Detection and awareness of child sexual abuse in adult psychiatry

We investigated the detection and awareness of child sexual abuse by examining case notes. Child sexual abuse was recorded in 4.7% of cases. There was no evidence that enquiry about child sexual abuse or detection of the problem had increased in recent years, and recording of the details of abuse was rare. Victims received more psychological help and less medication than others. We conclude that awareness of the issue has not increased. Previous findings about child sexual abuse are rarely used in evaluation, and diagnosis and drug treatment may be overlooked in some victims.

Child sexual abuse is an important issue in psychiatry. It is associated with later psychiatric illness such as depression, drug misuse and eating disorders, and this association seems greatest when the abuse was penetrative or perpetrated by a relative (Mullen et al, 1988(Mullen et al, , 1993Beitchman et al 1992). It has been reported in at least a significant minority of subjects in various populations, and recent more rigorous studies have found that approximately 10% of individuals (17% of women) in the community were sexually abused in childhood (Fergusson et al 1996). There is also some evidence that diagnosis of such abuse is increas ing (Hobbs & Wynne, 1987).
There has been both exceptional and increas ing public and media interest in child sexual abuse in recent years. However, there is little information about the detection and manage ment of child sexual abuse by psychiatrists and about the impact of public concern and media headlines on clinical work. While most members of the psychiatric team work with abused patients, supervision and training appear to be inadequate (MacPherson & Babiker, 1994), and child sexual abuse is often either undetected or not considered in treatment (Jacobson & Herald, 1990).
We aimed to determine the recorded frequency of both enquiry into and detection of child sexual abuse. We also aimed to determine whether either enquiry or detection had increased with time. We further investigated psychiatrists' awareness of child sexual abuse by finding the frequency of any reference to the details of abuse. and by comparing the management strategies between abused and other patients.

The study
We randomly selected case notes of 680 female patients aged from 16 to 65 years who had presented to a psychiatric unit in north London between 1976 and 1995. Notes of men and older women were replaced and the next selection taken. We recorded details on a structured proforma after reading all entries for the first year of treatment.
We used the SPSS computer program to analyse data and all cases were included in the analysis. The year of presentation was compared between abused cases and the rest using the Mann-Whitney (/-test. This was repeated for recorded enquiry into child sexual abuse. We examined any trend in the frequency of each treatment modality across three groups using the Mantel-Haenszel test. These groups were (a) known victims of child sexual abuse, (b)recorded negative history of child sexual abuse and (c) unknown (that is no reference to child sexual abuse) in the notes. This was repeated for each agency seen, treatment setting and the assign ment of a diagnosis.

Findings
A history of child sexual abuse was recorded in 4.7% (32/680) of cases. There was no difference in year of presentation between known victims and the rest of the sample (Mann-Whitney U P=0.5), and not one record of the nature of abuse was found. Some reference to the identity of the abuser was recorded in 10/32 cases.
Only 17% (121/680) of cases had any refer ence to enquiry about child sexual abuse in their notes of whom 26% (32/121) had been abused. Once more there was no difference in the year of presentation between these cases and the rest of the sample (Mann-Whitney UP=0.4).
We found trends in management. Victims of child sexual abuse were least likely to be prescribed drugs (Mantel-Haenszel P<0.05), to be assigned a diagnosis (P<0.01), and to have Psychiatric Bulletin(1998), 22, 211-213 been an in-patient (P=0.05). There were no trends in the use of any other treatments or services.

Comment
There are problems with the study as it is retrospective and uses case note data. Our results are still important, however, as we are interested in practice and change rather than absolute values alone. It is likely that any recent change in note keeping has either affected different issues uniformly, or has favoured the recording of child sexual abuse due to public and media interest.
Detection of child sexual abuse in 4.7% of this clinical sample is lower than previous estimates. Cases are likely to have been missed therefore, as reported previously (Jacobson & Herald, 1990). Despite this a significant minority of female patients are known by their psychiatrists to have been abused.
Neither enquiry about child sexual abuse nor detection of abuse was more likely in recent years. Medical practice in relation to the problem is thus unlikely to have improved. We suggest that awareness of the issue has not increased despite both research findings and media pub licity, and that child sexual abuse is actively considered in only a minority (17%) of female patients. It should be remembered that there were only 32 cases of child sexual abuse when interpreting the results.
Unfortunately, the results also suggest that clinicians either lack detailed knowledge about child sexual abuse or fail to apply it in practice. For Instance the nature of abuse was never recorded and the identity of the abuser was known in less than one-third of victims, despite the associations of these variables with psychi atric morbidity (Mullen et al, 1988). This is consistent with the finding that child sexual abuse is considered rarely in treatment (Jacobson & Herald, 1990) and with the reported inadequacy of training and supervision (Mac-Pherson & Babiker, 1994). It is also possible that a more 'medical' approach including formal diagnosis and drug treatment was neglected in some victims of child sexual abuse as both were least likely in abused patients.
It is important to note that known victims of child sexual abuse were most likely to receive psychological intervention. This may be appro priate and the few guidelines on management have highlighted psychological help. They have also stressed the intense transference, plus the demands and complexity of the work (Babiker, 1993), emphasising the need for adequate supervision.
We propose that the perceived relevance of child sexual abuse helps to determine clinical approach. The management trends show that psychological help was more frequent, and both drug treatment and assignment of a diagnosis less frequent when child sexual abuse was denied than not considered at all. It is likely that both psychological help and enquiry about child sexual abuse seem appropriate to the psychi atrist in some cases because of assumptions about a case or factors such as type of presen tation or symptoms. It is also likely that consideration of child sexual abuse is in part opportunistic as enquiry about the problem and detection of child sexual abuse were more likely if the patient had been admitted.

Conclusion
A significant minority of women in contact with psychiatric services have suffered child sexual abuse although there is no evidence that aware ness of the issue among psychiatrists has increased. The clinical approach to child sexual abuse is influenced by assumptions about a case and opportunities for history taking, and it is likely that many cases are missed. It is also likely that drug treatments and diagnosis are over looked in some victims although they may receive appropriate psychological help. There is little evidence that clinicians use the available facts about child sexual abuse while assessing patients.
These findings raise important issues about training, supervision and the standardisation of assessment.
We recommend routine enquiry about child sexual abuse in order to increase detection, and attention to the details of abuse as an indicator of severity.