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Clinical practice guidelines for child sexual abuse

2019; Medknow; Volume: 61; Issue: 8 Linguagem: Inglês

10.4103/psychiatry.indianjpsychiatry_502_18

1998-3794

Shekhar Seshadri, Sheila Ramaswamy,

Child and Adolescent Health

INTRODUCTION Child sexual abuse (CSA) is the involvement of children and adolescents in sexual activities (usually for adult sexual stimulation or gratification) that they cannot fully comprehend and to which they cannot consent as a fully equal, self-determining participant, because of their early stage of development [Box 1].Box 1: Defining child sexual abuseIt is important to understand the nature and type of CSA as the severity of the impact of the abuse depends on not only on the type of abuse but also on the duration of the abuse and very importantly, whether the abuser is a known/trusted person or a stranger [Table 1].Table 1: Nature or type of child sexual abuseThus, CSA is a complex issue, wherein impact and recovery depend on all of the above variables and how they combine to influence the child's experience of abuse. Even where there are two children, who have been impacted by identical forms and processes of abuse (similar variables), they may still be different in terms of their responses. This difference is accounted for personality and temperament of each child, and social context and circumstances of each child, due to which each child perceives and internalizes the abuse differently, thus resulting in different emotional and behavioral states to the abuse, and necessitating different psychosocial and mental health responses. CSA is not a clinical condition or diagnosis. Clinical practice guidelines for standard child psychiatric conditions can be developed based on existing knowledge and practices. However, to develop clinical practice guidelines for an experience that is both nuanced and complicated by psychological and social processes is a particular challenge. Clinical practice guidelines for CSA, therefore, necessitate mental health professionals to work with many processes and systems to effectively assist the child. CONTEXT OF CONSULTATION There are broadly three contexts in which children present for consultation on sexual abuse issues. The first is when CSA is already established by agencies and individuals, and they refer the child to the mental health system. Such referrals may be received from: (i) District Child Protection Units; (ii) Childline and child care agencies/service providers; (ii) Police; and (iii) Courts and judicial personnel. Children are brought by such agencies and bodies either for interventions in the wake of trauma and emotional problems and/or for inquiry and evidence gathering for use in court cases. Thus, in this context, the mental health system is not required to establish whether or not CSA has occurred, as it is already known – usually, children would have reported abuse or in case of children in sex trafficking, they have been rescued through a raid on sex work institutions, and so the abuse has come to light. The second context is one in which the child has reported to his/her parents but they, in turn, have not reported the abuse to police or legal systems. However, they seek consultation to provide the child with mental health interventions. The third context is when it is not (yet) known that he/she has been sexually abused; the child comes to the mental health system for some psychological or psychiatric manifestation, but on enquiry and examination, CSA issues emerge in one of the following ways: The child discloses or reports abuse An adolescent girl is found to be pregnant (Frequent) urinary tract infections in the child are reported by the child/caregivers and/or genital injuries in the child are reported/observed Emotional and behavioral issues that are associated with anxiety, anger, and depression. There is what is called an index of suspicion in CSA, i.e., when to suspect CSA and how true one's suspicions likely to be. Figure 1 represents the index of suspicion in CSA. At the peak of the triangle, the index of suspicion is the highest, i.e., there is no doubt when a child reports or discloses that abuse has taken place, especially when a child spontaneously reports without particular inquiry by an adult.Figure 1: Index of suspicion in child sexualEqually high on the index is pregnancy (in adolescent girls) – a sure sign that sexual abuse has occurred. Genital injuries and frequent urinary tract infections must lead to suspicion that there is digital handling and sexual abuse is very likely to have taken place. Emotional and behavioral changes observed in the child are important indicators of CSA; however, they come lower on the index of suspicion because these psychological changes may occur due to some reasons (unlike pregnancy or genital injuries which do not have a range of reasons for their occurrence!). Emotional and behavioral issues relating to anxiety and depression may occur due to sexual abuse but may also be due to other difficult and traumatic experiences such as parental marital conflict, bullying, learning difficulties and academic pressures, loss, and grief (death-related) experiences… so, while emotional and behavioral changes may lead to CSA suspicion, further examination and inquiry needs to be made (by a psychosocial or mental health professional) to understand exactly what difficult event(s) or experiences they are attributable to in a given child. During the inquiry, if sexual abuse is ruled out, then the signs and symptoms may be attributable to other difficult experiences. Below are indices of CSA [Table 2].Table 2: Emotional and behavioral indices of child sexual abusePROCEDURE FOR ESTABLISHING AND CONFIRMING CHILD SEXUAL ABUSE The procedure for establishing and/or confirming CSA has three components, namely, (i) Psychosocial and Mental Health Assessment; (ii) Developmental Assessment; (iii) Abuse Inquiry or Forensic Interviewing for CSA. The third component particularly, is predicated on the first two components, which makes it necessary for the three assessments to be done in the order in which they are listed and described. Psychosocial and mental health assessment It is important to obtain a detailed history and assessment of the child, including information on family and school context, developmental level and functionality, emotional and behavioral issues (pre- and post-sexual abuse), circumstances of the alleged abuse, the child's experience and understanding of the abuse and other related problems. Treatment and interventions for abuse must be developed based on the complete assessment of the child's context and issues; this is because every child is unique and has his/her own unique ways, based on age, developmental stage, personality and temperament, family and social circumstances, and the nature of abuse, of processing the abuse experience. Information requires to be obtained through the assessment of the child and family/caregivers. The immediate aftermath of the abuse, i.e., within the first few days is not the time for asking the child to provide the abuse narrative in great detail as this is likely to distress and traumatize the child further. The objective of the Psychosocial and Mental Health Assessment [Box 2] is to establish that abuse has occurred and to know the nature of abuse, i.e., contact versus non-contact, penetrative versus nonpenetrative abuse with a view to making decisions regarding medical interventions, as well as posttraumatic stress disorder (PTSD) interventions, as necessary.Box 2: Psychosocial and mental health assessmentIt is important to understand any emotional and behavioral issues the child had before the abuse and compare these to those that may have occurred post-abuse. This is because (i) we need to understand exactly which emotional and behavioral problems that are attributable to abuse; (ii) we need to understand how pre-abuse emotional and behavioral issues may have determined the ways in which the child has processed the abuse experience and been impacted by it. In either case, the child would need to receive treatment and assistance for all emotional and behavioral issues, both pre-existing ones as well as those that developed as a result of the abuse. Developmental assessment The developmental assessment requires to be completed before any forensic interviewing processes and/or interventions are entered into with children for eliciting abuse narratives. The purposes of conducting a developmental assessment in the context of CSA are two-fold: To make decisions about the feasibility and use of methods to elicit the abusive narrative in accordance with the developmental abilities of the child, for treatment and intervention purposes and/or as part of evidence gathering for court cases/legal processes To be able to design and/or deliver age-appropriate interventions; this includes the use of communication and methodologies that are comprehensible to a child in the course of treatment, including to provide personal safety education and awareness (which forms a part of the treatment interventions). There are five specific domains of development that children require to be assessed in: physical or locomotor, speech and language, cognitive, social and emotional development. If the abilities and skills in these domains are not age-appropriate, then there are implications for forensic interviewing and evidence gathering for court cases and legal processes [Box 3].Box 3: Applying child development assessment to CSA inquiry and interventionInquiry with the child: Forensic interviewing for child sexual abuse This includes interviewing the child to obtain information on the sequence of abuse events and how they occurred according to the child, and how the child perceived and understood the abuse. The interview may have to be carried out in well-planned sessions, over a period of time, especially in the case of younger children or children with posttraumatic disorder. Creative play methods, such as stories, art and toys/dolls may have to be used to elicit children's narratives. Such indirect methods are gentle and nonthreatening and also allow younger children with less developed verbal abilities to communicate their experiences of abuse. During these sessions, while eliciting children's abuse narratives, open-ended questions that encourage children to express themselves freely should be used. A detailed verbatim recording of the interview should be done through written documentation as well as video recordings in case of play sessions with young children so that these can also be used for legal proceedings. Introduction and rapport building Greet the child and tell him/her your name and then, ask the child his/her name Sit at the same physical level as child (if the child is on the floor, sit on the floor… if the child is sitting on a chair, sit on the chair next to her) Use toys and play activities (dolls, puzzles, picture books, and coloring books…) to engage young children and give it to the child as soon as (s)he comes to the court (while waiting for you) Enter into play with the child and spend 5–10 min engaging child in play activity… "what are you doing? What is the doll doing? May I see what you are coloring?" Engage in neutral conversation with the child for a few minutes (this also helps to assess the child's developmental abilities and skills as well as mental state)--What did you eat for breakfast today? How did you come here today? Who are these people who have come with you?.... " For older children and adolescents, you may say "I really want to know you better. Tell me about the things you like to do" Introduce the space and the purpose of the child being there, including your role: "My name is… my job here is to make sure that children are safe and no one hurts them. If we hear that someone is hurting or troubling children, then we do things to stop that from happening" "You may be wondering about this busy place and many rooms…many people come here, just like you to talk about people who have hurt or troubled them…that's why we need a big space like this and many people to help" "Although this place may seem a little scary and confusing, you are safe here…and after we have spent a little time talking, you can go back home with your parents or caregiver." Explain the need for video camera/microphone (in case you are using such equipment) – "As you can see, we have a video-camera and microphones here. They will record our conversation so I can remember everything you tell me. Sometimes, I forget things and the recorder allows me to listen to you without having to write everything down." (In case you are taking notes, you may provide a similar explanation to the child). Ensuring accurate reporting This is to ensure that the child has the competency to differentiate between truth and lies and to ensure that children tell the truth. Establish the need for telling the truth, and child's capacity to differentiate between what's true or not and to say "I don't understand" or to tell examiner when he makes a wrong statement: Part of my job is to talk to children (teenagers) about things that have happened to them. I meet with lots of children (teenagers) so that they can tell me the truth about things that have happened to them. Hence, before we begin, I want to make sure that you understand how important it is to tell the truth For younger children, explain: ("What is true and what is not true"). "If I say that my shoes are red (or green) is that true or not true?" (Wait for an answer, then say:) "That would not be true, because my shoes are really (black/blue/etc.). And if I say that I am sitting down now, would that be true or not true (right or not right)?" (Wait for an answer.) It would be (true/right) because you can see I am really sitting down.' "I see that you understand what telling the truth means. It is very important that you only tell me the truth today. You should only tell me about things that really happened to you." (Pause) "If I ask a question that you don't understand, just say, "I don't understand." Okay?" (Pause) "If I don't understand what you say, I'll ask you to explain. "What would you say if I made a mistake and called you a 2-year-old girl (when interviewing a 5-year-old boy, etc.)?" (Wait for an answer.) "That's right. Now you know you should tell me if I make a mistake or say something that is not right. You may record your observations as follows: Capacity to differentiated "truth" established Yes No Capacity to say "I don't understand" established Yes No Capacity to tell interviewer that she/he "is not right" established Yes No. Training in episodic memory Episodic memory represents our memory of experiences and specific events in time in a serial form, from which we can reconstruct the actual events that took place at any given point in our lives. It is the memory of autobiographical events (times, places, associated emotions, and other contextual knowledge) that can be explicitly stated. Individuals tend to see themselves as actors in these events, and the emotional charge and the entire context surrounding an event is usually part of the memory, not just the bare facts of the event itself (http://www.human-memory.net/types_episodic.html). It is essential to encourage children to provide detailed responses early in the interview as this enhances their descriptive responses to open-ended prompts in other parts of the interview, particularly those related to the abuse incident. Hence, at this stage of the interview, training in episodic memory or narrative practice should be done as follows: " It is very important that you tell me everything you remember about things that have happened to you. You can tell me both good things and bad things" Identify a recent event the child experienced- the first day of school, birthday party, holiday) and build up on that using qualifiers like tell me, what happened next, "Think hard about (activity or event) and tell me what happened on that day from the time you got up that morning until (some portion of the event mentioned by the child in response to the previous question). "Tell me more about (activity mentioned by the child)." (Wait for an answer.) Use this prompt as often as needed throughout this section] "Earlier you mentioned [activity mentioned by the child]. Tell me everything about that." Note: Focus on real-life events; avoid focusing on accounts relating to television, videos, and fantasy. Abuse enquiry Now transition to substantive issues to enable the child to provide you with the narrative by using open questions such as: "Now that I know a little about you, I want to talk about why (you are here) today" "I heard you talked to "X" about something that happened – tell me what happened" "I see you have (a bruise, a broken arm, etc.,) – tell me what happened" "I heard you saw (the doctor, a policeman, etc.) last week – tell me how come/what you talked about" "Is (your mom, another person) worried about something that happened to you? Tell me what she is worried about" "I understand someone might have troubled you – tell me what happened" "I understand someone may have done something that wasn't right – tell me what happened" "I understand something may have happened at (location) – tell me what happened" Young children, who either do not have the language to name private parts and genitals or are unwilling to name these parts due to fear and embarrassment, use pictures or dolls to assist the child--"I will show you a picture (here is a doll)… can you show me/point to where this person touched or hurt you…" Probe for disclosure Use gentle probes, including some close-ended questions to confirm some details. If child has mentioned telling someone about the incident(s), ask details, if not then probe about possible immediate disclosure by saying: "Does anybody else know what happened?" How did they come to know? [Box 4]Box 4: Techniques of Inquiry: Leading questionsClosing the interview The closure phase helps to provide an end to a conversation that may have been emotionally difficult for the child. "You have told me lots of things today, and I want to thank you for helping me." "I want to especially tell you how brave you are for telling me all that happened… things like this happen to many children, but they don't always want to tell others about it… because they are afraid. You may also have been scared, but you were brave to tell people about it – I am sure your parents are proud of you… I am too" "Is there anything else you think I should know?" "Is there anything you want to tell me?" "Are there any questions you want to ask me?" "If you want to talk to me again, you can call me at this phone number and come and see me again." (Give the child or caregiver your name and phone number). IMPACT OF CHILD SEXUAL ABUSE AND IMPLICATIONS FOR INTERVENTION After eliciting the abuse narrative, it is critical to understand the methods and processes used by the perpetrator to sexually abuse the child. CSA is a process that consists of a series of actions entailing lure, seduction, manipulation and/or coercion and threat. Different methods and processes of abuse have different psychological impacts on children and adolescents. Not all CSA results in trauma; in fact, where CSA methods use lure, seduction, and manipulation to "manufacture" the consent of the child (versus methods of threat, violent coercion, and aggression), there may be the less overt or visible traumatic reaction in the child [Table 3].Table 3: Understanding trauma dynamics: The impact of child sexual abuseAbuse in the context of "manufactured consent" When abuse has taken place through grooming processes (i.e., lure, inducement, and manipulation) and violence, threat and coercion methods have played little or no role in the abuse process, children/adolescents are less likely to be aware of and acknowledge the abuse [Box 5].Box 5: When and why children do not acknowledge abuse experiencesImplications for intervention Focus on helping children recognize various types of child (sexual) abuse, including understanding why and how certain actions constitute abuse Reassurances to child on safety and protection (from the perpetrator) Arrangements with parents/caregiver to ensure the child's safety and protection. Abuse of young children In younger children, the methods of abuse entail (i) inducement and lure and/or (ii) coercion and threat. Inducement and lure entail the use of sweets and toys to get children to perform or cooperate in sexual acts for adult stimulation. Perpetrators also use attention and affection in exchange for sexual favors, i.e., provision of attention and affection when the child complies with the adult on sexual acts and withdrawal of attention and affection when the child does not. These methods are followed by the perpetrator creating excitement and secrecy around the sexual act, often presenting it to the child as a "special new game," a "secret game" that no one else plays and no one else knows about; and young children, who have no understanding of sexuality are vulnerable to such ruses. Implications for intervention Medical assistance in case of violent abuse and physical injury Teaching children about safety issues related to strangers as well as known persons Enabling children to learn how to protect their bodies, i.e., which body parts should not be touched by anyone except for select family members such as mothers/caregivers during personal hygiene activities Helping children discern between "safe" and "unsafe" secrets Validation of emotions and provision of reassurance for children who may be traumatized by the CSA. Abuse of adolescents In older children and adolescents, the processes of abuse are similar, but the use of lure and inducement are slightly different and these processes are also known as 'grooming' [Box 6]. Given that adolescents are at a life stage wherein they are interested in issues of love, attraction and sexuality and are also keen to experiment with these experiences, perpetrators tend to use lure and inducements that are more emotional in nature (rather than the more material ones used with younger children). This means that they smooth talk adolescents about their physical appeal and qualities, making promises of long-term emotional, and romantic relationships with them—and adolescents interpret these actions as being loving and romantic.Box 6: The grooming processAgain, given the life stage adolescents are at, often also under peer pressure to experiment with sexuality, offenders have the perfect opportunity to manipulate them into sexual engagement by transmitting all sorts of misconceptions about sexual behaviors and norms. For instance, appealing to adolescents' need to "fit in" with their peers, perpetrators tell adolescents that it is necessary to gain sexual experience, that it would be "uncool" if they are ignorant about sexual acts. As a result, adolescents, who are still acquiring life skills such as (sexual) decision-making, are negatively influenced, believing in the misconceptions transmitted to them, confused by how they should respond. Following such manipulation and abuse, adolescents experience feelings of tremendous confusion, especially as they have shared "deep" sexual and romantic relationships with the offender. They find it exceedingly difficult to discern this as an abused process and defend the offender, often refusing to accept that this is abuse. Implications for intervention Medical assistance in case of violent abuse and physical injury In case of pregnancy, decisions around medical termination of pregnancy, depending on the medical issues as well as the adolescent's desire to have/keep the child, i.e., from a child rights' perspective, facilitating discussions with the adolescent to help her make decisions about her pregnancy Helping adolescents explore notions of love, romance, and relationships Enabling adolescents to understand various forms of coercion, ranging from material lure to persuasion and threat; focussing on an understanding of consent in sexual relationships [Box 7] Personal safety awareness and education focussing on equipping adolescents with sexual decision-making skills (a life skills approach) Validation of emotions and working with notions of self-identity, including feelings of guilt and shame, in children and adolescents who may be traumatized by the CSA. Box 7: The issue of consentINTERVENTIONS As also shown in Figure 2, CSA interventions can be broadly categorized into three types of responses:Figure 2: Child sexual abuse interventions Medical assistance Psychosocial interventions First level responses for children Depth therapeutic interventions for children Interventions for parents and caregivers. Legal assistance. Medical assistance In case a child is referred immediately after abuse, i.e., within a few hours or days), it is necessary to first proceed with a medical evaluation and requisite medical interventions as a priority. Treatment history and response to treatment (in case the child has already undergone or is undergoing treatment) should be recorded. Ideally, it must be ensured that the child is provided with emergency medical services within 24 h of filing the first information report (FIR) in case a police report has been filed or even otherwise. Physical examination Physical examination of the child to be conducted including 2 ID marks The child's family or caregiver should be present in the room during the examination Permission of the child and consent of the parent to be taken before the examination What physical symptoms does the child have at present/(e.g., burning sensation during micturition, White Discharge per Vagina, itching in the perineal area, bleeding, any injury, pain in any area, etc.) Post-exposure prophylaxis If a child is within the 36 h window period (especially in case of penetrative abuse): Has the child received Postexposure prophylaxis (PEP) (within 36 h) in case of penetrative abuse? If not, refer to Paediatric ART Centre for PEP Even if the child is not in the window period and the penetrative abuse has occurred within a month, refer to the Paediatric ART Centre so that a decision can be taken regarding initiation of PEP Ensure that the child/adolescent has received oral contraceptive pills to prevent pregnancy Ensure that the child has been medically evaluated by a Registered Medical Practitioner, namely a pediatrician or gynecologist from a government hospital, for sexually transmitted diseases (STDs), urinary tract infection and/or injuries. The STD investigation must be repeated at the end of 4 weeks, 3 months, and 6 months. Forensic examination Check whether an additional specific forensic evaluation has been done (examination requested by police documenting abuse, if swabs have been taken in case of penetrative abuse), and if so, whether the report is available. Obtain the report from the relevant source. Pregnancy tests Ensure that a urine pregnancy test has been done In case the results are a false negative, it would be best to obtain an additional gynecological opinion In case the child/adolescent is under 20 weeks pregnant, discussions about abortion may need to be done with the child/adolescent and her caregivers. It is also advisable to liaise with an obstetrician at this time. Psychosocial and mental health interventions for children and families Following medical assistance, or simultaneously, psychosocial and mental health interventions should be initiated for the child and family, based on the Psychosocial and Mental Health Assessment completed. Developmental assessments and forensic interviewing may follow subsequently, and be embedded in the counseling and therapy processes. Pharmacotherapy Pharmacotherapy is not specifically indicated for CSA unless it results in severe anxiety and depressive states. Children who have undergone CSA and present with severe PTSD will require medication in addition to other psychosocial interventions: These medications include specific serotonin reuptake inhibitors (SSRIs) and/or benzodiazepines, in dosages recommended as per body weight. SSRIs are also indicated in situations where CSA results in severe depression associated with self-harm behaviors, dissociation, and agitation. States of agitation may call for SOS medication with low dosage benzodiazepines There are a group of children with pre-existing vulnerabilities or those in whom the trauma is so destabilizing that it results in mood dysregulation. This group of children may require mood stabilizers. Older children and adolescents, particularly, must not be coerced to take medication in case they are unwilling i.e. they require to be counselled, including on issues of need and adherence [Box 8].Box 8: Preparing the children and adolescents for medical tests and treatmentFirst level psychosocial responses for children Asking questions, and attempting to establish depth interventions when the child is facing a crisis, i.e., in the immediate aftermath of abuse, is not a useful beginning. This is not the time to for detailed enquiry. If there are serious and disruptive manifestations such as self-harm behaviors, incapacitating anxiety, PTSD symptoms with severe panic, appropriate psychiatric referral at this stage is important (as psychiatric medication may be required for anxiety symptoms to reduce before any counseling work is initiated). However, certain initial responses or what are know as first level responses [Box 9] of a supportive nature require to be provided to the child.Box 9: Objectives of first level responses to child sexual abuseEnsuring child's safety Depending on where the abuse occurred and who the perpetrator is, it is essential to immediately take measures to protect the child from further abuse. This is especially applicable when the perpetrator is a family member or a person known to the child, and where the abuse has occurred at home or in places the child frequents on a daily or regular basis (such as school/tutorials, etc). Even in insta