216 Chapter 27
parent or another trusted adult; telephone helplines are increasingly used
too. Changes in behaviour are common. While precocious sexualised
behaviour should clearly raise the suspicion of abuse, more non-specific
changes occur frequently, such as sullenness and withdrawal, increased
irritability and aggressiveness for no obvious reason, declining school
performance and loss of friends. Older children and adolescents may take
overdoses, run away from home, or abuse other children. There may be
presentations directly related to penetrative acts: anal or vaginal bleeding
or infections, urinary tract infections, enuresis or faecal soiling, venereal
disease or pregnancy.
Risk factors for maltreatment
With physical and emotional abuse, there is no single risk factor that
predisposes a carer to abuse a child, but rather a range of influences that
make abuse more likely. Broadly, they can be divided into the following:
1 Poor parenting skills with deficient moment-to-moment interaction
patterns; this is the final common pathway through which abuse is
transmitted.
2 Stressful circumstances.
3 Child characteristics.
4 Weak parental attachment to the child.
These well-established risk factors are summarised in Table 27.1.
With sexual abuse, perpetrators are most commonly men, although
around 10% of sexual abuse is committed by women, who may be co-
abusers with men, sometimes acting under duress. The proportion where
the perpetrator is a family member varies according to the study from
around one-third to two-thirds. Within the home, fathers are the com-
monest perpetrators, accounting for around half of clinically seen cases.
Stepfathers are disproportionately commonly involved, accounting for
around a quarter of clinical cases. Girls living in a home with a stepfather
are around six times more likely to be sexually abused than girls living
with both biological parents. When sexual abuse does occur outside the
home, the perpetrator is, nonetheless, still usually known to the child and
has been trusted to be left alone with him or her, for example, a neighbour,
friend of the family, friend of the child, teacher, babysitter, club leader, etc.
Abuse by strangers is relatively uncommon, accounting for around 5–10%
of all abuse. Sex rings are being increasingly recognised. The term refers
to a group of adults who are abusing several children. Initially, they often
bribe the children to become involved, but then go on to blackmail them
and may use them to make pornographic videos or involve them in child
prostitution. The prevalence is unknown, but one survey over two years,
of an English city of three-quarters of a million inhabitants, uncovered
31 child sex rings involving 47 male perpetrators and 334 children ranging
from 4–15 years old; 90% of victims were girls; two-thirds had been forced
to perform oral intercourse, one-third anal or vaginal intercourse.