Usual and Less Usual Presentation Of Child Sexual Abuse

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Usual and Less Usual Presentation Of Child Sexual
Abuse

• Dr Julia Hale
• Named Doctor for Safeguarding
• Greenwich Teaching PCT
• October 2008

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Programme

• Case presentation
• Usual presentation
• Less Usual presentation

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Stacey and Sarah

• Stacey 8½ yrs ,Sarah 6 yrs
• Lived with mother and her partner
• Spent some weekends with father and his partner
• Parents had not been married
• Father did not have parental responsibility

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Stacey and Sarah

• Father and his partner came to children's GP
  paediatric outreach clinic alone to express their
  concerns about neglect by mother
• Poor clothes, no coat, shoes too small
• Poor personal hygiene
• Bedwetting
• Recurrent head lice
• Behaviour a little difficult

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Stacey and Sarah

• In GP record was a report of hospital admission
  of Stacey at 8 yrs with Pseudoseizures
• Episode reported where mothers partner held her
  hanging over a balcony
• Concerns about domestic violence
• Recommended father took legal advice to obtain
  parental responsibility and ask for access to GP
  record
• Referred to Social Services on basis of fathers
  concerns

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Stacey and Sarah

• No contact from Social Services
• No case conference called
• Mother moved to Wales with partner and girls, who
  attended a school with all lessons in Welsh
• 9 yrs Stacey referred for sexual abuse medical,
  no conclusive findings made

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Stacey and Sarah

• 9 ½ yrs Stacey referred for physical abuse
  medical with some bruising to body and arms
• School reported concerns about poor hygiene,
  hungry and poor weight
• Paediatrician found extensive bruising indicating
  NAI. Also dirty, visibly thin and underweight
• Placed on CPR and taken into foster care for
  neglect

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Stacey and Sarah

• Within 2 months Stacey put on 3 kg from 24kg
  (2-9th centile)
• In care both girls disclosed a long history of
  physical, emotional and sexual abuse over several
  years by mother and by several of mothers
  partners

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Stacey and Sarah

• Disclosure of
• Repeatedly physically beaten
• Tied to chairs and left alone in house
• Locked in cupboard for hours
• Repeatedly sexually assaulted
• Not fed regularly or enough

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Stacey and Sarah

• After 7 months in care in Wales they were placed
  back in London with father and his partner
• Criminal proceedings were taken against mother
  and her partner

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Stacey and Sarah

• When Stacey 11 ½ yrs father asked to see me to
  discuss the difficulties with her behaviour
• Sexualised, provocative, risky behaviours
• Staying out with older boys and men on estate
• Smoking
• Truanting
• Learning difficulties and attitude problems in
  school
• Very challenging at home, especially to fathers
  partner
• Weight had gone up 12 kg in 18 months, now on
  50th centile
• Referred to CAMHS

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Stacey and Sarah

• 6 months later GP asked me to see Sarah, now 9 ½
  yrs with an acute genital problem
• On examination she had genital herpes
• Presumed to be recurrence from a primary
  infection during the past sexual abuse

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Stacey and Sarah

• Father reported Staceys behaviour was escalating
  putting whole family under stress
• Following Court conviction of the mother and her
  partner, he was making a claim for both girls
  under the Criminal Injury Compensation Board
• He was pursuing a formal complaint against the
  London borough Social Services for failing to
  protect his daughters from when they first came
  to attention 2 years before being taken into care
  in Wales

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(No Transcript)
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Usual Presentation of Child Sexual Abuse

• Acute presentation
• Acute genital injury
• Stranger assault
• Chronic presentation
• Disclosure by child
• To parent
• To teacher or social worker
• Suspicion of parent
• Police identify Paedophile
• Internet user
• Schedule 1 offender

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Less Usual Presentation of Child Sexual Abuse

• Physical indicators
• Behavioural signs
• Psychological
• Functional or Psychosomatic
• Sexualised behaviour

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1. Physical indicators

• Co-incidental with physical abuse (15)
• Sexually transmitted disease
• Pregnancy
• Anal fissure
• Rectal bleeding
• Enuresis (wetting)
• Encopresis (soiling)
• Gonoccoccal eye infection

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Co-incidental with Physical Abuse

• Grip marks
• inner thigh, knee or upper arm
• Bruises over lower abdomen,pubis,hips
• Love bites and tooth bite marks
• Lacerations of penis, labia or perineum
• Burns and scalds
• Buttocks, genitalia, back of hand
• Signs of partial suffocation
• Petechiae on neck and face (pin point bruising)

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Sexually transmitted disease
Disease CSA Likelihood Other considerations
Gonorrhoae Most likely Some transmission at birth
Chlamydia Most likely Some transmission at birth
HIV Likely If exclude blood or maternal
Trichomonas Likely Some transmission at birth
Anogenital Warts Significant proportion Some transmission at birth
Genital Herpes Significant proportion
Bacterial Vaginosis Possible Unknown significance
Hepatitis B Unknown significance
Hepatitis C Unknown significance
Syphilis Unknown significance
Mycoplasma Unknown significance
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2. Behavioural signs

• Acute traumatic response
• Regression
• Sleep disturbance
• Eating disorder
• School performance problems
• Truanting
• Aggression or acting out
• Running away
• Prostitution

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3. Psychiatric / Psychological

• Psychiatric conditions
• Anxiety
• Depression
• Self mutilation
• Suicide or attempt
• Total refusal syndrome
• Anorexia or bulimia
• Drug and solvent abuse

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4. Functional or Psychosomatic

• Recurrent abdominal pain
• Irritable bowel syndrome
• Headache or migraine
• Elective mutism
• Psychogenic non epileptic seizure

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Irritable Bowel Syndrome

• Significant number of adults with irritable bowel
  syndrome report histories of physical, emotional,
  and sexual abuse.
• In one case-control study in children, 72 abused
  children reported more functional disorders than
  did controls (48 v 26).
• In a prospective study, abused and non-abused
  boys reported comparable rates of functional
  disorders the duration of the problems, however,
  was significantly longer in abused boys than
  non-abused boys

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Psychogenic Non Epileptic seizure

• A type of episodic behaviour that mimics
  epileptic seizures but is to be distinguished
  from them
• A dissociative state secondary to trauma
• Can occur in children with epilepsy
• Also known as Pseudoepileptic seizures or
  Pseudoseizures

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Psychogenic non-epileptic seizures management
and prognosisArch Dis Child 200082474478
Irwin, Edwards, Robinson

• Admissions to a London hospital of 35 children
  over 2 years
• 24 non epileptic, 11 with epilepsy
• Types of seizures in group without epilepsy (24)
• Swoons 9
• Prolonged blank spells 8
• Clonic movements with pelvic thrusting 5
• Other 2

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Psychogenic non-epileptic seizures management
and prognosisArch Dis Child 200082474478
Irwin, Edwards, Robinson

• Causes of psychogenic non-epileptic seizures in
  the group without epilepsy (24 of 35)
• History physical or sexual abuse 6
• Domestic stress 6
• School avoidance 4
• Maternal over dependence 3

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5. Sexualised Behaviour

• Preoccupation with own or others genitals
• Masturbation, rubbing and rocking
• Insertion of objects into anus or vagina
• Precocious and seductive behaviour
• Intimate touching of adults
• Acting out sex acts with doll
• Precocious knowledge of sexual activity

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Characteristics of young children with sexual
behavior problems a pilot study.Silovsky et al.
Child Maltreatment. 7(3)187-97, 2002

• 37 young children with sexualised behaviour
  problems
• 38 had substantiated histories of sexual abuse.
• 47 experienced physical abuse
• 58 witnessed interparental violence
• 11 had no known history of sexual abuse,
  physical abuse, or witnessing domestic violence.

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Services identifying Less Usual Presentation of
CSA
Physical indicators GP, Acute Community Paeds or Family planning, Gynae Antenatal
Behavioural signs GP, School, Social Services,CAMHS
Psychiatric / Psychological Acute Paeds, CAMHS,
Functional or Psychosomatic Acute Paeds, CAMHS, Paed Neurology
Sexualised behaviour School or Nursery,
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Late Presentation as Adult

• Post traumatic stress disorder
• Psychosomatic manifestations of skin diseases,
  particularly factitious disorders
• Chronic pelvic pain (48 had CSA)
• Irritable bowel syndrome
• Extreme obesity (32 had CSA)
• Conversion disorder (severely disturbed)
• Borderline personality disorder
• Multiple Personality Disorder