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% Neglect
15% Physical Abuse
<10%
Sexual Abuse
<10%
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

Finkelhor 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 dont 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

Age

Sexual abuse RI laws

<=13

<=13
14
15
16
17
>=18

Mark Massi

14

15

16

17

>=18
Unable to consent
Child molestation
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 STIs
-- 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 prepubertal children

Colposcope
Tool for magnification and photodocumentation
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 Physicians 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 childs genital anatomy

Ladson et al AJDC l987

Physical Examination
Findings

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!

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 childs 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

Its 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
childs 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 STIs 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*
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;506-512

*Reading. Arch Dis Child 2007;92:608613. doi: 10.1136/adc.2005.086835

*Adams. Current Opinion in Obstetrics and Gynecology 2008, 20:435441

Sexually Transmitted
Disease (STD)
Infections (STI)

HPV- Human Papilloma

Virus
P

Sinclair Study- Anogenital and Oral

Pharyngeal Warts
31% likelihood of Sexual Abuse
No actual cut off-age

Sinclair KJ, et al. Pediatrics 2005; 116:815825.

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

Friedrichs 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)

Friedrichs 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

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 animals sex parts
Draws sex parts

Normal Sexual Behaviors

A Childs sexual behaviors are influenced

by:
Age
Family Stress and Violence
Family Sexuality
Culture/Religion
Surroundings, exposure to ageinappropriate 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 childs 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
Childs language
Remember children think concretely

Childs History
Build rapport
Use open-ended questions
Use childs language
Reassurance

Questions used in
Interviewing

General/Open: How are you? Do you

know why youre 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 dont all kids talk?

Not developmentally ready, acts werent

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

Childs initial statement was that

he/she was NOT a victim of sexual
abuse

Three-fourths of children denied

when initially questioned

Disclosure

Tentative (78%): childs 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 childs 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 childs 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
calculatedFaller & 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
patients 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 childs
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

Dont 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 selfprotection

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 parents 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
Health
ACE study
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!