Accidental scratch--or a sign of self-cutting?

Having a high index of suspicion is key to identifying adolescents who cut themselves. The approach described here can help you properly evaluate these patients and get them the help they need.

Genital and anal injuries requiring surgical repair in females less than 21 years of age.

STUDY OBJECTIVE: The injuries of sexually abused and assaulted girls seldom require surgical repair, and genital and anal injuries due to other causes appear to require repair uncommonly. We sought to determine the causes of genital and anorectal injuries requiring surgical repair in relation to such variables as injury sites and severity. DESIGN: Retrospective study SETTING: A large tertiary care children's hospital PARTICIPANTS: Forty-four girls less than 21 years of age who required surgical repair of genital injuries between June 1986 and April 2007 were identified. MAIN OUTCOME MEASURES: Information collected included the victims' ages, trauma mechanisms, and sites and severity of injuries. RESULTS: Injuries requiring repair of the genital and anal areas were uncommon in the 20 year period of this study. Although most injuries were due to straddle and impalement mechanisms, sexual abuse or assault was identified in 25% of the girls. The remaining 11% were victims of motor vehicle accidents. Straddle/impalement injuries involved only the external genitalia, vestibule, perineum, or posterior fourchette of 21 of the 28 girls (76%) with those injuries. The injuries of 9 of the 11 sexually abused/assaulted girls (82%) also involved the hymen, vagina, anus, or rectum. Injuries due to sexual abuse/assault and motor vehicle accidents (MVA) had average severity scores of 2.1 and 2.2, respectively, while straddle injuries had an average severity score of 1.4. (Exact Pearson chi-square P < 0.003.) The ages of the girls were unrelated to the severity of their injuries. CONCLUSIONS: Although straddle/impalement was the most commonly found mechanism of genital and anorectal injury requiring surgical repair, sexual abuse or assault was identified in 25% of the girls. Sexual abuse and assault should always be considered and assessed appropriately when such injuries are found. Consultation of a social worker or child abuse specialist may be appropriate, especially when injuries clearly not due to an MVA involve the vagina or anorectum. A suspicion of sexual abuse or assault should be reported to the legally mandated state agency in accordance with the laws of state.

Forensic laboratory evidence in sexually abused children and adolescents.

OBJECTIVES: To determine if forensic laboratory evidence could be recovered from alleged sexual abuse victims more than 24 hours after the event and to determine if age or historical factors could be used to determine the need for forensic evidence collections. DESIGN: Retrospective study of hospital records matched with forensic evidence reports from the Arkansas State Crime Laboratory, Little Rock. SETTING: The emergency department at Arkansas Children's Hospital, Little Rock. PARTICIPANTS: Eighty children (aged <12 years) and adolescents (aged > or =12 years) who presented to the emergency department within 72 hours of an alleged event of sexual abuse or assault with genital contact. MAIN OUTCOME MEASURES: Cases positive for semen were correlated with age of the victim and post-event length of time to presentation to the emergency department. RESULTS: Of the 80 subjects, 16 had positive findings for semen. All 16 subjects who tested positive for semen presented to the emergency department less than 24 hours after the alleged abuse or assault event (P<.001). Of the 16 subjects who tested positive, 13 (81%) were adolescents. None of the prepubertal children had semen recovered from any body site; semen was recovered only from clothing or linen in those 3 children. CONCLUSIONS: Forensic evidence collections from body sites in child and adolescent rape patients are unlikely to yield positive results for semen (1) more than 24 hours after the event and (2) when taken from prepubertal patients. Consideration should be given to amending guidelines regarding forensic evidence collections in child and adolescent sexual abuse or assault victims.

Management of sexually abused children by non-forensic sexual abuse examiners.

Physicians who do not intend to examine children suspected of having been sexually abused still need information about the disorder and its management. A history from the caretaker and child is vital to determine the safety of the child from further abuse and the urgency of a physical evaluation for health and forensic purposes. The disclosure interview of a young child in Arkansas generally should be by an agency investigator to avoid multiple interviews, after a legally mandated report to the Child Abuse Hotline. The physical evaluation can be delayed when the conditions listed in the Table are met, and a referral to a secondary or tertiary level examiner would follow. Otherwise, immediate referral likely will be to a primary level examiner, such as in an emergency department; the child will receive an examination and tests for acute findings and possible referral to a secondary or tertiary level examiner for a more thorough examination. The child and frequently an adult family member should be referred for counseling.

A videotape series for teaching physicians to evaluate sexually abused children.

A free videotape subscription series was utilized to increase the knowledge of general physicians in clinical practice about the medical evaluation of sexually abused children. Of the 65 physicians who requested the first tape, 39 (60%) completed it. Fourteen of the 39 physicians who completed the first tape (36%) completed the 5-tape series. Completion data suggested that series completion was unrelated to prior knowledge, years since training or number of sexual abuse examinations performed in the previous year. Evaluative comments suggested that quality of the tapes was not a factor in completion rate. On tests of immediate retention, the average posttest percent correct was significantly higher than on the pretest. In a 3-year follow-up of the 14 physicians who completed the series, 10 reported that they were still performing sexual abuse examinations.