**How Do We Recognize Recent Sexual Abuse in Children Less than 10 Years of Age? What Is the Role of Paediatric Wards? Experience in a French Paediatric Hospital**

G. Picherot, N. Vabres, J. Fleury, E. Launay and C. Gras-Leguen *Clinique Médicale Pédiatrique, UAED, CHU Nantes, France* 

#### **1. Introduction**

126 Sexual Abuse – Breaking the Silence

WHO. Preventing child maltreatment: a guide to taking action and generating evidence. In:

*WHO-ISPCAN*, ed. Geneva, 2006 Zambia Health Demographics Survey 2007

> A diagnosis of sexual abuse in children is being made increasingly in France and in all Western countries. Sexual abuses in France represent a third of all cases of maltreatment 1. In children less than 10 years of age, discovery of the circumstances varies according to the situations experienced by the adolescents. Stories can involve silence or a revelation by indirect signs or consequences of abuses. To approach this diagnosis, we will successively address three aspects: the usual circumstances of the revelation or evocation of this diagnosis, a speech and behavioral side, and a clinical examination and its difficulties.

#### **2. Circumstances**

Generally, children under the age of 10 years are brought by their parents, and come more rarely with a social worker or forensic expertise.

A child's speech or a sudden change in behavior could disturb the relatives [2]. The diagnosis can be done in an environmental context of sexual assault: the revelation of a sibling or the child himself. It sometimes involves an investigation around an abuser or abnormal behavior of parents [2-3-4-5].

The evocation in less than three years old chidren may revolve around a child-minder, represented by doubt concerning behavioral or clinical abnormalities after returning home following a child-minding period, or more frequently, a situation evoking suspicion in the context of parental separation [6].

The diagnosis can be sought in circumstances of clinical abnormalities discovered by the parents or physician, as represented by suspicious perineal lesions or the consequences of sexual assault such as sexually transmitted disease atypical for the child's age [5].

The American Academy of Pediatrics established several factors which may lead to suspicion of sexual assault in children 7:

How Do We Recognize Recent Sexual Abuse in Children Less than 10 Years of Age?

fear related to unsuitable for any age experiences may inhibit expression.

sexual curiosity in young children is widespread [5].

their association to the context will lead to the diagnosis.

therefore raise the possibility of sexual assault.

**4. Clinical examination** 

but rarely as a contributing factor.

applicable in younger children [13].

[1-5-7].

What Is the Role of Paediatric Wards? Experience in a French Paediatric Hospital 129

Professionals must link the interpretation of a child's speech with its emotional and cognitive development and remember that memory for detail is unstable. The perception of time is more revealing than a chronological relation of facts as many temporal expressions have no meaning for younger children [11]. Emotional factors are also significant: the child's

Early sexualized behaviors of children are not in themselves proof of aggression. Within three years there may be "periods of intense masturbation" without a past sexual assault as

Strategies for assessing the validity of the statements described by Yuille are hardly

At this age, repeted situations of interrogation lead to an even greater possibility for misinterpretation and this is an important argument for filmed audition strategies [5]. None of these signs as a consequence of trauma is *a priori* indicative of sexual assault, and only

The circumstances of abuse would lead to a discernment of different disorders of the child by its family. Extrafamilial abuse may lead to earlier recognition of changes in the child.

Situations of alleged sexual assault in connection with parental separation are increasingly frequent. The interpretation of anxious behavior after a weekend at the ex-spouse's home, or confusion with necessary care and intimate assaults may lead to repeated investigations and traumatic experiences. This is also the case in the same situations of actual sexual assault

There is no way to support an instrumental evaluation.14 The use of sexed dolls is very controversial: the method is not recommended in the assessment of Yuille [13], and is to be used with great caution and interpretation by experts as reported by August [15]. The child can use ordinary toys (Bear, Figurines) to stage events or to describe the assaulted body parts. Older children may use drawings to express themselves. Among younger girls (less than 5 years of age), this method rarely leads to get a direct word or a specific behavioral sign, but "gives the child to see and hear something of grave concern," [16] and we must

Clinical examination of a child in circumstances of sexual abuse is difficult for a child of any age. Its interpretation requires a skill that will avoid repetition of intolerable procedures

The legal and social services eagerly await objective evidence of sexual assault. **However,** 

The work of Heger et al. and their analysis with a rigorous methodology of 2384 records shows that an abused child and clinical abnormalities are found in only 4% of cases [3]. In 96% of cases, the diagnosis is based on the child's words and on the circumstances. Without denying the importance of a clinical examination, it must be considered in the course of the child's assessment as an important and sometimes significant element specific to this age,

[17]. Misinterpretations are common, particularly in young children.

**this rarely leads to a review of the findings of abnormalities.** 


In all cases, the evocation depends on the vigilance of the physician who receives the child 1. Process of protection is possible if the child can be "heard" in those circumstances 7.
