Clinical practice: recognizing child sexual abuse-what makes it so difficult?

Recognizing child sexual abuse (CSA) in children is difficult, as there can be many hurdles in the assessment of alleged CSA. With this paper, we try to improve the recognition of CSA by discussing: (1) the difficulties regarding this matter and (2) the diagnostic evaluation of alleged CSA, combining both practical clinical recommendations based on recent research. Children are restrained to disclose CSA due to various reasons, such as fears, shame, and linguistic or verbal limitations. Associations between CSA and urogenital or gastrointestinal symptoms, internalizing and externalizing behavioral problems, post-traumatic stress symptoms, and atypical sexual behavior in children have been reported. However, these symptoms are non-specific for CSA. The majority of sexually abused children do not display signs of penetrative trauma at anogenital examination. Diagnosing a STI in a child can indicate CSA. However, other transmission routes (e.g., vertical transmission, auto-inoculation) need to be considered as well.Conclusion: The assessment consists of medical interview and child interview (parents and child separate and together) with special attention to the child's development and behavior (problems), psychosocial situation and physical complaints, the child's mental health, and the child's trauma history; anogenital examination should be done in all cases of alleged CSA. The examination should be documented by photo or video graphically. Recent research suggests that videography may be the preferred method, and testing on STIs. The assessment should be done multidisciplinary by experienced professionals. Health-care professionals who care for children need to know how child protective agencies and law enforcement are organized. In case there are concerns about a child's safety, the appropriate authorities should be alarmed. What is Known: • Sexual abuse in children often remains unrecognized in the majority of cases. What is New: • Research suggests that videographic documentation is preferred above photographic documentation for anogenital examination; observations of children's behavioral reactions during examinations might be valuable in the evaluation of suspected sexual abuse; nucleic acid amplification testing can be used on vaginal swabs or urine samples for chlamydia and gonorrhea; the CRIES-13 and the CAPS-CA can be used to assess trauma-symptoms in children after sexual abuse.

The Diagnostic Utility of the Child Sexual Behavior Inventory for Sexual Abuse: A Systematic Review.

Children with alleged child sexual abuse (CSA) need to be assessed systematically. The use of validated instruments during the assessment, like the Child Sexual Behavior Inventory (CSBI), could add diagnostic value. We aim to assess the diagnostic utility of the CSBI to differentiate between sexually abused and non-abused children. We conducted a systematic review. We searched the electronic databases MEDLINE and PsychInfo for studies comparing CSBI scores in sexually abused children and non-abused children (2-12 years old). Two independent reviewers extracted data and assessed the methodological quality. We included 7 (out of 1048) articles. The CSBI total scores were significantly higher in CSA-victims compared with non-abused children (in case-control settings). However, in children with suspected CSA, the results were ambiguous. One study reported significant differences. Another study reported weak diagnostic ability for the CSBI-3 in children with suspected CSA (a sensitivity and specificity of 0.50, with a positive predictive value of 0.28, and a negative predictive value of 0.72). Research on the diagnostic utility of the CSBI for suspected CSA is limited and shows disappointing results. Until more research is done, the CSBI should not be used on its own to differentiate between sexually abused and non-abused children.

Physical symptoms in very young children assessed for sexual abuse: a mixed method analysis from the ASAC study.

So far, a recognizable pattern of clinical symptoms for child sexual abuse (CSA), especially in young male children, is lacking. To improve early recognition of CSA, we reviewed physical complaints, physical examination, and tests on sexually transmitted infections (STIs) in confirmed victims (predominantly preschool boys) of CSA from the Amsterdam sexual abuse case (ASAC). We retrospectively analyzed the outcomes of the primary assessment using mixed methods: descriptive analysis of physical complaints, physical exams, and STI tests from medical files and a qualitative analysis on expert's interpretations of physical complaints and children's behavior during physical examination. We included 54 confirmed CSA victims, median age 3.2 (0-6) years, 43 boys (80%), and 11 girls (20%). Physical complaints were reported in 50%, of which gastrointestinal and anogenital complaints were most common. None of the children showed CSA-specific genital signs at physical examination. Most prominent finding during physical examination was a deviant behavioral response (anxiety, withdrawal, too outgoing) in 15 children (28%), especially in children who experienced anal/vaginal penetration. Testing for STIs was negative. CONCLUSION: Physical complaints and physical signs at examinations were non-specific for CSA. Deviant behavioral reactions during physical examination were the most prominent finding. Precise observation of a child's behavior during physical examination is needed. What is known • Child sexual abuse (CSA) affects many children on both the short and the long term but remains unrecognized in most cases. • So far, there is a lack of studies on symptom patterns of CSA in male, preschool children. What is new • None of the children showed CSA-specific findings at physical and anogenital examination; STIs were not found in the confirmed victims of CSA. • The most prominent finding was the deviant behavioral response of the children examined, especially in children who experienced anal/vaginal penetration; therefore, precise observation of a child's behavior during physical examination is a crucial part of the evaluation of suspected CSA.

Assessments carried out by a child abuse and neglect team in an Amsterdam teaching hospital led to interventions in most of the reported cases.

AIM: This study described cases of child abuse and neglect (CAN) that were reported to the multiagency CAN team at the Emma Children's Hospital in Amsterdam and the resulting interventions. METHODS: We carried out a retrospective review of all cases that were reported to the CAN team from 1 January 2010 to 31 December 2012. RESULTS: There were 27 prenatal cases, 92 referrals based on parental characteristics and 523 children. Overall, 1.2% of the children visiting the emergency department of our hospital, attending the outpatients department or being admitted were reported to the team. More than half of the referrals (55.1%) were confirmed as CAN. The most common diagnoses were as follows: witnessing intimate partner violence, physical neglect and emotional abuse. If CAN was confirmed an intervention was offered in 98.3% of cases. If a CAN diagnosis was undetermined or rejected, the figures were still 83.5% and 64.2%, respectively. CONCLUSION: Our results showed that CAN affected more than one in every 100 children visiting our hospital, and the expertise of our hospital-based CAN Team led to an intervention in the majority of the reported cases. The broad scope of problems that were encountered underlined the importance of a multidisciplinary CAN team.

The Amsterdam Sexual Abuse Case (ASAC)-study in day care centers: longitudinal effects of sexual abuse on infants and very young children and their parents, and the consequences of the persistence of abusive images on the internet.

BACKGROUND: Little research has been done on the signs of child sexual abuse (CSA) in infants and very young children, or on the consequences that such abuse - including the persistence of the abusive pornographic images on the internet - might have for the children and their parents. The effects of CSA can be severe, and a variety of risk- and protective factors, may influence those effects. CSA may affect the psychosocial-, emotional-, cognitive-, and physical development of children, their relationships with their parent(s), and the relations between parents. In the so called 'the Amsterdam sexual abuse case' (ASAC), infants and very young children were victimized by a day-care employee and most of the victims were boys. Research involving the children and their parents would enable recognition of the signs of CSA in very young children and understanding the consequences the abuse might have on the long term. METHODS/DESIGN: The proposed research project consists of three components: (I) An initial assessment to identify physical- or psychological signs of CSA in infants and very young children who are thought to have been sexually abused (n = 130); (II) A cross-sequential longitudinal study of children who have experienced sexual abuse, or for whom there are strong suspicions; (III) A qualitative study in which interviews are conducted with parents (n = 25) and with therapists treating children from the ASAC. Parents will be interviewed on the perceived condition of their child and family situation, their experiences with the service responses to the abuse, the effects of legal proceedings and media attention, and the impact of knowing that pornographic material has been disseminated on the internet. Therapists will be interviewed on their clinical experiences in treating children and parents. The assessments will extend over a period of several years. The outcome measures will be symptoms of posttraumatic stress disorder (PTSD), dissociative symptoms, age-inappropriate sexual behaviors and knowledge, behavioral problems, attachment disturbances, the quality of parent-child interaction, parental PTSD, parental partner relation, and biological outcomes (BMI and DNA). DISCUSSION: The ASAC-project would facilitate early detection of symptoms and prompt therapeutic intervention when CSA is suspected in very young children.

Prevalence of suspected child abuse in children with constipation: a case-control study.

BACKGROUND: A possible association between child abuse and neglect (CAN) and functional constipation (FC) has been described in adults, however, limited data are available in children. Our objective was to determine the prevalence of suspected CAN in children with FC as compared with their healthy peers. METHODS: A case-control study was carried out in children aged 3-10 years. Children with FC were recruited at a tertiary outpatient clinic, and healthy controls were recruited at schools. Parents were asked to fill out questionnaires about the history and behaviour of their child, children were inquired using a semistructured interview about experienced traumatic events and sexual knowledge. The interview was scored by two independent observers. The prevalence of suspected CAN was determined according to the questionnaires and interview. RESULTS: In total, 228 children with FC and 153 healthy controls were included. Both groups were age and gender comparable (50% females, median age 6 years (not significant)). No significant difference in the prevalence of suspected CAN was found between children with FC and healthy controls (23.3% vs 30.1%, 95% CI 0.44 to 1.12, p=0.14), including a suspicion of sexual, emotional and physical abuse. CONCLUSION: Suspected CAN was detected in both children with FC as in healthy controls. The possible association between CAN and FC in children could not be confirmed.

Sexual abuse in very young children: a psychological assessment in the Amsterdam Sexual Abuse Case study.

Background: Child sexual abuse (CSA) is a worldwide problem affecting children of all ages and socioeconomic backgrounds. A knowledge gap exists regarding the psychological outcomes for children, boys in particular, who are abused during their early lives. Objective: To provide a descriptive psychological profile of children who experienced sexual abuse as infants or toddlers from a male daycare worker and babysitter, and to assess the psychopathological impact on their parents. Method: Parents of children involved in the Amsterdam Sexual Abuse Case (41 parents; 44 children, age range 3-11 years, 30 boys, 14 girls) completed measures on post-traumatic stress disorder (PTSD), dissociation, sexual and non-sexual behaviour problems, and attachment insecurity in their children, as well as on parental psychological well-being, 3 years after disclosure. Sexual abuse characteristics were obtained from police records. Results: We found that 3% of confirmed child victims had PTSD, 30% sexual behaviour problems, 24% internalizing problems, 27% attachment insecurity, and 18% any psychiatric disorder (including PTSD); 39% were asymptomatic. In parents, we found feelings of guilt, shame, and anger about the abuse of their child; 19% showed PTSD symptoms and 3% showed avoidant and 8% anxious attachment problems in their intimate relationship. Parental symptomatology was related to child symptomatology, except for child sexual behaviour problems. One-quarter of confirmed child victims and 45% of parents had received psychological treatment. Conclusions: Three years after disclosure, extrafamilial CSA in very young children was associated with sexual and non-sexual behaviour problems and attachment insecurity, but rarely with PTSD or dissociation. For parents it was associated with PTSD symptoms and emotional reactions. Assessments and interventions should focus on the wide spectrum of problems that follow CSA, as well as on parental psychopathology and the parent-child relationship. Future follow-up assessments in our longitudinal study should provide insights into longer-term outcomes.

Antecedentes: el abuso sexual infantil (ASI) es un problema mundial que afecta a niños de todas las edades y de todos los estratos socioeconómicos. Existe una brecha de conocimiento con respecto a los resultados psicológicos para los niños, en particular los varones, quienes son abusados durante sus primeros años de vida.Objetivo: Proporcionar un perfil psicológico descriptivo de niños que experimentaron abuso sexual cuando eran bebés o niños pequeños de un trabajador de guardería y niñera, y evaluar el impacto psicopatológico en sus padres.Método: Padres de niños involucrados en el caso de abuso sexual de Amsterdam (ASAC) (41 padres, 44 niños-rango de edad 3­11 años, 30 niños, 14 niñas) completaron medidas sobre trastorno de estrés postraumático (TEPT), disociación, problemas de conducta sexualy no sexualy apego inseguro en sus hijos, así como en el bienestar psicológico de los padres, 3 años después de la develación. Las características de abuso sexual se obtuvieron de los registros policiales.Resultados: encontramos que el 3% de las víctimas infantiles confirmadas tenían TEPT, 30% tenían problemas de conducta sexual, 24% problemas de internalización, 27% apego inseguro y 18% cualquier trastorno psiquiátrico (incluido el TEPT); 39% fueron asintomáticos. En los padres encontramos sentimientos de culpa, vergüenza e ira por el abuso de sus hijos; El 19% mostró síntomas de TEPT y el 3% mostró problemas de apego evitativo y el 8% ansioso en sus relaciones íntimas. La sintomatología de los padres se relacionó con la sintomatología de los niños, a excepción de los problemas de conducta sexual infantil. Una cuarta parte de las víctimas infantiles confirmadas y el 45% de los padres habían recibido tratamiento psicológico.Conclusiones: Tres años después de la develación, el ASI extrafamiliar en niños muy pequeños se asoció con problemas de comportamiento sexual y no sexual y apego inseguro, sin embargo, raramente con trastorno de estrés postraumático o disociación. Para los padres se asoció con síntomas de TEPT y reacciones emocionales. Las evaluaciones e intervenciones deben enfocarse en el amplio espectro de problemas que siguen al ASI, así como en la psicopatología de los padres y la relación entre padres e hijos. Las futuras evaluaciones de seguimiento en nuestro estudio longitudinal deberían proporcionar información sobre los resultados a más largo plazo.

[How do you recognise sexual abuse in children?] / Hoe herken je seksueel misbruik bij kinderen?

One in three children will experience sexual violence before they are 18 years old. The recognition and evaluation of alleged child sexual abuse is complex. Presently there are no validated, self-contained instruments that can be used to evaluate (alleged) sexual abuse in children. Allegations of child sexual abuse need to be evaluated in a systematic and multidisciplinary (medical and psychosocial) manner by professionals with relevant expertise, preferably in a specialised centre. When a child has psychosocial symptoms after sexual abuse, it is advised to refer the child for psychosocial care. For all other children, psycho-education and watchful-waiting are recommended. Clinicians can consult a guideline, published by the Paediatric Association of the Netherlands (Nederlandse Vereniging voor Kindergeneeskunde), titled 'Evaluation of (alleged) child sexual abuse'. Furthermore, advice can also be obtained from Dutch organisations such as Veilig Thuis, het Landelijk Expertise Centrum Kindermishandeling and the Sexual Assault Center (Centrum Seksueel Geweld).

Paediatric femur fractures at the emergency department: accidental or not?

Only a small proportion of all paediatric fractures is caused by child abuse or neglect, especially in highly prevalent long bone fractures. It can be difficult to differentiate abusive fractures from non-abusive fractures. This article focuses on femoral fractures in young children. Based on three cases, this article presents a forensic evidence-based approach to differentiate between accidental and non-accidental causes of femoral fractures. We describe three cases of young children who were presented to the emergency department because of a suspected femur fracture. Although in all cases, the fracture had a similar location and appearance, the clinical history and developmental stage of the child led to three different conclusions. In the first two cases, an accidental mechanism was a plausible conclusion, although in the second case, neglect of parental supervision was the cause for concern. In the third case, a non-accidental injury was diagnosed and appropriate legal prosecution followed. Any doctor treating children should always be aware of the possibility of child abuse and neglect in children with injuries, especially in young and non-mobile children presenting with an unknown trauma mechanism. If a suspicion of child abuse or neglect arises, a thorough diagnostic work-up should be performed, including a full skeletal survey according to the guidelines of the Royal College of Radiologists and the Royal College of Paediatrics and Child Health. In order to make a good assessment, the radiologist reviewing the skeletal survey needs access to all relevant clinical and social information.