Investigating Child Sexual Abuse Christine E. Barron, MD Assistant Professor, Pediatrics Warren Alpert Medical School at Brown University Objectives National Data Physical Examination “Red Flag” Behaviors Disclosures and Forensic Interviewing Multidisciplinary Team Prevention 2008 National Data ~ 3.3 million reports involving ~6 million children 772,000 children were found to be victims of maltreatment 70% 15% <10% <10% Neglect Physical Abuse Sexual Abuse Psychological maltreatment Child Maltreatment 2008 Sexual abuse is common National survey of US adults Childhood sexual abuse reported by 27% of women 16% of men1 Each year ~1% of children are victims of CSA Adolescents: highest rates for sexual assaults 1Finkelhor et al. Child Abuse & Neglect 1990;14:19-28. Risk Factors CSA occurs across all socioecomonic and ethnic groups Race and ethnicity have NOT been identified as risk factors Disabilities are a risk factor Family Constellations Putnam. J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 42:3, MARCH 2003 Myths of Sexual Abuse Perpetrators are strangers Perpetrators who touch boys don’t touch girls Children tell about the abuse immediately Children tell fantasies Any child victim with penetration will have an abnormal examination Disclosures in custody issues are all false allegations Pedophiles Can have normal peer sexual relationships Can be sexually oriented only to children Can be abuse reactive Child-on-Child Often someone family knows Sexual abuse – RI laws Age <=13 <=13 14 15 16 17 >=18 Unable to consent Child molestation 14 15 16 17 >=18 Mark Massi Third degree Consensual sex Physical Examinations Evaluations for the Diagnosis & Treatment of Child Sexual Abuse American Academy of Pediatrics Developmentally appropriate interview Complete examination to include growth, development, social, and emotional state Directed genital examination for specific signs or physical indicators Laboratory evaluation, cultures for STI’s -- as indicated by history or physical Culture versus NAAT testing Physical Examination Provides reassurance Examine for treatable conditions, STIs Collect legal evidence Chronic sequelae Assists in the protection of the child Triage Nonurgent (within few weeks) Urgent (within a few days) Vaginal discharge, odor, possible pregnancy Emergent (within 24 hours) Vaginal, rectal bleeding Psychological crisis Safety concerns Forensic Evidence Collection 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. General Physical Examination Head to toe physical examination Attention to: Abdominal Exam Skin- appropriate UV light source Bruising Ligature/control marks Oral Sign of penetration Sexually transmitted diseases Physical Examination Genitals Completed in a non-traumatic manner External inspection A speculum is infrequently used in adolescents and rarely used in pre-pubertal children Colposcope Tool for magnification and photo-documentation Does not see what is not there Estrogen Effect on Hymen Circulating maternal hormones causes estrogenization of hymen Hormonal influences decrease in childhood Hormonal influences become obvious once again during puberty Estrogen- Thickened, redundant and pale. Physical Signs and Symptoms Bruises, scratches, bites Abdominal pain Genital bleeding – “blood on underwear” Genital discharge, sexually transmitted disease Genital or Anal Pain Genital Skin Lesions Genital/Urethral/Anal Trauma Enuresis, Recurrent Urinary Tract Infections Encopresis, Anal Fissures Diagnosing Sexual Abuse Can the doctor tell? Can any doctor complete these evaluations? Physicians Not trained Feel uncomfortable Call normal findings abnormal Call abnormal findings normal Do Physician’s Recognize Sexual Abuse? 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 Ladson et al AJDC l987 Physical Examination Findings Untrained physicians are more likely to overdiagnosis -- 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! “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 Child Abuse Physicians: 32 (70%) normal 4 (9%) nonspecific 2 (4%) concerning Makoroff et al Child Abuse Negl 2002 Physical Exam 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 2008. Current opinion in obstetrics and gynecology 2008;20(5):435 -441 Physical Exam Findings commonly seen in non abused children Findings commonly caused by other medical conditions Ex: periurethral bands Ex: erythema of the vestibule Indeterminate findings (conflicting data from research, requires further evaluation to determine significance) ex: deep notch in hymen Physical Exam Findings diagnostic of trauma and/or sexual contact Examples: Lacerations or bruising Hymenal transection (area of hymen torn through or nearly through the base) Infection such as chlamydia > 3years old Pregnancy Sperm on sample taken from child’s body Examination Techniques Physical Findings 5-10% of children have physical findings Genital (female) Bruising Transections Absent hymenal tissue Abrasions Sexually Transmitted Diseases Physical Findings Genital (Male) Penile Abrasions Bites, Bruises Urethral/Anal Discharge Sexually Transmitted Infections Scars “It’s normal to be normal.” Joyce Adams, MD “Genital Anatomy in Pregnant Adolescents: “Normal” Does Not Mean “Nothing Happened”; 36 pregnant adolescents seen for sexual abuse evaluations 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) Kellogg N et al Pediatrics 2004 Repetitive Penetration Study 506 girls 5-17 with reported penile-vaginal penetration 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. Anderst Pediatrics 2009: 124-;e403-e409 Physical Exam A normal exam does not exclude the possibility of sexual abuse or prior penetration “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 “Children Referred for Possible Sexual Abuse: Medical Findings in 2384 Children” Referrals based on disclosure, behavior changes, medical findings Overall 96% had normal exams 5.5% abnormal when disclosed penetration 1.7% abnormal without history penetration 8% exams abnormal when had medical findings STIs, acute genital trauma, healed hymenal trauma, transections Heger et al Child Abuse & Neglect 2000 Why are exams normal? Nature of assault may not be damaging Perception of “penetration” Disclosures often delayed Complete healing can occur The hymen changes with puberty Physical Exam 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 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) Try to understand families’ perceptions and explain significance of exam findings Additional Exam Findings Stay Moral, Go Oral Adolescents do not consider oral sex to be sexual activity. Need to ask if anything has been in the mouth! Mimickers of Sexual Abuse Medical Conditions Accidental Trauma Vaginal Bleeding Case 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. Prepubertal Vaginal Bleeding Endometrial Shedding EndocrineHypothyroidism Liver Cirrhosis Coagulopathy Precocious puberty McCune-Albright Syndrome Ovarian Cyst Case # 2 Urethral Prolapse Exam- annular mass from urethral meatus Urethral mucosa is friable bleeding, pain and dysuria. Prolapse can be more pronounced with Valsalva maneuver Not associated with child abuse More prevalent in African-American females Tx: Nonsurgical unless Urinary retention, or lesion is necrotic Case Lichen Sclerosus et Atrophicus Hypopigmented, well-circumscribed areas of atrophic skin around genital and/or anus. “Figure-of-eight” Subepithelial hemorrhages Frequently mistaken for bruising or bleeding caused by trauma from SA Straddle Injuries Site of impact often anterior External to hymen Unilateral Painful Bleeding may be significant Occasional penetrating trauma to hymen with external to internal injury Case Vaginal Foreign Body Intermittent bloody discharge. Toilet paper is the most common foreign body Not indicative of abuse Summary Differential Dx for Vaginal Bleeding Sexual Abuse Physiologic Endometrial Shedding Urethral Prolapse Lichen Sclerosus et Atrophicus Labial Agglutination Foreign body Accidental trauma Continued Tumors Clear Cell Carcinoma Rhadomyosarcoma Ovarian Adrenal Urinary Tract Urethral Prolapse Hemorrhagic cystitis Urate Crystals Hematuria UTI Continued GI Tract Hematochezia Anal Fissure Dermatology Lichen Sclerosis et Atrophicus Forensic Evidence Collection Sexual Assault has occurred within 72-hours Disclosure Witnessed Confession Contact could have resulted in transfer of bodily fluids “Forensic Evidence Findings in Prepubertal Victims of Sexual Assault” Christian et al Pediatrics 2000 90% of children with positive kits were seen within 24 hours of assault 64% evidence found on clothing and linens (Only 35% children had clothing/linens collected) No swab positive for semen/sperm after 9 hrs Forensic Evidence Collected on Examination (1) (2) 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 and when taken from prepubertal patients. Young. Arch Pediatr Adolesc Med. 2006;160:585-588 “Date Rape” Drugs (Alcohol) Not typically screened for in routine toxicology screen Specifically must request urine screen Found in urine up to 24 hours after ingestion “Date Rape” Drugs GHB and metabolites Loss of consciousness, hypothermia, clonic jerking Effects begin after 10-15 minutes Peak within 25- 45 minutes Persists up to 5 hours “Date Rape” Drugs Rohypnol- Flunitrazepam Benzodiazepine Sedation, loss of consciousness Effects begin after 30 minutes Peak within 2 hours Persist up to 8-12 hours Physical Examination The health and welfare of the child take precedence over legal and investigative needs Sexually Transmitted Infections How often do STI’s help to make the diagnosis of Child Sexual Abuse? Symptoms Burning Discharge Itching Bleeding Anogenital Pain Pubertal- may have no symptoms Sexually Transmitted Diseases 2973 Children evaluated for sexual abuse: 1.7% Gonorrhea 1.3% Chlamydia 0.2% Syphilis <1% Trichomonas 1.7% Condyloma acuminata (warts) 0.3% Herpes Simplex Virus Who do we test? Age of child High risk of STI in assailant (incarceration) Household member with STI Type of sexual abuse Symptoms (vaginal discharge) Acuity of abuse Patient/family concern High incidence in community Multiple/unknown offenders STDs for the Diagnosis of CSA Gonorrhea* Syphilis* HIV § C trachomatis* T vaginalis HPV Herpes simplex Virus (HSV) Diagnostic† Diagnostic Diagnostic Diagnostic† Highly suspicious *Suspicious (Indeterminate) *Suspicious (Probable, Indeterminate) Bacterial vaginosis Inconclusive Kellogg, The Evaluation of Sexual Abuse in Children. Pediatrics 2005;116;506-512 *Reading. Arch Dis Child 2007;92:608–613. doi: 10.1136/adc.2005.086835 *Adams. Current Opinion in Obstetrics and Gynecology 2008, 20:435–441 Sexually Transmitted Disease (STD) Infections (STI) HPV- Human Papilloma Virus Sinclair Study- Anogenital and Oral Pharyngeal Warts 31% likelihood of Sexual Abuse No actual “cut off-age” Sinclair KJ, et al. Pediatrics 2005; 116:815–825. Physical Examination In only a very small percentage will it help to make the diagnosis of child sexual abuse by itself. Corroboration: Evidence exists more often than you think Physical evidence (FEK) Behavioral symptoms Adult witnesses and suspects Medical evidence (exam) Other victims Child witnesses Child pornography Computers Cell Phones Photos Text Messages Perpetrator confessions Sexualized Behaviors Can the diagnosis of sexual abuse be made based on sexualized behaviors? Behavioral Signs Is that a red flag being waved? Infants (0-18 months) Rarely show symptoms Fussy, diaper change reluctance Fearful of offender Imitate sexual acts Toddlers (18-36 months) All of the above plus: Difficulty toilet training, sleep disturbances Minimal embarassment Masturbation common (normal) Preschool (3-5 years) All of the above plus: Sexualized play, perpetration Headaches, abdominal pain, painful urination, genital discomfort Nightmares Regression Anger, aggression, mood swings School Age (6-9 years) Any of the above plus: Confusion, guilt Withdrawn, depression, nightmares Poor school performance, lying, stealing Sexualized behavior, somatic complaints Enuresis, encopresis, dysuria Puberty (9-12 years) Feel responsible, overwhelming guilt/shame Shoplifting, substance abuse Sexual identity crisis Uncomfortable with body and disclosure Adolescents (13 years +) Defiance, aggression, truancy, school failure, promiscuity, suicidal ideations, self-mutilation, runaway behavior Somatic complaints Peer Sexual Contact Behaviors Parents are not always good historians regarding stress. Exposure to adult sexual information Pornography Cable Internet Adult interpretation of sexualized play. Normative Sexual Behavior in Children 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) Friedrich – Normative Sexual Behavior in Children 1991-- 880 Children ages 2-12 1998 -- 1114 Children ages 2-12 Administered specialized surveys 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” Friedrich’s Top 10 (most common) 10. 9. 8. 7. 6. Dresses like opposite sex Hugs adults not known well Shows sex parts to adults Masturbates with hand Very interested in opposite sex (**10-12yo) Friedrich’s Top 10 (most common) 5. 4. 3. 2. 1. Touches sex parts in public Tries to look at people when they are nude Stands too close Touches breasts Touches sex parts at home 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 Normal Sexual Behaviors A Child’s sexual behaviors are influenced by: Age Family Stress and Violence Family Sexuality Culture/Religion Surroundings, exposure to age-inappropriate information and materials Concerning Sexual Behaviors Influenced by: Media (television, internet, videos, magazines) Decreased parental supervision Decreased boundaries Overt exposure Sexually Abused When to be concerned? Sexual expression is more adult than childlike Other children complain Continues despite requests to stop Children sexualize nonsexual things Genitals are persistent and prominent in drawings Disclosure of CSA in Art and Play Specific Concerns with playing Sand-Tray Therapy Therapy not Diagnostic Assessment Art- should not have to be interpreted “ I know he was sexually abuse because he is drawing sharks” Examples Interactive Session Sexualized behavior does not mean that a child is a victim Developmental component Toddler/Preschooler? School Age? Assessment component Playing Doctor Plays doctor/inspects others’ bodies Frequently plays doctor even after getting caught and reprimanded Forces others to play doctor and/or to remove clothes, touching privates Placing Objects in Genital Orifices Tries to place objects in own genitalia/rectum one time – curious Places object in genitalia or rectum of self/others Uses coercion/pain in placing object in genitalia/rectum of self and others Disclosures in Sexual Abuse The most important piece of the puzzle This may make your diagnosis Disclosures in Sexual Abuse Can the diagnosis of sexual abuse be made based on a disclosure of sexual abuse? YES A child’s disclosure alone CAN make the diagnosis of sexual abuse… Disclosure is a Process Children disclose gradually versus rapidly. BUT… The disclosure needs to be obtained appropriately without direct and leading questions Context of any Disclosure Was this a spontaneous disclosure? Was the child asked multiple questions? Was the child asked leading questions? Case Case: Interview Interviewing Trained Interviewers Limiting number of interviews First responders need to learn how to obtain information A Good Interview Should… Assess competence Address context initial disclosure Avoid direct and leading questions Document body language Child’s language Remember children think concretely Child’s History Build rapport Use open-ended questions Use child’s language Reassurance 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 The Leading Question Pt complains of genital pain “Did Uncle Joey put his pee-pee in your flower ? Why don’t all kids talk? Not developmentally ready, acts weren’t “bad” Sworn to secrecy Trapped and Helpless Afraid to upset family Fears no one will believe May have disclosed and told “ She would never do that” Threats Feels responsible, overwhelming guilt/shame “How Children Tell: The Process of Disclosure in Child Sexual Abuse” Sorenson and Snow Child Welfare 1991 630 child victims (1985-1989) (3-17 ages) 116 confirmed cases Confession (80%) Conviction (14%) Medical Findings (6%) Types of Disclosures – part of continuum 4 Steps of the Process Denial Disclosure Tentative Active Recant Reaffirm Denial Child’s initial statement was that he/she was NOT a victim of sexual abuse Three-fourths of children denied when initially questioned Disclosure Tentative (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” Disclosure Active: a personal admission by the child of having experienced a specific sexually abusive activity 7% of initial denials move directly to active 96% of all eventually give active disclosure Recant Refers to the child’s retraction of a previous allegation of abuse that was formally made and maintained over a period of time Recantations Common, 22% of children in study Often influenced by the perpetrator but more often influenced by the “non-offending” family members Intentionally Unintentionally Reaffirm 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 Conclusion 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 Minimal Facts Interview Where on the body touched Who touched him/her What did the touching Where did the touching occur When did this happen NOT WHY Disclosures Suggestibility 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 Depend on adults Defer to adults Aware of adult authority Tendency to want to please adults Infants (0-18 months) NO DISCLOSURES Rarely show symptoms By 18 months majority have only 10 words Confirmed only with sexually transmitted disease, semen, offender confession, eye witness, abnormal exam Toddlers (18-36 months) 50-200 word vocabulary Two word sentences start at 21 months “Daddy owie” “Papa down” Accidental disclosures Masturbation normal Substantiate with sexually transmitted disease, semen, offender confession, eye witness, abnormal exam Preschool (3-5 years) Improved Vocabulary!! (2500-3000 words) Partial disclosures Minimization, denial, irrelevant details Better at who, what, where (not when or number of times) History now more important Substantiation with HISTORY, STDs, semen, confession, eye witness, abnormal exam School Age (6-9 years) More independent, learning boundaries Tentative disclosures Build rapport Fear of jail Substantiate with HISTORY, labs/STDs, semen, confession, eye witness, abnormal exam Puberty and Adolescents Peers often more influential than family Family withdrawal Disclose due to peers, anger Uncomfortable with body and disclosure Reassurance of being normal important Substantiate with HISTORY, labs/STDs, semen, confession, eye witness, abnormal exam 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 Interview Stages Introduction Rapport-building/Developmental Assessment/Narrative Practice Ground rules Substantive questions Closure Use of Media Anatomical Dolls Anatomical Drawings Gingerbread Drawings: Language Considerations Interview Interview What next? Interview False Allegations Risk situations for false allegations by adults: 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 Phases of disclosure I. Denial Initial statement that he/she has not been abused Case example 9 4 year old female Neighbor in adjacent apartment witnessed patient’s adult male roommate sexually abusing her Witnessed filmed incident and called 911 Perpetrator confessed Patient denied sexual abuse Parental response to disclosure Response of the non-offending parent is associated with short and long-term psychological outcomes Lack of support / belief associated with Depression Anxiety Behavioral problems PTSD 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):387-389 Parental Response Non offending parents experience emotional distress following their child’s sexual abuse disclosure Parental response impacts child Parental response influenced by: Prior history of depression History of sexual abuse Relationship to the perpetrator Social isolation Substance abuse Parental Response Examples of information provided to supportive parents Emphasize importance of parents’ role in the healing process Encourage continued support, reassurance, affirmation that child is believed Do not repeatedly question child about disclosure Acknowledge parents’ emotional distress Recommend an outlet for parents’ distress separate from the children (ex. counseling, adult supports) MDT Strengthens the investigative process Expertise from Law Enforcement, Child Protective Services, Medical, Forensic Interviews, Prosecutors, and others Don’t drop the ball Immediate response During the Investigation by CPS and Law Enforcement Afterwards MDT in Action MDT in Action When each member is available and does their part, cases will go much smoother 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 PREVENTION Parental Education Truth versus myths When to start- 10 yo is too late! How often Mental Health Care for parent’s prior abuse Communication Young children are concrete thinkers Judgment Caregivers Myth Case Alleged Perpetrators- Still allowed Access Prevention Types: Education Home Visiting Programs Adult Focus The Relationship of Adverse Childhood Experiences to Adult Health Status ACE Child Maltreatment Physical Sexual Psychological Parental Etoh and Drug abuse Domestic Violence Incarceration ACE Direct relationship between the number of ACE and adverse health outcomes Include Mental Health and Physical Health ACE Long term physical health consequences ACE study • Health problems • Abuse • Neglect • Household dysfunction • • • • • • Heart disease Liver disease Depression Substance abuse Lung disease Fetal death Long term physical health consequences Dong et al. Arch Intern Med. 2003;163:1949-1956 Take Home Points Child Sexual Abuse is prevalent Diagnosis of CSA not usually by physical exam findings or behavior alone Many “sexual behaviors” are normal Disclosures -- most important and need to be obtained appropriately Think about any other possible evidence!