Sonja N. Brilleslijper-Kater

Prevalence of child sexual abuse in pediatric patients with chronic abdominal pain

Background and Objectives: A history of sexual abuse is to be found in approximately 40% of all adult patients with gastrointestinal complaints. Data on the prevalence of child sexual abuse (CSA) in children with chronic abdominal pain (CAP) are lacking. The objective of this systematic review is to determine the prevalence of CSA in pediatric patients with CAP. Methods: We conducted a systematic literature search in the electronic databases MEDLINE, EMBASE, PsychInfo, and ERIC. Reference lists of relevant articles were scanned for additional citations. We selected case-control, cohort and cross-sectional studies investigating the prevalence of CSA in children with CAP, ages 0 to 18 years. Data were extracted from relevant studies, which were assessed for methodological quality by 2 independent reviewers. Prevalence of CSA was the main outcome measure. Results: The literature search yielded a total of 269 articles. Only 2 studies met our inclusion criteria, reporting CSA in 2.1% and 8.0% of children (age range 4–21 years) with CAP. Both studies were conducted in small groups (n = 48 and n = 50) without control group(s) and did not use standardized or validated instruments for diagnosing CSA. Conclusions: According to existing data, the prevalence of a history of CSA in pediatric patients with CAP is lower than in adult patients; however, no well-designed studies have been conducted in children. Future research is required to determine a reliable prevalence of CSA in children with CAP.

Stressful Life Events in Children With Functional Defecation Disorders.

Objectives: The aim of the study was to determine the prevalence of stressful life events including (sexual) abuse in children with functional defecation disorders by performing a systematic review. Methods: We searched MEDLINE, EMBASE, and PsycINFO for cohort, case-control and cross-sectional studies investigating the prevalence of stressful life events, including (sexual) abuse in children with functional defecation disorders. Results: The search yielded 946 articles, of which 8 were included with data from 654 children with functional constipation and 1931 children with (constipation-associated) fecal incontinence (FI). Overall, children with functional defecation disorders had been significantly more exposed to stressful life events than healthy children, with prevalence rates ranging from 1.6% to 90.9%. Being bullied, being a relational victim, interruption of toilet training, punishment by parents during toilet training, and hospitalization were significantly related to FI, whereas separation from the best friend, failure in an examination, severe illness in a close family member, loss of job by a parent, frequent punishment, and living in a war-affected area were significantly related to constipation. Only 1 study measured the prevalence of child abuse, which reported a significantly higher prevalence of child (sexual) abuse in children with FI compared with controls. Conclusions: The prevalence of stressful life events, including (sexual) abuse is significantly higher in children with functional defecation disorders compared with healthy children. To gain more insight into the true prevalence of child (sexual) abuse in children with functional defecation disorders, more studies are clearly needed.

Physical symptoms in very young children assessed for sexual abuse: a mixed method analysis from the ASAC study

AbstractSo far, a recognizable pattern of clinical symptoms for child sexual abuse (CSA), especially in young male children, is lacking. To improve early recognition of CSA, we reviewed physical complaints, physical examination, and tests on sexually transmitted infections (STIs) in confirmed victims (predominantly preschool boys) of CSA from the Amsterdam sexual abuse case (ASAC). We retrospectively analyzed the outcomes of the primary assessment using mixed methods: descriptive analysis of physical complaints, physical exams, and STI tests from medical files and a qualitative analysis on expert’s interpretations of physical complaints and children’s behavior during physical examination. We included 54 confirmed CSA victims, median age 3.2 (0–6) years, 43 boys (80%), and 11 girls (20%). Physical complaints were reported in 50%, of which gastrointestinal and anogenital complaints were most common. None of the children showed CSA-specific genital signs at physical examination. Most prominent finding during physical examination was a deviant behavioral response (anxiety, withdrawal, too outgoing) in 15 children (28%), especially in children who experienced anal/vaginal penetration. Testing for STIs was negative. Conclusion: Physical complaints and physical signs at examinations were non-specific for CSA. Deviant behavioral reactions during physical examination were the most prominent finding. Precise observation of a child’s behavior during physical examination is needed.What is known• Child sexual abuse (CSA) affects many children on both the short and the long term but remains unrecognized in most cases.• So far, there is a lack of studies on symptom patterns of CSA in male, preschool children.What is new• None of the children showed CSA-specific findings at physical and anogenital examination; STIs were not found in the confirmed victims of CSA.• The most prominent finding was the deviant behavioral response of the children examined, especially in children who experienced anal/vaginal penetration; therefore, precise observation of a child’s behavior during physical examination is a crucial part of the evaluation of suspected CSA.

The Amsterdam Sexual Abuse Case (ASAC)-study in day care centers: longitudinal effects of sexual abuse on infants and very young children and their parents, and the consequences of the persistence of abusive images on the internet

BackgroundLittle research has been done on the signs of child sexual abuse (CSA) in infants and very young children, or on the consequences that such abuse - including the persistence of the abusive pornographic images on the internet - might have for the children and their parents. The effects of CSA can be severe, and a variety of risk- and protective factors, may influence those effects. CSA may affect the psychosocial-, emotional-, cognitive-, and physical development of children, their relationships with their parent(s), and the relations between parents. In the so called `the Amsterdam sexual abuse case’ (ASAC), infants and very young children were victimized by a day-care employee and most of the victims were boys. Research involving the children and their parents would enable recognition of the signs of CSA in very young children and understanding the consequences the abuse might have on the long term.Methods/designThe proposed research project consists of three components:(I) An initial assessment to identify physical- or psychological signs of CSA in infants and very young children who are thought to have been sexually abused (n = 130);(II) A cross-sequential longitudinal study of children who have experienced sexual abuse, or for whom there are strong suspicions;(III) A qualitative study in which interviews are conducted with parents (n = 25) and with therapists treating children from the ASAC. Parents will be interviewed on the perceived condition of their child and family situation, their experiences with the service responses to the abuse, the effects of legal proceedings and media attention, and the impact of knowing that pornographic material has been disseminated on the internet. Therapists will be interviewed on their clinical experiences in treating children and parents.The assessments will extend over a period of several years. The outcome measures will be symptoms of posttraumatic stress disorder (PTSD), dissociative symptoms, age-inappropriate sexual behaviors and knowledge, behavioral problems, attachment disturbances, the quality of parent-child interaction, parental PTSD, parental partner relation, and biological outcomes (BMI and DNA).DiscussionThe ASAC-project would facilitate early detection of symptoms and prompt therapeutic intervention when CSA is suspected in very young children.

Assessments carried out by a child abuse and neglect team in an Amsterdam teaching hospital led to interventions in most of the reported cases.

This study described cases of child abuse and neglect (CAN) that were reported to the multiagency CAN team at the Emma Childrens Hospital in Amsterdam and the resulting interventions.

Psychosocial symptoms in very young children assessed for sexual abuse : A qualitative analysis from the ASAC study

Child sexual abuse (CSA) is a worldwide problem with serious consequences. No recognizable symptom pattern for suspected CSA has yet been identified in very young children. We aim to investigate psychosocial symptoms in a sample of children with confirmed or strongly suspected CSA and the interpretations given to such symptoms by independent clinical experts. Secondly we examined whether experts were able to identify confirmed victims of severe CSA. A qualitative study including inductive content analysis of medical files and focus group discussions with independent experts on the interpretation of psychosocial symptoms was conducted. We included 125 children (76 boys, 60.8%, and 49 girls, 39.2%; median age 3.3 years; age range 0-11) who were involved in the Amsterdam sexual abuse case (ASAC) and had been examined for strongly suspected CSA. We identified four themes among the psychosocial symptoms: problems concerning emotions, behavior, toilet training, and development, whether or not associated with the daycare center or the perpetrator. Clinical experts identified signs of posttraumatic stress disorder (PTSD), regression in continence skills (not otherwise explained), and problems triggered by exposure to the perpetrator or the abuse location as concerning symptoms for CSA. Less concerning symptoms were designated as worrisome if they were numerous and there was no clear explanation for these symptoms. A clear symptom pattern was lacking and about half of the confirmed severe victims of CSA did not display any psychosocial problems. Therefore, it is difficult for experts to identify confirmed CSA victims. Thus, the assessment of suspected CSA should be over time and multidisciplinary.

The Diagnostic Utility of the Child Sexual Behavior Inventory for Sexual Abuse: A Systematic Review

ABSTRACT Children with alleged child sexual abuse (CSA) need to be assessed systematically. The use of validated instruments during the assessment, like the Child Sexual Behavior Inventory (CSBI), could add diagnostic value. We aim to assess the diagnostic utility of the CSBI to differentiate between sexually abused and non-abused children. We conducted a systematic review. We searched the electronic databases MEDLINE and PsychInfo for studies comparing CSBI scores in sexually abused children and non-abused children (2–12 years old). Two independent reviewers extracted data and assessed the methodological quality. We included 7 (out of 1048) articles. The CSBI total scores were significantly higher in CSA-victims compared with non-abused children (in case–control settings). However, in children with suspected CSA, the results were ambiguous. One study reported significant differences. Another study reported weak diagnostic ability for the CSBI-3 in children with suspected CSA (a sensitivity and specificity of 0.50, with a positive predictive value of 0.28, and a negative predictive value of 0.72). Research on the diagnostic utility of the CSBI for suspected CSA is limited and shows disappointing results. Until more research is done, the CSBI should not be used on its own to differentiate between sexually abused and non-abused children.

Clinical practice: recognizing child sexual abuse—what makes it so difficult?

Recognizing child sexual abuse (CSA) in children is difficult, as there can be many hurdles in the assessment of alleged CSA. With this paper, we try to improve the recognition of CSA by discussing: (1) the difficulties regarding this matter and (2) the diagnostic evaluation of alleged CSA, combining both practical clinical recommendations based on recent research. Children are restrained to disclose CSA due to various reasons, such as fears, shame, and linguistic or verbal limitations. Associations between CSA and urogenital or gastrointestinal symptoms, internalizing and externalizing behavioral problems, post-traumatic stress symptoms, and atypical sexual behavior in children have been reported. However, these symptoms are non-specific for CSA. The majority of sexually abused children do not display signs of penetrative trauma at anogenital examination. Diagnosing a STI in a child can indicate CSA. However, other transmission routes (e.g., vertical transmission, auto-inoculation) need to be considered as well.Conclusion: The assessment consists of medical interview and child interview (parents and child separate and together) with special attention to the child’s development and behavior (problems), psychosocial situation and physical complaints, the child’s mental health, and the child’s trauma history; anogenital examination should be done in all cases of alleged CSA. The examination should be documented by photo or video graphically. Recent research suggests that videography may be the preferred method, and testing on STIs. The assessment should be done multidisciplinary by experienced professionals. Health-care professionals who care for children need to know how child protective agencies and law enforcement are organized. In case there are concerns about a child’s safety, the appropriate authorities should be alarmed.What is Known:• Sexual abuse in children often remains unrecognized in the majority of cases.What is New:• Research suggests that videographic documentation is preferred above photographic documentation for anogenital examination; observations of children’s behavioral reactions during examinations might be valuable in the evaluation of suspected sexual abuse; nucleic acid amplification testing can be used on vaginal swabs or urine samples for chlamydia and gonorrhea; the CRIES-13 and the CAPS-CA can be used to assess trauma-symptoms in children after sexual abuse.

Mo1993 The Prevalence of Stressful Life Events Including Sexual Child Abuse in Children With Functional Defecation Disorders: A Systematic Review

Background: Early life exposure to antibiotics might alter the development of the host microbiome and influence Crohns disease (CD) risk. Although this association has been suggested by a few recent studies, larger studies with longer duration of follow-up and more rigorous control of confounding are needed. We sought to further evaluate the association between antibiotic use during the first year of life and subsequent CD by performing a nationwide birth cohort study in Denmark.Methods: All children born in Denmark between 1995 and 2007 were identified in the Danish Medical Birth Registry, and followed until death, emigration, or end of study (January 1, 2011). Outpatient antibiotic use was identified using the National Prescription Registry. Cases of CD were identified using the Danish National Patient Registry; a subset was confirmed by linkage to the National Pathology Registry. As a negative control, we analyzed exposure to systemic adrenergic agents, the second most commonly prescribed class of medications in the first year of life. Relative risk was determined by Cox proportional hazards models, after adjusting for route of delivery, birth order, gender, birth year, and family history of CD.Results: The birth cohort consisted of 850,962 children followed for a mean of 8.5 years (7,206,533 person-years of follow up). Of these, 51.3% were male, 17.5% were born by c-section, 1.0% had a family history of CD and 41.1% had ≥ 1 filled antibiotic prescription in the first year of life. 291 cases of CD were observed during follow-up. A positive association between antibiotic use and CD did not reach statistical significance (adjusted HR 1.2, 95% CI 0.9-1.5). Results of a subanalysis of confirmed cases were similar (adjusted HR 1.4, 95% CI 0.9-2.2). As expected, there was a positive association with family history of CD (adjusted HR 16.4, 95% CI 8.631.1). There was no association between use of systemic adrenergic drugs and CD (adjusted HR 1.0, 95% CI 0.5-1.8).Discussion: We found a non-significant trend for the association between early-life antibiotic exposure and risk of CD. No association was observed in our negative control group. Our findings are consistent with previously observed associations between antibiotic use and CD.