Maltreatment 221confusion and anxiety about their sexual identity. The proportion who
go on to be sexually abusive of others is uncertain, but it is clear that a
significant minority do.
Factors affecting the impact of sexual abuse include:
How much coercion and violence were used.
The duration of the abuse.
The nature and severity of the abuse, including whether penetration
occurred.
The relationship with the perpetrator, with abuse by a trusted figure
such as a father being particularly disturbing.
Subsequent events, such as being taken away from the family home to
a disruptive residential setting.
Another factor exacerbating the effect of sexual abuse is disbelief by the
parent, typically the mother. Around a third of seriously abused girls are
not supported by their own mothers, who may deny the abuse ever took
place (despite clear evidence to the contrary) and elect to stay with the
perpetrators, so rejecting their daughters. Studies of the impact of sexual
abuse according to the age at which it occurs do not show any clear period
when it is less damaging.
Assessment
The overriding principle in suspected child abuse is to get help. Notifying
someone of concerns about children being abused is everyone’s business –
not just child professionals. In England there is a legal duty to do this,
so that, for example, one cannot decide to ignore worrying suspicions of
abuse if, say, one is a researcher who sees it happening in a family during
a home visit. If suspected in clinical practice, a senior colleague should
be informed as soon as possible, and the local social services department
consulted. Physical abuse is often picked up initially by paediatricians,
and managed in conjunction with social services. Child mental health
professionals, however, may see injuries or detect other forms of abuse
or neglect while seeing a child for a behavioural or emotional problem.
If court proceedings are being contemplated, child mental health profes-
sionals may be asked whether significant harm has occurred to the child,
what the prospects are for improvement in parenting style and whether
the child should be removed from the family.
A thorough general assessment is very useful because less obvious
aspects can be overlooked by an exclusive focus on the circumstances
of abuse. It is especially important to see all members of a household,
whether or not they are blood relatives, including step-parents, lodgers,
etc. External reports are essential. GP and health visitor records provide
information on regularity of attendance, previous injuries in the index
child and other family members, and parental health and behaviour (hav-
ing obtained parental permission). School reports are equally important.
The assessment should cover all the factors depicted in Table 27.1, as