Child and Adolescent Psychiatry

Maltreatment 223

of semen, venereal disease and pregnancy should be considered. Because
recovery from the physical sequelae can occur quickly, a negative physical
examination does not rule out the occurrence of sexual abuse. In one series
where the presence of penetrative abuse was well established, fewer than
40% of the children had physical signs.

Intervention

The management of established abuse is guided by three aims. The first
is to prevent further abuse. The second is to mitigate the effects of what
has already happened. The third is to meet the child’s emotional, social
and educational needs in the longer term, which may include deciding
whether it is best for the child to live in their own family, making special
educational provision and providing positive social experiences outside the
home. A wide range of methods may be used, according to the particular
circumstances of the case and resources of the agencies involved. For
example, the interventions in one particular case might include:

A court order forbidding access by the stepfather.

Training in parenting skills for the mother to help her manage her child’s

conduct problems.

Antidepressant therapy for the mother’s low mood.

Individual counselling sessions for the child.

Extra educational provision for the child’s learning problems.

An anti-bullying programme at school.

An application to rehouse the family in better conditions.

To achieve all this successfully requires good inter-agency liaison. Man-
agement of sexual abuse is guided by the same three aims:

1 There needs to be an assessment of the likelihood of re-abuse if the child
is to remain in, or be returned to, the family where it happened.
2 Prevention of further abuse may require the removal of the offender or
an enforceable system of protection.
3 The ability of the mother to accept what has happened and protect her
child is important, as is the ability of the perpetrator to acknowledge his
responsibility.
This is relevant for risk assessment, and to help the child begin to
reverse guilt and self-blame; it may pave the way for the perpetrator’s
eventual reintegration into the family. However, court orders may need to
be taken forbidding access if the child is believed to be at risk. Mitigation
of the effects of abuse is likely to be helped by skilled therapy. Enabling
the child to talk freely about sexual matters can allow them to go on
to confront the awful experiences within a safe setting, and so begin to
process them emotionally without dissociating and cutting off, or becom-
ing paralysed with fear and anxiety. A variety of psychotherapeutic and
cognitive-behavioural techniques may help in this task, and a number of