Children who have been abused manifest pleomorphic symptoms in a variety of emotional, behavioral, and psychosomatic reactions. Abused children may have internalizing symptoms such as withdrawal, anxiety, depression, and sleep problems. Abused children may exhibit externalizing symptoms, such as aggression. Children who have been sexually abused are likely to display inappropriate sexual behavior. Table 42–1 lists symptoms that are associated with child abuse: they are not specific or pathognomonic; the same symptoms may occur in the absence of a history of abuse.
Table 42–1. Symptoms Associated with Child Maltreatment ||Download (.pdf)
Table 42–1. Symptoms Associated with Child Maltreatment
Type of Abuse
Psychological symptoms related to emotional distress, such as fear, anxiety, nightmares, phobias, depression, low self-esteem, anger, and hostility
More serious psychological problems such as the following: suicidal behavior; posttraumatic stress disorder; and dissociative reactions, with periods of amnesia, trance-like states, and, in some cases, dissociative identity disorder
Sexual hyperarousal (open masturbation, excessive sexual curiosity, talking excessively about sexual acts, masturbating with an object, imitating intercourse, inserting objects into the vagina or anus)
Sexually aggressive behavior (frequent exposure of the genitals, trying to undress other people, rubbing against other people, and sexual perpetration)
Avoidance of sexual stimuli through phobias and inhibitions
In adolescents: sexual acting out may occur with promiscuity and, possibly, homosexual contact
Physical symptoms (such as somatic complaints, encopresis, and eating disorders) and somatoform symptoms (such as pseudoseizures)
The parents of physically abused children have certain characteristics. Typically, they have delayed seeking help for the child's injuries. The history given by the parents is implausible or incompatible with the physical findings. There may be evidence of repeated suspicious injuries. The parents may blame a sibling or claim the child injured himself or herself.
In cases of intrafamilial sexual abuse and other sexual abuse that occurs over a period of time, there is a typical sequence of events: (1) engagement, when the perpetrator induces the child into a special relationship; (2) sexual interaction, in which the sexual behavior progresses from less intimate to more intimate forms of abuse; (3) the secrecy phase; (4) disclosure, when the abuse is discovered; and (5) suppression, when the family pressures the child to retract his or her statements (Sgroi, 1988).
The child sexual abuse accommodation syndrome is sometimes seen when children are sexually abused over a period of time. This syndrome has five characteristics: (1) secrecy; (2) helplessness; (3) entrapment and accommodation; (4) delayed, conflicted, and unconvincing disclosure; and (5) retraction (Summit, 1983). The process of accommodation occurs as the child learns that he or she must be available without complaint to the parent's demands. The child often finds ways to accommodate: by maintaining secrecy in order to keep the family together, by turning to imaginary companions, and by inducing in herself altered states of consciousness. Other children become aggressive, demanding, and hyperactive.
It is possible to distinguish the psychological sequelae of children who have experienced single-event and repeated-event trauma (Terr, 1991). The following four characteristics occur after both types of trauma: (1) visualized or repeatedly perceived intrusive memories of the event; (2) repetitive behavior; (3) fears specifically related to the trauma; and (4) changed attitudes about people, life, and the future. Children who sustain single-event traumas manifest full, detailed memories of the event; an interest in “omens,” such as looking retrospectively for reasons why the event occurred; and misperceptions, including visual hallucinations and time distortion. In contrast, many children who have experienced severe, chronic trauma (e.g., repeated sexual abuse) manifest massive denial and psychic numbing, self-hypnosis, dissociation, and rage.
Sgroi SM:Vulnerable Populations: Evaluation and Treatment of Sexually Abused Children and Adult Survivors, Vol. 1. New York: Free Press, 1988.
Summit RC: The child sexual abuse accommodation syndrome. Child Abuse Negl
Terr LC: Childhood traumas: An outline and overview. Am J Psychiatry 1991;148:12–20.
The professional who evaluates children who may have been abused has several important tasks: finding out what happened; evaluating the child for emotional disorder; considering other possible explanations for any disorder; being aware of developmental issues, avoiding biasing the outcome with his or her preconceptions; pursuing these objectives in a sensitive manner so as not to retraumatize the child; being supportive to family members; and keeping an accurate record which may be subpoenaed for future court proceedings.
It is important to be familiar with the normative sexual behavior of children for two reasons. First, normal sexual play activities between children should not be taken to be sexual abuse. In assessing this issue, the evaluator should consider the age difference between the children; their developmental level; whether one child dominated or coerced the other child; and whether the act itself was intrusive, forceful, or dangerous. Second, sexually abused children often manifest more sexual behavior than do typical children. Sometimes they have sexual knowledge beyond what would be expected for their age and developmental level. For example, behavior such as trying to undress other people, masturbating with an object, performing fellatio, and imitating sexual intercourse are red flags that suggest a child has been sexually abused.
The clinical interview may need modification when assessing a child who may have been abused. The following sections describe the components of an interview that is particularly suited for forensic evaluations (Poole & Lamb, 1998; Yuille et al., 1993):
Build Rapport and Make Informal Observations
Build rapport with the child and make informal observations of the child's behavior, social skills, and cognitive abilities.
Ask the Child to Describe Two Specific Past Events
In order to assess the child's memory and to model the form of the interview for the child by asking nonleading, open-ended questions, a pattern that will hold through the rest of the interview. For example, prior to interviewing the child, one can obtain specific information from the parent about a recent birthday party, trip to the zoo, etc.
Establish the Need to Tell the Truth
Reach an agreement that in this interview only the truth will be discussed, not “pretend” or imagination. For example, the interviewer can say, “If I said I’m wearing a purple hat today, would that be the truth or a lie?” Reach an agreement that it is fine to say, “I don't know.” For example, the interviewer can say, “Do I have a dog named Charlie?” and the child should say, “I don't know.”
Introduce the Topic of Concern
Start with more general questions, such as, “Do you know why you are talking with me today?” Proceed, only if necessary, to more specific questions, such as, “Has anything happened to you?” or “Has anyone done something to you?” Drawings may be helpful in initiating disclosure. For example, either the child or the interviewer draws an outline of a person. Then the child is asked to add and name each body part and describe its function. If sexual abuse is suspected, the interviewer could ask, when the genitals are described, if the child has seen that part on another person and who has seen or touched that part on the child. If physical abuse is suspected, the interviewer could ask if particular parts have been hurt in some way.
Once the topic of abuse has been introduced, the interviewer encourages the child to describe each event from the beginning without leaving out any details. The child is allowed to proceed at his or her pace, without correction or interruption. If abuse has occurred over a period of time, the interviewer may ask for a description of the general pattern and then for an account of particular episodes.
The interviewer may ask general questions in order to elicit further details. These questions should not be leading and should be phrased in such a way that an inability to recall or lack of knowledge is acceptable.
Pose Specific Questions, If Necessary
It may be helpful to obtain clarification by asking specific questions. For example, the interviewer may follow up on inconsistencies in a gentle, nonthreatening manner. Avoid repetitive questions and the appearance of rewarding particular answers in any way.
Use Interview AIDS, If Necessary
Anatomically correct dolls may be useful in developing exactly what sort of abusive activity occurred. The dolls are not used to diagnose child abuse, only to clarify what happened (Everson & Boat, 1994).
Toward the end of the interview, the interviewer may ask a few leading questions about irrelevant issues (e.g., “You came here by taxi, didn't you?”). If the child demonstrates a susceptibility to suggestions, the interviewer would need to verify that the information obtained earlier did not come about through contamination. Finally, the interviewer thanks the child for participating, regardless of the outcome of the interview. The interviewer should not make promises that cannot be kept.
In order to evaluate a child who may have been abused, it is necessary to do more than simply interview the child and ask him or her what happened. It is also important to interview the parents and perhaps other caregivers. The parents should be able to provide information regarding the child's experiences with particular people; the duration and evolution of the child's symptoms; the child's developmental and medical history; and factors in the child's life, other than abuse, that might explain the symptoms. It may also be important to assess the parents’ motivations and psychological strengths and weaknesses. For instance, some parents (who perpetrated the abuse or allowed another individual to do so) may be motivated to deny or minimize the possibility that the child was abused. Other parents (who are vengeful or overly suspicious of another person) may be motivated to exaggerate the possibility that the child was abused or may even fabricate symptoms of abuse.
Although psychological testing cannot diagnose child abuse, it may be a useful part of the evaluation. For example, the Child Sexual Behavior Inventory is a questionnaire to be completed by a parent, usually the child's mother. This questionnaire helps the clinician identify sexual behaviors that can be considered normative for the child's age and gender and sexual behaviors that can be viewed as relatively atypical for the child's age and gender, and which raise the suspicion of possible sexual abuse. Intellectual testing may be used to establish the child's developmental level. A general psychiatric evaluation may help with the differential diagnosis and clarify the child's treatment needs.
In evaluating a child who may have been abused, it is frequently important to obtain information from outside sources such as medical, mental health, and educational records. It may be helpful to review the investigation conducted by child protective services, although those records may not be available.