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Investigating Child Sexual Abuse Christine E. Barron, MD Assistant Professor, Pediatrics Warren Alpert Medical School at Brown University.

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Presentation on theme: "Investigating Child Sexual Abuse Christine E. Barron, MD Assistant Professor, Pediatrics Warren Alpert Medical School at Brown University."— Presentation transcript:

1 Investigating Child Sexual Abuse Christine E. Barron, MD Assistant Professor, Pediatrics Warren Alpert Medical School at Brown University

2 Objectives National Data National Data Physical Examination Physical Examination “Red Flag” Behaviors “Red Flag” Behaviors Disclosures and Forensic Interviewing Disclosures and Forensic Interviewing Multidisciplinary Team Multidisciplinary Team Prevention Prevention

3 2008 National Data ~ 3.3 million reports involving ~6 million children ~ 3.3 million reports involving ~6 million children 772,000 children were found to be victims of maltreatment 772,000 children were found to be victims of maltreatment 70%Neglect 70%Neglect 15% Physical Abuse 15% Physical Abuse <10%Sexual Abuse <10%Sexual Abuse <10%Psychological maltreatment <10%Psychological maltreatment Child Maltreatment 2008 Child Maltreatment 2008

4 Sexual abuse is common National survey of US adults National survey of US adults Childhood sexual abuse reported by Childhood sexual abuse reported by 27% of women 27% of women 16% of men 1 16% of men 1 Each year ~1% of children are victims of CSA Each year ~1% of children are victims of CSA Adolescents: highest rates for sexual assaults Adolescents: highest rates for sexual assaults 1 Finkelhor et al. Child Abuse & Neglect 1990;14:19-28.

5 Risk Factors CSA occurs across all socioecomonic and ethnic groups CSA occurs across all socioecomonic and ethnic groups Race and ethnicity have NOT been identified as risk factors Race and ethnicity have NOT been identified as risk factors Disabilities are a risk factor Disabilities are a risk factor Family Constellations Family Constellations Putnam. Putnam. J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 42:3, MARCH 2003

6 Myths of Sexual Abuse Perpetrators are strangers Perpetrators are strangers Perpetrators who touch boys don’t touch girls Perpetrators who touch boys don’t touch girls Children tell about the abuse immediately Children tell about the abuse immediately Children tell fantasies Children tell fantasies Any child victim with penetration will have an abnormal examination Any child victim with penetration will have an abnormal examination Disclosures in custody issues are all false allegations Disclosures in custody issues are all false allegations

7 Pedophiles Can have normal peer sexual relationships Can have normal peer sexual relationships Can be sexually oriented only to children Can be sexually oriented only to children Can be abuse reactive Can be abuse reactive Child-on-Child Child-on-Child Often someone family knows Often someone family knows

8 Sexual abuse – RI laws <= >=18 Unable to consent Child molestation Third degree Consensual sex Age Mark Massi

9 Physical Examinations Evaluations for the Diagnosis & Treatment of Child Sexual Abuse Evaluations for the Diagnosis & Treatment of Child Sexual Abuse

10 American Academy of Pediatrics Developmentally appropriate interview Developmentally appropriate interview Complete examination to include growth, development, social, and emotional state Complete examination to include growth, development, social, and emotional state Directed genital examination for specific signs or physical indicators Directed genital examination for specific signs or physical indicators Laboratory evaluation, cultures for STI’s -- as indicated by history or physical Laboratory evaluation, cultures for STI’s -- as indicated by history or physical Culture versus NAAT testing Culture versus NAAT testing

11 Physical Examination Provides reassurance Provides reassurance Examine for treatable conditions, STIs Examine for treatable conditions, STIs Collect legal evidence Collect legal evidence Chronic sequelae Chronic sequelae Assists in the protection of the child Assists in the protection of the child

12 Triage Nonurgent (within few weeks) Nonurgent (within few weeks) Urgent (within a few days) Urgent (within a few days) Vaginal discharge, odor, possible pregnancy Vaginal discharge, odor, possible pregnancy Emergent (within 24 hours) Emergent (within 24 hours) Vaginal, rectal bleeding Vaginal, rectal bleeding Psychological crisis Psychological crisis Safety concerns Safety concerns Forensic Evidence Collection Forensic Evidence Collection

13 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. When 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 examination Head to toe physical examination Attention to: Attention to: Abdominal Exam Abdominal Exam Skin- appropriate UV light source Skin- appropriate UV light source Bruising Bruising Ligature/control marks Ligature/control marks Oral Oral Sign of penetration Sign of penetration Sexually transmitted diseases Sexually transmitted diseases

15 Physical Examination Genitals Completed in a non-traumatic manner Completed in a non-traumatic manner External inspection External inspection A speculum is infrequently used in adolescents and rarely used in pre-pubertal children A speculum is infrequently used in adolescents and rarely used in pre-pubertal children Colposcope Colposcope Tool for magnification and photo-documentation Tool for magnification and photo-documentation Does not see what is not there Does not see what is not there

16 Estrogen Effect on Hymen Circulating maternal hormones causes estrogenization of hymen Circulating maternal hormones causes estrogenization of hymen Hormonal influences decrease in childhood Hormonal influences decrease in childhood Hormonal influences become obvious once again during puberty Hormonal influences become obvious once again during puberty Estrogen- Thickened, redundant and pale. Estrogen- Thickened, redundant and pale.

17 Physical Signs and Symptoms Bruises, scratches, bites Bruises, scratches, bites Abdominal pain Abdominal pain Genital bleeding – “blood on underwear” Genital bleeding – “blood on underwear” Genital discharge, sexually transmitted disease Genital discharge, sexually transmitted disease Genital or Anal Pain Genital or Anal Pain Genital Skin Lesions Genital Skin Lesions Genital/Urethral/Anal Trauma Genital/Urethral/Anal Trauma Enuresis, Recurrent Urinary Tract Infections Enuresis, Recurrent Urinary Tract Infections Encopresis, Anal Fissures Encopresis, Anal Fissures

18 Diagnosing Sexual Abuse Can the doctor tell? Can any doctor complete these evaluations?

19 Physicians Not trained Not trained Feel uncomfortable Feel uncomfortable Call normal findings abnormal Call normal findings abnormal Call abnormal findings normal Call abnormal findings normal

20 Do Physician’s Recognize Sexual Abuse? More than half could not recognize clear evidence of chronic sexual trauma 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 More than half of primary care physicians could not identify major parts of a female child’s genital anatomy Ladson et al AJDC l987 Ladson 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… 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! 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 abuse ER Physician: Diagnosed patients with non-acute genital findings indicative of sexual abuse Child Abuse Physicians: Child Abuse Physicians: 32 (70%) normal 32 (70%) normal 4 (9%) nonspecific 4 (9%) nonspecific 2 (4%) concerning 2 (4%) concerning

23 Physical Exam Adams approach to interpretation of medical findings in suspected child sexual abuse 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 Current opinion in obstetrics and gynecology 2008;20(5): Adams 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 Findings commonly seen in non abused children Ex: periurethral bands Ex: periurethral bands Findings commonly caused by other medical conditions Findings commonly caused by other medical conditions Ex: erythema of the vestibule Ex: erythema of the vestibule Indeterminate findings (conflicting data from research, requires further evaluation to determine significance) Indeterminate findings (conflicting data from research, requires further evaluation to determine significance) ex: deep notch in hymen ex: deep notch in hymen

25 Physical Exam Findings diagnostic of trauma and/or sexual contact Findings diagnostic of trauma and/or sexual contact Examples: Examples: Lacerations or bruising Lacerations or bruising Hymenal transection (area of hymen torn through or nearly through the base) Hymenal transection (area of hymen torn through or nearly through the base) Infection such as chlamydia > 3years old Infection such as chlamydia > 3years old Pregnancy Pregnancy Sperm on sample taken from child’s body Sperm on sample taken from child’s body

26 Examination Techniques

27 Physical Findings 5-10% of children have physical findings 5-10% of children have physical findings Genital (female) Genital (female) Bruising Bruising Transections Transections Absent hymenal tissue Absent hymenal tissue Abrasions Abrasions Sexually Transmitted Diseases Sexually Transmitted Diseases

28 Physical Findings Genital (Male) Genital (Male) Penile Abrasions Penile Abrasions Bites, Bruises Bites, Bruises Urethral/Anal Discharge Urethral/Anal Discharge Sexually Transmitted Infections Sexually Transmitted Infections Scars Scars

29 “It’s normal to be normal.” Joyce Adams, MD

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 evaluations 36 pregnant adolescents seen for sexual abuse evaluations 2/36 (6%) had definitive findings of penetration (cleft to base of hymen) 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) 4/36 (8%) had suggestive findings of penetration (deep notches or clearly visible scars)

31 Repetitive Penetration Study 506 girls 5-17 with reported penile-vaginal penetration Study 506 girls 5-17 with reported penile-vaginal penetration 85% of victims reporting > 10 penetrative events had no definitive findings on exam 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. This was true even if this occurred over a long period of time. Anderst Pediatrics 2009: 124-;e403-e409 Anderst Pediatrics 2009: 124-;e403-e409

32 Physical Exam A normal exam does not exclude the possibility of sexual abuse or prior penetration A 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 findings Referrals based on disclosure, behavior changes, medical findings Overall 96% had normal exams Overall 96% had normal exams 5.5% abnormal when disclosed penetration 5.5% abnormal when disclosed penetration 1.7% abnormal without history penetration 1.7% abnormal without history penetration 8% exams abnormal when had medical findings 8% exams abnormal when had medical findings STIs, acute genital trauma, healed hymenal trauma, transections STIs, acute genital trauma, healed hymenal trauma, transections

35 Why are exams normal? Nature of assault may not be damaging Nature of assault may not be damaging Perception of “penetration” Perception of “penetration” Disclosures often delayed Disclosures often delayed Complete healing can occur Complete healing can occur The hymen changes with puberty The hymen changes with puberty

36 Physical Exam 2 year old female living in home with father after 9 year old half sister disclosed sexual abuse by him. 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 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 penetration 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) This may contradict beliefs of families (and jurors, some law enforcement workers) Try to understand families’ perceptions and explain significance of exam findings Try to understand families’ perceptions and explain significance of exam findings

38 Additional Exam Findings

39 Stay Moral, Go Oral Adolescents do not consider oral sex to be sexual activity. Need to ask if anything has been in the mouth!

40 Mimickers of Sexual Abuse Medical Conditions Medical Conditions Accidental Trauma Accidental Trauma

41 Vaginal Bleeding

42 Case

43 Physiologic Endometrial Shedding Vaginal bleeding is occasionally observed in female infants during the first few weeks of life. 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 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. The bleeding occurs as the stimulated endometrial lining is shed, usually ceases within 7-10 days.

44 Prepubertal Vaginal Bleeding Endometrial Shedding Endometrial Shedding Endocrine- Endocrine- Hypothyroidism Hypothyroidism Liver Cirrhosis Liver Cirrhosis Coagulopathy Coagulopathy Precocious puberty Precocious puberty McCune-Albright Syndrome McCune-Albright Syndrome Ovarian Cyst Ovarian Cyst

45 Case # 2

46 Urethral Prolapse Exam- annular mass from urethral meatus Exam- annular mass from urethral meatus Urethral mucosa is friable- Urethral mucosa is friable- bleeding, pain and dysuria. bleeding, pain and dysuria. Prolapse can be more pronounced with Valsalva maneuver Prolapse can be more pronounced with Valsalva maneuver Not associated with child abuse Not associated with child abuse More prevalent in African-American females More prevalent in African-American females Tx: Nonsurgical unless Tx: Nonsurgical unless Urinary retention, or lesion is necrotic Urinary retention, or lesion is necrotic

47 Case

48 Lichen Sclerosus et Atrophicus Hypopigmented, well-circumscribed areas of atrophic skin around genital and/or anus. Hypopigmented, well-circumscribed areas of atrophic skin around genital and/or anus. “Figure-of-eight” “Figure-of-eight” Subepithelial hemorrhages Subepithelial hemorrhages Frequently mistaken for bruising or bleeding caused by trauma from SA Frequently mistaken for bruising or bleeding caused by trauma from SA

49 Straddle Injuries Site of impact often anterior Site of impact often anterior External to hymen External to hymen Unilateral Unilateral Painful Painful Bleeding may be significant Bleeding may be significant Occasional penetrating trauma to hymen with external to internal injury Occasional penetrating trauma to hymen with external to internal injury

50 Case

51 Vaginal Foreign Body Intermittent bloody discharge. Intermittent bloody discharge. Toilet paper is the most common foreign body Toilet paper is the most common foreign body Not indicative of abuse Not indicative of abuse

52 Summary Differential Dx for Vaginal Bleeding Differential Dx for Vaginal Bleeding Sexual Abuse Sexual Abuse Physiologic Endometrial Shedding Physiologic Endometrial Shedding Urethral Prolapse Urethral Prolapse Lichen Sclerosus et Atrophicus Lichen Sclerosus et Atrophicus Labial Agglutination Labial Agglutination Foreign body Foreign body Accidental trauma Accidental trauma

53 Continued Tumors Tumors Clear Cell Carcinoma Clear Cell Carcinoma Rhadomyosarcoma Rhadomyosarcoma Ovarian Ovarian Adrenal Adrenal Urinary Tract Urinary Tract Urethral Prolapse Urethral Prolapse Hemorrhagic cystitis Hemorrhagic cystitis Urate Crystals Urate Crystals Hematuria Hematuria UTI UTI

54 Continued GI Tract GI Tract Hematochezia Hematochezia Anal Fissure Anal Fissure Dermatology Dermatology Lichen Sclerosis et Atrophicus Lichen Sclerosis et Atrophicus

55 Forensic Evidence Collection Sexual Assault has occurred within 72-hours Sexual Assault has occurred within 72-hours Disclosure Disclosure Witnessed Witnessed Confession Confession Contact could have resulted in transfer of bodily fluids Contact could have resulted in transfer of bodily fluids

56 “Forensic Evidence Findings in Prepubertal Victims of Sexual Assault” Christian et al Pediatrics 2000 Christian et al Pediatrics % of children with positive kits were seen within 24 hours of assault 90% of children with positive kits were seen within 24 hours of assault 64% evidence found on clothing and linens 64% evidence found on clothing and linens (Only 35% children had clothing/linens collected) (Only 35% children had clothing/linens collected) No swab positive for semen/sperm after 9 hrs 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: (1) (1) more than 24 hours after the event and (2) (2) when taken from prepubertal patients. Young. Arch Pediatr Adolesc Med. 2006;160:

58 “Date Rape” Drugs (Alcohol) (Alcohol) Not typically screened for in routine toxicology screen Not typically screened for in routine toxicology screen Specifically must request urine screen Specifically must request urine screen Found in urine up to 24 hours after ingestion Found in urine up to 24 hours after ingestion

59 “Date Rape” Drugs GHB and metabolites GHB and metabolites Loss of consciousness, hypothermia, clonic jerking Loss of consciousness, hypothermia, clonic jerking Effects begin after minutes Effects begin after minutes Peak within minutes Peak within minutes Persists up to 5 hours Persists up to 5 hours

60 “Date Rape” Drugs Rohypnol- Flunitrazepam Rohypnol- Flunitrazepam Benzodiazepine Benzodiazepine Sedation, loss of consciousness Sedation, loss of consciousness Effects begin after 30 minutes Effects begin after 30 minutes Peak within 2 hours Peak within 2 hours Persist up to 8-12 hours Persist up to 8-12 hours

61 Physical Examination The health and welfare of the child take precedence over legal and investigative needs The 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 Burning Discharge Discharge Itching Itching Bleeding Bleeding Anogenital Pain Anogenital Pain Pubertal- may have no symptoms Pubertal- may have no symptoms

64 Sexually Transmitted Diseases 2973 Children evaluated for sexual abuse: 1.7% Gonorrhea 1.7% Gonorrhea 1.3% Chlamydia 1.3% Chlamydia 0.2% Syphilis 0.2% Syphilis <1% Trichomonas <1% Trichomonas 1.7% Condyloma acuminata (warts) 1.7% Condyloma acuminata (warts) 0.3% Herpes Simplex Virus 0.3% Herpes Simplex Virus

65 Who do we test? Age of child Age of child High risk of STI in assailant (incarceration) High risk of STI in assailant (incarceration) Household member with STI Household member with STI Type of sexual abuse Type of sexual abuse Symptoms (vaginal discharge) Symptoms (vaginal discharge) Acuity of abuse Acuity of abuse Patient/family concern Patient/family concern High incidence in community High incidence in community Multiple/unknown offenders Multiple/unknown offenders

66 STDs for the Diagnosis of CSA Gonorrhea* Diagnostic† Syphilis* Diagnostic HIV § Diagnostic C trachomatis* Diagnostic† T vaginalis Highly suspicious HPV *Suspicious (Indeterminate) Herpes simplex Virus (HSV)*Suspicious (Probable, Indeterminate) Bacterial vaginosis Inconclusive Kellogg, 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, 20:435–441

67 Sexually Transmitted Disease (STD) Infections (STI) HPV- Human P HPV- Human Papilloma Virus Sinclair Study- Anogenital and Oral Pharyngeal Warts Sinclair Study- Anogenital and Oral Pharyngeal Warts 31% likelihood of Sexual Abuse 31% likelihood of Sexual Abuse No actual “cut off-age” No actual “cut off-age” Sinclair KJ, et al. Pediatrics 2005; 116:815–825.

68 HIV Risk factors Type of sexual contact Type of sexual contact Unknown Assailant Unknown Assailant Known Assailant Known Assailant Known HIV status Known HIV status Multiple sexual partners Multiple sexual partners IVDU IVDU Incarceration Incarceration

69 Physical Examination In 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) Physical evidence (FEK) Behavioral symptoms Behavioral symptoms Adult witnesses and suspects Adult witnesses and suspects Medical evidence (exam) Medical evidence (exam) Other victims Child witnesses Child pornography Computers Cell Phones Photos Text Messages Perpetrator confessions

71 Sexualized Behaviors Can the diagnosis of sexual abuse be made based on sexualized behaviors?

72 Behavioral Signs Is that a red flag being waved? Is that a red flag being waved?

73 Infants (0-18 months) Rarely show symptoms Rarely show symptoms Fussy, diaper change reluctance Fussy, diaper change reluctance Fearful of offender Fearful of offender Imitate sexual acts Imitate sexual acts

74 Toddlers (18-36 months) All of the above plus: Difficulty toilet training, sleep disturbances Difficulty toilet training, sleep disturbances Minimal embarassment Minimal embarassment Masturbation common (normal) Masturbation common (normal)

75 Preschool (3-5 years) All of the above plus: Sexualized play, perpetration Sexualized play, perpetration Headaches, abdominal pain, painful urination, genital discomfort Headaches, abdominal pain, painful urination, genital discomfort Nightmares Nightmares Regression Regression Anger, aggression, mood swings Anger, aggression, mood swings

76 School Age (6-9 years) Any of the above plus: Confusion, guilt Confusion, guilt Withdrawn, depression, nightmares Withdrawn, depression, nightmares Poor school performance, lying, stealing Poor school performance, lying, stealing Sexualized behavior, somatic complaints Sexualized behavior, somatic complaints Enuresis, encopresis, dysuria Enuresis, encopresis, dysuria

77 Puberty (9-12 years) Feel responsible, overwhelming guilt/shame Feel responsible, overwhelming guilt/shame Shoplifting, substance abuse Shoplifting, substance abuse Sexual identity crisis Sexual identity crisis Uncomfortable with body and disclosure Uncomfortable with body and disclosure

78 Adolescents (13 years +) Defiance, aggression, truancy, school failure, promiscuity, suicidal ideations, self-mutilation, runaway behavior Defiance, aggression, truancy, school failure, promiscuity, suicidal ideations, self-mutilation, runaway behavior Somatic complaints Somatic complaints Peer Sexual Contact Peer Sexual Contact

79 Behaviors Parents are not always good historians regarding stress. Parents are not always good historians regarding stress. Exposure to adult sexual information Exposure to adult sexual information Pornography Pornography Cable Cable Internet Internet Adult interpretation of sexualized play. Adult interpretation of sexualized play.

80 Normative Sexual Behavior in Children Friedrich, W. Pediatrics 1991 and again in 1998 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) Questionnaire-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 Children ages Children ages Children ages 2-12 Administered specialized surveys Administered specialized surveys Excluded those with concerns sexual abuse 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”

82 Friedrich’s Top 10 (most common) 10.Dresses like opposite sex 9.Hugs adults not known well 8.Shows sex parts to adults 7.Masturbates with hand 6.Very interested in opposite sex (**10-12yo)

83 Friedrich’s Top 10 (most common) 5. Touches sex parts in public 4. Tries to look at people when they are nude 3. Stands too close 2. Touches breasts 1. Touches sex parts at home

84 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

85 Normal Sexual Behaviors A Child’s sexual behaviors are influenced by: A Child’s sexual behaviors are influenced by: Age Age Family Stress and Violence Family Stress and Violence Family Sexuality Family Sexuality Culture/Religion Culture/Religion Surroundings, exposure to age-inappropriate information and materials Surroundings, exposure to age-inappropriate information and materials

86 Concerning Sexual Behaviors Influenced by: Influenced by: Media (television, internet, videos, magazines) Media (television, internet, videos, magazines) Decreased parental supervision Decreased parental supervision Decreased boundaries Decreased boundaries Overt exposure Overt exposure Sexually Abused Sexually Abused

87 When to be concerned? Sexual expression is more adult than childlike Sexual expression is more adult than childlike Other children complain Other children complain Continues despite requests to stop Continues despite requests to stop Children sexualize nonsexual things Children sexualize nonsexual things Genitals are persistent and prominent in drawings Genitals are persistent and prominent in drawings

88 Disclosure of CSA in Art and Play Specific Concerns with playing Specific Concerns with playing Sand-Tray Therapy Sand-Tray Therapy Therapy not Diagnostic Assessment Therapy not Diagnostic Assessment Art- should not have to be interpreted Art- should not have to be interpreted “ I know he was sexually abuse because he is drawing sharks” “ I know he was sexually abuse because he is drawing sharks” Examples Examples

89 Interactive Session Sexualized behavior does not mean that a child is a victim Sexualized behavior does not mean that a child is a victim Developmental component Developmental component Toddler/Preschooler? School Age? Toddler/Preschooler? School Age? Assessment component Assessment component

90 Playing Doctor Plays doctor/inspects others’ bodies Plays doctor/inspects others’ bodies Frequently plays doctor even after getting caught and reprimanded Frequently plays doctor even after getting caught and reprimanded Forces others to play doctor and/or to remove clothes, touching privates Forces others to play doctor and/or to remove clothes, touching privates

91 Placing Objects in Genital Orifices Tries to place objects in own genitalia/rectum one time – curious Tries to place objects in own genitalia/rectum one time – curious Places object in genitalia or rectum of self/others Places object in genitalia or rectum of self/others Uses coercion/pain in placing object in genitalia/rectum of self and others Uses coercion/pain in placing object in genitalia/rectum of self and others

92 Disclosures in Sexual Abuse The most important piece of the puzzle This may make your diagnosis

93 Disclosures in Sexual Abuse Can the diagnosis of sexual abuse be made based on a disclosure of sexual abuse? Can the diagnosis of sexual abuse be made based on a disclosure of sexual abuse?

94 YES A child’s disclosure alone CAN make the diagnosis of sexual abuse… A child’s disclosure alone CAN make the diagnosis of sexual abuse…

95 Disclosure is a Process Children disclose gradually versus rapidly. Children disclose gradually versus rapidly.

96 BUT… The disclosure needs to be obtained appropriately without direct and leading questions The disclosure needs to be obtained appropriately without direct and leading questions

97 Context of any Disclosure Was this a spontaneous disclosure? Was this a spontaneous disclosure? Was the child asked multiple questions? Was the child asked multiple questions? Was the child asked leading questions? Was the child asked leading questions?

98 Case

99 Case: Interview

100 Interviewing Trained Interviewers Trained Interviewers Limiting number of interviews Limiting number of interviews First responders need to learn how to obtain information First responders need to learn how to obtain information

101 A Good Interview Should… Assess competence Assess competence Address context initial disclosure Address context initial disclosure Avoid direct and leading questions Avoid direct and leading questions Document body language Document body language Child’s language Child’s language Remember children think concretely Remember children think concretely

102 Child’s History Build rapport Build rapport Use open-ended questions Use open-ended questions Use child’s language Use child’s language Reassurance Reassurance

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” 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?” Focused: “What did he poke you with?” Yes/no: “Were your clothes off?” Yes/no: “Were your clothes off?” Multiple choice: “Did he poke you with his finger, his private, or something else?” 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” Not developmentally ready, acts weren’t “bad” Sworn to secrecy Sworn to secrecy Trapped and Helpless Trapped and Helpless Afraid to upset family Afraid to upset family Fears no one will believe Fears no one will believe May have disclosed and told “ She would never do that” May have disclosed and told “ She would never do that” Threats Threats Feels responsible, overwhelming guilt/shame Feels responsible, overwhelming guilt/shame

106 “How Children Tell: The Process of Disclosure in Child Sexual Abuse” Sorenson and Snow Child Welfare 1991 Sorenson and Snow Child Welfare child victims ( ) (3-17 ages) 630 child victims ( ) (3-17 ages) 116 confirmed cases 116 confirmed cases Confession (80%) Confession (80%) Conviction (14%) Conviction (14%) Medical Findings (6%) Medical Findings (6%) Types of Disclosures – part of continuum Types of Disclosures – part of continuum

107 4 Steps of the Process Denial Denial Disclosure Disclosure Tentative Tentative Active Active Recant Recant Reaffirm Reaffirm

108 Denial Child’s initial statement was that he/she was NOT a victim of sexual abuse Child’s initial statement was that he/she was NOT a victim of sexual abuse Three-fourths of children denied when initially questioned Three-fourths of children denied when initially questioned

109 Disclosure Tentative (78%): child’s partial and vague acknowledgement of sexual abuse Tentative (78%): child’s partial and vague acknowledgement of sexual abuse “It only happened once” “It only happened once” “It happened to Joe” “It happened to Joe” “He tried to touch me but I hit him” “He tried to touch me but I hit him” “I was only kidding” “I was only kidding”

110 Disclosure Active: a personal admission by the child of having experienced a specific sexually abusive activity Active: a personal admission by the child of having experienced a specific sexually abusive activity 7% of initial denials move directly to active 7% of initial denials move directly to active 96% of all eventually give active disclosure 96% of all eventually give active disclosure

111 Recant Refers to the child’s retraction of a previous allegation of abuse that was formally made and maintained over a period of time Refers 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 Common, 22% of children in study Often influenced by the perpetrator but more often influenced by the “non-offending” family members Often influenced by the perpetrator but more often influenced by the “non-offending” family members Intentionally Intentionally Unintentionally Unintentionally

113 Reaffirm Defined as the child’s reassertion of the validity of a previous statement of sexual abuse that has been recanted 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 Of those who recanted, 92% reaffirmed the allegations over time

114 Conclusion Only a small percentage of children will be in ACTIVE disclosure at the first interview 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 Disclosure of sexual abuse is a process not an EVENT

115 Minimal Facts Interview Where on the body touched Where on the body touched Who touched him/her Who touched him/her What did the touching What did the touching Where did the touching occur Where did the touching occur When did this happen When did this happen NOT WHY NOT WHY

116 Disclosures Suggestibility Suggestibility Misleading questions, direct questions and negative feedback to answers can affect what is recalled and reported 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 Children (especially younger children) are particularly vulnerable to suggestibility Depend on adults Depend on adults Defer to adults Defer to adults Aware of adult authority Aware of adult authority Tendency to want to please adults Tendency to want to please adults

117 Infants (0-18 months) NO DISCLOSURES NO DISCLOSURES Rarely show symptoms Rarely show symptoms By 18 months majority have only 10 words By 18 months majority have only 10 words Confirmed only with sexually transmitted disease, semen, offender confession, eye witness, abnormal exam Confirmed only with sexually transmitted disease, semen, offender confession, eye witness, abnormal exam

118 Toddlers (18-36 months) word vocabulary word vocabulary Two word sentences start at 21 months Two word sentences start at 21 months “Daddy owie” “Papa down” “Daddy owie” “Papa down” Accidental disclosures Accidental disclosures Masturbation normal Masturbation normal Substantiate with sexually transmitted disease, semen, offender confession, eye witness, abnormal exam Substantiate with sexually transmitted disease, semen, offender confession, eye witness, abnormal exam

119 Preschool (3-5 years) Improved Vocabulary!! ( words) Improved Vocabulary!! ( words) Partial disclosures Partial disclosures Minimization, denial, irrelevant details Minimization, denial, irrelevant details Better at who, what, where (not when or number of times) Better at who, what, where (not when or number of times) History now more important History now more important Substantiation with HISTORY, STDs, semen, confession, eye witness, abnormal exam Substantiation with HISTORY, STDs, semen, confession, eye witness, abnormal exam

120 School Age (6-9 years) More independent, learning boundaries More independent, learning boundaries Tentative disclosures Tentative disclosures Build rapport Build rapport Fear of jail Fear of jail Substantiate with HISTORY, labs/STDs, semen, confession, eye witness, abnormal exam Substantiate with HISTORY, labs/STDs, semen, confession, eye witness, abnormal exam

121 Puberty and Adolescents Peers often more influential than family Peers often more influential than family Family withdrawal Family withdrawal Disclose due to peers, anger Disclose due to peers, anger Uncomfortable with body and disclosure Uncomfortable with body and disclosure Reassurance of being normal important Reassurance of being normal important Substantiate with HISTORY, labs/STDs, semen, confession, eye witness, abnormal exam Substantiate with HISTORY, labs/STDs, semen, confession, eye witness, abnormal exam

122 Delayed Disclosures “When children do disclose, it often takes them a long time to do so” (London, et al, 2005) “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 Elliott & Briere (1994) found that 75% of children in substantiated cases had delayed over a year before telling anyone

123 Interview Stages Introduction Introduction Rapport-building/Developmental Assessment/Narrative Practice Rapport-building/Developmental Assessment/Narrative Practice Ground rules Ground rules Substantive questions Substantive questions Closure Closure

124 Use of Media Anatomical Dolls Anatomical Dolls Anatomical Drawings Anatomical Drawings Gingerbread Drawings: Gingerbread Drawings:

125 Language Considerations

126 Interview

127 Interview What next? What next?

128 Interview

129 False Allegations Risk situations for false allegations by adults: Risk situations for false allegations by adults: Divorce/Custody Disputes 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 Disagreement 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 I. Denial Initial statement that he/she has not been abused Initial statement that he/she has not been abused Case example 9 Case example 9 4 year old female 4 year old female Neighbor in adjacent apartment witnessed patient’s adult male roommate sexually abusing her Neighbor in adjacent apartment witnessed patient’s adult male roommate sexually abusing her Witnessed filmed incident and called 911 Witnessed filmed incident and called 911 Perpetrator confessed Perpetrator confessed Patient denied sexual abuse Patient denied sexual abuse

131 Parental response to disclosure Response of the non-offending parent is associated with short and long-term psychological outcomes Response of the non-offending parent is associated with short and long-term psychological outcomes Lack of support / belief associated with Lack of support / belief associated with Depression Depression Anxiety Anxiety Behavioral problems Behavioral problems PTSD PTSD Provide this information to parents 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):

132 Parental Response Non offending parents experience emotional distress following their child’s sexual abuse disclosure Non offending parents experience emotional distress following their child’s sexual abuse disclosure Parental response impacts child Parental response impacts child Parental response influenced by: Parental response influenced by: Prior history of depression Prior history of depression History of sexual abuse History of sexual abuse Relationship to the perpetrator Relationship to the perpetrator Social isolation Social isolation Substance abuse Substance abuse

133 Parental Response Examples of information provided to supportive parents Examples of information provided to supportive parents Emphasize importance of parents’ role in the healing process Emphasize importance of parents’ role in the healing process Encourage continued support, reassurance, affirmation that child is believed Encourage continued support, reassurance, affirmation that child is believed Do not repeatedly question child about disclosure Do not repeatedly question child about disclosure Acknowledge parents’ emotional distress Acknowledge parents’ emotional distress Recommend an outlet for parents’ distress separate from the children (ex. counseling, adult supports) Recommend an outlet for parents’ distress separate from the children (ex. counseling, adult supports)

134 MDT Strengthens the investigative process Strengthens the investigative process Expertise from Law Enforcement, Child Protective Services, Medical, Forensic Interviews, Prosecutors, and others Expertise from Law Enforcement, Child Protective Services, Medical, Forensic Interviews, Prosecutors, and others

135 Don’t drop the ball Immediate response Immediate response During the Investigation by CPS and Law Enforcement During the Investigation by CPS and Law Enforcement Afterwards Afterwards

136 MDT in Action

137 When each member is available and does their part, cases will go much smoother When each member is available and does their part, cases will go much smoother

138 PREVENTION School-based child education programs successful teaching children CSA concepts and self-protection Negative: increased anxiety, feeling less in control for younger children, and feeling more discomfort with normal touch in older children Putnam. J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 42:3, MARCH 2003

139 PREVENTION Parental Education Parental Education Truth versus myths Truth versus myths When to start- 10 yo is too late! When to start- 10 yo is too late! How often How often Mental Health Care for parent’s prior abuse Mental Health Care for parent’s prior abuse Communication Communication Young children are concrete thinkers Young children are concrete thinkers Judgment Judgment Caregivers Caregivers

140 Myth Case

141 Alleged Perpetrators- Still allowed Access

142 Prevention Types: Types: Education Education Home Visiting Programs Home Visiting Programs Adult Focus Adult Focus

143 The Relationship of Adverse Childhood Experiences to Adult Health Status ACE ACE Child Maltreatment Child Maltreatment Physical Physical Sexual Sexual Psychological Psychological Parental Parental Etoh and Drug abuse Etoh and Drug abuse Domestic Violence Domestic Violence Incarceration Incarceration

144 ACE Direct relationship between the number of ACE and adverse health outcomes Direct relationship between the number of ACE and adverse health outcomes Include Mental Health and Physical Health Include Mental Health and Physical Health

145 ACE Long term physical health consequences Long term physical health consequences ACE study ACE study Abuse Neglect Household dysfunction Health problems Heart disease Liver disease Depression Substance abuse Lung disease Fetal death

146 Long term physical health consequences Dong et al. Arch Intern Med. 2003;163:

147 Take Home Points Child Sexual Abuse is prevalent Child Sexual Abuse is prevalent Diagnosis of CSA not usually by physical exam findings or behavior alone Diagnosis of CSA not usually by physical exam findings or behavior alone Many “sexual behaviors” are normal Many “sexual behaviors” are normal Disclosures -- most important and need to be obtained appropriately Disclosures -- most important and need to be obtained appropriately Think about any other possible evidence! Think about any other possible evidence!


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