eMedicine Specialties > Pediatrics: Developmental and Behavioral > Medical Topics

Child Abuse & Neglect, Sexual Abuse: Follow-up

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

Follow-up

Prognosis

  • For recovery from the emotional trauma associated with child sexual abuse (CSA), prognosis varies depending on a number of abuse-specific and individual and environmental factors. These factors include the following:
    • The child's inherent coping mechanisms and response to trauma and its aftermath
    • Response evident in the child's environment to the victimization
    • Age when the abuse occurred
    • Relationship of the perpetrator to the child
    • Length of time over which the abuse occurred
    • Pattern of the abuse
  • The response within the caregiving environment to the victimization appears to have an important impact on the ability of the child to work through the difficult issues raised by the sexual abuse.
  • Looking at children 5 years after presentation for sexual abuse and comparing them to a similarly aged group of children who were not abused, one study found that the children who were sexually abused displayed the following:
    • More disturbed behavior
    • Lower self-esteem
    • Increased tendency for depression
    • Increased tendency for anxiety
  • Retrospective studies of adults with severe personality disorders characterized by dissociation, impaired interpersonal relationships, and self-mutilation have found a high and significant correlation with histories of sexual abuse.
  • Prognosis related to any physical injury or infection resulting from the sexual abuse is expected to follow a typical healing course and respond to standard medical interventions.
  • Paolucci et al's meta-analysis of 37 studies involving 25,367 individuals reported no universal response to child sexual abuse; however, they did confirm that in most cases the experience is negative and that clear evidence proves a link between child sexual abuse and subsequent negative short-term and long-term developmental effects.16  Paolucci et al conclude that, rather than thinking about a single, specific child sexual abuse response syndrome, the data support a much more complex, multifaceted model of traumatization.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • How to report child sexual abuse (CSA) is detailed in each state's child abuse reporting laws. Health care providers are mandated to report known incidents of abuse. When these reports are made in good faith, with the well-being of the child in mind, health care providers are typically granted immunity should any legal action occur. This is true especially in cases in which, after investigation, the occurrence of abuse cannot be determined. Physicians may be required to provide testimony in court proceedings. Often, law enforcement personnel are involved since criminal prosecution of the perpetrator may be pursued.
  • The physician called to court generally may serve in 2 roles.
    • A physician may serve as a lay fact witness and provide first-hand information about what occurred during the child's medical evaluation, including what was seen and heard during the evaluation. Accurate and detailed medical records are vital to this function, since the court appearance may occur many months to several years after the visit.
    • Physicians with advanced training or considerable experience with child sexual abuse may be called as expert witnesses who offer opinions to the court on the specifics of the evaluations they performed. Unlike the fact witness who is limited to the specifics of the evaluation performed with the child, the expert witness may draw upon knowledge of the child abuse field and interpret issues related to the case. Meticulous documentation during the evaluation of suspected child sexual abuse is of great assistance to the physician called to testify; ultimately, documentation's best potential is to serve the child's interests.
  • For additional details related to child maltreatment that also can be applicable to child sexual abuse, please see Child Abuse & Neglect: Physical Abuse.

Special Concerns

  • Health care evaluation versus investigation
    • The health care evaluation of suspected child sexual abuse includes a history, physical examination, laboratory assessment, and observations of the caregiver and child that lead to a differential diagnoses and diagnostic impression. The multidisciplinary team that ideally handles cases of suspected sexual abuse is typically composed of a physician, nurse, and social worker, and information collected during the health care evaluation is then relayed to the police and child protective services (CPS) workers. The health care evaluation completed by this clinical team is related to, but distinct from, the investigation completed by CPS and/or law enforcement (ie, the police).
    • However, the health care information obtained during the clinician's evaluation is central to the investigation process and focuses on assessing the child's health status and treatment to restore health when necessary. The physician should focus on the health care and well being of the child and family while documenting and relaying any information obtained during the medical history that will help the investigators and law enforcement individuals prosecute the case.
    • On the other hand, the investigators are individuals from various disciplines and agencies mandated by laws and regulations to explore allegations of suspected maltreatment. The police determine whether or not a crime has been committed and begin appropriate legal action. CPS agencies and CPS workers operate alongside the police to protect children, as well. CPS's role in the investigation of child abuse focuses on the family's functioning and ability to protect the child. CPS agencies provide support services to families in need and may ultimately remove children from environments that are determined to be unsafe.
  • Allegations of child sexual abuse during custody battles
    • Allegations of sexual abuse during ongoing custody disputes are a particular challenge to the professionals working with the child and family. The custody issues further complicate the evaluation of an already difficult situation. Questions arise such as the following: "Did the child actually sustain these injuries or did the other parent prompt the child to make the accusations? Did the presenting parent overreact to a set of events that might have been thought innocent if there was no custody battle?"
    • Despite professional cynicism, these cases warrant the same comprehensive evaluation as other allegations of sexual abuse and should not be dismissed. The American Bar Association reports that few divorces involve custody disputes and that very few involve allegations of sexual abuse. Paradise et al (1988) found that, in cases of custody disputes, allegations of sexual abuse were substantiated 67% of the time.17 Therefore, the clinician should proceed in the evaluation as directed by all aspects of the history, keeping in mind that delayed disclosure is not uncommon in cases of childhood sexual abuse.
 
Acknowledgments

The authors acknowledge the consistent support and mentorship by Carol D Berkowitz who, despite multiple clinical, teaching, and administrative responsibilities, has found the time to share her considerable expertise and even took the time out of her busy schedule to provide the photographs used to illustrate the physical findings possible when evaluating cases of suspected child sexual abuse. Dr. Berkowitz exemplifies the characteristics of a committed medical educator who is not limited by organizational or geographic boundaries. 



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
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Further Reading

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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

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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.

 
 
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