‘Practical’ guide helps in evaluation of children who report sexual abuse
- Copyright © 2013 by the American Academy of Pediatrics
“Is anything bothering you?” “Tell me why you’re here today.”
These are open-ended, non-suggestive examples of questions pediatricians can use when evaluating a patient who has disclosed sexual abuse. The importance of the quality of the interview is one point discussed in an updated clinical report that can help pediatricians respond to claims of possible child abuse raised in the clinical setting.
An update to a 2005 document, the report is a resource for pediatricians seeking to learn more about making the diagnosis, doing exams, testing for sexually transmitted infections, dealing with parents and tapping resources for referral. The report’s appendix highlights eight conditions that can be mistaken for possible sexual abuse.
The Evaluation of Children in the Primary Care Setting When Sexual Abuse is Suspected is published in the August issue of Pediatrics (2013; 132:e558-e567; http://pediatrics.aappublications.org/cgi/doi/10.1542/peds.2013-1741).
“The major difference in this report and others is this is really very practical advice — like nuts and bolts,” said Carole Jenny, M.D., M.B.A., FAAP, lead author of the report from the AAP Committee on Child Abuse and Neglect.
Dr. Jenny said it takes into account pediatricians who have experts in the community as opposed to those in areas where there may not be a single child abuse doctor in the whole state.
Sexual abuse of children occurs commonly, is underdiagnosed and can have lifelong effects. In 2006, 1.8 children per 1,000, or 135,000 children, were victims, according to one national study. Other studies say 5% to 25% of adults reported being sexually abused as children.
Victims often wait years before revealing abuse. One study cited in the report notes that more than half of sexually abused children do not disclose their abuse until they are adults.
A major factor in the child’s long-term mental health outcome is whether he or she was believed and supported, according to Dr. Jenny. Yet one of the misperceptions surrounding child sexual abuse — sometimes believed by medical and legal experts — is that kids lie. “I don’t think there’s any evidence to think that this is an extensive problem,” she said. “Kids are much more likely not to talk about it than to make something up.”
Still, very young children can be suggestible, Dr. Jenny said, such as in the case where a parent constantly asks a young child coming home from a visitation with the other parent if somebody touched him or her.
Parents should not repeatedly press a child to reveal details of an incident of abuse because this can contaminate the interview. “We want to keep the child’s words as clear as possible in their own perceptions,” Dr. Jenny noted.
Advice in the clinical report includes the following:
Guidance for pediatricians
Understand state child abuse reporting laws and how to report.
Be aware of normal, developmentally appropriate variations in children’s sexual behaviors, as well as normal and abnormal genital and anal anatomy.
Stay up-to-date on community resources for help in evaluation of alleged abuse.
Seek second expert opinions when a child’s physical exam is thought to be abnormal.
Know when and where to refer cases of acute abuse or assault that require forensic testing, prophylaxis for sexually transmitted infections, HIV and emergency contraception.
Interviewing children about possible sexual abuse
A child spontaneously disclosing abuse should know it’s OK to talk about it.
During the interview, the child should be separated from the parent, if possible. (The parent will be present for the exam if that is the child’s preference.)
When there is no pre-established relationship with the patient, spend time talking about nonthreatening issues. The child should know it’s the doctor’s job to keep kids healthy, and it’s OK to talk about difficult subjects.
Don’t ask leading or suggestive questions.
Use developmentally appropriate language, with translators if necessary. The parents can be asked about terms the family uses.
Record descriptions of abuse given by the child verbatim, using quotation marks. Attribute the remarks to the child. Record impressions but identify them as such.
Do not coerce the child to talk about abuse, and don’t offer rewards for doing so.
Be supportive and empathic, but don’t act shocked, outraged or dismissive.