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Child Sexual Abuse: Evaluation and Outcomes
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Evaluation, Diagnosis, and Outcomes of Child Sexual Abuse
Jessica Smith
Penn
State College of Medicine
March 2002
- Definition:
“Sexual abuse of children refers to sexual behavior between a child and an
adult or between two children when one of them is significantly older or
uses coercion. The perpetrator
and the victim may be of the same sex of the opposite sex.
The sexual behaviors include touching breasts, buttocks, and genitals
whether the victim is dressed or undressed; exhibitionism; fellatio;
cunnilingus; and penetration of the vagina or anus with sexual organs or
with objects. Pornographic
photography is usually included in the definition of sexual abuse. It is important to consider developmental factors in
assessing whether sexual behaviors between two children is abusive or
normative.”5
- Epidemiology1:
- Women:
16.8% , Men: 7.9%
- Number
of substantiated or indicated cases has decreased by 41% in the time
period of 1992 to 2000.
- Risk
Factors4:
- Age:
incidence of child sexual abuse increases with age
- 0-3
y/o: 10% of victims
- 4-7
y/o: 28.4% of victims
- 8-11
y/o: 25% of victims
- 12
and older: 35.9% of victims
- Gender:
- 2.5-3:1
female predominance
- 25%
of victims are male
- Disabilities:
- Risk
increased for those with physical disabilities, especially those that
impair the child’s perceived credibility: blindness, deafness, and
mental retardation
- Gender
effect: boys are over represented among sexually abused children when
compared to sexually abused children without disabilities
- Family
Constellation:
- Absence
of one or both parents is a risk factor
- Presence
of stepfather in home doubles the risk for girls
- Parental
impairments are also associated with increased risk
- Socioeconomic
status:
- More
important for physical abuse and neglect
- Much
less impact on child sexual abuse
- Race
and Ethnicity:
- May
influence symptom expression
- Do
not seem to be risk factors for child sexual abuse
- Evaluation
- No
gold standard3
- Interview:
- Assumed
to be more reliable and more valid3
- Time
consuming3
- Guidelines6:
- Establish
a rapport
- Truth
telling
- Reduce
the number of times interviewed
- Make
the environment comfortable
- Obtain
accurate history including development, cognitive assessment, history
of prior abuse or traumas, medical history, behavioral changes,
parent’s abuse as children, family attitude toward sex and modesty
- Interview
both parents when abuse is intrafamilial
- Consider
false allegations
- Assess
credibility of child
- Dolls
are not necessarily reliable and anatomical correctness is not
necessary
- Children’s
drawings are helpful
- Questionnaire3:
- Helpful
in large populations because less time consuming
- Some
are too detailed because they are meant as a substitute for an interview
- Medical
examination2 :
- Relied
on too much for diagnosing sexual abuse
- History
is the single most diagnostic feature for sexual abuse
- Only
4% of children referred for medical evaluation have abnormal
examinations
- Outcomes4
: Psychiatric disorders, dysfunctional behaviors, neurobiological
dysregulation
- Depression
and dysthymia
- 3-5
times more common in women with a history of child sexual abuse
- Gender
differences disappear for depression when controlled for a history of
child sexual abuse
- Altered
clinical presentation- reversed neurovegetative signs such as increased
appetite, weight gain, and hypersomnia
- Sexualized
behaviors
- Increased
arrest rate for sex crimes and prostitution irrespective of gender
- Sexually
abused adolescents are at increased risk for earlier pregnancy
- Child
sexual abuse is a predictor of HIV risk related behaviors
- Neurobiological
effects
- Deleterious
effects on the hypothalamic-pituitary-adrenal axis, the sympathetic
nervous system and possibly the immune system
- Sexually
abused females demonstrate increased morning cortisol levels and
decreased evening basal levels of cortisol
- Sexually
abused females had increased 24 hour urinary catecholamine levels
- Borderline
personality disorder, somatization disorder, substance abuse disorder,
PTSD, dissociative identity disorder, and bulimia nervosa
- Principles
of Psychopathology in child sexual abuse4
- Twin
studies- in twins discordant for child sexual abuse, affected twins had
significantly higher rates of major depression, attempted suicide, conduct
disorder, alcohol dependence, nicotine dependence, social anxiety, rape
after age 18 and divorce
- Basic
clinical features that link different clinical outcomes associated with
child sexual abuse
- Affect
regulation
- Impulse
control
- Somatization
- Sense
of self
- Cognitive
distortions
- Socialization
problems
- DSM-IV
Diagnosis4
- Individually
based on symptoms
- Disorder
of extreme stress not otherwise specified (DESNOS)
- Treatment4
- Asymptomatic
children
- 40%
of sexually abused children present with few or no symptoms
- ‘sleeper
effects’: 10-20% will deteriorate over the next 12 to 18 months
- Need
to be evaluated for additional risk factors
- Symptomatic
children
- 62.8%
qualify for at least one psychiatric diagnosis
- 29.5%
qualify for 2 or more psychiatric diagnoses
- Cognitive
behavioral therapy is affective for some symptoms of child sexual abuse
- Appropriately
treat for psychiatric diagnoses
References
- Gorey,
K. and Donald Leslie. (1997). “The prevalence of child sexual abuse:
Integrative review adjustment for potential response and measurement
biases.” Child Abuse and Neglect. Vol. 21(4): 391-398.
- Heger,
A., Ticson, L., Velasquez, O., and Bernier, R. (2002). “Children referred
for possible sexual abuse: medical findings in 2384 children.” Child
Abuse and Neglect. Vol. 26: 645-659.
- Kooiman,
C.G., Ouwehand, A.W., and ter Kuile, M.M. (2002). “The sexual abuse
questionnaire (SPAQ): A screening instrument for adults to assess past and
current experiences of abuse. Child Abuse and Neglect. Vol. 26:
939-953.
- Putnam,
Frank W. (2003) “Ten year research update review: child sexual abuse.” J.
Am. Acad. Child Adolesc. Psychiatry. Vol. 42(3): 269-278.
- “Practice
Parameters for the forensic evaluation of children and adolescents who may
have been physically or sexually abused.” AACAP Partial text.
- “Guidelines
for: The clinical evaluation of child and adolescent sexual abuse.”
(2001). www.aacap.org/violence/guide.htm.
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