Usual and Less Usual Presentation Of Child Sexual Abuse

1. Usual and Less Usual Presentation Of Child Sexual Abuse Dr Julia Hale Named Doctor for Safeguarding Greenwich Teaching PCT October 2008

2. Programme • Case presentation • Usual presentation • Less Usual presentation

3. Stacey and Sarah Stacey 8½ yrs ,Sarah 6 yrs Lived with mother and her partner Spent some weekends with father and his partner Parents had not been married Father did not have parental responsibility

4. Stacey and Sarah Father and his partner came to children's GP paediatric outreach clinic alone to express their concerns about neglect by mother: • Poor clothes, no coat, shoes too small • Poor personal hygiene • Bedwetting • Recurrent head lice • Behaviour a little difficult

5. Stacey and Sarah In GP record was a report of hospital admission of Stacey at 8 yrs with Pseudoseizures • Episode reported where mother’s partner held her hanging over a balcony • Concerns about domestic violence Recommended father took legal advice to obtain parental responsibility and ask for access to GP record Referred to Social Services on basis of father’s concerns

6. Stacey and Sarah No contact from Social Services No case conference called Mother moved to Wales with partner and girls, who attended a school with all lessons in Welsh 9 yrs Stacey referred for sexual abuse medical, no conclusive findings made

7. Stacey and Sarah 9 ½ yrs Stacey referred for physical abuse medical with some bruising to body and arms School reported concerns about poor hygiene, hungry and poor weight Paediatrician found extensive bruising indicating NAI. Also dirty, visibly thin and underweight Placed on CPR and taken into foster care for neglect

8. Stacey and Sarah Within 2 months Stacey put on 3 kg from 24kg (2-9th centile) In care both girls disclosed a long history of physical, emotional and sexual abuse over several years by mother and by several of mothers partners

9. Stacey and Sarah Disclosure of: • Repeatedly physically beaten • Tied to chairs and left alone in house • Locked in cupboard for hours • Repeatedly sexually assaulted • Not fed regularly or enough

10. Stacey and Sarah After 7 months in care in Wales they were placed back in London with father and his partner Criminal proceedings were taken against mother and her partner

11. Stacey and Sarah When Stacey 11 ½ yrs father asked to see me to discuss the difficulties with her behaviour: • Sexualised, provocative, risky behaviours • Staying out with older boys and men on estate • Smoking • Truanting • Learning difficulties and attitude problems in school • Very challenging at home, especially to fathers partner Weight had gone up 12 kg in 18 months, now on 50th centile Referred to CAMHS

12. Stacey and Sarah 6 months later GP asked me to see Sarah, now 9 ½ yrs with an acute genital problem On examination she had genital herpes Presumed to be recurrence from a primary infection during the past sexual abuse

13. Stacey and Sarah Father reported Stacey’s behaviour was escalating putting whole family under stress Following Court conviction of the mother and her partner, he was making a claim for both girls under the Criminal Injury Compensation Board He was pursuing a formal complaint against the London borough Social Services for failing to protect his daughters from when they first came to attention 2 years before being taken into care in Wales

15. Usual Presentation of Child Sexual Abuse Acute presentation • Acute genital injury • Stranger assault Chronic presentation • Disclosure by child • To parent • To teacher or social worker • Suspicion of parent • Police identify Paedophile • Internet user • Schedule 1 offender

16. Less Usual Presentation of Child Sexual Abuse • Physical indicators • Behavioural signs • Psychological • Functional or Psychosomatic • Sexualised behaviour

17. 1. Physical indicators • Co-incidental with physical abuse (15%) • Sexually transmitted disease • Pregnancy • Anal fissure • Rectal bleeding • Enuresis (wetting) • Encopresis (soiling) • Gonoccoccal eye infection

18. Co-incidental with Physical Abuse • Grip marks • inner thigh, knee or upper arm • Bruises over lower abdomen,pubis,hips • Love bites and tooth bite marks • Lacerations of penis, labia or perineum • Burns and scalds • Buttocks, genitalia, back of hand • Signs of partial suffocation • Petechiae on neck and face (pin point bruising)

19. Sexually transmitted disease

20. 2. Behavioural signs • Acute traumatic response • Regression • Sleep disturbance • Eating disorder • School performance problems • Truanting • Aggression or acting out • Running away • Prostitution

21. 3. Psychiatric / Psychological • Psychiatric conditions • Anxiety • Depression • Self mutilation • Suicide or attempt • Total refusal syndrome • Anorexia or bulimia • Drug and solvent abuse

22. 4. Functional or Psychosomatic • Recurrent abdominal pain • Irritable bowel syndrome • Headache or migraine • Elective mutism • Psychogenic non epileptic seizure

23. Irritable Bowel Syndrome • Significant number of adults with irritable bowel syndrome report histories of physical, emotional, and sexual abuse. • In one case-control study in children, 72 abused children reported more functional disorders than did controls (48 v 26). • In a prospective study, abused and non-abused boys reported comparable rates of functional disorders; the duration of the problems, however, was significantly longer in abused boys than non-abused boys

24. Psychogenic Non Epileptic seizure • A type of episodic behaviour that mimics epileptic seizures but is to be distinguished from them • A dissociative state secondary to trauma • Can occur in children with epilepsy Also known as Pseudoepileptic seizures or Pseudoseizures

25. Psychogenic non-epileptic seizures: management and prognosisArch Dis Child 2000;82:474–478 Irwin, Edwards, Robinson Admissions to a London hospital of 35 children over 2 years 24 non epileptic, 11 with epilepsy Types of seizures in group without epilepsy (24) • Swoons 9 • Prolonged blank spells 8 • Clonic movements with pelvic thrusting 5 • Other 2

26. Psychogenic non-epileptic seizures: management and prognosisArch Dis Child 2000;82:474–478 Irwin, Edwards, Robinson Causes of psychogenic non-epileptic seizures in the group without epilepsy (24 of 35) • History physical or sexual abuse 6 • Domestic stress 6 • School avoidance 4 • Maternal over dependence 3

27. 5. Sexualised Behaviour • Preoccupation with own or others genitals • Masturbation, rubbing and rocking • Insertion of objects into anus or vagina • Precocious and seductive behaviour • Intimate touching of adults • Acting out sex acts with doll • Precocious knowledge of sexual activity

28. Characteristics of young children with sexual behavior problems: a pilot study.Silovsky et al. Child Maltreatment. 7(3):187-97, 2002 37 young children with sexualised behaviour problems • 38% had substantiated histories of sexual abuse. • 47% experienced physical abuse • 58% witnessed interparental violence • 11% had no known history of sexual abuse, physical abuse, or witnessing domestic violence.

29. Services identifying Less Usual Presentation of CSA

30. Late Presentation as Adult • Post traumatic stress disorder • Psychosomatic manifestations of skin diseases, particularly factitious disorders • Chronic pelvic pain (48% had CSA) • Irritable bowel syndrome • Extreme obesity (32% had CSA) • Conversion disorder (severely disturbed) • Borderline personality disorder • Multiple Personality Disorder