**12. The jigsaw approach**

In Cleveland we saw the medical intervention as creating a window of opportunity, through which light could be shone on a problem that might otherwise remain hidden. For Group B children, especially those who were pre-verbal, this was potentially the only way their plight would be recognised. The medical 'window' by which possible abuse is identified by physical examination, has since given way to a 'jigsaw' approach, in which medical evidence is just one of several pieces gathered from several sources [15]. This development has improved our recognition of the factors associated with sexual abuse, for example domestic violence. However, it is bound to be detrimental for children in cases where the medical evidence is the only piece of the jigsaw available. The Royal College of Paediatrics and Child Health (RCPCH) [7] confirmed this approach: 'The child's story of what happened, together with the child's demeanour and emotional response whilst describing what took place, is the single most important factor in coming to a diagnosis'. This leaves many Group B children without a paediatric route, and few will now come to paediatric attention without having first made an alerting comment. The Ministry of Justice guidance for criminal investigations includes a section on the medical examination, making the comment that 'children who do not allege penetration should not receive unnecessary medical examinations' [16]. It assumes that the child will be Group A, that is, will already have disclosed.

Despite the existence of guidelines for doctors, very few children are now referred to the child protection system as a result of a paediatric examination.

#### **13. Why the disclosure process creates difficulties for investigations**

We know that disclosure is a process rather than a single event. This is why it does not fit the requirements of evidential interviewing and the court. In response to Cleveland's children we developed the concept of a 'continuum of disclosure' on which children, particularly those in Group B, are highly dependent on external factors, especially the presence of an adult to advocate on their behalf [17].

Although still a contentious issue in the courtroom, since 1987 the problems of such children including delayed disclosure, active withholding, traumatic amnesia and not being believed have been well documented in research and practice [18]. A review by London et al. [19] of the evidence for the child sexual abuse accommodation syndrome [20], concluded that children who disclose in an informal setting are often able to give an account in a forensic interview, and that children are likely to disclose after an intervention such as a medical examination. This echoes what we saw in Cleveland: some children disclosed abuse only after being taken into care following the medical diagnosis, and, despite increased internal pressures, managed to tell once in a safe place. Out of a sample of 40 children seen by the psychologist because abuse was suspected or confirmed, nine disclosed shortly after the medical examination, whilst still in hospital ([17] Figure 5.2 p. 124).

It is now better understood that the process of disclosure is a dynamic one of the child balancing the need to tell with the need to contain the secrecy. This creates a pressure within the child which any successful intervention must understand and respect, giving some control over when and to whom the child or young person will be able to speak out. For the most part, and particularly in older children, nondisclosure is not a passive non-disclosing experience, but rather an active withholding of information. This has enormous implications for policy, particularly for investigations.

The Children's Commissioner for England has since confirmed this picture and the barriers to disclosure which result in only one in eight sexually abused children being identified by professionals [21]. The report states that the majority of victims go unidentified because the services that protect them, including the police and social services, are geared towards children self-referring or reporting abuse, although they rarely do so. Longfield concluded that the true scale of child sex abuse in England is likely to be significantly greater than official figures suggest.

Some children will remain unable to say what has happened to them, or will even deny proven abuse, especially when they are very young and the abuse is by a parent or other attachment figure on whom the child depends.

The optimal conditions for disclosure can be summarized as: having someone who will listen, believe and respond appropriately and effectively; having knowledge and language about what abuse is; being able to access help; having a sense of control over the process in terms of anonymity (not being identified until they are ready) and confidentiality (the right to control who knows); being asked directly about any experiences of abuse [22].

### **14. Group B: the silent majority of victims**

We subdivide Group B into children who can be helped to disclose their plight, and can then protected; and those who remain trapped in silence with no prospect of protection. The narratives of children and adults in group B are often fragmented and unprocessed and may be dissociated from conscious awareness. They present with a high index of suspicion of abuse but depend on a third party for recognition and protection. The children may be very young and without the ability to communicate other than through their bodies and their behaviour.

In the post-Cleveland climate of reactive rather than proactive intervention, some Group B children were nevertheless recognised when they presented to child mental health services [23]. Work with children and young people who came to attention because of symptoms of trauma such as disturbed, sometimes sexualised behaviour, dissociation and self-harming, confirmed our belief that even these children could be helped, by addressing their internal barriers so that the child's experience could be reached. Despite the inadequacies of the child protection system, children with protective mothers could often be enabled to disclose, even without

a protective intervention, provided they were both supported [24]. However, there were very few successful police investigations. Even when abuse was recognised by other means, some children remained unable to disclose.

Our 20-year review in two linked papers [25, 26] observed that changes in the child protection system had been directed only at children in Group A. In our opinion, the dilemma of children in Group B who cannot climb the continuum of disclosure remains unacknowledged and unaddressed, and the loss of the medical window adds to the number who remain unheard. The significance for policy and practice of the concept of Groups A and B, the continuum of disclosure and the role of the medical diagnosis was highlighted by Itzin [27].
