SEARCH WITHIN CONTENT
Citation Information : Scandinavian Journal of Child and Adolescent Psychiatry and Psychology. Volume 1, Issue 2, Pages 51-62, DOI: https://doi.org/10.21307/sjcapp-2013-008
License : (CC BY-SA 4.0)
Published Online: 30-November-2012
Child abuse is a broad term that includes physical, sexual, and emotional (e.g., psychological, verbal) abuse. There are huge variations with regard to the level of severity and the consequences of abuse. Because child abuse is such a sensitive topic, it is a challenging task to conduct studies concerning this subject.
The aim of the study was to identify areas that could be improved to offer better health care services to patients. Therefore, routine assessments, the characteristics of the cases, and the types of follow up were emphasized.
The Norwegian Ministry of Health and Care Services provided an exception from the principle of informed consent so that this study could be conducted. We had access to the medical records of all children between the ages of 0 and 14 years old who were referred to the regional child abuse management unit in 2006 and 2007. A descriptive, cross-sectional study was performed.
One hundred and six children were referred to the child abuse management unit. For the majority of these patients (80.2%), sexual abuse was the only concern. The children presented diverse psychological and somatic symptoms and problems. Psychosocial functioning was in general not properly described in the records. Four out of five of the children were referred to services for follow up after the first examination in the child abuse management unit. Only 36% of the children were referred to child protective services.
This study revealed that psychosocial functioning is seldom documented and that psychological symptoms could be described more reliably and in more detail. A systematic approach may be helpful for health care providers, and we suggest the implementation of valid evidence-based instruments, such as the Child Behavior Checklist and the Children’s Global Assessment Scale.
Child abuse is a broad term that includes physical, sexual, and emotional (e.g., psychological, verbal) abuse. There are huge variations with regard to the level of severity and the consequences of abuse. In extreme cases, abuse can cause death, but mostly the physical damage will have limited influence on the development and future well-being of the child. The psychological effects and the long-term consequences of abuse on the child’s cognitive, emotional, and neurological development will generally be more important (1-3). Previous studies have shown an association between childhood abuse and a number of mental and physical health problems later in life, such as depression, post-traumatic stress disorder (PTSD), anxiety disorders, and attention-deficit/hyperactivity disorder (2-10). The young human brain is highly plastic and able to change. Adverse experiences, such as childhood abuse, can modify brain structures and increase the risk of impaired health later in life (7;11-14).
The estimated prevalence of child abuse is substantial throughout the world. International studies in high-income countries based on self- or parental reports estimate a yearly prevalence of child physical abuse of 5% to 35%, of child psychological abuse of 4% to 33%, and of child sexual abuse of 15% to 30% for girls and 5% to 15% for boys (5). These numbers seem to be representative for the Norwegian population as well (15).
Health care for alleged victims of abuse can be organized in different ways. The main purposes of child abuse management units (CAMUs) are to treat acute and long-term health problems and to provide forensic services. One of the challenges involving the organization of CAMUs concerns how to provide mental health care to patients (16). In the county of Sør-Trøndelag in Norway, one CAMU has chosen to establish a low-threshold hospital-based service for children that is organized in the specialist health care service located at St. Olav’s Hospital in Trondheim. Nurses, pediatricians, and psychologists work as an interdisciplinary team that optimizes services and care for these patients. Patients are offered emergency medical care, which is available at all hours, as well as long-term follow-up care with professionals, if needed. The treatment team also cooperates with law enforcement, child protective services, and child and adolescent mental health services (CAMHS).
When organizing an interdisciplinary, low-threshold, hospital-based unit of this kind, health-service research should also be included. However, few studies have been conducted in Scandinavian countries on this topic, and matters of confidentiality complicate this task.
Adult survivors of childhood abuse are at severely increased risk of developing impaired physical and mental health (2-3;7). An optimized health service for children and adolescents who have been exposed to abuse may prevent some of these problems, but, to achieve this, it is essential for the clinician to know what kinds of assessments and treatments are best for each patient. A systematic and evidence-based assessment would be an important prerequisite for gaining this knowledge.
The primary aim of this study was to identify areas that could be improved to offer better and more holistic health care services to patients. To achieve this, we wanted to focus on the routine assessment that occurs in the unit; the characteristics of the abuse, including the diversity of symptoms presented; and the type of follow-up services provided to children referred to the CAMU.
This is a descriptive, cross-sectional study in which we have included all patients between the ages of 0 and 14 years old who were assessed by a psychologist in a hospital-based CAMU from January 1, 2006, to December 31, 2007. The majority (79%) of these patients were also examined by a pediatrician. The patients were identified by searching the hospital patient administrative system and by gathering information from colleagues in the CAMU. A total of 106 patients (79 girls and 27 boys) were seen in the unit, either by direct contact or after referral from other professionals. The patient records were studied, and they contained the reports of both psychologists and pediatricians. The ages of the patients were registered in age intervals (0 to 4, 5 to 9, and 10 to 14) after a recommendation from the Norwegian Ministry of Health and Care Services. The demographic distribution is shown in Table 1.
|Age||0 to 4 years||25||23.6|
|5 to 9 years||41||38.7|
|10 to 14 years||40||37.7|
|Residence (missing = 1)||City||45||42.5|
|Care situation (missing = 1)||Both biol. parents||28||26.7|
|One biol. parent||41||39.0|
|Biol. parent and step-parent||19||18.1|
We developed a scoring manual for retrospectively collecting information from the patient records. Before reading the records, scoring categories were chosen after literature studies and discussions with experienced colleagues (17). For example some of the variables related to mental symptoms (e.g., externalizing, internalizing, attention problems) were constructed on the basis of the main categories of the Child Behavior Checklist (CBCL) (18). The CBCL is an integrated part of the Achenbach System of Empirically Based Assessment, which provides an evaluation of children and adolescents from several informants. The CBCL measures the total emotional and behavioral problems of the child, and it can identify different syndrome clusters, including the variables mentioned previously.
One of our variables addressed whether it was concluded that abuse had taken place or not. This scoring was based on the following: 1) medical findings (i.e., the presence of hymenal transection, sexually transmitted disease, scars, and wounds (19)); 2) information in the patient record about a suspected abuser’s conviction in court; and 3) information in the patient record about whether the abuser had confessed to the incident. We chose to categorize abuse with regard to its type and severity, because we wanted to investigate whether there were differences in symptom load or assessment that were dependent on these factors. It has been shown in earlier studies that different types of childhood abuse can have long-term consequences on mental and physical health (5;20). Severe sexual abuse included forced masturbation and anal, vaginal, or oral penetration. Moderate sexual abuse included the touching or fondling of an intimate area, the viewing of pornography, and other sexual acts. Severe physical abuse included violence that resulted in fractures, internal bleeding, or other injuries that demanded medical attention and care, whereas moderate physical abuse included violence that resulted in wounds, bruises, or no visible marks at all. Psychological abuse was not categorized by severity.
We also registered what kind of follow up the children received after their first examination. For some of the patients, especially those from other regions of the country, this included the follow-up care that was recommended by either pediatricians or psychologists at the CAMU. Further adjustments were made after reading the medical records. Variables that proved not to be useful for organizing the text of the medical records were omitted, and we ended up with a scoring manual that included 171 variables (Appendix).
The Children’s Global Assessment Scale (CGAS) is widely used by health professionals to assess the psychosocial functioning of children and adolescents on a scale from 0 to 100, where 100 = “Excellent psychosocial functioning” and 0 = “Extreme and pervasive dysfunction.” The CGAS has demonstrated satisfactory psychometric properties (21). In this study, we tried to set a CGAS value that was based on information taken only from the patient records. The CGAS is mainly used for children in the age range of 4 to 16 years. We therefore chose not to use the CGAS to rate children in the youngest age group.
The first author read all of the identified patients’ medical and psychological records (DocuLive) and registered the information according to the scoring manual during the period from October 2011 to December 2011. The second author also read 11 medical records, which were arbitrarily selected. Potential differences in interpretation and scoring between the authors were then discussed to increase the quality of the scoring procedures.
We used descriptive statistics. Categorical variables were analyzed with the chi-squared test. An alpha of .05 was chosen to indicate the level of significance needed for the study.
Because of the sensitive nature of the study, we applied to the Norwegian Ministry of Health and Care Services for exception from the principle of informed consent. The reason for this was that we wanted to protect children and their families from retraumatization by reliving unpleasant memories that may occur during the process of asking for their consent. We also expected a very low response rate from parents if we applied the principle of informed consent, because some of the parents would have been suspected of abusing their own children. It is highly probable that many of these parents would not have wanted to participate in this kind of study. Ethics approval was obtained from the Norwegian Ministry of Health and Care Services, which provided us with an exception from professional secrecy to perform the study as described (201005216-/SVE).
As a result of the sensitivity of the subject and related matters of confidentiality, the list of patients included in the study was destroyed after the reading and scoring of the medical records. Thus, all information was registered anonymously in the research database. We hope that the knowledge gained from this study will help the team at the CAMU to improve their services for children and their families and that it will also be of value for other CAMUs. It was felt that these advantages were greater than the disadvantages involved in the avoidance of the principle of informed consent.
The medical examination was performed by a trained pediatrician. It routinely included a history from the child and his or her caregiver; a general physical examination from head to toe; an anogenital examination with a colposcope; and supplementary examinations as indicated (e.g., microbiology, blood tests, forensic sampling, radiographs).
The psychological interviews were performed by trained psychologists. The consultations with the children and their caregivers focused on background history, the family and social environment, symptom load, coping, and supporting factors around the child. Instruments and methods such as rating scales, play sessions, and structured interviews were used when indicated. The psychologists would routinely discuss reporting to the police with the children or the parents.
In 80.2% of the cases, sexual abuse was the only concern. In 10.3% of the cases, physical abuse was the only concern. In 1.9% of cases, psychological abuse and neglect were the only concerns. For 7.5% of the children, combinations of these types of abuse were suspected.
In the youngest group of children, biological fathers were the most commonly suspected abusers (Table 2). The next most likely suspect was a person of authority to the child (e.g., teacher, adult working in a kindergarten, sports coach). In the middle age group, the biological father still was the most common suspected abuser, followed by a friend or acquaintance, a stepfather or foster father, and the biological mother. For the oldest children, the abuser most often was a friend or acquaintance of the child, followed by the biological father, a stepfather or foster father, and an uncle or another relative. When comparing the age groups, there were significant differences with regard to the biological father being the suspected abuser (P < .001). For the other categories, the differences were not significant.
|Relationship to suspected abuser||0 to 4 years old n = 25||5 to 9 years old n = 41||10 to 14 years old n = 40||P value|
|Person of authority||12.0||2.6||2.5||.156|
The children and their caregivers reported a wide spectrum of symptoms and problems during their contact with the unit. Several children reported sadness and anxiousness, and some were also described in the records as demonstrating sexualized behavior in addition to abusing others. As shown in Table 3, some children reported symptoms that may be part of PTSD, including flashbacks, nightmares, avoidance, and irritability. A total of 53 children (50.0%) were described as having one or more psychological symptoms.
|Symptoms||0 to 4 years old (%)||n||5 to 9 years old (%)||n||10 to 14 years (%)||n||Total (n)||P value|
|Internalizing problems||Tired/exhausted/lack of initiative||4.0||1||0.0||0||7.5||3||4||.208|
|Attention problems||Attention problems||0.0||0||7.3||3||12.5||5||8||.178|
|Post-traumatic stress disorder-associated symptoms||Flashbacks||0.0||0||0.0||0||7.5||3||3||.078|
|Other mental symptoms||8.0||2||19.5||8||7.5||3||13||.195|
We were interested in studying the psychosocial functioning of the children, because this can be a valuable variable when it comes to assessing the needs of the individual child. When it is scored appropriately, with the use of all available information about the child, the CGAS can help to identify persons in need of psychiatric treatment, have predictive value, and measure changes over time, including treatment effects (21). In this study, functioning in school or kindergarten was mentioned in the patient records in only 27 out of 106 cases; therefore, it was not possible to set a valid CGAS score.
Table 4 shows the spectrum of psychosomatic and physical complaints of the children in question. Several of the children reported pain, either as headaches, pelvic pain, or diffuse pain. A total of 40 children were registered as having “other symptoms and findings from sexual organs or anal area.” These include findings such as genital redness and synechiae, which are fairly common abnormalities, especially in the youngest age group. Sixty-three children reported one or more somatic or psychosomatic symptoms (59.4%). There were no significant differences between the age groups with regard to psychological, psychosomatic, or somatic symptoms, except for the presence of significantly more “other symptoms and findings from sexual organs or anal area” in the youngest age group (P < 0.05).
|Symptoms||0 to 4 years old (%)||n||5 to 9 years old (%)||n||10 to 14 years old (%)||n||Total (n)||P value|
|Other symptoms and findings from sexual organs or anal area||56.0||14||39.0||16||25.0||10||40||.042|
|Other somatic symptoms||16.0||4||19.5||8||2.5||1||13||.053|
In 24.5% of cases, it was concluded in the records that abuse had probably taken place. This was based on convincing medical findings (i.e., hymenal transection, sexually transmitted disease, scars, and wounds), information about a suspected abuser’s conviction in court (5.7%), or information in the patient record system that the abuser had admitted to the incident. In 70.8% of cases, no conclusion was possible, and abuse was found to be unlikely in 4.7% of cases. For those cases in which abuse was confirmed, it was significantly more likely (as compared with the cases in which abuse was not confirmed) that the child belonged to the oldest group of children (i.e., 10 to 14 years old; P < .001) and that the suspected offender was a friend or acquaintance (P = .002) or a relative other than a parent (P = .001). The type of abuse was more often categorized as severe sexual (P = .002) or moderate physical (P = .003); there was significantly more often suspected previous abuse (P = .003); and the examination was completed during the first 24 hours after the assault (P = .011). Table 5 lists some additional characteristics of cases in which abuse was confirmed.
|Abuse confirmed (n)||Abuse not confirmed (n)||P value|
|Sex||Girl||20 (77%)||59 (74%)|
|Boy||6 (23%)||21 (26%)||.747|
|Age||0 to 4 years old||1 (4%)||24 (30%)|
|5 to 9 years old||6 (23%)||35 (44%)|
|10 to 14 years old||19 (73%)||21 (26%)||<.001|
|Suspected offender||Father||6 (23%)||40 (50%)||.012|
|Stepfather/foster father||3 (12%)||8 (10%)||.854|
|Other relative||7 (27%)||3 (4%)||.001|
|Friend/acquaintance||9 (35%)||7 (9%)||.002|
|Person of authority||0||5 (6%)||.186|
|Stranger||2 (8%)||4 (5%)||.627|
|Type of abuse||Severe sexual abuse||13 (50%)||15 (19%)||.002|
|Moderate sexual abuse||8 (31%)||18 (23%)||.433|
|Severe physical abuse||0||0|
|Moderate physical abuse||8 (31%)||6 (8%)||.003|
|Psychological abuse||3 (12%)||4 (5%)||.259|
|Suspected previous abuse||15 (58%)||21 (26%)||.003|
|Medical examination findings*||12 (63%)||17 (26%)||.003|
|Contact with unit within 24 hours after abuse||4 (2%)||2 (3%)||.011|
Four out of five of the children received some kind of follow-up care or were referred to other services for follow up after the first examination at the CAMU. The most common follow-up care was provided by a psychologist at the unit, by child protective services, and by CAMHS. Several of the children were later evaluated by more than one service unit (Table 6). Of those children with confirmed abuse, significantly more were followed up with by a psychologist in the CAMU (P = .011). Otherwise there were no significant differences in follow-up treatment between those with or without confirmed abuse. Significantly more of the youngest children were among those not referred for any kind of follow-up care (P < .05), but there were otherwise no significant differences regarding sex, type of abuse, symptom pattern, symptom load, or documented findings in the patient record.
|Follow-up services||Abuse confirmed (n)||Abuse not confirmed (n)||Total (n)|
|Child and adolescent mental health services||8 (31%)||24 (30%)||32 (30%)|
|Pediatrician||0||2 (3%)||2 (2%)|
|Psychologist employed at the child abuse management unit||15 (58%)||24 (30%)||39 (37%)|
|Child protective services||8 (31%)||30 (38%)||38 (36%)|
|Community health services||3 (12%)||8 (10%)||11 (10%)|
|School psychologist||1 (4%)||9 (11%)||10 (9%)|
|Others||0||4 (5%)||4 (4%)|
|None||3 (12%)||17 (21%)||20 (19%)|
|Two or more services||9 (35%)||29 (36%)||38 (36%)|
One strength of this study is that we had access to complete patient record files for all children referred to the CAMU during a 2-year period. The age distribution is also balanced, with the age groups including 25 (0 to 4 years old), 41 (5 to 9 years old), and 40 children (10 to 14 years old). There are limited personnel connected to the CAMU (i.e., three to five people), which was helpful in that the records were written in a uniform manner. Because the involved staff members are well aware that the records may be used for legal purposes, one could also assume that the records are more carefully obtained than what might be expected in other medical departments. However, the awareness of the possible use of the records as legal documents may also have limited what was actually written in them. Retrospective assessment by reading and scoring medical records has clear methodological limitations. We had to rely on the information that was written in the records, without being able to confirm that this information was correct. We did not know if the children and their parents were asked about more details than were documented or if some details may have been left out. To assess the validity of our text interpretations, the first and second authors discussed every tenth record, thereby excluding variables that proved to not reflect the content of the medical record text appropriately. This procedure may have had an impact on the registered prevalence of, for example, the somatic and mental symptoms registered for each child. These numbers are therefore most certainly slightly underestimated, but they are nonetheless interesting as minimum estimates. Further, the retrospective assessment of psychological and psychosomatic symptoms resulted in a variety of categories, thereby reducing statistical power as compared with an assessment involving standardized questionnaires.
Our list of variables was very comprehensive as result of the chosen research method of investigating medical records. To obtain meaningful scoring categories, we had to reduce the original number of variables, which was 235, to the final 171. A shorter list from the beginning might have resulted in more significant results given the limitations of the present sample size, but it could also have resulted in the loss of important information. However, we found this approach useful, and the resulting scoring manual was convenient for our purposes.
The results demonstrated that children of both genders and all age groups that we investigated had been referred to the CAMU. Among the children, only 26.7% were living with both of their biological parents (see Table 1). In the general population, 75% of children who are less than 18 years old are living with both parents. The proportion decreases with age, from 88% during the first year of life to 62% when the children reach 17 years of age (22). Similar patterns have also been reported in other studies (23). There could be different possible reasons for this deviation. Abusive behavior on the part of one parent can, in some cases, be the reason for splitting up the family. However, this pattern may also reflect conflicts between parents who are not living together or even more complex difficulties in certain families.
Sexual abuse was the main concern in the vast majority of the referred cases. In Norway, a tradition for the assessment of child abuse has developed in which the larger pediatric departments are responsible for medical examinations in sexual abuse cases. Victims of other kinds of abuse are often taken care of locally, either by local health care services, surgical departments, child welfare services, or other organizations. The use of this tradition can be questioned. It is known that exposure to physical abuse during childhood is as important a risk factor as exposure to sexual abuse for the development of somatic and psychiatric disease. The prevalence of sexual and physical abuse is approximately equal in the general population (5, 15). One could argue that all children exposed to abuse of the same degree of severity should be offered the best possible and most competent health services. Another reason for this skewness in the cause of referral in our study may be that the public and health workers are not aware that the CAMU is also concerned with physical and emotional abuse.
The patient records in our study describe a variety of both mental and somatic symptoms and problems. We assume that the problem rates registered were a minimum rate, because the children and their parents were not systematically asked about all problem areas. The heterogeneity of the expressed and reported symptoms reflects what is already known about victimized children, their diversity of symptoms, and the challenges of identifying the optimal treatment plan for each individual child (24, 25). There were only limited significant differences in the expression of mental, somatic, or psychosomatic symptoms among the age groups. The oldest children expressed more sadness than the younger ones (P = .015), and the youngest age group had significantly more “other symptoms and findings from sexual organs or anal area,” including soreness (P < .05). This is not a rare finding, especially in toddlers, and it was also the main cause of referral in some of the cases. Irritation and soreness in young children are seldom signs of sexual abuse, unless there are other findings that confirm the suspicion (26). Some of the children reported symptoms that could be part of PTSD. However, these symptoms are often vague and unspecific, especially in children, and they could often be explained by other means. Diagnosing PTSD in children is a challenging task by itself; in addition, the time span between the assault and the examination may not be long enough for PTSD to develop. According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, the symptoms must last for more than one month after the event for the diagnostic criteria to be fulfilled (27). Some patients may present with their symptoms later as part of delayed-onset PTSD.
It is often difficult to conclude whether suspected abuse has taken place. Medical findings are often unspecific, and, depending on the age of the child, there can be doubts about to what degree the child’s statements are valid. In this study, we chose a rather narrow definition. Therefore, only those cases with convincing medical findings, a convicted offender, or a confession would be coded as “confirmed.” Information about the status of the legal process was often lacking; this is due to the fact that legal processes may take years to conclude. However, most patients are not followed for years by the CAMU, and results would therefore not be provided in the victim’s medical file. Because many of the children had only limited contact with the unit and during a short time span, the registered percentage of cases in which an offender was convicted (5.7%) was probably underestimated.
It is not surprising that most of the cases that could be concluded were found among the oldest children. Younger children are less likely to verbalize their victimization. The older children were also more exposed to severe sexual abuse. In these cases, the chance of documenting confirmed medical findings is higher. The results in Table 5 show that, when abuse is confirmed, the offender is most often a relative other than a parent (e.g., sibling, uncle, aunt, cousin) or a friend or acquaintance. Victims of severe sexual abuse are more likely to seek help within the first 24 hours. This increases the chance of documenting substantial medical findings as well as the success of forensic sampling. These variables seem to reflect different aspects of the same patterns. Some of the huge challenges in this field are how to conclude cases in which young children and toddlers are exposed to abuse and in which no certain findings are documented.
Not all children will require specialized follow-up care after being referred to a CAMU. Therefore, it is satisfactory that four out of five children were referred to a health or social service provider after contact with the CAMU. Many of the children were referred to (or recommended referral to) more than one service; most commonly, this was a psychologist at the unit, CAMHS, or child protective service. We consider it a positive sign that so many children and their families have had further contact with health or social services after such a serious and potentially distressful experience as a referral to a CAMU can be. However, the number of children that are referred to (or recommended referral to) child protective services is only 38 out of 106, which is a surprisingly low figure. We found that, in 4.7% of cases, abuse was unlikely; thus, this study reveals that, in about 95% of cases, abuse is either confirmed or suspected. It is possible that a larger proportion of these children and their families could benefit from child protective services. Several of the children in the study were referred from police authorities, who represent a main collaborator for the CAMU and who also play an important role in following up with some of the children afterward. In this study, however, follow-up evaluation was registered only with regard to medical and social services.
The organization of CAMUs nationwide has been performed in different ways. The units are supposed to serve several functions, including advising the judiciary authorities and decreasing the health problems of the children. In what ways units of this kind should handle psychosocial problems has been questioned (28), and the unit in Trondheim is one of only a few that provide routine interdisciplinary assessment. Nevertheless, we observed through this study that psychosocial functioning was seldom documented in the patient record. Children in different age groups are at different levels with regard to their ability to describe their own problems and symptoms. Mental health providers will often have to rely on the interpretation of children’s behavior. A systematic approach would be helpful for identifying children who need more extensive help (29). There are several reliable and valid instruments that are already commonly used by the regional CAMHS that could easily be incorporated into daily practice. Such measures should not be too time consuming for the staff, and they should reflect different perspectives, such as the clinician’s evaluation and the parent report. Examples of such instruments are the CGAS, which measures psychosocial functioning, and the CBCL, which measures competence as well as emotional and behavioral problems.
The CAMU in Trondheim serves the population of middle Norway and is available to children in all age groups and of both sexes. It is challenging to meet children and parents in crisis and to decide who requires more extensive evaluation and mental health care. This case study reveals that psychosocial functioning is seldom documented and that psychological symptoms could be described in a more detailed and reliable manner. A systematic approach could be helpful for health care providers, and we suggest the implementation of valid and reliable instruments such as the CBCL and the CGAS. It is important to remember the documented negative long-term health effects of child abuse. In addition to sexual abuse, physical child abuse and emotional child abuse are important risk factors that seem to contribute substantially to the burden of health problems in the adult population. The observed skewness with regard to the cause of referral should therefore be discussed further. For now, there is a wider target group of children that could possibly profit from this unique interdisciplinary competence.
|2||Age||0 to 4, 5 to 9, 10 to 14|
|3||Number of siblings|
|4||Care situation||Both biological parents, single parent, foster care, and so on|
|6||Kind of familial disease|
|7||Biol. Parents drug abuse||Yes/no|
|8||Biol. Parents chronic somatic illness||Yes/no|
|9||Biol. Parents chronic psychiatric disease||Yes/no|
|10||Biol. Parents other health problem||Yes/no|
|11||Caregiver (if not biological parent) drug abuse||Yes/no|
|12||Caregiver chronic somatic illness||Yes/no|
|13||Caregiver chronic psychiatric disease||Yes/no|
|14||Caregiver other health problem||Yes/no|
|15||Parents in conflict with each other||Yes/no|
|16||Parents in conflict with others||Yes/no|
|17||Residence||City, village, district|
|Former disease/disability of the child:|
|22||Chronic somatic disease||Yes/no|
|23||Type of somatic disease|
|24||Chronic psychiatric disease||Yes/no|
|25||Type of psychiatric disease|
|27||Self-harm, suicidal behavior||Yes/no|
|35||Urinary tract infection or other symptoms||Yes/no|
|Later diagnosed disease/problems with possible relevance|
|41||Chronic somatic disease||Yes/no|
|42||Type of somatic disease|
|43||Chronic psychiatric disease||Yes/no|
|44||Type of psychiatric disease|
|46||Self-harm, suicidal behavior||Yes/no|
|54||Urinary tract infection or other symptoms||Yes/no|
|56||Former referred to community health service for psychiatric difficulties||Yes/no|
|57||Type of health service|
|58||Former referred to child and adolescent mental health service (CAMHS) or pediatric clinic for psychiatric difficulties||Yes/no|
|59||Type of health service|
|61||Type of medication|
|62||Who referred patient||Direct contact, police, general practitioner, school nurse, child protective service, CAMHS, and so on|
|Registered contacts in patient record system|
|64||Indirect contact (with other services)||Number|
|65||Direct contact with child present||Number|
|66||Direct contact without child present||Number|
|75||Non-judiciary actions (e.g., regulation of visitation)||Yes/no|
|76||Child protective actions||Yes/no|
|Characteristics of abuse|
|Relationship to suspected offender|
|91||Person of authority||Yes/no|
|94||Psychological reaction at first contact||None, moderate (e.g., anxious, sadness), severe (e.g., depression, despair, disorientation), not possible to evaluate|
|Severity of abuse|
|95||Severe physical violence (e.g., fractures, internal bleeding)||Yes/no|
|96||Moderate physical violence (e.g., bruises, wounds)||Yes/no|
|97||Severe sexual abuse (oral, vaginal, anal penetration, forced masturbation)||Yes/no|
|98||Moderate sexual abuse (e.g., touching/fondling of intimate area, showing pornography)||Yes/no|
|101||Threats from offender||Yes/no|
|102||Conclusion||Confirmed, uncertain/suspected abuse, disproved|
|103||Previous abuse (sexual, physical, psychological)||Yes/no|
|104||Time span since abuse at time of examination||<24 hours, 1 to 7 days, 1 to 4 weeks, 1 to 2 months, 3 to 6 months, >6 months, unknown|
|105||If repeated abuse, time since first event||<2 months, 2 to 6 months, 6 to 12 months, 1 to 2 years, 2 to 5 years, >5 years, unknown|
|Psychological symptoms reported by patient/caregiver or other|
|108||Tired/exhausted/lack of initiative||Yes/no|
|124||Other problems reported by patient||Yes/no|
|125||Other problems reported by caregiver||Yes/no|
|126||Other problems reported by others||Yes/no|
|127||If others, who|
|Psychiatric findings reported by doctor or psychologist:|
|Somatic and psychosomatic symptoms and findings|
|143||Other symptoms and findings from sexual organs or anal area||Yes/no|
|144||Other problems reported by patient||Yes/no|
|145||Other problems reported by caregiver||Yes/no|
|146||Other problems reported by others||Yes/no|
|147||If others, who|
|148||Physical findings documented in patient record||Yes/no|
|149||Light (superficial wounds, bruises)||Yes/no|
|150||Moderate (wounds, cuts)||Yes/no|
|151||Severe (fractures, internal bleeding)||Yes/no|
|152||Marks on neck/throat||Yes/no|
|153||Injuries in sexual area||Yes/no|
|154||Injuries in anal area||Yes/no|
|155||Sexually transmitted disease||Yes/no|
|158||Increased absence since time of abuse||Yes/no|
|161||Alcohol use||Never, mild (1 to 2 times), heavy (several times)|
|162||Drug abuse||Never, mild (cannabis), heavy|
|163||Referred to CAMHS||Yes/no|
|164||Pediatrician at children’s clinic||Yes/no|
|165||Psychologist at children’s clinic||Yes/no|
|166||Child protective service||Yes/no|
|167||Community health service||Yes/no|