Results

A total of 105 school health and 95 hospital records were found for the abuse group. Some record was found for 140 of 148 abused children; no record was found for eight. Review of the 1990 analysis of these eight cases revealed no pattern of factors common to the group. For the control group, SHR records were available for 83 of 83; hospital records were not sought. Seventy two per cent of the abused and 74% of the control children were female. Mean age for both groups was 12 years (range 8–15 years). The diagnosis was “definite” for 83 (59%) of the 140 children in the abuse group.

Table 1 shows the proportion of each group for whom information was found in the SHR record that related to selected characteristics. There were significantly more changes in the lives of the abused. These included surname change, and more changes in living address and school attended. Further abuse was documented for 35% of the abused (from SHR) compared with 0% for the controls. For the 140 in the abuse group, the HR and/or SHR indicated further abuse of 53 (38%). The types of abuse were sexual in 43 (with additional physical or emotional abuse or neglect for 13) and physical, emotional, or neglect in 10. Of the 56 identified perpetrators, 73% were male, 64% were family members, and 14% were members of foster families.

A wide variety of adverse behaviours were recorded with substantially increased frequency for the abused as compared to controls (60%v 16%). The difference was greater for the more serious behaviours that involved aggression (22%v 1%) and sexualised behaviour (19%v 1%).

Educational problems were found much more frequently in the records of the abused compared with the controls (24%v 5%). Sixteen per cent of the abuse group had a Statement of Special Educational Needv 1% of controls. The current figure for schoolchildren in the local population is around 3%.

Chronic health problems were generally more common in the abuse group. However, significant differences were found in the types of problems. For example, asthma was noted in the records of 7% of both abused and controls. Genitourinary complaints (for example, vaginitis, vaginal discharge, genital sores, and dysuria) however were noted for 10% of the abused and none of the controls. Obesity and failure to thrive were more frequently mentioned in the records of the abuse group, as were wetting (20% v 6%) and soiling problems (10% v 1%). The differences in genitourinary signs and symptoms may be spurious because of the likelihood of a greater attention to these matters for the abuse group.

Thirty two per cent of the abused were referred to mental health services compared to only one of the controls. This usually meant referral to a child and adolescent psychiatrist or a clinical psychologist or to teams under their supervision. It was generally not possible to know to what extent these referrals were acted on.

The frequencies of behavioural and educational problems noted for a variety of subsets of the abuse group were compared with the group as a whole. There were significantly more of these problems among children who were removed from their home; who suffered further abuse after initial detection in 1989; and whose further abuser was a parent figure (table 2). No significant differences were found for the following subsets: those whose 1989 diagnosis was “definite” as opposed to “probable”; those categorised in 1990 as having suffered “penetrative” abuse; and those for whom there had been a case conference before the 1990 record review. Children who at the 1990 review had received mental health services were not significantly different from the group as a whole except that more (35%v 17%, p = 0.02) had a statement of special educational need.

It is interesting to note that the frequencies of problems discovered by review of the SHR were essentially unchanged by the addition of HR. This reflects the two way exchange of information between school and hospital doctors and the inclusion of the school health service as a recipient of child protection information.

Discussion

The identification of children who have been abused and later access to them for follow up information is especially difficult for a variety of reasons. The many professionals (for example, health and medical care providers, social workers, police, and lawyers) who become involved may reach conflicting conclusions as to whether abuse has occurred. Moreover, the child's family will have their own views. All this presents difficulties for accessing follow up information. Child sexual abuse is often considered to be a highly unpleasant and threatening matter whose certainty may be denied by the family and also by authority. Health professionals may be able to enlist the cooperation of the family because their relationship may be perceived to be less threatening when compared to social workers or police officers. They may also be free of many of the constraints that restrict other professionals. For example law enforcement has a need for evidence enabling criminal prosecution, and Social Services need to conclude ongoing risk of abuse or neglect to remain involved. It is hoped that as child abuse becomes increasingly recognised as a major threat to health, that health professionals will apply tried and true tenets of public health and medical practice to implement case finding, intervention, and prevention of this disease.

This is one of only a few follow up studies whose subjects are identified at the outset by paediatricians. Our results are in agreement with other studies that major problems arise in the years following sexual abuse. Moreover, all studies in the burgeoning literature agree that abuse may adversely affect the individual's health over a long period of time. What is less clear are the relative contributions of the abuse itself and the frequently associated family dysfunction. This study does not contribute to the answer to this question. Our main point is that the diagnosis of sexual abuse simply marks the child as likely to have significant problems in the future; we do not assert that the cause of these problems is solely that of the abuse.

We recognise a possible confounder in that our control group, although classmates of the abused children, were not matched for socioeconomic status.

The study showed that the SHR clearly documents the striking chronicle of serious, multifaceted morbidity, affecting children identified by a single medical diagnosis. The challenge now is how to intervene more effectively than in the past. How can health professionals work with others including social services, police, and legal agencies to improve the outlook for this group of children? Evidence is emerging, in support of common sense, that the key person for future healing and wellbeing of the abused child is an able and enabled, committed, non-offending caretaker, that is a mother and/or father figure.11 ,12 A greater effort to identify and support this person is a place to start.