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Assessing child abuse in childhood condyloma acuminatum
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Assessing child abuse in childhood condyloma acuminatum Lawrence Schachner, M.D., and Dorie E. Hankin, M.D. Miami, FL Adults with condyloma acuminatum are considered to have a sexually transmitted disease. Childhood condyloma acuminatum may often, but not always, be a manifestation of sexual abuse. We provide a checklist of criteria for suspecting child abuse. We recommend that if clinicians find a " y e s " response on this checklist when caring for a child with condyloma acuminatum, consultation with local child protective services (CPS) be deemed mandatory. (J AM ACAD DERMATOL12:157-160, 1985.)
Condylomata acuminata of childhood have been well reported in the recent literature. 1-3 While all authors reiterate the need to consider sexual abuse in these children, no exacting criteria for these considerations are offered. Sexual abuse is reported in approximately 12% of all child abuse c a s e s , 3'4 with many child abuse experts feeling that this figure is modest. Recent reviews of condyloma acuminatum in childhood document that sexual encounters are responsible for at least 25% of cases in children 13 years of age or less. 2 Many of the remaining 75 % of childhood cases in these reviews did not have documentation of thorough investigation for possible sexual child abuse. Other possible mechanisms of transmission are neonatal contact during delivery and close nonsexual contacts in the family. At a recent meeting of the Society for Pediatric Dermatology, however, experts estimated that 40% to 80% of cases of childh o o d condyloma acuminatum resulted from noninnocent sexual encounters.
From the Departments of Pediatrics and Dermatology, University of Miami School of Medicine. Reprint requests to: Dr. Lawrence Schaehner, University of Miami School of Medicine, P.O. Box 016960 (D4-8), Miami, FL 33101/ 305-547-6742.
DISCUSSION Child abuse experts and the Centers for Disease Control define children with venereal disease as sexually abused until proved otherwise. While eondylomata acuminata are primarily sexually transmitted, 4.5 the literature also provides examples of presumed nonvenereal transmissions from common warts such as verruca vulgaris and inoculation during childbirth from an infected mother. 2,6 Children rarely admit to sexual activity with an adult. This is especially true when the adult is a family member. Incestual molestation can go on for years before being discovered. In all fifty states the law requires a professional to report suspected abuse. To help clinicians decide when abuse is likely, a set of subjective and objective criteria are provided (Table I). Criteria for suspecting child abuse can be divided into four main areas: physical findings, medical experience, behavioral abnormalities, and psychosocial conditions. Each of these areas has a number of subdivisions that appear in checklist form in Table I. We believe any " y e s " response to this checklist mandates a CPS consultation. The most definitive category to evaluate is that of physical findings. Bruises, bums, and other lesions, when present, are easily recognized. When they appear on unusual locations such as the back, 157
158
Journal of the American Academy of Dermatology
Schachner and Hankin
T a b l e I. Criteria for suspecting child abuse Yes
Physical findings: Are there: Fresh bruises? Unusual locations or shapes? Old scars? Unusual locations or shapes? Past or current bums? Unusual locations or slmpes? Signs of rectal, genital, or oral injury or infection? Medical experience: Is abuse or neglect suggested by: Current medical Pr9blems? Prior medical problems? Prior emergency visits---ingestions or trauma? ,Prior hospitalizations? Prior surgical interventions? Current or past venereal disease or pregnancy? Poor compliance with prior medical care or treatment? Incomplete !mmunizations for age? Poor mental or physical growth and development for age"? Behavioral abnormalities: Is there evidence of: Withdrawal or hyperactivity? Overcompliance with physical examination? "Compliant posturing"? Phobias? Sleeping problems? Recent onset of enuresis or encopresis? "Sexualized play,?" Excessive interest in genitalia? Psychosocial conditions: Is there evidence of: Disturbed parent-child interaction? Violent interaction between parents? .............. Violent interaction between siblings? Violent interaction with friends and relatives? Parents being a..bused as children? Parents being victims of sexual abuse? Extra stresses on the family? Marital discord? Unemployment? Alcoholism? Substance abuse? Recent death or illness in the family? Inappropriate custodial care of the child? Daytime? After school? Evening? Nights? Weekends? Inappropriate responsibilities for a child? Heavy chores such as cooking and housekeeping? Care of siblings? Family isolation? ........ Lack of telephone? Lack of. supportive relatives, friends, or neighbors to whom they can turn in a crisis situation? Previous referrals for abuse or neg.l.ect?
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Volume 12 Number 1, Part 1 January, 1985
ChiM abuse in childhood condyloma acuminatum
buttocks, or genitalia and when they are inadequately explained, they are most suspicious of child abuse. The presence of scars and/or multiple injuries of different ages are always suspicious of ongoing maltreatment. Loop marks, cigarette bums, bites, and other such lesions are characteristically associated with abuse. When looking for physical findings, it is important to examine the oral mucosa, genitalia, and rectum for symptoms of current or past infection or trauma. The absence of genital trauma does not exclude sexual abuse, which can involve fondling, masturbation, etc. Several recently published texts have in-depth information about the physical findings in child abuse. 7,8 The next category to evaluate is that of medical experience. Questions about existing or previous medical problems may elicit a history of multiple hospitalizations or emergency visits for trauma, which may indicate an abusive situation. A current or previous history of venereal disease or pregnancy should alert one to the possibility of sexual abuse. Medical neglect might be demonstrated by chronically poor compliance with therapy or lack of appropriate immunizations for age. Physical neglect may be documented by poor physical growth, as in the syndrome of nonorganic failure to thrive and/or delayed developmental milestones. Behavioral abnormalities that might alert the professional to abuse include excessive withdrawal, activity, and compliance. Some children in abusive families withdraw and demonstrate autistic-like behavior. Others crave attention and get it by unmoderated activity. Questions should be raised when a child is overly compliant with the physical examination, especially when it involves the genital area. Such behavior may indicate the child's familiarity with this type of touching. Similarly, "compliant posturing," a condition in which the child remains in any position requested, regardless of how uncomfortable, for prolonged periods of time should be regarded suspiciously. Observation of, or a history of "sexualized play" and/or age-inappropriate interest in genitals should suggest sexual abuse. Questions concerning phobias, sleeping problems, and recent onset of enuresis or encopresis also may uncover sexual abuse.
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The psychosocial conditions associated with child abuse are varied and cross both socioeconomic and ethnic lines. The physician should not dismiss the possibility of abuse because a child comes from a middle class family or has a parent who is a professional. Observation of the parentchild interaction in waiting and examining areas is important in assessing the potential for abuse or neglect. Items to consider about the parent-child interaction are: appropriate handling: is this child struck for minor things or held warmly? comforting: is this child kindly treated or comforted before, during, and after examination? and speaking: is this child constantly belittled or dismissed by the parent? Parental experience influences the parent-child interaction. Abusive parents often were abused as children. Mothers of incest victims may relate a history of forced premature sexual activity in their own past. Questions about living arrangements, child care, and the child's home responsibilities will provide insight into the parental attitude toward the child and the child's "role" in the family. Questions about the family interactions also may be helpful. Families prone to violence between adults frequently react violently toward their children. Marital discord, unemployment, alcoholism, substance abuse, and the recent death or illness of a family member will increase the stress on the family and may result in violence. Some families may have been referred previously for abuse or neglect. Local child protective agencies should respond to appropriate requests for information about past referrals. Lastly, a common characteristic of sexually abused families is their isolation from relatives, friends, and neighbors. These families tend to be insular, not have telephones, and are devoid of social organizational contact. CONCLUSION Over 1,000,000 children are victims of child abuse each year in the United States. Of these, over 100,000 are sexually abused. Condylomata acuminata have been recognized and reported with increased frequency as a childhood disease, transmissible by sexual abuse as well as nonsexual contact3 We present criteria for assessing child abuse in children with condyloma acuminatum. We rec-
160 Schachner and Hankin
ommend that a " y e s " answer to a checklist of subjective and objective criteria of child abuse should mandate a report to child protective services (CPS) in children with condyloma acuminatum. A totally negative checklist does not restrict the clinician from reporting those children with condyloma acuminatum who still invoke a high index of suspicion vis-t~-vis the clinician's acumen and experience. Furthermore, the clinician should also consider and evaluate the possibility of other venereal infections concurrent with condyloma acuminatum. REFERENCES
Journal of the American Academy of Dermatology
2. De Jong AR, Weiss JC, Brent RL: Condyloma acuminata in children. Am J Dis Child 136:704-706, 1982. 3. McCoy CR, Applebaum H, Besser AS: Condyloma acuminata: An unusual presentation of child abuse. J Pediatr Surg 17:505-507, 1982. 4. Greenberg NH: The epidemiology of childhood sexual abuse. Pediatr Ann g:289-299, 1979. 5. Felman YM, Nikitas JA: Condyloma acuminata. NY State J Med 79:1747-1749, 1979. 6. Oriel JD: Genital warts. SexTransm Dis 4:153-159, 1977. 7. KempeCH, HelferRE:ThebatteredchiId. Chicago, 1974, University of Chicago Press, pp. 128-271. 8. Ellerstein NS: Child abuse and neglect. A medical reference. New York, 1981, John Wiley & Sons, Inc., pp.73306. 9. American Academy of Dermatology Task Force on Pediatric Dermatology: Genital warts and sexual abuse in children. J Art ACADD~RMATOL11:529-530, 1984.
1. Seidel J, Zonana J, "rotten E: Condyloma acuminata as a sign of sexual abuse in children. J Pediatr 95:553-554, 1979.
BOUND VOLUMES AVAILABLETO SUBSCRIBERS Bound volumesof the JOURNALOFTHEAMERICANACADEbIYOFDERMATOLOGYarc availableto subscribers(only) for the 1985 issues from the Publisherat a cost of $56.20 ($68,60 international)for volume 12 (January-June)and volume 13 (July-December).Shi1~p~g charges are included.Each boundvolumecontainsa subjectand authorindexand all advertisingis removed. Copies are shipped within30 days after publicationof the last issue in the volume.The bindingis durable buckramwith the journal name, volume number, and year stamped in goldon the spine.Payment must accompany all orders. ContactThe C. V. MosbyCompar,y, CirculationI~partment, 11830 Westline hduslrial Drive, St. Louis, Missouri63146, USA;phone (800) 325-.4177, ext. 351. Subscriptions must be in force to qualifi.'. Bound volumes are not available in place of a regular journal subscription,
III
I
I
I
1
I
I1
II IIII
Assessing child abuse in childhood condyloma acuminatum Lawrence Schachner, M.D., and Dorie E. Hankin, M.D. Miami, FL Adults with condyloma acuminatum are considered to have a sexually transmitted disease. Childhood condyloma acuminatum may often, but not always, be a manifestation of sexual abuse. We provide a checklist of criteria for suspecting child abuse. We recommend that if clinicians find a " y e s " response on this checklist when caring for a child with condyloma acuminatum, consultation with local child protective services (CPS) be deemed mandatory. (J AM ACAD DERMATOL12:157-160, 1985.)
Condylomata acuminata of childhood have been well reported in the recent literature. 1-3 While all authors reiterate the need to consider sexual abuse in these children, no exacting criteria for these considerations are offered. Sexual abuse is reported in approximately 12% of all child abuse c a s e s , 3'4 with many child abuse experts feeling that this figure is modest. Recent reviews of condyloma acuminatum in childhood document that sexual encounters are responsible for at least 25% of cases in children 13 years of age or less. 2 Many of the remaining 75 % of childhood cases in these reviews did not have documentation of thorough investigation for possible sexual child abuse. Other possible mechanisms of transmission are neonatal contact during delivery and close nonsexual contacts in the family. At a recent meeting of the Society for Pediatric Dermatology, however, experts estimated that 40% to 80% of cases of childh o o d condyloma acuminatum resulted from noninnocent sexual encounters.
From the Departments of Pediatrics and Dermatology, University of Miami School of Medicine. Reprint requests to: Dr. Lawrence Schaehner, University of Miami School of Medicine, P.O. Box 016960 (D4-8), Miami, FL 33101/ 305-547-6742.
DISCUSSION Child abuse experts and the Centers for Disease Control define children with venereal disease as sexually abused until proved otherwise. While eondylomata acuminata are primarily sexually transmitted, 4.5 the literature also provides examples of presumed nonvenereal transmissions from common warts such as verruca vulgaris and inoculation during childbirth from an infected mother. 2,6 Children rarely admit to sexual activity with an adult. This is especially true when the adult is a family member. Incestual molestation can go on for years before being discovered. In all fifty states the law requires a professional to report suspected abuse. To help clinicians decide when abuse is likely, a set of subjective and objective criteria are provided (Table I). Criteria for suspecting child abuse can be divided into four main areas: physical findings, medical experience, behavioral abnormalities, and psychosocial conditions. Each of these areas has a number of subdivisions that appear in checklist form in Table I. We believe any " y e s " response to this checklist mandates a CPS consultation. The most definitive category to evaluate is that of physical findings. Bruises, bums, and other lesions, when present, are easily recognized. When they appear on unusual locations such as the back, 157
158
Journal of the American Academy of Dermatology
Schachner and Hankin
T a b l e I. Criteria for suspecting child abuse Yes
Physical findings: Are there: Fresh bruises? Unusual locations or shapes? Old scars? Unusual locations or shapes? Past or current bums? Unusual locations or slmpes? Signs of rectal, genital, or oral injury or infection? Medical experience: Is abuse or neglect suggested by: Current medical Pr9blems? Prior medical problems? Prior emergency visits---ingestions or trauma? ,Prior hospitalizations? Prior surgical interventions? Current or past venereal disease or pregnancy? Poor compliance with prior medical care or treatment? Incomplete !mmunizations for age? Poor mental or physical growth and development for age"? Behavioral abnormalities: Is there evidence of: Withdrawal or hyperactivity? Overcompliance with physical examination? "Compliant posturing"? Phobias? Sleeping problems? Recent onset of enuresis or encopresis? "Sexualized play,?" Excessive interest in genitalia? Psychosocial conditions: Is there evidence of: Disturbed parent-child interaction? Violent interaction between parents? .............. Violent interaction between siblings? Violent interaction with friends and relatives? Parents being a..bused as children? Parents being victims of sexual abuse? Extra stresses on the family? Marital discord? Unemployment? Alcoholism? Substance abuse? Recent death or illness in the family? Inappropriate custodial care of the child? Daytime? After school? Evening? Nights? Weekends? Inappropriate responsibilities for a child? Heavy chores such as cooking and housekeeping? Care of siblings? Family isolation? ........ Lack of telephone? Lack of. supportive relatives, friends, or neighbors to whom they can turn in a crisis situation? Previous referrals for abuse or neg.l.ect?
No
Volume 12 Number 1, Part 1 January, 1985
ChiM abuse in childhood condyloma acuminatum
buttocks, or genitalia and when they are inadequately explained, they are most suspicious of child abuse. The presence of scars and/or multiple injuries of different ages are always suspicious of ongoing maltreatment. Loop marks, cigarette bums, bites, and other such lesions are characteristically associated with abuse. When looking for physical findings, it is important to examine the oral mucosa, genitalia, and rectum for symptoms of current or past infection or trauma. The absence of genital trauma does not exclude sexual abuse, which can involve fondling, masturbation, etc. Several recently published texts have in-depth information about the physical findings in child abuse. 7,8 The next category to evaluate is that of medical experience. Questions about existing or previous medical problems may elicit a history of multiple hospitalizations or emergency visits for trauma, which may indicate an abusive situation. A current or previous history of venereal disease or pregnancy should alert one to the possibility of sexual abuse. Medical neglect might be demonstrated by chronically poor compliance with therapy or lack of appropriate immunizations for age. Physical neglect may be documented by poor physical growth, as in the syndrome of nonorganic failure to thrive and/or delayed developmental milestones. Behavioral abnormalities that might alert the professional to abuse include excessive withdrawal, activity, and compliance. Some children in abusive families withdraw and demonstrate autistic-like behavior. Others crave attention and get it by unmoderated activity. Questions should be raised when a child is overly compliant with the physical examination, especially when it involves the genital area. Such behavior may indicate the child's familiarity with this type of touching. Similarly, "compliant posturing," a condition in which the child remains in any position requested, regardless of how uncomfortable, for prolonged periods of time should be regarded suspiciously. Observation of, or a history of "sexualized play" and/or age-inappropriate interest in genitals should suggest sexual abuse. Questions concerning phobias, sleeping problems, and recent onset of enuresis or encopresis also may uncover sexual abuse.
159
The psychosocial conditions associated with child abuse are varied and cross both socioeconomic and ethnic lines. The physician should not dismiss the possibility of abuse because a child comes from a middle class family or has a parent who is a professional. Observation of the parentchild interaction in waiting and examining areas is important in assessing the potential for abuse or neglect. Items to consider about the parent-child interaction are: appropriate handling: is this child struck for minor things or held warmly? comforting: is this child kindly treated or comforted before, during, and after examination? and speaking: is this child constantly belittled or dismissed by the parent? Parental experience influences the parent-child interaction. Abusive parents often were abused as children. Mothers of incest victims may relate a history of forced premature sexual activity in their own past. Questions about living arrangements, child care, and the child's home responsibilities will provide insight into the parental attitude toward the child and the child's "role" in the family. Questions about the family interactions also may be helpful. Families prone to violence between adults frequently react violently toward their children. Marital discord, unemployment, alcoholism, substance abuse, and the recent death or illness of a family member will increase the stress on the family and may result in violence. Some families may have been referred previously for abuse or neglect. Local child protective agencies should respond to appropriate requests for information about past referrals. Lastly, a common characteristic of sexually abused families is their isolation from relatives, friends, and neighbors. These families tend to be insular, not have telephones, and are devoid of social organizational contact. CONCLUSION Over 1,000,000 children are victims of child abuse each year in the United States. Of these, over 100,000 are sexually abused. Condylomata acuminata have been recognized and reported with increased frequency as a childhood disease, transmissible by sexual abuse as well as nonsexual contact3 We present criteria for assessing child abuse in children with condyloma acuminatum. We rec-
160 Schachner and Hankin
ommend that a " y e s " answer to a checklist of subjective and objective criteria of child abuse should mandate a report to child protective services (CPS) in children with condyloma acuminatum. A totally negative checklist does not restrict the clinician from reporting those children with condyloma acuminatum who still invoke a high index of suspicion vis-t~-vis the clinician's acumen and experience. Furthermore, the clinician should also consider and evaluate the possibility of other venereal infections concurrent with condyloma acuminatum. REFERENCES
Journal of the American Academy of Dermatology
2. De Jong AR, Weiss JC, Brent RL: Condyloma acuminata in children. Am J Dis Child 136:704-706, 1982. 3. McCoy CR, Applebaum H, Besser AS: Condyloma acuminata: An unusual presentation of child abuse. J Pediatr Surg 17:505-507, 1982. 4. Greenberg NH: The epidemiology of childhood sexual abuse. Pediatr Ann g:289-299, 1979. 5. Felman YM, Nikitas JA: Condyloma acuminata. NY State J Med 79:1747-1749, 1979. 6. Oriel JD: Genital warts. SexTransm Dis 4:153-159, 1977. 7. KempeCH, HelferRE:ThebatteredchiId. Chicago, 1974, University of Chicago Press, pp. 128-271. 8. Ellerstein NS: Child abuse and neglect. A medical reference. New York, 1981, John Wiley & Sons, Inc., pp.73306. 9. American Academy of Dermatology Task Force on Pediatric Dermatology: Genital warts and sexual abuse in children. J Art ACADD~RMATOL11:529-530, 1984.
1. Seidel J, Zonana J, "rotten E: Condyloma acuminata as a sign of sexual abuse in children. J Pediatr 95:553-554, 1979.
BOUND VOLUMES AVAILABLETO SUBSCRIBERS Bound volumesof the JOURNALOFTHEAMERICANACADEbIYOFDERMATOLOGYarc availableto subscribers(only) for the 1985 issues from the Publisherat a cost of $56.20 ($68,60 international)for volume 12 (January-June)and volume 13 (July-December).Shi1~p~g charges are included.Each boundvolumecontainsa subjectand authorindexand all advertisingis removed. Copies are shipped within30 days after publicationof the last issue in the volume.The bindingis durable buckramwith the journal name, volume number, and year stamped in goldon the spine.Payment must accompany all orders. ContactThe C. V. MosbyCompar,y, CirculationI~partment, 11830 Westline hduslrial Drive, St. Louis, Missouri63146, USA;phone (800) 325-.4177, ext. 351. Subscriptions must be in force to qualifi.'. Bound volumes are not available in place of a regular journal subscription,