eMedicine Specialties > Pediatrics: Developmental and Behavioral > Medical Topics

Child Abuse & Neglect, Sexual Abuse: Differential Diagnoses & Workup

Author: Angelo P Giardino, MD, PhD, Clinical Associate Professor, Department of Pediatrics, Baylor College of Medicine; Medical Director, Texas Children's Health Plan, Inc
Coauthor(s): Eileen R Giardino, PhD, RN, MSN, FNP-BC, ANP-BC, Associate Professor of Nursing, Department of Acute and Continuing Care, University of Texas Health Sciences Center Houston School of Nursing
Contributor Information and Disclosures

Updated: Dec 11, 2008

Workup

Laboratory Studies

  • Children who have been abused sexually are at risk of contracting STDs including gonorrhea, chlamydia, syphilis, condyloma acuminata, herpes simplex virus, human immunodeficiency virus (HIV), pediculosis pubis, and trichomoniasis vaginalis.
  • Rapid tests are not appropriate for prepubertal children in the context of a child sexual abuse (CSA) evaluation because of their higher potential for false-positive results.
  • Cultures remain the criterion standard and are valuable from a forensic evidence standpoint.
  • Depending on the contact suspected and the clinical situation recommended, testing includes the following:
    • Gram stain of vaginal and/or anal discharge
    • Genital, anal, and pharyngeal culture for gonorrhea
    • Genital and anal culture for chlamydia
    • Serology for syphilis
    • Wet prep of vaginal discharge for Trichomonas vaginalis
    • Culture of lesions for herpes virus
    • Serology for HIV (based on suspected risk)
  • The American Academy of Pediatrics (AAP) views nonvertically transmitted gonorrhea, syphilis, chlamydia, and HIV as diagnostic of sexual abuse in the prepubertal child.14
  • In a child, the AAP views the presence of T vaginalis as highly suggestive of sexual abuse.
  • Nonvertically transmitted condyloma acuminata and herpes with no clear history of autoinoculation are also suggestive of sexual abuse.

Other Tests

  • The collection of forensic evidence, via the rape kit, may be indicated if the child presents within 72 hours of last sexual contact with the perpetrator and if a belief exists that the perpetrator may have left evidence on the child's body. The 72-hour standard that triggers forensic evidence collection in cases of suspected child sexual abuse is derived from adult pathology studies of adult sexual assault cases. As more pediatric studies are performed based on the timing of forensic evidence collection, this 72-hour standard may be changed to reflect the unique issues present in most cases of child sexual abuse.
  • For example, in 2000, Christian et al evaluated forensic evidence in prepubertal victims of sexual assault.15 Forensic evidence was found in 25% of children, all of whom were evaluated within 44 hours of assault. Sixty-four percent of evidence was found on their clothing and linens. However, only 35% of children in the study had their clothing collected for analysis. No swabs from the children's bodies were positive for blood after 13 hours or for semen after 9 hours.
  • In addition, consider obtaining a urine toxicology screen if the abuse or assault was substance facilitated, especially in the setting of dating violence.
    • Carefully follow procedures outlined in standard forms that are included in the rape kit.
    • Maintain a documented "chain of custody"; the actual kit is extremely important.
    • Cultures for STDs are not part of the rape kit and should be handled separately based on the typed culture procedures.
    • Finally, place clothing in a paper bag and not in plastic, which may seal in moisture and lead to evidence degradation.
    • Evidence that may be collected includes the following:
      • Child's clothing that was worn at the time of the sexual contact
      • Swabs for semen, sperm, and acid phosphatase
      • Fingernail scrapings from underneath the child's nails
      • Pubic hairs found on the child's body (If the child has pubic hair, sampling 5-10 hairs, which then are placed in separate envelopes for comparison, is necessary.)
      • Debris found on the child
      • Child's samples of saliva and blood to determine blood type and secretor status

More on Child Abuse & Neglect, Sexual Abuse

Overview: Child Abuse & Neglect, Sexual Abuse
Differential Diagnoses & Workup: Child Abuse & Neglect, Sexual Abuse
Treatment & Medication: Child Abuse & Neglect, Sexual Abuse
Follow-up: Child Abuse & Neglect, Sexual Abuse
Multimedia: Child Abuse & Neglect, Sexual Abuse
References
[ CLOSE WINDOW ]

References

  1. Finkelhor D, Hotaling GT. Sexual abuse in the National Incidence Study of Child Abuse and Neglect: an appraisal. Child Abuse Negl. 1984;8(1):23-32. [Medline].

  2. Sgroi SM, Blick LC, Porter FS. A conceptual framework for child sexual abuse. In: Sgroi SM, ed. Handbook of Clinical Intervention in Child Sexual Abuse. Lexington, MA: Lexington Books; 1982:9-37.

  3. Finkelhor D, Browne A. The traumatic impact of child sexual abuse: a conceptualization. Am J Orthopsychiatry. Oct 1985;55(4):530-41. [Medline].

  4. Adams JA. Guidelines for medical care of children evaluated for suspected sexual abuse: an update for 2008. Curr Opin Obstet Gynecol. Oct 2008;20(5):435-41. [Medline].

  5. Child Maltreatment. 2006. Washinton DC: U.S. Department of Health & Human Services Administration for Children and Families Administration on Children, Youth and Families Children's Bureau U.S. Department of Health & Human Services Administration for Children and Families Administration on Children, Youth and Families Children's Bureau.

  6. Fourth National Incidence Study of Child Abuse and Neglect (NIS-4). Washington DC: US Department of Health and Human Services. Administration for Children and Families; [Full Text].

  7. Sedlak AJ, Broadhurst DD. Third National Incidence Study of Child Abuse and Neglect. Final Report NIS-3. US Department of Health and Human Services; 1996.

  8. Finkelhor D, Jones LM. Explanations for the Decline in Child Sexual Abuse Cases. US Department of Justice, Office of Justice Programs, Office of Juvenile Justice Delinquency. Available at http://www.ncjrs.gov/pdffiles1/ojjdp/199298.pdf. Accessed October 14, 2008.

  9. Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. Am J Prev Med. May 1998;14(4):245-58. [Medline].

  10. Douglas Em, finkelhor D. Child Sexual Abuse Fact Sheet. Crimes against Children Research Laboratory, University of New Hampshire. Available at http://www.unh.edu/ccrc/factsheet/pdf/CSA-FS20.pdf. Accessed September 2007.

  11. Heger A, Ticson L, Velasquez O, Bernier R. Children referred for possible sexual abuse: medical findings in 2384 children. Child Abuse Negl. Jun 2002;26(6-7):645-59. [Medline].

  12. Adams JA. Evolution of a classification scale: medical evaluation of suspected child sexual abuse. Child Maltreat. Feb 2001;6(1):31-6. [Medline].

  13. Adams JA, Kaplan RA, Starling SP, Mehta NH, Finkel MA, Botash AS. Guidelines for medical care of children who may have been sexually abused. J Pediatr Adolesc Gynecol. Jun 2007;20(3):163-72. [Medline].

  14. AAP. Guidelines for the evaluation of sexual abuse of children: subject review. American Academy of Pediatrics Committee on Child Abuse and Neglect. Pediatrics. Jan 1999;103(1):186-91. [Medline]. [Full Text].

  15. Christian CW, Lavelle JM, De Jong AR, et al. Forensic evidence findings in prepubertal victims of sexual assault. Pediatrics. Jul 2000;106(1 Pt 1):100-4. [Medline].

  16. Paolucci EO, Genuis ML, Violato C. A meta-analysis of the published research on the effects of child sexual abuse. J Psychol. Jan 2001;135(1):17-36. [Medline].

  17. Paradise JE, Rostain AL, Nathanson M. Substantiation of sexual abuse charges when parents dispute custody or visitation. Pediatrics. Jun 1988;81(6):835-9. [Medline].

  18. Adams JA. Medical evaluation of suspected child sexual abuse. J Pediatr Adolesc Gynecol. Jun 2004;17(3):191-7. [Medline].

  19. Adams JA, Harper K, Knudson S. A proposed system for the classification of anogenital findings in children with suspected sexual abuse. J Pediatr Adolesc Gynecol. 1992;5:73-5.

  20. Adams JA, Harper K, Knudson S, Revilla J. Examination findings in legally confirmed child sexual abuse: it's normal to be normal. Pediatrics. Sep 1994;94(3):310-7. [Medline].

  21. Atabaki S, Paradise JE. The medical evaluation of the sexually abused child: lessons from a decade of research. Pediatrics. Jul 1999;104(1 Pt 2):178-86. [Medline].

  22. Bays J. Conditions mistaken for child abuse. In: Reece RM, Ludwig S, eds. Child Abuse: Medical Diagnosis and Management. 2nd ed. Baltimore, MD: Lippincott Williams & Wilkins; 2001:287-306.

  23. Bays J, Chadwick D. Medical diagnosis of the sexually abused child. Child Abuse Negl. Jan-Feb 1993;17(1):91-110. [Medline].

  24. Bays J, Jenny C. Genital and anal conditions confused with child sexual abuse trauma. Am J Dis Child. Dec 1990;144(12):1319-22. [Medline].

  25. Berenson AB. Normal anogenital anatomy. Child Abuse Negl. Jun 1998;22(6):589-96; discussion 597-603. [Medline].

  26. Berkowitz CD. Medical consequences of child sexual abuse. Child Abuse Negl. Jun 1998;22(6):541-50; discussion 551-4. [Medline].

  27. Briere JN, Elliott DM. Immediate and long-term impacts of child sexual abuse. Future Child. Summer-Fall 1994;4(2):54-69. [Medline].

  28. Burgess AW, Groth AN, Holmstrom LL, Sgroi SM. Sexual Assault of Children and Adolescents. New York, NY: Lexington Books; 1978.

  29. CDC. Sexually Transmitted Diseases Treatment Guidelines. Centers for Disease Control and Prevention. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5106a1.htm.

  30. Cooper A. Thoracoabdominal trauma. In: Ludwig S, Kornberg AE, eds. Child Abuse: A Medical Reference. 2nd ed. Churchill Livingstone; 1991:131-50.

  31. De Jong AR, Rose M. Frequency and significance of physical evidence in legally proven cases of child sexual abuse. Pediatrics. Dec 1989;84(6):1022-6. [Medline].

  32. De Jong AR, Rose M. Legal proof of child sexual abuse in the absence of physical evidence. Pediatrics. Sep 1991;88(3):506-11. [Medline].

  33. DeLago C, Deblinger E, Schroeder C, Finkel MA. Girls who disclose sexual abuse: urogenital symptoms and signs after genital contact. Pediatrics. Aug 2008;122(2):e281-6. [Medline].

  34. Emans SJ, Goldstein DP. Pediatric and Adolescent Gynecology. 3rd ed. Boston, MA: Little Brown & Co Inc; 1990.

  35. Feldman W, Feldman E, Goodman JT, et al. Is childhood sexual abuse really increasing in prevalence? An analysis of the evidence. Pediatrics. Jul 1991;88(1):29-33. [Medline].

  36. Finkel M. Physical examination. In: Finkel M, Giardino A, eds. Medical Evaluation of Child Sexual Abuse: A Practical Guide. Thousand Oaks, CA: SAGE Publications; 2001:39-98.

  37. Finkel M. The evaluation. In: Finkel M, Giardino A, eds. Medical Evaluation of Child Sexual Abuse: A Practical Guide. Thousand Oaks, CA: SAGE Publications; 2001:23-37.

  38. Finkel MA. "I can tell you because you're a doctor". Pediatrics. Aug 2008;122(2):442. [Medline].

  39. Finkel MA. Sexual abuse: The medical evaluation. In: Giardino AG, Alexander R, eds. Child Maltreatment: A Clinical Guide and Reference. St Louis, MO: GW Medical Publishing Inc; 2005:253-88.

  40. Finkel MA. Technical conduct of the child sexual abuse medical examination. Child Abuse Negl. Jun 1998;22(6):555-66. [Medline].

  41. Finkel MA, DeJong AJ. Medical findings in child sexual abuse. In: Reece RM, Ludwig S, eds. Child Abuse: Medical Diagnosis and Management. 2nd ed. Boston, MA: Lippincott Williams & Wilkins; 2001:207-86.

  42. Finkelhor D. Current information on the scope and nature of child sexual abuse. Future Child. Summer-Fall 1994;4(2):31-53. [Medline].

  43. Finkelhor D. Epidemiological factors in the clinical identification of child sexual abuse. Child Abuse Negl. Jan-Feb 1993;17(1):67-70. [Medline].

  44. Finkelhor D, et al. A Sourcebook on Child Sexual Abuse. London UK: Sage Publications; 1988.

  45. Finkelhor D, Moore D, Hamby SL, Straus MA. Sexually abused children in a national survey of parents: methodological issues. Child Abuse Negl. Jan 1997;21(1):1-9. [Medline].

  46. Finkelhor DH. Child sexual abuse: New Theory and research. New York, NY: Free Press; 1984.

  47. Friedrich WN. Behavioral manifestations of child sexual abuse. Child Abuse Negl. Jun 1998;22(6):523-31; discussion 533-9. [Medline].

  48. Gorey KM, Leslie DR. The prevalence of child sexual abuse: integrative review adjustment for potential response and measurement biases. Child Abuse Negl. Apr 1997;21(4):391-8. [Medline].

  49. Gushurst CA. Child abuse: behavioral aspects and other associated problems. Pediatr Clin North Am. Aug 2003;50(4):919-38. [Medline].

  50. Dubowitz H, DePanfilis D, eds. Handbook for Child Protection Practice. Thousand Oaks, CA: SAGE Publications; 2000.

  51. Jones LM, Finkelhor D, Halter S. Child maltreatment trends in the 1990s: why does neglect differ from sexual and physical abuse?. Child Maltreat. May 2006;11(2):107-20. [Medline].

  52. Kellogg ND, Parra JM, Menard S. Children with anogenital symptoms and signs referred for sexual abuse evaluations. Arch Pediatr Adolesc Med. Jul 1998;152(7):634-41. [Medline].

  53. Kempe CH. Sexual abuse, another hidden pediatric problem: the 1977 C. Anderson Aldrich lecture. Pediatrics. Sep 1978;62(3):382-9. [Medline].

  54. Kerns DL, Terman DL, Larson CS. The role of physicians in reporting and evaluating child sexual abuse cases. Future Child. Summer-Fall 1994;4(2):119-34. [Medline].

  55. Ladson S, Johnson CF, Doty RE. Do physicians recognize sexual abuse?. Am J Dis Child. Apr 1987;141(4):411-5. [Medline].

  56. Larson C, Terman DL, Gomby DS, et al. Sexual abuse of children: recommendations and analysis. Future Child. Summer-Fall 1994;4(2):4-30. [Medline].

  57. Lentsch KA, Johnson CF. Do physicians have adequate knowledge of child sexual abuse? The results of two surveys of practicing physicians, 1986 and 1996. Child Maltreat. Feb 2000;5(1):72-8. [Medline].

  58. Leventhal JM. Epidemiology of sexual abuse of children: old problems, new directions. Child Abuse Negl. Jun 1998;22(6):481-91. [Medline].

  59. Levitt C. Further technical considerations regarding conducting and documenting the child sexual abuse medical examination. Child Abuse Negl. Jun 1998;22(6):567-8; discussion 569-71. [Medline].

  60. Ludwig S. Child abuse. In: Fleisher GR, Ludwig S, eds. Textbook of Pediatric Emergency Medicine. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2000.

  61. Marshall WN, Locke C. Statewide survey of physician attitudes to controversies about child abuse. Child Abuse Negl. Feb 1997;21(2):171-9. [Medline].

  62. McCann J, Voris J, Simon M. Genital injuries resulting from sexual abuse: a longitudinal study. Pediatrics. Feb 1992;89(2):307-17. [Medline].

  63. Muram D. Child sexual abuse: relationship between sexual acts and genital findings. Child Abuse Negl. 1989;13(2):211-6. [Medline].

  64. Myers JE. Adjudication of child sexual abuse cases. Future Child. Summer-Fall 1994;4(2):84-101. [Medline].

  65. Myers JE. Legal Issues in Child Abuse and Neglect Practice (Interpersonal Violence). 2nd ed. SAGE Publications; 1998.

  66. Myers JE. Expert testimony. In: Briere J, Berliner L, Buckley JA, et al, eds. The APSAC Handbook on Child Maltreatment. Sage Publications; 1996:319-40.

  67. Nadal FM, Giardino AP. Differential diagnosis: conditions that mimic child maltreatment. In: Giardino ER, Giardino AP. Nursing Approach to the Evaluation of Child Maltreatment. St. Louis, MO: GW Medical Publishing; 2003:215-50.

  68. Nicholson EB, Bulkley J. Sexual Abuse Allegations in Custody and Visitation Cases: A Resource Book for Judges and Court Personnel. Washington, DC: American Bar Association; 1988.

  69. Pence DM, Wilson CA. Reporting and investigating child sexual abuse. Future Child. Summer-Fall 1994;4(2):70-83. [Medline].

  70. Royal College of Paediatrics and Child Health. The Physical Signs of Child Sexual Abuse. An Evidence-Based Review and Guidance for Best Practice. London UK: Stephan Austin & Sons Ltd; 2008.

  71. Russell DE. The incidence and prevalence of intrafamilial and extrafamilial sexual abuse of female children. Child Abuse Negl. 1983;7(2):133-46. [Medline].

  72. Sgroi SM. Sexual molestation of children. The last frontier in child abuse. Child Today. May-Jun 1975;4(3):18-21, 44. [Medline].

  73. Swanston HY, Tebbutt JS, O'Toole BI, Oates RK. Sexually abused children 5 years after presentation: a case-control study. Pediatrics. Oct 1997;100(4):600-8. [Medline].

  74. US Dept of Health and Human Services. Child Maltreatment 2002: Summary of Key Findings. 2002. Washington DC: 2004.

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

child sexual abuse, sexual abuse, sexual misuse, sexual maltreatment, sexual child abuse, molestation, sexual molestation, intrafamilial sexual abuse, incest, assault, sexual assault, rape, inappropriate observation, inappropriate touching, sexualized kissing, fondling, masturbation, penetration of the vagina, oral-genital, genital-genital, anal-genital, sexualized behaviors, phobias, sleep disturbances, changes in appetite, change in or poor school performance, regression to an earlier developmental level, running away, truancy, aggressiveness, acting out behaviors

social withdrawal, sadness, depression, genital bleeding, lichen sclerosis, dermatitis, sexually transmitted diseases, STDs, vaginal discharge, Staphylococcus aureus, Haemophilus influenzae, Mycoplasma species, anogenital bruising, Crohn disease, Kawasaki syndrome, Stevens-Johnson syndrome, eating disorders, anxiety disorders, substance abuse, somatization, posttraumatic stress disorder, PTSD, dissociative disorders, irritable bowel syndrome, dyspepsia, chronic abdominal pain, ischemic heart disease, cancer, stroke, chronic bronchitis, emphysema, diabetes, hepatitis, skeletal fractures

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Angelo P Giardino, MD, PhD, Clinical Associate Professor, Department of Pediatrics, Baylor College of Medicine; Medical Director, Texas Children's Health Plan, Inc
Angelo P Giardino, MD, PhD is a member of the following medical societies: Academic Pediatric Association, American Academy of Pediatrics, American Professional Society on the Abuse of Children, Harris County Medical Society, Helfer Society, and International Society for Prevention of Child Abuse and Neglect
Disclosure: Nothing to disclose.

Coauthor(s)

Eileen R Giardino, PhD, RN, MSN, FNP-BC, ANP-BC, Associate Professor of Nursing, Department of Acute and Continuing Care, University of Texas Health Sciences Center Houston School of Nursing
Eileen R Giardino, PhD, RN, MSN, FNP-BC, ANP-BC is a member of the following medical societies: American Academy of Nurse Practitioners, American College Health Association, American Nurses Association, American Professional Society on the Abuse of Children, and International Society for Prevention of Child Abuse and Neglect
Disclosure: Nothing to disclose.

Medical Editor

Chet Johnson, MD, Medical Director, Child Development Unit, Department of Pediatrics, Professor, University of Kansas Medical Center
Chet Johnson, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

CME Editor

Carrie Sylvester, MD, MPH, Director of Education in Child and Adolescent Psychiatry, Professor, Departments of Psychiatry and Pediatrics, Northwestern University Medical School
Carrie Sylvester, MD, MPH is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, American Academy of Pediatrics, American Medical Women's Association, American Psychiatric Association, and American Society for Adolescent Psychiatry
Disclosure: Nothing to disclose.

Chief Editor

Caroly Pataki, MD, Professor of Clinical Psychiatry and Behavioral Sciences, Department of Psychiatry, Division Chair, Child and Adolescent Psychiatry, Director of Training, Child and Adolescent Psychiatry Residency Program, University of Southern California Keck School of Medicine
Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.