● The child has bruises that resemble objects such as a hand, fist, belt buckle, or rope. ● The child has burns. ● The parent/caregiver offers conflicting, unconvincing, or no explanation for the child’s injury, or provides an explanation that is not consistent with the injury. ● The parent/caregiver describes the child as evil or in some other very negative way. ● The parent/caregiver uses harsh physical discipline with the child. ● The parent/caregiver has a history of abuse as a child. ● The parent/caregiver has a history of abusing animals or pets. Sexual abuse Sexual abuse is defined as “a type of maltreatment that refers to the involvement of the child in sexual activity to provide sexual gratification or financial benefit to the perpetrator, including contacts for sexual purposes, molestation, statutory rape, prostitution, pornography, exposure, incest, or other sexually exploitative activities” (USHHS, 2019). This definition includes situations in which a child engages in sexual activity for which they cannot give consent, is developmentally unprepared, is unable to comprehend, and violates the law or social taboos (Bechtel & Bennett, 2019a). It includes fondling and all forms of oral–genital, genital, and anal contact with the child (whether clothed or not), as well as nontouching abuses such as exhibitionism, voyeurism, and involving the child in pornography (Bechtel & Bennett, 2019a). In Pennsylvania, children younger than 13 years of age cannot give consent to sexual activity (Pennsylvania Coalition Against Rape [PCAR], 2021). Teenagers between the ages of 13 and 15 years cannot consent to sexual activity with anyone four years older than they are (PCAR, 2021). Individuals ages 16 years and older can legally consent to sexual activity with anyone they choose as long as it is not with an individual they know from school (teacher/coach), jail, personal care/group home, or other licensed residential facility serving youth (PCAR, 2021). Any of the following are offenses committed against a child (PCAR, 2021): ● Rape as defined in 18 Pa.C.S. § 3121. ● Statutory sexual assault as defined in 18 Pa.C.S. § 3122.1. ● Involuntary deviant sexual intercourse as defined in 18 Pa.C.S. § 3123. ● Sexual assault as defined in 18 Pa.C.S. § 3124.1. ● Institutional sexual assault as defined in 18 Pa.C.S. § 3124.2. ● Aggravated indecent assault as defined in 18 Pa.C.S. § 3125. ● Indecent assault as defined in 18 Pa.C.S. §3126. ● Indecent exposure as defined in 18 Pa.C.S. § 3127. ● Incest as defined in 18 Pa.C.S. § 4302. ● Prostitution as defined in 18 Pa.C.S. § 5902. ● Sexual abuse as defined in 18 Pa.C.S. § 6312. ● Unlawful contact with a minor as defined in 18 Pa.C.S. § 6318. ● Sexual exploitation as defined in 18 Pa.C.S. § 6320.
Evidence-based practice It is important for the nurse to not assume that the child is injury free just because the child does not cry or look upset. In a recent study of accidental fractures in children younger than six years of age, a notable minority of them with long-bone fractures did not cry or use their affected limb abnormally after injury (Christian & Committee on Child Abuse and Neglect, 2015). This caused some delay in seeking medical care (Christian & Committee on Child Abuse and Neglect, 2015). Healthcare consideration: When documenting an encounter with a child with suspected abuse, the nurse should remember that medical records and additional testing are important to assist CPS and police investigations (Christian & Committee on Child Abuse and Neglect, 2015). Self-Assessment Quiz Question #5 Based on the Child Protective Service Law definition, sexual abuse occurs in the case of consensual sexual contact between a 17-year-old male and a 14-year-old female.
a. True. b. False.
Signs of sexual abuse The following are possible signs and symptoms of sexual abuse that may be seen in a medical context, at school, or in a day care (Stop It Now! 2019): ● The child has nightmares or sleep problems. ● The child seems distant or distracted. ● The child has a change in eating habits, refuses to eat, or has trouble swallowing. ● The child has sudden mood swings. ● The child leaves clues that seem likely to provoke discussion about sexual issues. ● The child writes, draws, plays, or dreams of sexual or frightening images. ● The child develops new or unusual fear of certain people or places. ● The child refuses to talk about a shared secret with an adult or older child. ● The child talks about a new older friend. ● The child suddenly has money, toys, or gifts without reason. ● The child thinks of self or body as bad or dirty. ● The child exhibits sexual behaviors, language, or knowledge. Signs in younger children include: ● An older child behaving like a younger child, for example, thumb-sucking or bed-wetting. ● Having new words for genitals. ● Resisting removing clothes during toileting, bathing. ● Asking other children to behave sexually or play sexual games. ● Mimicking adult-like behaviors with toys. ● Wetting and soiling accidents. Signs in adolescents include: ● Self-injury.
● Poor personal hygiene. ● Drug and alcohol use. ● Sexual promiscuity. ● Truancy from home. ● Depression, anxiety.
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