratches, bites
Abdominal pain
Genital bleeding – “blood on underwear”
Genital discharge, sexually transmitted disease
Genital or Anal Pain
Genital Skin Lesions
Genital/Urethral/Anal Trauma
Enuresis, Recurrent Urinary Tract Infections
Encopresis, Anal Fissures
Diagnosing Sexual
Abuse
Can the doctor tell?
Can any doctor complete these
evaluations?
Physicians
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Not trained
Feel uncomfortable
Call normal findings abnormal
Call abnormal findings normal
Do Physician’s Recognize Sexual
Abuse?

More than half could not recognize clear
evidence of chronic sexual trauma

More than half of primary care physicians could
not identify major parts of a female child’s
genital anatomy

Ladson et al AJDC l987
Physical Examination Findings

Untrained physicians are more likely to overdiagnosis -- meaning calling normal variations
evidence of abuse when they are not…

Or miss chronic findings of abuse and call the
examination normal when it is not!
“Genital Examinations for Alleged Sexual Abuse
of Prepubertal Girls: Findings by Pediatric
Emergency Medicine Physicians Compared With
Child Abuse Trained Physicians”


ER Physician: Diagnosed patients with non-acute
genital findings indicative of sexual abuse
Child Abuse Physicians:
 32 (70%) normal
 4 (9%) nonspecific
 2 (4%) concerning
Makoroff et al Child Abuse Negl 2002
Physical Exam

Adams approach to interpretation of medical
findings in suspected child sexual abuse

Adams et al. Guidelines for medical care of
children evaluated for suspected sexual abuse: an
update for 2008. Current opinion in obstetrics
and gynecology 2008;20(5):435 -441
Physical Exam
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Findings commonly seen in non abused children
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Findings commonly caused by other medical
conditions
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Ex: periurethral bands
Ex: erythema of the vestibule
Indeterminate findings (conflicting data from
research, requires further evaluation to determine
significance)
 ex: deep notch in hymen
Physical Exam

Findings diagnostic of trauma and/or sexual
contact
Examples:
 Lacerations or bruising
 Hymenal transection (area of hymen torn through
or nearly through the base)
 Infection such as chlamydia > 3years old
 Pregnancy
 Sperm on sample taken from child’s body

Examination
Techniques
Physical Findings


5-10% of children have physical findings
Genital (female)
Bruising
 Transections
 Absent hymenal tissue
 Abrasions
 Sexually Transmitted Diseases

Physical Findings
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Genital (Male)
Penile Abrasions
 Bites, Bruises
 Urethral/Anal Discharge
 Sexually Transmitted Infections
 Scars

“It’s normal to be
normal.”
Joyce Adams, MD
“Genital Anatomy in Pregnant
Adolescents: “Normal” Does Not
Mean “Nothing Happened”;
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36 pregnant adolescents seen for sexual abuse
evaluations
2/36 (6%) had definitive findings of penetration
(cleft to base of hymen)
4/36 (8%) had suggestive findings of penetration
(deep notches or clearly visible scars)
Kellogg N et al Pediatrics 2004
Repetitive Penetration
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Study 506 girls 5-17 with reported penile-vaginal
penetration
85% of victims reporting > 10 penetrative
events had no definitive findings on exam
This was true even if this occurred over a long
period of time.

Anderst Pediatrics 2009: 124-;e403-e409
Physical Exam
A
normal exam does not
exclude the possibility of sexual
abuse or prior penetration
“The genital examination of the abused
child rarely differs from that of the
nonabused child. Thus legal experts
should focus on the child’s history as the
primary evidence of abuse.”
Berenson, A. Am J. OB/Gyn 2000
“Children Referred for Possible Sexual
Abuse: Medical Findings in 2384 Children”

Referrals based on disclosure, behavior changes,
medical findings
 Overall 96% had normal exams
 5.5% abnormal when disclosed penetration
 1.7% abnormal without history penetration
 8% exams abnormal when had medical
findings
 STIs, acute genital trauma, healed hymenal
trauma, transections
Heger et al Child Abuse & Neglect 2000
Why are exams normal?
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Nature of assault may not be damaging
Perception of “penetration”
Disclosures often delayed
Complete healing can occur
The hymen changes with puberty
Physical Exam

2 year old female living in home with father after
9 year old half sister disclosed sexual abuse by
him.

brought 2 year old to the pediatrician for a genital
“rash” but did not report history of half-siblings
disclosure. When the pediatrician said everything
“looked fine” mother concluded that 2 year old was
not sexually abused and could continue living with
father

Evidence based medicine, experience and reason
support that a normal exam does not rule out
sexual abuse or prior penetration

This may contradict beliefs of families (and
jurors, some law enforcement workers)

Try to understand families’ perceptions and
explain significance of exam findings
Additional Exam Findings
Stay Moral, Go Oral
Adolescents do not consider oral sex
to be sexual activity. Need to ask if
anything has been in the mouth!
Mimickers of Sexual Abuse
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Medical Conditions
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Accidental Trauma
Vaginal Bleeding
Case
Physiologic Endometrial
Shedding
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Vaginal bleeding is occasionally observed in female
infants during the first few weeks of life.
The condition results from the reduction in high level
of placentally acquired maternal estrogens that takes
place after birth.
The bleeding occurs as the stimulated endometrial
lining is shed, usually ceases within 7-10 days.
Prepubertal Vaginal Bleeding


Endometrial Shedding
EndocrineHypothyroidism
 Liver Cirrhosis
 Coagulopathy
 Precocious puberty
 McCune-Albright Syndrome
 Ovarian Cyst

Case # 2
Urethral Prolapse
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Exam- annular mass from urethral meatus
Urethral mucosa is friable
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bleeding, pain and dysuria.
Prolapse can be more pronounced with Valsalva
maneuver
Not associated with child abuse
More prevalent in African-American females
Tx: Nonsurgical unless
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Urinary retention, or lesion is necrotic
Case
Lichen Sclerosus et Atrophicus
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Hypopigmented, well-circumscribed areas of
atrophic skin around genital and/or anus.
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“Figure-of-eight”
Subepithelial hemorrhages
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Frequently mistaken for bruising or bleeding caused
by trauma from SA
Straddle Injuries
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Site of impact often anterior
External to hymen
Unilateral
Painful
Bleeding may be significant
Occasional penetrating trauma to hymen with
external to internal injury
Case
Vaginal Foreign Body
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Intermittent bloody discharge.
Toilet paper is the most common foreign body
Not indicative of abuse
Summary
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Differential Dx for Vaginal Bleeding
Sexual Abuse
 Physiologic Endometrial Shedding
 Urethral Prolapse
 Lichen Sclerosus et Atrophicus
 Labial Agglutination
 Foreign body
 Accidental trauma
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Continued
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Tumors
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Clear Cell Carcinoma
Rhadomyosarcoma
Ovarian
Adrenal
Urinary Tract
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Urethral Prolapse
Hemorrhagic cystitis
Urate Crystals
Hematuria
UTI
Continued
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GI Tract
Hematochezia
 Anal Fissure
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Dermatology
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Lichen Sclerosis et Atrophicus
Forensic Evidence Collection
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Sexual Assault has occurred within 72-hours
Disclosure
 Witnessed
 Confession

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Contact could have resulted in transfer of bodily
fluids
“Forensic Evidence Findings in
Prepubertal Victims of Sexual Assault”
 Christian
et al Pediatrics 2000
90% of children with positive kits were seen within
24 hours of assault
 64% evidence found on clothing and linens
 (Only 35% children had clothing/linens collected)
 No swab positive for semen/sperm after 9 hrs

Forensic Evidence Collected on
Examination

(1)
(2)
Conclusions: Forensic evidence collections
from body sites in child and adolescent rape
patients are unlikely to yield positive results for
semen:
more than 24 hours after the event and
when taken from prepubertal patients.

Young. Arch Pediatr Adolesc Med. 2006;160:585-588
“Date Rape” Drugs
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(Alcohol)

Not typically screened for in routine toxicology
screen
Specifically must request urine screen
Found in urine up to 24 hours after ingestion
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“Date Rape” Drugs
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GHB and metabolites
Loss of consciousness, hypothermia, clonic jerking
 Effects begin after 10-15 minutes
 Peak within 25- 45 minutes
 Persists up to 5 hours

“Date Rape” Drugs
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Rohypnol- Flunitrazepam
Benzodiazepine
 Sedation, loss of consciousness
 Effects begin after 30 minutes
 Peak within 2 hours
 Persist up to 8-12 hours

Physical Examination

The health and welfare of the child take
precedence over legal and investigative needs
Sexually Transmitted
Infections
How often do STI’s help to make the
diagnosis of Child Sexual Abuse?
Symptoms
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Burning
Discharge
Itching
Bleeding
Anogenital Pain
Pubertal- may have no symptoms
Sexually Transmitted Diseases
2973 Children evaluated for sexual abuse:
 1.7% Gonorrhea
 1.3% Chlamydia
 0.2% Syphilis
 <1% Trichomonas
 1.7% Condyloma acuminata (warts)
 0.3% Herpes Simplex Virus
Who do we test?
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Age of child
High risk of STI in assailant (incarceration)
Household member with STI
Type of sexual abuse
Symptoms (vaginal discharge)
Acuity of abuse
Patient/family concern
High incidence in community
Multiple/unknown offenders
STDs for the Diagnosis of CSA

Gonorrhea*
Syphilis*
HIV §
C trachomatis*
T vaginalis
HPV
Herpes simplex Virus (HSV)
Diagnostic†
Diagnostic
Diagnostic
Diagnostic†
Highly suspicious
*Suspicious (Indeterminate)
*Suspicious
(Probable, Indeterminate)

Bacterial vaginosis
Inconclusive
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Kellogg, The Evaluation of Sexual Abuse in Children. Pediatrics 2005;116;506-512

*Reading. Arch Dis Child 2007;92:608–613. doi: 10.1136/adc.2005.086835
*Adams. Current Opinion in Obstetrics and Gynecology 2008, 20:435–441

Sexually Transmitted Disease (STD)
Infections (STI)

HPV- Human Papilloma Virus

Sinclair Study- Anogenital and Oral Pharyngeal
Warts
31% likelihood of Sexual Abuse
 No actual “cut off-age”


Sinclair KJ, et al. Pediatrics 2005; 116:815–825.
Physical Examination
In only a very small percentage will it
help to make the diagnosis of child
sexual abuse by itself.
Corroboration:
Evidence exists more often than you
think
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Physical evidence (FEK)
Behavioral symptoms
Adult witnesses and
suspects
Medical evidence (exam)
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Other victims
Child witnesses
Child pornography
Computers
Cell Phones
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Photos
Text Messages
Perpetrator confessions
Sexualized Behaviors
Can the diagnosis of sexual abuse be
made based on sexualized behaviors?
Behavioral Signs

Is that a red flag
being waved?
Infants (0-18 months)
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Rarely show symptoms
Fussy, diaper change reluctance
Fearful of offender
Imitate sexual acts
Toddlers (18-36 months)
All of the above plus:
 Difficulty toilet training, sleep disturbances
 Minimal embarassment
 Masturbation common (normal)
Preschool (3-5 years)
All of the above plus:
 Sexualized play, perpetration
 Headaches, abdominal pain, painful urination,
genital discomfort
 Nightmares
 Regression
 Anger, aggression, mood swings
School Age (6-9 years)
Any of the above plus:
 Confusion, guilt
 Withdrawn, depression, nightmares
 Poor school performance, lying, stealing
 Sexualized behavior, somatic complaints
 Enuresis, encopresis, dysuria
Puberty (9-12 years)
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Feel responsible, overwhelming guilt/shame
Shoplifting, substance abuse
Sexual identity crisis
Uncomfortable with body and disclosure
Adolescents (13 years +)
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Defiance, aggression, truancy, school failure,
promiscuity, suicidal ideations, self-mutilation,
runaway behavior
Somatic complaints
Peer Sexual Contact
Behaviors


Parents are not always good historians regarding
stress.
Exposure to adult sexual information
Pornography
 Cable
 Internet

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Adult interpretation of sexualized play.
Normative Sexual Behavior in Children


Friedrich, W. Pediatrics 1991 and again in 1998
Questionnaire-demographic information, Child
Sexual Behavior Inventory (CSBI), and the
Problem Behavior portion of the Child Behavior
Checklist (CBCL)
Friedrich – Normative Sexual
Behavior in Children
1991-- 880 Children ages 2-12
 1998 -- 1114 Children ages 2-12
 Administered specialized surveys
 Excluded those with concerns sexual abuse

“There is a broad range of sexual behaviors
exhibited by children who there is no reason
to believe have been sexually abused”
Friedrich’s Top 10 (most common)
10.
9.
8.
7.
6.
Dresses like opposite sex
Hugs adults not known well
Shows sex parts to adults
Masturbates with hand
Very interested in opposite sex
(**10-12yo)
Friedrich’s Top 10 (most common)
5.
4.
3.
2.
1.
Touches sex parts in public
Tries to look at people when they are nude
Stands too close
Touches breasts
Touches sex parts at home
Least common behaviors…
Makes sexual sounds, asks others to do sex acts
Masturbates with or puts objects in vagina/rectum
Pretends toys are having sex
Undresses other children
Tries to have intercourse
Puts mouth on sex parts
Touches animal’s sex parts
Draws sex parts
Normal Sexual Behaviors

A Child’s sexual behaviors are influenced by:
 Age
 Family Stress and Violence
 Family Sexuality
 Culture/Religion
 Surroundings, exposure to age-inappropriate
information and materials
Concerning Sexual Behaviors

Influenced by:
 Media (television, internet, videos, magazines)
 Decreased parental supervision
 Decreased boundaries
 Overt exposure
 Sexually Abused
When to be concerned?
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Sexual expression is more adult than childlike
Other children complain
Continues despite requests to stop
Children sexualize nonsexual things
Genitals are persistent and prominent in
drawings
Disclosure of CSA in Art and Play


Specific Concerns with playing
Sand-Tray Therapy


Therapy not Diagnostic Assessment
Art- should not have to be interpreted
“ I know he was sexually abuse because he is
drawing sharks”
 Examples
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Interactive Session

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Sexualized behavior does not mean that a child
is a victim
Developmental component


Toddler/Preschooler? School Age?
Assessment component
Playing Doctor

Plays doctor/inspects others’ bodies

Frequently plays doctor even after getting
caught and reprimanded

Forces others to play doctor and/or to
remove clothes, touching privates
Placing Objects in Genital
Orifices

Tries to place objects in own
genitalia/rectum one time – curious

Places object in genitalia or rectum of
self/others

Uses coercion/pain in placing object in
genitalia/rectum of self and others
Disclosures in Sexual
Abuse
The most important piece of the puzzle
This may make your diagnosis
Disclosures in Sexual Abuse

Can the diagnosis of sexual abuse be made
based on a disclosure of sexual abuse?
YES

A child’s disclosure alone CAN make the
diagnosis of sexual abuse…
Disclosure is a Process

Children disclose gradually versus rapidly.
BUT…

The disclosure needs to be obtained
appropriately without direct and leading
questions
Context of any Disclosure

Was this a spontaneous disclosure?

Was the child asked multiple questions?

Was the child asked leading questions?
Case
Case: Interview
Interviewing

Trained Interviewers

Limiting number of interviews

First responders need to learn how to obtain
information
A Good Interview Should…
Assess competence
 Address context initial disclosure
 Avoid direct and leading questions
 Document body language
 Child’s language
 Remember children think concretely

Child’s History
Build rapport
 Use open-ended questions
 Use child’s language
 Reassurance

Questions used in Interviewing




General/Open: “How are you?” “Do you
know why you’re here today?” “What happened
next?” “ Tell me about that”
Focused: “What did he poke you with?”
Yes/no: “Were your clothes off?”
Multiple choice: “Did he poke you with his
finger, his private, or something else?”
Kathleen Coulborn Faller
The Leading Question
Pt complains of genital pain
“Did Uncle Joey put his pee-pee in your
flower
?
Why don’t all kids talk?



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Not developmentally ready, acts weren’t “bad”
Sworn to secrecy
Trapped and Helpless
Afraid to upset family
Fears no one will believe



May have disclosed and told “ She would never do that”
Threats
Feels responsible, overwhelming guilt/shame
“How Children Tell: The Process of
Disclosure in Child Sexual Abuse”


Sorenson and Snow Child Welfare 1991
630 child victims (1985-1989) (3-17 ages)
116 confirmed cases
 Confession (80%)
 Conviction (14%)
 Medical Findings (6%)


Types of Disclosures – part of continuum
4 Steps of the Process


Denial
Disclosure
Tentative
 Active



Recant
Reaffirm
Denial

Child’s initial statement was that he/she was
NOT a victim of sexual abuse

Three-fourths of children denied when initially
questioned
Disclosure

Tentative (78%): child’s partial and vague
acknowledgement of sexual abuse
“It only happened once”
 “It happened to Joe”
 “He tried to touch me but I hit him”
 “I was only kidding”

Disclosure

Active: a personal admission by the child of
having experienced a specific sexually abusive
activity
7% of initial denials move directly to active
 96% of all eventually give active disclosure

Recant

Refers to the child’s retraction of a previous
allegation of abuse that was formally made and
maintained over a period of time
Recantations

Common, 22% of children in study

Often influenced by the perpetrator but more
often influenced by the “non-offending” family
members
Intentionally
 Unintentionally

Reaffirm

Defined as the child’s reassertion of the validity
of a previous statement of sexual abuse that has
been recanted

Of those who recanted, 92% reaffirmed the
allegations over time
Conclusion

Only a small percentage of children will be in
ACTIVE disclosure at the first interview

Disclosure of sexual abuse is a process not an
EVENT
Minimal Facts Interview
 Where
on the body touched
 Who touched him/her
 What did the touching
 Where did the touching occur
 When did this happen
 NOT
WHY
Disclosures

Suggestibility


Misleading questions, direct questions and negative
feedback to answers can affect what is recalled and
reported
Children (especially younger children) are
particularly vulnerable to suggestibility
Depend on adults
 Defer to adults
 Aware of adult authority
 Tendency to want to please adults

Infants (0-18 months)




NO DISCLOSURES
Rarely show symptoms
By 18 months majority have only 10 words
Confirmed only with sexually transmitted
disease, semen, offender confession, eye witness,
abnormal exam
Toddlers (18-36 months)




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50-200 word vocabulary
Two word sentences start at 21 months
 “Daddy owie” “Papa down”
Accidental disclosures
Masturbation normal
Substantiate with sexually transmitted disease,
semen, offender confession, eye witness,
abnormal exam
Preschool (3-5 years)
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Improved Vocabulary!! (2500-3000 words)
Partial disclosures
Minimization, denial, irrelevant details
Better at who, what, where (not when or
number of times)
History now more important
Substantiation with HISTORY, STDs, semen,
confession, eye witness, abnormal exam
School Age (6-9 years)
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More independent, learning boundaries
Tentative disclosures
Build rapport
Fear of jail
Substantiate with HISTORY, labs/STDs,
semen, confession, eye witness, abnormal exam
Puberty and Adolescents
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Peers often more influential
than family
Family withdrawal
Disclose due to peers, anger
Uncomfortable with body
and disclosure
Reassurance of being normal
important
Substantiate with
HISTORY, labs/STDs,
semen, confession, eye
witness, abnormal exam
Delayed Disclosures
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“When children do disclose, it often takes them
a long time to do so” (London, et al, 2005)
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Elliott & Briere (1994) found that 75% of
children in substantiated cases had delayed over
a year before telling anyone
Interview Stages
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Introduction
Rapport-building/Developmental
Assessment/Narrative Practice
Ground rules
Substantive questions
Closure
Use of Media
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Anatomical Dolls
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Anatomical Drawings
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Gingerbread Drawings:
Language Considerations
Interview
Interview
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What next?
Interview
False Allegations
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Risk situations for false allegations by adults:
Divorce/Custody Disputes
Disagreement re: motivation; Benedek &
Schetky, 1985 said majority are
calculated…Faller & DeVoe, 1995 said most
falsely accusing parents genuinely believe child
has been abused
Phases of disclosure
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I. Denial
Initial statement that he/she has not been
abused
Case example 9
 4 year old female
 Neighbor in adjacent apartment witnessed patient’s
adult male roommate sexually abusing her
 Witnessed filmed incident and called 911
 Perpetrator confessed
 Patient denied sexual abuse
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Parental response to disclosure
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Response of the non-offending parent is
associated with short and long-term
psychological outcomes
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Lack of support / belief associated with
 Depression
 Anxiety
 Behavioral problems
 PTSD
Provide this information to parents
Rickerby et al. Family response to disclosure of childhood sexual abuse: Implications
for secondary prevention. Mental Health Rhode Island 2003;86(12):387-389
Parental Response
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Non offending parents experience emotional
distress following their child’s sexual abuse
disclosure
Parental response impacts child
Parental response influenced by:
Prior history of depression
 History of sexual abuse
 Relationship to the perpetrator
 Social isolation
 Substance abuse
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Parental Response
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Examples of information provided to supportive
parents
Emphasize importance of parents’ role in the healing
process
 Encourage continued support, reassurance,
affirmation that child is believed
 Do not repeatedly question child about disclosure
 Acknowledge parents’ emotional distress
 Recommend an outlet for parents’ distress separate
from the children (ex. counseling, adult supports)
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MDT
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Strengthens the
investigative process
Expertise from Law
Enforcement, Child
Protective Services,
Medical, Forensic
Interviews, Prosecutors,
and others
Don’t drop the ball
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Immediate response
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During the Investigation by CPS and Law
Enforcement
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Afterwards
MDT in Action
MDT in Action
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When each member is available and does their
part, cases will go much smoother
PREVENTION
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School-based child education programs
successful
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teaching children CSA concepts and self-protection
Negative:
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increased anxiety, feeling less in control for younger
children, and feeling more discomfort with normal
touch in older children
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Putnam. J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 42:3, MARCH 2003
PREVENTION
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Parental Education
Truth versus myths
 When to start- 10 yo is too late!
 How often
 Mental Health Care for parent’s prior abuse
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Communication
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Young children are concrete thinkers
Judgment
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Caregivers
Myth Case
Alleged Perpetrators- Still allowed
Access
Prevention
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Types:
Education
 Home Visiting Programs
 Adult Focus
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The Relationship of Adverse Childhood
Experiences to Adult Health Status
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ACE
Child Maltreatment
Physical
 Sexual
 Psychological
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Parental
Etoh and Drug abuse
 Domestic Violence
 Incarceration
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ACE
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Direct relationship between the number of ACE
and adverse health outcomes
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Include Mental Health and Physical Health
ACE
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Long term physical health consequences
ACE study
• Health problems
• Abuse
• Neglect
• Household
dysfunction
•
•
•
•
•
•
Heart disease
Liver disease
Depression
Substance abuse
Lung disease
Fetal death
Long term physical health consequences
Dong et al. Arch Intern Med. 2003;163:1949-1956
Take Home Points
Child Sexual Abuse is prevalent
 Diagnosis of CSA not usually by physical
exam findings or behavior alone
 Many “sexual behaviors” are normal
 Disclosures -- most important and need to
be obtained appropriately
 Think about any other possible evidence!
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