The laboratory evaluation of a sexually abused child is dictated by the child’s age, history, and symptoms. Universalscreening for sexually transmitted infections for prepubertalchildren is unnecessary because the risk of infection is lowin asymptomatic young children. The type of assault, identityand known medical history of the perpetrator, and the epidemiology of sexually transmitted infections in the communityalso are considered. Many clinicians use nucleic acid amplification testing to screen for sexually transmitted infectionsin sexually abused children because these tests have excellentsensitivity while maintaining good specificity for STIs in children and adolescents. The diagnosis of most sexually transmitted infections in young children requires an investigationfor sexual abuse (see Chapter 116).
The management of child abuse includes medical treatment for injuries and infections, careful medical documentation of verbal statements and findings, andongoing advocacy for the safety and health of the child(Fig. 22-5). Parents always should be informed of thesuspicion of abuse and the need to report to CPS, focusing on the need to ensure the safety and well-beingof the child. Crimes that are committed against childrenalso are investigated by law enforcement, so the policebecome involved in some, but not all, cases of suspectedabuse. Physicians occasionally are called to testify in courthearings regarding civil issues, such as dependency and custody, or criminal issues. Careful review of the medicalrecords and preparation for court are needed to provide aneducated, unbiased account of the child’s medical condition and diagnoses.
The prevention of child maltreatment is a great challenge.There are a few partially successful primary prevention programs. Visiting home nursing programs that begin during pregnancy and continue through early childhood may reducethe risk of abuse and neglect. Physician training in screening for risk factors in parents has shown to be supportive offamilies and reduce child maltreatment in some populations.Ultimately physicians always need to remain cognizant of thediagnosis, aware of their professional mandates, and willingto advocate on behalf of these vulnerable patients.
Is there a history of trauma?
Is the mechanism accidental? Are the injuries diagnostic of abuse? Does the child have injuries? Is history consistent Yes Yes NoNo with injuries?
Can caregiver provide adequate accidental mechanism? Is there an unexplained delay in seeking medical care? Consider reporting (see B) Confirmed by workup? Do other medical conditions explain findings?
Yes No Was the child injured by a parent or caregiver? Report to Child Protective Services Report to police No reporting needed Did the child sustain serious injury or illness as a result of abuse or neglect? Did the child sustain serious injury or illness as a result of abuse or neglect? NoYes Yes No
Report to police No further reporting needed
Figure 22-5 A, Approach to initiating the civil and criminal investigation of suspected abuse. B, Reporting to Child Protective Services (CPS) or law enforcement or both in child abuse cases. CPS reports are required when a child is injured by a parent, by an adult acting as a parent, or by a caregiver of the child. The police investigate crimes against children committed by any person, including parents or other caregivers. (From Christian CW: Child abuse. In Schwartz MW, editor: Clinical Handbook of Pediatrics, ed 3, Baltimore, 2003, Lippincott Williams & Wilkins, pp 192−193.)
The development of sexuality occurs throughout a child’s life. Sexuality includes gender roles, gender identity, sexual orientation, and sexual behaviors. It is influenced by biologic and social factors and individual experience. Pediatricians are likely to be consulted if parents have a concern about their child’s sexual development. A pediatrician who provides an open and nonjudgmental environment may be a valuable resource for an adolescent with questions about heterosexual behaviors, homosexuality, or gender identity (Table 23-1).