Child Safe:
By Nancy Kellogg, MD,
ChildSafe Medical Director
Sara, an 8-year-old girl, presents to your office with “behavioral problems.” Her mother explains that Sara’s grades have been dropping and the teacher reports that Sara “doesn’t seem to focus.”
Mother also reports that Sara has nightmares and often seems tired during the day. You talk to Sara alone and ask her how things are going at home and at school. She is shy, says little and seems sad.
When you say, “Sometimes kids tell me that something has happened to their body or their feelings that made them sad, scared or confused. Has anything like that ever happened to you?” Sara looks at you, then down at her hands, and says, “Well, my mom’s boyfriend sometimes comes into my room at night – and touches me where he shouldn’t….”
What do you do next? Send her to the emergency room, call Child Protective Services, talk with her mother, do an exam?
Child sexual abuse is, unfortunately, a common childhood experience. Most often, child sexual abuse is first uncovered when the child discloses the abuse to another person. While children tend to disclose when they feel safe or when they can no longer cope with the abuse alone, some disclose simply because an adult asks them whether anything happened.
While fewer than 10 percent of victims will have an abnormal examination, most worry that their bodies are affected or changed by the abuse. All victims suffer the emotional aftereffects of abuse, which include confronting the sobering fact that not all mothers believe or support them after abuse is disclosed.
If the psychological effects of abuse are not addressed, however, the victim faces a future of uncertainty with increased risks for teen pregnancy, substance abuse, delinquent behaviors, personality disorders, mental health illnesses and dysfunctional and violent relationships.
Without detection and intervention, child sexual abuse becomes a chronic, potentially debilitating disease.
What is the role of the health care provider in the detection and management of child sexual abuse? Physicians play several critical roles: prevention, diagnosis, treatment, investigation and advocacy.
Physicians are uniquely positioned to prevent both victimization and perpetration, a particularly important role given the dramatic recent increases in numbers of juvenile sex offenders. Enhanced parent-child communication, which the physician can model during office visits, is the touchstone of child sexual abuse prevention.
Limiting access to sexually explicit and violent media, as well as close monitoring of internet activities can reduce inadvertent exposure to such material, on-line solicitation for sex and on-line sexual bullying by peers.
Once there is a suspicion of sexual abuse, many parents turn to their pediatrician for help. Like other medical diagnoses such as a migraine headache, the diagnosis of sexual abuse depends primarily on the child’s history. The physician should carefully document what the child tells them, including the child’s words in quotes, when possible.
Once a suspicion of abuse is confirmed, the immediate management depends on when the last incident of abuse occurred, the need for forensic evidence collection, the child’s acute symptoms of pain and bleeding, and the availability of resources in the community.
The physician should evaluate and ensure that three basic needs are provided: safety, medical and mental health, and investigation. Finally, physicians serve as advocates for children by employing prevention techniques in their practices, and by ensuring that victims receive the appropriate interventions after abuse has been diagnosed.
At ChildSafe, a medical training program was established in 1993 to assist clinicians in the detection, evaluation and management of child sexual abuse. Supported by funding from the Children’s Justice Act Grant to Texas (the training is provided free of charge to health care professionals), this program has provided training for more than 300 physicians, nurses and physician’s assistants.
The program provides opportunities for clinical observations, reviewing educational materials, observations of case staffings and court testimony, case reviews and accessing articles.
While five days is recommended for optimal training, clinicians may schedule any number of full or half-day trainings. Only one trainee is usually scheduled per day. Additional opportunities are available for observations in physical abuse assessments.
And what about Sara? Returning to the basic needs of the child: safety, health and investigation, the physician should first ensure that Sara does not have any emergent medical (pain and/or bleeding) or mental health (depression, suicidal behaviors or thoughts) needs.
The physician should assess whether recent sexual contact has occurred and the need for forensic evidence collection. In addressing Sara’s safety needs, the physician must report immediately to Child Protective Services, then assess whether Sara’s mother will be supportive and protective of Sara before releasing Sara from the office.
A call to ChildSafe (210-675-9000) or CHRISTUS Santa Rosa Hospital SANE (Sexual Assault Nurse Examiner) program (210-704-3706) can assist the physician through this process. Additional information on ChildSafe’s medical training program and other services can also be found online at www.childsafe-sa.org.
