11.12 Assessment of the Mother as a Protective Parent

11.12 Assessment of the Mother as a Protective Parent

Contents

1. Introduction
2. Defining the Social Work Assessment of Needs and Strengths
3. Using Research not Prejudice to Construct an Assessment Framework
4. Reactions to the Discovery that her Child has been Abused
5. Possible Assessment Outcomes
6. Couple Relationship
7. Victims of Sexual Abuse: Recognition and Assessment Issues  

 

1. Introduction

It is quite possible that mothers will initially be in a state of shock and denial/disbelief is a common reaction.  They need a lot of support to make the necessary changes and movement needs to be assessed over time.  It is important that she is interviewed separately from the perpetrator; cultural/disability issues are considered when selecting a worker; and she is assessed over a period of time.

For the mother a number of issues need addressing therapeutically, i.e. bereavement/loss, guilt, anger, believing the abuse has taken place, to protect her children, assertiveness, encouraging her to place responsibility with the perpetrator, self-esteem/image, social isolation, re-establishing sexual identity and coping with sexual worries, victim issues, understanding and responding positively to the system/procedures, minimising the risk of being targeted by other perpetrators, willingness to accept external control “function,” coping with the child’s/children’s behaviour.

It is important the mother is empowered in terms of her relationship with the perpetrator.  The perpetrator can never be the primary protector or have equal responsibility for the child in the future.  The relationship between the mother and child also needs to be strengthened. Individual work with the mother and couple work will be necessary to achieve this.  A mother’s ability to supervise contact can also be assessed using this continuum.  Clearly in situations where the mother’s ability is assessed as dismal at the outset, then supervision of contact can be something which she can work towards.

The assessment of the mother should aim:

• To identify their strengths.
• To identify the difficulties they have in facing the disclosure of the information.
• To help them identify the choices available to them in the presenting situation.
• To assess the kind of support needed by the mother.
• To help the mother identify her own strategies for managing the problem.
• To assess the mother’s ability to protect.

Workers should approach the work with the following assumptions:

• Most mothers will only be learning of the sexual abuse as the professionals do.
• Mothers require professional help to work through the process of disclosure and subsequent activities.
• Mothers have been groomed (by the perpetrator), in a similar way to the child. The mother may also be a victim.
• Most mothers have a considerable amount to lose from the professional intervention.
• Mothers will not respond positively to a professional focus on them as in some way culpable with the perpetrator for the abuse.

There are several useful mechanisms for eliciting the co-operation of the mother:

• Acknowledge their shock/numbness/shame/humiliation/feelings of failure and powerlessness, and give them space to feel uncertain and vulnerable.
• Give them information on abusing behaviour as well as the procedure and process of response.
• Advise them that they can be very influential in a discovery and recovery process.
• Encourage them to be a part of the assessment.
• Address their denial (if it exists), recognizing that it is a common initial response, but becomes maladaptive if sustained. Denial is a block that they currently have about the need to change. The worker then has the task of finding the mechanism that will help the mother confront her worst fears.
• Supervise/monitor the child/ren if remaining at home, or during any contact periods.
• Stress the family strengths.
• Normalize without minimizing.
• Watch for signs of depression.
• Identify intra-familial sources of support (excluding the perpetrator’s mother) especially other mothers who have shared their experience.
• Despite overt distrust, assume that they are searching for explanations and answers underneath.
• Adopt realistic time-scales.

2. Defining the Social Work Assessment of Needs and Strengths

The Social Work Assessment of Needs and Strengths of the mother is likely to be based on the child’s disclosure, the known history of the family, the child’s wishes and feelings, and the reactions of other family members. It is designed to establish whether abuse has occurred, the likelihood of future abuse, the degree of protection available, the necessity of legal intervention, and the placement needs of the child.

The Social Work Assessment of Needs and Strengths should be part of a broader child protection plan, often agreed at child protection conference. It is likely to sit alongside assessments of the child’s needs, wishes and feelings, the same of any siblings, and the perpetrator. It is imperative that the process of comprehensive assessment is two-way: with the professionals providing the mother with support, understanding and information. This variation from the norm often requires new techniques, which allow the mother to share her feelings and emotions as well as factual information. It is very important to assess a mother’s ability to believe, support and protect the children. At no time, however, should the work with the mother, or her views, predominate over a consideration of the child’s wishes and feelings, and action deemed to be in their ‘best interests’.

3. Using Research not Prejudice to Construct an Assessment Framework

Calder, Peake and Rose (2001) developed an evidence-based framework for assessing mothers, whilst understanding and supporting them.

Reactions to the discovery that her child has been abused.

• Behaviour at the point of discovery of the abuse.
• Capacity to cope with the details of the abuse.
• Reactions to the abused child.
• Ability to deal with family, friends, community, school networks.

Link with the perpetrator.

• Any involvement with the abuse.
• Ability to evaluate past events\behaviours.
• Previous relationships.
• A partner who was the perpetrator.
• Perpetrator from the extended family.
• Perpetrator who is friend\acquaintance.
• Perpetrator who is a juvenile abuser.
• Feeling debilitated by the perpetrator.

Personal qualities, resources and networks.

• History of previous relationships.
• Personality features.
• Communication skills.
• Self esteem.
• A history of abuse.
• Physical health and self care.
• Depression and mental health problems.
• Alcohol\drug\substance abuse.
• Attitudes and beliefs.
• Race, culture, religion, class issues.

Capacity to parent the abused child (ren) and siblings.

• Recognising the needs of the children.
• History of relationship with the child.
• Quality of relationship with the child.
• Accommodation
• Supervision
• Support for the child’s education.
• Capacity to talk to the children.
• Abilities to manage behaviours.

Work with professional agencies and\or support systems.

• Worker for the family.
• The nature of the work offered.
• Inter agency liaison and co-operation.
• Capacity to work with professionals.
• Family\friend networks of support.

The following discussion examines some of the essential issues in each of the five areas to provide some insight into the assessment framework.

4. Reactions to the Discovery that her Child has been Abused

There are four reasons why mothers rarely know at the time of the sexual abuse:

• Children cannot tell about sexual abuse: either because they are too young and/or don’t have the language to tell them what is happening to them. They may have been threatened, tricked or bribed into secrecy.
• Society has been slow to recognise the prevalence of child sexual abuse and that the principal perpetrators are those the child knows or trusts, rather than a complete stranger. Even where abuse is recognised, there are powerful obstacles to societal acceptance. Thus, to set mothers up as needing to be more insightful about potential risks is unfair.
• There is little support for prevention programmes to educate people and warn mothers and the children about the problem in advance. Most mothers do concede, with hindsight, that there were indicators that something was wrong, but this is an unfair baseline against which to judge them.  Most mothers have no basis on which they could have known.
• Perpetrators are clever. They are meticulous in planning and executing their offences. They often groom the mother as part of the process, and it is often noted that the mother is dependent on the man to have some of her own needs met (there is a variance on the degree of dependency). It is difficult for mothers to know that someone they know and trust, such as a friend, relative, or a professional, may be the abuser. The fact that many other people in contact with the child and the family did not identify a problem pre-disclosure also supports the assertion that mothers did not know what was going on.

A child’s reluctance to tell of abuse should never be attributed as a fault in the mother, as this over-simplifies the difficulties of telling in sexual abuse cases. There are a number of reasons why children feel unable to tell:

• Children are dependent on adults for a lot of things e.g. food, warmth, shelter as well as love, laughter and discipline etc. Children learn to look to adults to meet these needs as part of growing up.
• Children are taught to obey parents and/or adults as having power and authority over them as a right.
• The perpetrator may be probably someone who the child both likes and trusts. They may thus want to protect their perpetrator.
• The child may not understand that what is happening is wrong as the perpetrator may tell the child that this happens to all children.
• The perpetrator may make threats or bribes to the child or be violent. The child will therefore be too scared to tell, as they believe something worse will happen or they will be punished.
• The child may not know or understand the consequences of telling.
• Or they may feel such guilt and shame that they cannot tell. This maybe especially true if their body responded to the sexual stimulation.
• The child may think they have told and nothing happened. This will give or make stronger the message that the child is at fault or has done something wrong.
• Generally, adults are not good at talking openly about sex, sexuality and most of all, sexual abuse. The child might therefore have the message that this is something that they cannot talk about.
• The child may be passive because s/he believes the perpetrator when he says that the sexual abuse is acceptable.
• The child may feel there is no use in telling. If the parents are rarely around or are preoccupied with their own lives, the child may think that their parents simply do not care about what happens to them.
• The child who is sexually abused may receive many rewards from the perpetrator, both in terms of presents and affection/attention. The child will not want this part to stop, or are bribed not to say anything.
• They have a sense of loyalty and/or love for the perpetrator that makes it impossible for them to speak out against someone who is supposed to be protecting and caring for them.
• The child may not be getting love and cuddles and affection from other adults and so the abuse may be all the child receives in terms of these needs.
• The child may well fear the reactions of others, or has had unhelpful responses from people they told already.
• The child may feel too much guilt and shame to tell anyone.
• They fear they will be blamed.
• They fear breaking up the family (adapted from Engel, 1994; Hall and Lloyd, 1989).

The majority of children wish to tell their mother about the abuse. Many do so, some repeatedly. The likelihood of and circumstances leading to, a child telling her mother vary and are dependent upon several factors:

• The younger the child, the more likely the first disclosure is to be to the mother.
• Younger children may have greater difficulty in comprehending the abusive experience, and the mother is usually the person to whom the child turns with physical soreness, etc.
• Younger children are also less likely to be fully aware of the negative consequences of disclosure and may disobey instructions by the perpetrator not to tell, impelled by their own developmentally appropriate inability to contain their anxiety.
• The more distant the relationship between the mother and the perpetrator, the more likely the child is to disclose to her mother.
• There are also identifiable situations where children who are less likely to disclose to their mothers. These include
  • Boys and older girls who are aware of the consequences of disclosure and who are often feeling protective of their families in the face of predicted disruption to family life that disclosure will bring.
  • In addition, sexually abusive situations, which bring a degree of apparent gain for the girl, such as emotional and/or physical gratification, are less likely to be disclosed to the mother where the perpetrator is not a member of the immediate family.
  • The girl may be getting some of her own unmet needs within the family fulfilled outside of it. The associated guilt may further deter the girl from disclosing.

The reactions of those whom the child first tells will determine whether they feel encouraged to seek or accept further help. Positive responses to the child upon disclosure might include: acknowledging the difficulty of disclosing; relating the sexual abuse as linked to identified difficulties; offering immediate support; remaining calm and not showing any feelings of shock, disgust or distress.

Unfortunately, it can also end there if the disclosure is managed in an insensitive or intrusive way. Unhelpful reactions might include ignoring or minimising the effects of being sexually abused; showing an excessive interest in the sexual details; or appearing very angry, shocked or disgusted by the disclosure. Unhelpful comments might include ‘It’s in the past. Do try to forget about it’; ‘That is not as bad as some sexual abuse that I have heard about’; ‘It only happened a few times, so maybe there isn’t really anything to worry about’.

Any significant delay in responding to a disclosure can have the following effects:

• the child feels that her history of sexual abuse is too shocking or disgusting for her to be helped; they may feel rejected after plucking up the courage to tell;
• they may minimise/deny/retract that they have been abused;
• they may feel that their abuse is not serious enough to warrant attention; and
• there is the potential for self-injurious behaviour.

There are a number of other factors relevant to the mother’s responses to any disclosure. These might include:

• her relationship with the perpetrator;
• the nature of the child’s relationship with the perpetrator;
• the power of the perpetrator in their life;
• the character of the intimate relationship between the mother and the perpetrator;
• the duration of the abuse;
• the violation of trust; and
• the level of support and resources available to her.

There are some obstacles to believing the child and these include:

• a parental history of abuse, which they promised would not happen to their child;
• a belief that they must terminate a relationship with the perpetrator once abuse is confirmed;
• excessive dependence on the perpetrator; or
• prior family rejection of the perpetrator, resulting in a situation where to believe is to accept family condemnation.

Link with the perpetrator.

The future relationship the mother chooses to have with the perpetrator is the litmus test of whether she will be able to offer her children any protection from further abuse. This often depends on the nature of the mother’s relationship with the perpetrator. For example, offering protective action to the child and separation from the perpetrator usually presents relatively little difficulty if the perpetrator is a stranger to the family. The mother’s protective abilities may similarly be mobilized if she learns of abuse, of which she was previously unaware. For example, when the perpetrator was a family friend or is in a relationship with the child that exists relatively independently of the family.

The difficulties of ensuring protection for the child multiply as the perpetrator’s emotional proximity to the family increases. This is particularly true when there is a close relationship between the mother and the perpetrator: leaving the mother with an extremely painful choice – break the relationship with the perpetrator or lose the child. This can be where the perpetrator is the partner or a valued relative, such as a grandfather. Only a minority of perpetrators agree to leave the home as an expression of their responsibility for the abuse. Any mother that undertakes to exclude the perpetrator from the home will need considerable professional support to maintain the decision in the face of emotional and economic strains and stresses, and even threats of violence from the perpetrator and his family or friends.

Mothers who are able to confront the perpetrator and are more able to exist independently from him are more likely to be able to effectively protect their children from further abuse. Those who are more dependent will require considerable external support to protect the child.

In response to the disclosure, the mother may become alarmed and distressed for her child and she may immediately feel very angry toward the perpetrator. She may have previously harbored suspicions, particularly if abused herself, possibly by the same man. The confirmation of her suspicions might lead to relief and enable her to pursue the protection of her child.

However, there are cases where a mother will have explicitly concealed the sexual abuse, and workers need to understand why, as there is still some potential to work with them later if they accept and believe the sexual abuse has taken place.

The following continuum for understanding the mother’s role in the sexual abuse should be considered:

• The mother did not know about the abuse: either because of her reactions to the disclosure or from circumstances in which the abuse took place. Mothers may have known nothing about the abuse because: they were not in the home when it was taking place; she was caring for other children; the perpetrator ensured silence; it occurred in the context of normal family situations, such as bathing or putting to bed; and each incident took a very short time and no-one else could possibly have known about it. Mothers are helped if the child states they believe that the mother did not know about the abuse.
• The mother suspected that sexual abuse was taking place but could not acknowledge it: some mothers pick up signals from their daughters that something is amiss, only to block or disregard the information or have other explanations for the signals they see. The mother may also doubt her perceptions, believing herself to be crazy for thinking that such a thing could happen. Children who tried to tell their mother only to have the information ignored, will conclude that her mother failed to protect her from further abuse.
• The mother knew of the abuse but did nothing to stop it: the child may have told the mother on more than one occasion, only to be responded with disbelief, anger, or resigned acceptance, which we know are normal reactions. The child would conclude that the mother failed to protect her.
• The mother knew of the abuse and condoned it: the mother may even have set up the abuse by putting her in situations where she would be alone with the perpetrator, or by making her available for Child Sexual Exploitation or pornography. The child will blame her mother for failing to protect, be very angry towards her, as well as struggling to understand her mother’s behaviour.
• The mother sexually abused her: in which case the child will experience intense feelings of isolation and betrayal and feel that the mother has abdicated her maternal role. Few children disclose sexual abuse by their mother and they are likely to be met with a greater potential for disbelief.

Personal qualities, resources and networks.

The field is beginning to realise that the needs of the protective mother are as important as the needs of the children and these might include:

• Someone to talk to: to express trust and belief in them, often for weeks or months afterwards.
• Someone to counsel them about their own abuse: as the child’s disclosure may have resurrected memories.
• To know what happened: as this is essential as well as painful: they need to know the nature, the frequency, extent, the time and place, the child’s feelings, etc.
• To know they weren’t the first mother this had happened to: so they are not alone, and can possibly meet and learn from shared feelings.
• To have a break from him: they need space away from the perpetrator in order to gain a perspective, consider their feelings about the relationship, etc.
• To be treated as a person: to have their feelings listened to seriously, to feel respected, to be acknowledged when they are present, etc.
• To regain control of their lives and minds: particularly in incest cases where they need to resume control over the day-to-day events and their personal thoughts.
• To obtain basic information on survival: to embrace new aspects of their life, such as courts, police, treatment, etc.
• To understand how domestic violence and sexual abuse were related: and to understand they are separate issues that need to be addressed.
• To make basic life decisions: to move away, separate or divorce their husband, tell people, etc.
• To know options regarding contact and custody: both in relation to their partner, but also if the child has been removed from home by the local authority.
• To know how the child/ren will react: as everyone will be affected to some degree by the trauma.
• To ensure this will not happen again: taking steps to safeguard the child from continued sexual abuse is important, such as no contact or supervised contact.

The needs of protective parent can be neglected as professional responses’ focus on the children who have been abused, their siblings, and on the perpetrators of the abuse. However, both for the women’s emotional survival and growth and so that they can provide appropriate parenting for their children, thereby reducing the need for their children to be removed from their care, or remain there long-term, these women need the therapeutic opportunity to deal with their feelings about what has happened and to adjust to the major change that has taken place in their lives.

Additional needs may be present for those mothers who have been sexually abused in their own background. For some mothers, their history of sexual abuse has remained hidden, sometimes even to themselves until an event in adult life brings the past to the surface. This can include the discovery that her child is being sexually abused by either the same perpetrator or another family member (such as her partner). Some factors which facilitate disclosure lie within the mother herself and include:

• whether she has learnt to dissociate herself from the abuse as a child;
• the reactions of others to her previous attempts to disclose as a child and as an adult;
• whether she has told anyone before;
• the extent of her recall of the abuse;
• her emotional reactions to the memories of the abuse; and
• whether she has had close relationships with protective adults during childhood.

Capacity to parent the abused child (ren) and siblings.

Victims of sexual abuse often have difficulties in their relationships with their mothers. Mothers are expected to love, support, and protect their children. They are expected to prevent bad things from happening to their children and always be there to listen and to make things better. The child who has been sexually abused did not get this help and protection. Despite this, difficulties between the mother and child are not inevitable. The mother may realize that her child is being sexually abused and support and protect her. The mother-child relationship can be strengthened if the child can share her feelings with her mother and feel loved and supported. This often doesn’t happen because mothers do not usually know that their child is being sexually abused as it happens in secret and is kept secret.

The victim’s feelings towards their mother are often a confused mixture of anger, love, hatred, pity, resentment and a desire to protect them. Frequently, the sexual abuse produces a crisis in a mother’s relationship with her child. The child may report the following difficulties with their mother:

• Feeling protective: few children tell their mothers that they are being sexually abused. They are frightened of the consequences of telling – of being blamed, disbelieved or punished. Many sexually abused children also fear the distress and pain their mothers might feel if they knew what was happening. Perpetrators often keep children silent by telling them their mothers would be upset if they knew. Children thus tolerate the pain themselves in order to protect their mothers. The child finds herself protecting her mother rather than being protected by her. The secrecy can create a barrier between mother and daughter and cause difficulties in the relationship.
• Feeling neglected: the child may resent the mother’s failure to notice either the child sexual abuse or any distress exhibited by it.
• Feeling abandoned and badly treated: in some cases mothers are aware that abuse is happening and take no action to stop it. They accuse the child of lying, or turn a blind eye to it and allow the continuation of the abuse. Some mothers support and stay with their abusive partners even if this means losing care of the child.
• Dealing with the mothers’ distress about the abuse: The mother may find herself being rejected by her daughter as time passes – either due to the internal sense of disappointment that her previously ‘all-knowing’ mum had failed to protect her, or even that she is responding to the subtle clues given out by the professionals which tell her that her own mother is no longer a good mummy.

The following framework offers some guidance for the issues for both parties that need to be addressed:

Mothers

Daughters

Acknowledging that the abuse has occurred. Feelings of guilt and failure to protect her child, of not being a good-enough parent. Vulnerability when confronted with the facts about the abuse. Finds it difficult to cope with daughter’s feelings. Is she able to let her daughter know what it was like for her, especially in her relationship with the abuser. Mother may have been abused by the same man.

Did she know about it? How could she not have known? Why did she not see that something was wrong? What did she do/could she have done to stop it? May want to protect mother from details of the abuse. May want to protect mother so disguises her true feelings. May not want to hear. Finds it difficult to acknowledge mother’s own difficulties. Why didn’t she protect me from him? She knew what he was like.

Work with professional agencies and\or support systems.

It is often difficult for mothers to co-operate closely with agencies whose intervention alienates them and subjects them to prescribed societal expectations.

Most mothers are willing to co-operate in the necessary assessment and treatment work once they trust that they are not being criticised or labelled for their confused and conflicting feelings. Professionals also need to acknowledge that they need to work with the mother’s needs as well as those of the child simultaneously rather than at the expense of.

5. Possible Assessment Outcomes

The assessment processes are likely to produce one of the following conclusions:

• The mother can protect and support the abused child (and siblings) and does not require further professional intervention.
• The mother can protect and support the abused child (and siblings) if provided with sufficient resources.
• The mother denies the actual offences have been committed, but argues clearly that she will act protectively ‘just in case’.
• The mother is ambivalent and the child’s support and protection must be ensured by external sources, such as professionals, extended family, etc.
• The mother denies the abuse occurred or is very dependent on the abuser and so is unable adequately to support or protect the child. This invariably leads to the need to remove the child from the family.

Recent experience tells us that many fall in the middle ground, and this makes planning and decision-making less clear, more anxious, and more prone to legal intervention. This position is often fuelled by the lack of any criminal prosecution and conviction for the recent offence, or where a previous allegation or conviction for a sexual offence comes to light, and the mother has not seen any evidence of sexual abuse, or concerns about their partner’s role in the family, often over a significant period of time.

The reader is referred to the prognosis framework for a more detailed framework for determining prognosis.

6. Couple Relationship

If couple work is about harnessing the strengths (and acknowledging the weaknesses) of both the perpetrator and their partner in the risk management process, both need to be able to recognise the potential for re-offending and to take on a protective or preventative role. However in the early stages of disclosure, ‘denial of risk’ is a stance often taken by both perpetrator and their partner.

Denial based on ignorance

Denial or risk may be as a result of ignorance – a lack of information about the process and motivation behind offending, and it is important that we recognise the basis of such denial. For example, a partner who claims that her husband is not a risk because he abused due to stress and now, perhaps due to medication, is able to cope with pressure, should not be perceived as unable to recognise or respond to risk.  In effect she has recognised the solution to a problem as she perceived it on the basis of her misconception as to its cause; I.e. He offended because he couldn’t cope with the stress; He’s dealt with the stress; and therefore the problem has gone away. For her to move into couple work she needs accurate information about the nature of abuse and motivation, and only at this point should her long-term ability to protect be judged.

Denial and self-preservation

However, denial of risk may also be based on the need for self-preservation and as such it holds an essential functional role. For the offender, acceptance of offending, of harm, of responsibility, or of future risk, creates a frightening challenge to his self-esteem and denial may ‘kick in’ to protect an image of an ‘ideal self,’ infinitely preferable to facing up to the ‘real self’ – the offender, perhaps with a primary sexual arousal to children. For their partner, the shock of abuse by a loved one, ignorance of the process of offending, and a tendency to misappropriate blame, particularly towards themselves may lead to the use of denial to support and protect their own self-image.

Denial then of risk is often understandable.  It needs to be challenge whilst at the same time seeking to strengthen and reform self-image by pointing to positive qualities.  However, it does need to be addressed by offenders and their partners if children are to be protected from offenders and preventative measures taken to reduce the risk of future abuse, and it needs to be addressed prior to the couple coming together for couple work.

Click here to view the Assessment Needs to Consider table.

Both adults must be interviewed separately and together.  Workers need to show sensitivity to race, cultural background and class.  If assessing a couple from an ethnic group different from your own then consult with an appropriate colleague.

Risk increased if:	Risk lowered if: (Including protective factors)
Joint participation i.e. drug/alcohol abuse, sado-masochism/violence.	Each partner has sought help.
Perpetrator takes charge of personal/intimate care of children.	Caring tasks negotiated and house rules agreed.
Denial of any problems with marriage.	Evidence of ability to discuss the abuse and no minimization/denial.
Poor marital relationship.	“Mature” couple, good support from extended family without collusion.
Each partner is “secretive” anger/anxieties not voiced.
History of domestic violence
Unstable life-style evidenced by work pattern.	Appropriate affection and physical contact.  Intimacy/sexual relations not a problem.
Poor communication – lack of empathy between partners.	Able to discuss sexual matters openly.
Overt use of pornography/ “sexualised” atmosphere in home	Draws appropriate boundaries around adult talk and behaviour.
PARENTING STYLES
Rigid role definition.	Children aware of boundaries. They are listened to and heard by both parents.
Social Isolation.	Appropriate use of community resources/schools/health service etc.
Perpetrator makes decisions and tight rules concerning family members.	Family working openly and together with professionals on rehabilitation plan.

7. Victims of Sexual Abuse: Recognition and Assessment Issues

Recognition 

The “warning signs” of sexual abuse are becoming more familiar, and professionals are now somewhat less likely to dismiss as fantasy stories told to them by children. It must be remembered that child sexual abuse is an extremely emotive and sensitive subject for all concerned. Boys and girls of all ages may be sexually abused and are frequently scared to say anything due to guilt and/or fear. Recognition can be difficult, as there may be no physical signs and indications are likely to be emotional/behavioural. Diagnosis and management in these situations is a complex multi-disciplinary process.

A child or young person may have disturbed behaviour or changes in behaviour. This is a very difficult area as most behaviour associated with child sexual abuse are not specific to sexual abuse, only indicating that a child or young person is distressed. The cause of this distress may have other causes such as parental disharmony or bullying at school. Those behaviours with a higher but not invariable association with sexual abuse include:

• Sexualised behaviour (particularly in young children)
• Sexual knowledge or awareness beyond that expected for their age
• Prostitution\promiscuity
• Self-mutilation
• Running away

Only a minority of sexually abused children will present with a physical complaint. The following symptoms should give cause for concern and further assessment:

• Soreness, discharge or unexplained bleeding in the genital area
• Chronic urinary or vaginal infections
• Bruising grazes or bites to the genital or breast area
• Sexually Transmitted Infections
• Pregnancy especially when the identity of the father is vague
• A change in bowel habit such as soiling or constipation
• Genitor-urinary abnormalities such as enlarged vaginal opening or scarred hymen
• Rectal abnormalities such as anal fissure or scars

There are several useful behavioural and emotional indicators

• Details of sexual activity in talk, play or drawings that show inappropriate sexual knowledge for the child’s age
• Compulsive masturbation in an inappropriate setting
• Exposure of or preoccupation with genitalia
• Overt sexual approaches to other children or adults
• Fear of particular people or situations, e.g. bathtime, toileting and bedtime
• Regressive behaviour, e.g. bedwetting or soiling in a child who has previously been toilet trained
• Sleep disturbance with fears or nightmares perhaps with a sexual context
• Sudden changes in mood
• Changes in eating pattern
• Inability to concentrate, sudden drop in school performance
• Drug and alcohol abuse (older children)
• Suicide attempts and self injury
• Persistent running away
• Unexplained large sums of money/gifts
• Psychosomatic conditions e.g. unexplained abdominal pain or headaches

It is important to remember that sexual abuse is just one of a number of factors that can adversely affect a child’s behaviour. It is necessary during any monitoring or assessment to explore with the child’s carer’s possible reasons for the child’s behaviour. Some indicators take on greater or lesser importance depending on the child’s age. Suspicion increases when several factors are present together and when the behaviour contains sexual elements. These lists are not exhaustive. Some sexually abused children will show none of these indicators effectively concealing the abuse.