Presentation on theme: "Investigating Child Sexual Abuse"— Presentation transcript:
1 Investigating Child Sexual Abuse Christine E. Barron, MDAssistant Professor, PediatricsWarren Alpert Medical Schoolat Brown University
2 Objectives National Data Physical Examination “Red Flag” Behaviors Disclosures and Forensic InterviewingMultidisciplinary TeamPrevention
3 2008 National Data ~ 3.3 million reports involving ~6 million children 772,000 children were found to be victims of maltreatment70% Neglect15% Physical Abuse<10% Sexual Abuse<10% Psychological maltreatmentChild Maltreatment 2008
4 Each year ~1% of children are victims of CSA Sexual abuse is commonNational survey of US adultsChildhood sexual abuse reported by27% of women16% of men1Each year ~1% of children are victims of CSAAdolescents: highest rates for sexual assaults1Finkelhor et al. Child Abuse & Neglect 1990;14:19-28.
5 Risk Factors CSA occurs across all socioecomonic and ethnic groups Race and ethnicity have NOT been identified as risk factorsDisabilities are a risk factorFamily ConstellationsPutnam. J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 42:3, MARCH 2003
6 Myths of Sexual Abuse Perpetrators are strangers Perpetrators who touch boys don’t touch girlsChildren tell about the abuse immediatelyChildren tell fantasiesAny child victim with penetration will have an abnormal examinationDisclosures in custody issues are all false allegations
7 Pedophiles Can have normal peer sexual relationships Can be sexually oriented only to childrenCan be abuse reactiveChild-on-ChildOften someone family knows
8 Sexual abuse – RI laws Age <=13 14 15 16 17 >=18 Unable to consent<=13Child molestation14Third degree1516Consensualsex17>=18Mark Massi
9 Physical Examinations Evaluations for the Diagnosis & Treatment of Child Sexual Abuse
10 American Academy of Pediatrics Developmentally appropriate interviewComplete examination to include growth, development, social, and emotional stateDirected genital examination for specific signs or physical indicatorsLaboratory evaluation, cultures for STI’s -- as indicated by history or physicalCulture versus NAAT testing
11 Physical Examination Provides reassurance Examine for treatable conditions, STIsCollect legal evidenceChronic sequelaeAssists in the protection of the child
12 Triage Nonurgent (within few weeks) Urgent (within a few days) Vaginal discharge, odor, possible pregnancyEmergent (within 24 hours)Vaginal, rectal bleedingPsychological crisisSafety concernsForensic Evidence Collection
13 ExaminationWhen possible examinations should be completed by specially trained physicians to ensure that the examination is not more traumatizing then the incidences of abuse.
14 General Physical Examination Head to toe physical examinationAttention to:Abdominal ExamSkin- appropriate UV light sourceBruisingLigature/control marksOralSign of penetrationSexually transmitted diseases
15 Physical Examination Genitals Completed in a non-traumatic mannerExternal inspectionA speculum is infrequently used in adolescents and rarely used in pre-pubertal childrenColposcopeTool for magnification and photo-documentationDoes not see what is not there
16 Estrogen Effect on Hymen Circulating maternal hormones causes estrogenization of hymenHormonal influences decrease in childhoodHormonal influences become obvious once again during pubertyEstrogen- Thickened, redundant and pale.
17 Physical Signs and Symptoms Bruises, scratches, bitesAbdominal painGenital bleeding – “blood on underwear”Genital discharge, sexually transmitted diseaseGenital or Anal PainGenital Skin LesionsGenital/Urethral/Anal TraumaEnuresis, Recurrent Urinary Tract InfectionsEncopresis, Anal Fissures
18 Diagnosing Sexual Abuse Can the doctor tell?Can any doctor complete these evaluations?
19 Physicians Not trained Feel uncomfortable Call normal findings abnormalCall abnormal findings normal
20 Do Physician’s Recognize Sexual Abuse? More than half could not recognize clear evidence of chronic sexual traumaMore than half of primary care physicians could not identify major parts of a female child’s genital anatomyLadson et al AJDC l987
21 Physical Examination Findings Untrained physicians are more likely to over-diagnosis -- 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!
22 Makoroff et al Child Abuse Negl 2002 “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 abuseChild Abuse Physicians:32 (70%) normal4 (9%) nonspecific2 (4%) concerningMakoroff et al Child Abuse Negl 2002
23 Physical ExamAdams approach to interpretation of medical findings in suspected child sexual abuseAdams et al. Guidelines for medical care of children evaluated for suspected sexual abuse: an update for Current opinion in obstetrics and gynecology 2008;20(5):
24 Physical Exam Findings commonly seen in non abused children Ex: periurethral bandsFindings commonly caused by other medical conditionsEx: erythema of the vestibuleIndeterminate findings (conflicting data from research, requires further evaluation to determine significance)ex: deep notch in hymen
25 Physical Exam Findings diagnostic of trauma and/or sexual contact Examples:Lacerations or bruisingHymenal transection (area of hymen torn through or nearly through the base)Infection such as chlamydia > 3years oldPregnancySperm on sample taken from child’s body
30 Kellogg N et al Pediatrics 2004 “Genital Anatomy in Pregnant Adolescents: “Normal” Does Not Mean “Nothing Happened”;36 pregnant adolescents seen for sexual abuse evaluations2/36 (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
31 Repetitive Penetration Study 506 girls 5-17 with reported penile-vaginal penetration85% of victims reporting > 10 penetrative events had no definitive findings on examThis was true even if this occurred over a long period of time.Anderst Pediatrics 2009: 124-;e403-e409
32 Physical ExamA normal exam does not exclude the possibility of sexual abuse or prior penetration
33 “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
34 Heger et al Child Abuse & Neglect 2000 “Children Referred for Possible Sexual Abuse: Medical Findings in 2384 Children”Referrals based on disclosure, behavior changes, medical findingsOverall 96% had normal exams5.5% abnormal when disclosed penetration1.7% abnormal without history penetration8% exams abnormal when had medical findingsSTIs, acute genital trauma, healed hymenal trauma, transectionsHeger et al Child Abuse & Neglect 2000
35 Why are exams normal? Nature of assault may not be damaging Perception of “penetration”Disclosures often delayedComplete healing can occurThe hymen changes with puberty
36 Physical Exam2 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
37 Evidence based medicine, experience and reason support that a normal exam does not rule out sexual abuse or prior penetrationThis may contradict beliefs of families (and jurors, some law enforcement workers)Try to understand families’ perceptions and explain significance of exam findings
43 Physiologic Endometrial Shedding 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.
46 Urethral Prolapse Exam- annular mass from urethral meatus Urethral mucosa is friable-bleeding, pain and dysuria.Prolapse can be more pronounced with Valsalva maneuverNot associated with child abuseMore prevalent in African-American femalesTx: Nonsurgical unlessUrinary retention, or lesion is necrotic
48 Lichen Sclerosus et Atrophicus Hypopigmented, well-circumscribed areas of atrophic skin around genital and/or anus.“Figure-of-eight”Subepithelial hemorrhagesFrequently mistaken for bruising or bleeding caused by trauma from SA
49 Straddle Injuries Site of impact often anterior External to hymen UnilateralPainfulBleeding may be significantOccasional penetrating trauma to hymen with external to internal injury
54 Continued GI Tract Dermatology Hematochezia Anal Fissure Lichen Sclerosis et Atrophicus
55 Forensic Evidence Collection Sexual Assault has occurred within 72-hoursDisclosureWitnessedConfessionContact could have resulted in transfer of bodily fluids
56 “Forensic Evidence Findings in Prepubertal Victims of Sexual Assault” Christian et al Pediatrics 200090% of children with positive kits were seen within 24 hours of assault64% evidence found on clothing and linens(Only 35% children had clothing/linens collected)No swab positive for semen/sperm after 9 hrs
57 Forensic Evidence Collected on Examination 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 andwhen taken from prepubertal patients.Young. Arch Pediatr Adolesc Med. 2006;160:Consideration should be given to amending guidelinesregarding forensic evidence collections in child andadolescent sexual abuse or assault victims.
58 “Date Rape” Drugs (Alcohol) Not typically screened for in routine toxicology screenSpecifically must request urine screenFound in urine up to 24 hours after ingestion
59 “Date Rape” Drugs GHB and metabolites Loss of consciousness, hypothermia, clonic jerkingEffects begin after minutesPeak within minutesPersists up to 5 hours
60 “Date Rape” Drugs Rohypnol- Flunitrazepam Benzodiazepine Sedation, loss of consciousnessEffects begin after 30 minutesPeak within 2 hoursPersist up to 8-12 hours
61 Physical ExaminationThe health and welfare of the child take precedence over legal and investigative needs
62 Sexually Transmitted Infections How often do STI’s help to make the diagnosis of Child Sexual Abuse?
63 Symptoms Burning Discharge Itching Bleeding Anogenital Pain Pubertal- may have no symptomsAnogenital
64 Sexually Transmitted Diseases 2973 Children evaluated for sexual abuse:1.7% Gonorrhea1.3% Chlamydia0.2% Syphilis<1% Trichomonas1.7% Condyloma acuminata (warts)0.3% Herpes Simplex Virus
65 Who do we test? Age of child High risk of STI in assailant (incarceration)Household member with STIType of sexual abuseSymptoms (vaginal discharge)Acuity of abusePatient/family concernHigh incidence in communityMultiple/unknown offendersTesting
66 STDs for the Diagnosis of CSA Gonorrhea* Diagnostic†Syphilis* DiagnosticHIV § DiagnosticC trachomatis* Diagnostic†T vaginalis Highly suspiciousHPV *Suspicious (Indeterminate)Herpes simplex Virus (HSV) *Suspicious(Probable, Indeterminate)Bacterial vaginosis InconclusiveKellogg, The Evaluation of Sexual Abuse in Children. Pediatrics 2005;116;*Reading. Arch Dis Child 2007;92:608–613. doi: /adc*Adams. Current Opinion in Obstetrics and Gynecology 2008, 20:435–4412nd Citation identified a study in UK where HSV was really only probable and did not meet the level of SuspiciousAdams lastest information- Inderterminate
67 Sexually Transmitted Disease (STD) Infections (STI) HPV- Human Papilloma VirusSinclair Study- Anogenital and Oral Pharyngeal Warts31% likelihood of Sexual AbuseNo actual “cut off-age”Sinclair KJ, et al. Pediatrics 2005; 116:815–825.
68 HIV Risk factors Type of sexual contact Unknown Assailant Known HIV statusMultiple sexual partnersIVDUIncarceration
69 Physical ExaminationIn only a very small percentage will it help to make the diagnosis of child sexual abuse by itself.
70 Corroboration: Evidence exists more often than you think Physical evidence (FEK)Behavioral symptomsAdult witnesses and suspectsMedical evidence (exam)Other victimsChild witnessesChild pornographyComputersCell PhonesPhotosText MessagesPerpetrator confessions
71 Sexualized BehaviorsCan the diagnosis of sexual abuse be made based on sexualized behaviors?
72 Behavioral SignsIs that a red flag being waved?
73 Infants (0-18 months) Rarely show symptoms Fussy, diaper change reluctanceFearful of offenderImitate sexual acts
74 Toddlers (18-36 months) All of the above plus: Difficulty toilet training, sleep disturbancesMinimal embarassmentMasturbation common (normal)
75 Preschool (3-5 years) All of the above plus: Sexualized play, perpetrationHeadaches, abdominal pain, painful urination, genital discomfortNightmaresRegressionAnger, aggression, mood swings
76 School Age (6-9 years) Any of the above plus: Confusion, guilt Withdrawn, depression, nightmaresPoor school performance, lying, stealingSexualized behavior, somatic complaintsEnuresis, encopresis, dysuria
77 Puberty (9-12 years) Feel responsible, overwhelming guilt/shame Shoplifting, substance abuseSexual identity crisisUncomfortable with body and disclosure
78 Adolescents (13 years +)Defiance, aggression, truancy, school failure, promiscuity, suicidal ideations, self-mutilation, runaway behaviorSomatic complaintsPeer Sexual Contact
79 Behaviors Parents are not always good historians regarding stress. Exposure to adult sexual informationPornographyCableInternetAdult interpretation of sexualized play.
80 Normative Sexual Behavior in Children Friedrich, W. Pediatrics and again in 1998Questionnaire-demographic information, Child Sexual Behavior Inventory (CSBI), and the Problem Behavior portion of the Child Behavior Checklist (CBCL)
81 Friedrich – Normative Sexual Behavior in Children Children ages 2-12Children ages 2-12Administered specialized surveysExcluded 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”
82 Friedrich’s Top 10 (most common) 10. Dresses like opposite sex9. Hugs adults not known well8. Shows sex parts to adults7. Masturbates with hand6. Very interested in opposite sex(**10-12yo)
83 Friedrich’s Top 10 (most common) 5. Touches sex parts in public4. Tries to look at people when they are nude3. Stands too close2. Touches breasts1. Touches sex parts at home
84 Least common behaviors… Makes sexual sounds, asks others to do sex actsMasturbates with or puts objects in vagina/rectumPretends toys are having sexUndresses other childrenTries to have intercoursePuts mouth on sex partsTouches animal’s sex partsDraws sex parts
85 Normal Sexual Behaviors A Child’s sexual behaviors are influenced by:AgeFamily Stress and ViolenceFamily SexualityCulture/ReligionSurroundings, exposure to age-inappropriate information and materials
86 Concerning Sexual Behaviors Influenced by:Media (television, internet, videos, magazines)Decreased parental supervisionDecreased boundariesOvert exposureSexually AbusedSexualized input from many different areas can confuse kids and push them to act out in order to understand the developmentally inappropriate inputParents who are more and more not available to kids because of their own psychological issues-or because they are left with caretakers who expose them to sexBoudaries difffer around sex- some parents discuss their sex lives and problems with childrenAnd in some cultures children’s genitals are inspected and their physical development is discussed making kids more aware of their own sexuality.*child whose mother and father talked about having sex, had sex in the shower when the child was in the other room watching t.v. etc
87 When to be concerned? Sexual expression is more adult than childlike Other children complainContinues despite requests to stopChildren sexualize nonsexual thingsGenitals are persistent and prominent in drawings
88 Disclosure of CSA in Art and Play Specific Concerns with playingSand-Tray TherapyTherapy not Diagnostic AssessmentArt- should not have to be interpreted“ I know he was sexually abuse because he is drawing sharks”Examples
89 Interactive Session Normal Aberrant Concerning Sexualized behavior does not mean that a child is a victimDevelopmental componentToddler/Preschooler? School Age?Assessment componentNormalAberrantConcerning
90 Playing Doctor Plays doctor/inspects others’ bodies NormalPlays doctor/inspects others’ bodiesFrequently plays doctor even after getting caught and reprimandedForces others to play doctor and/or to remove clothes, touching privatesConcerningAberrant
91 Placing Objects in Genital Orifices Tries to place objects in own genitalia/rectum one time – curiousPlaces object in genitalia or rectum of self/othersUses coercion/pain in placing object in genitalia/rectum of self and othersNormalConcerningAberrant
92 Disclosures in Sexual Abuse The most important piece of the puzzleThis may make your diagnosis
93 Disclosures in Sexual Abuse Can the diagnosis of sexual abuse be made based on a disclosure of sexual abuse?
94 YESA child’s disclosure alone CAN make the diagnosis of sexual abuse…
95 Disclosure is a Process Children disclose gradually versus rapidly.
96 BUT…The disclosure needs to be obtained appropriately without direct and leading questions
97 Context of any Disclosure Was this a spontaneous disclosure?Was the child asked multiple questions?Was the child asked leading questions?
100 Interviewing Trained Interviewers Limiting number of interviews First responders need to learn how to obtain information
101 A Good Interview Should… Assess competenceAddress context initial disclosureAvoid direct and leading questionsDocument body languageChild’s languageRemember children think concretely
102 Child’s History Build rapport Use open-ended questions Use child’s languageReassurance
103 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
104 The Leading Question Pt complains of genital pain “Did Uncle Joey put his pee-pee in your flower?
105 Why don’t all kids talk? Not developmentally ready, acts weren’t “bad” Sworn to secrecyTrapped and HelplessAfraid to upset familyFears no one will believeMay have disclosed and told “ She would never do that”ThreatsFeels responsible, overwhelming guilt/shame
106 “How Children Tell: The Process of Disclosure in Child Sexual Abuse” Sorenson and Snow Child Welfare 1991630 child victims ( ) (3-17 ages)116 confirmed casesConfession (80%)Conviction (14%)Medical Findings (6%)Types of Disclosures – part of continuum
107 4 Steps of the Process Denial Disclosure Recant Reaffirm Tentative ActiveRecantReaffirm
108 DenialChild’s initial statement was that he/she was NOT a victim of sexual abuseThree-fourths of children denied when initially questioned
109 DisclosureTentative (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”Minimizing, distancing, empowerment, discounting
110 DisclosureActive: a personal admission by the child of having experienced a specific sexually abusive activity7% of initial denials move directly to active96% of all eventually give active disclosure
111 RecantRefers to the child’s retraction of a previous allegation of abuse that was formally made and maintained over a period of time
112 Recantations Common, 22% of children in study Often influenced by the perpetrator but more often influenced by the “non-offending” family membersIntentionallyUnintentionally
113 ReaffirmDefined as the child’s reassertion of the validity of a previous statement of sexual abuse that has been recantedOf those who recanted, 92% reaffirmed the allegations over time
114 ConclusionOnly a small percentage of children will be in ACTIVE disclosure at the first interviewDisclosure of sexual abuse is a process not an EVENT
115 Minimal Facts Interview Where on the body touchedWho touched him/herWhat did the touchingWhere did the touching occurWhen did this happenNOT WHY
116 Disclosures Suggestibility Misleading questions, direct questions and negative feedback to answers can affect what is recalled and reportedChildren (especially younger children) are particularly vulnerable to suggestibilityDepend on adultsDefer to adultsAware of adult authorityTendency to want to please adults
117 Infants (0-18 months) NO DISCLOSURES Rarely show symptoms By 18 months majority have only 10 wordsConfirmed only with sexually transmitted disease, semen, offender confession, eye witness, abnormal exam
118 Toddlers (18-36 months) 50-200 word vocabulary Two word sentences start at 21 months“Daddy owie” “Papa down”Accidental disclosuresMasturbation normalSubstantiate with sexually transmitted disease, semen, offender confession, eye witness, abnormal exam
119 Preschool (3-5 years) Improved Vocabulary!! (2500-3000 words) Partial disclosuresMinimization, denial, irrelevant detailsBetter at who, what, where (not when or number of times)History now more importantSubstantiation with HISTORY, STDs, semen, confession, eye witness, abnormal exam
120 School Age (6-9 years) More independent, learning boundaries Tentative disclosuresBuild rapportFear of jailSubstantiate with HISTORY, labs/STDs, semen, confession, eye witness, abnormal exam
121 Puberty and Adolescents Peers often more influential than familyFamily withdrawalDisclose due to peers, angerUncomfortable with body and disclosureReassurance of being normal importantSubstantiate with HISTORY, labs/STDs, semen, confession, eye witness, abnormal examPeerspEErsPEERS
122 Delayed Disclosures“When children do disclose, it often takes them a long time to do so” (London, et al, 2005)Elliott & Briere (1994) found that 75% of children in substantiated cases had delayed over a year before telling anyone
129 False Allegations Risk situations for false allegations by adults: Divorce/Custody DisputesDisagreement re: motivation; Benedek & Schetky, 1985 said majority are calculated…Faller & DeVoe, 1995 said most falsely accusing parents genuinely believe child has been abused
130 Phases of disclosure I. Denial Initial statement that he/she has not been abusedCase example 94 year old femaleNeighbor in adjacent apartment witnessed patient’s adult male roommate sexually abusing herWitnessed filmed incident and called 911Perpetrator confessedPatient denied sexual abuse
131 Parental response to disclosure Response of the non-offending parent is associated with short and long-term psychological outcomesLack of support / belief associated withDepressionAnxietyBehavioral problemsPTSDProvide this information to parentsRickerby et al. Family response to disclosure of childhood sexual abuse: Implicationsfor secondary prevention. Mental Health Rhode Island 2003;86(12):
132 Parental ResponseNon offending parents experience emotional distress following their child’s sexual abuse disclosureParental response impacts childParental response influenced by:Prior history of depressionHistory of sexual abuseRelationship to the perpetratorSocial isolationSubstance abuse
133 Parental ResponseExamples of information provided to supportive parentsEmphasize importance of parents’ role in the healing processEncourage continued support, reassurance, affirmation that child is believedDo not repeatedly question child about disclosureAcknowledge parents’ emotional distressRecommend an outlet for parents’ distress separate from the children (ex. counseling, adult supports)
134 MDT Strengthens the investigative process Expertise from Law Enforcement, Child Protective Services, Medical, Forensic Interviews, Prosecutors, and others
135 Don’t drop the ball Immediate response During the Investigation by CPS and Law EnforcementAfterwards
137 MDT in ActionWhen each member is available and does their part, cases will go much smoother
138 PREVENTION School-based child education programs successful Negative: teaching children CSA concepts and self-protectionNegative:increased anxiety, feeling less in control for younger children, and feeling more discomfort with normal touch in older childrenPutnam. J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 42:3, MARCH 2003
139 PREVENTION Parental Education Communication Judgment Truth versus mythsWhen to start- 10 yo is too late!How oftenMental Health Care for parent’s prior abuseCommunicationYoung children are concrete thinkersJudgmentCaregivers
143 The Relationship of Adverse Childhood Experiences to Adult Health Status ACEChild MaltreatmentPhysicalSexualPsychologicalParentalEtoh and Drug abuseDomestic ViolenceIncarceration
144 ACEDirect relationship between the number of ACE and adverse health outcomesInclude Mental Health and Physical Health
145 ACE Long term physical health consequences ACE study Health problems AbuseNeglectHousehold dysfunctionHealth problemsHeart diseaseLiver diseaseDepressionSubstance abuseLung diseaseFetal death
146 Long term physical health consequences The ACE score showed a graded relationship to the risk of liver disease that appears to be mediated substantially by behaviors that increase the risk of viral and alcohol-induced liver disease. Understanding the effect of ACEs on the risk of liver disease and development of these behaviors provides insight into causal pathways, which may prove useful in the prevention of liver disease.Dong et al. Arch Intern Med. 2003;163:146
147 Take Home Points Child Sexual Abuse is prevalent Diagnosis of CSA not usually by physical exam findings or behavior aloneMany “sexual behaviors” are normalDisclosures -- most important and need to be obtained appropriatelyThink about any other possible evidence!
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