Performance indicators and child sexual abuse

In Spring 1987, when the issues leading to the Cleve land Inquiry meant an increased number of second opinions were being requested of our University child psychiatry department, all staff of the depart ment were asked to record the number of children they had seen in whom child sexual abuse was sus pected or validated. Staff were asked to distinguish between new and old cases. New cases were children coming to our department for the first time within the period studied where a suspicion of child sexual abuse was being investigated. Old cases were children attending for ongoing therapy following investi gation of suspected sexual abuse, or cases where the possibility of sexual abuse was picked up coincidentally during treatment of other conditions. On an independent dimension, a distinction was made between cases where sexual abuse was suspected and those where suspicions were considered to be vali dated after assessment based on a review of all avail able information. ("Validation involves assessing as many of the ... features [the child's statement, sup


The study
In Spring 1987, when the issues leading to the Cleve land Inquiry meant an increased number of second opinions were being requested of our University child psychiatry department, all staff of the depart ment were asked to record the number of children they had seen in whom child sexual abuse was sus pected or validated. Staff were asked to distinguish between new and old cases. New cases were children coming to our department for the first time within the period studied where a suspicion of child sexual abuse was being investigated. Old cases were children attending for ongoing therapy following investi gation of suspected sexual abuse, or cases where the possibility of sexual abuse was picked up coincidentally during treatment of other conditions. On an independent dimension, a distinction was made between cases where sexual abuse was suspected and those where suspicions were considered to be vali dated after assessment based on a review of all avail able information. ("Validation involves assessing as many of the ... features [the child's statement, sup porting features, physical and physiological evi dence] as possible, in any single case, weighting the relative weight of the individual elements". Jones & McQuiston, 1988).
The evaluative psychiatric assessment followed recommended guidelines and is a detailed and timeconsuming exercise (Kelvin et al, 1988). Staff were asked to estimate the time spent seeing such cases within any four working weeks in a ten week period.

Findings
Over this period the total number of child sexual abuse cases was 66, of which 30 children were new cases. We would suspect that this represented a mini mum number of cases seen over the full ten week period in whom there were suspicions of child sexual abuse.
This child psychiatry department has a district catchment area as well as regional commitments. Table I indicates that only 24 (36%) of the children came from outside Newcastle but the percentages differed according to whether they were old or new cases, i.e. the majority of old cases (80%) came from Newcastle and the majority of new cases (57%) were from outside the Newcastle district. The number of validated cases of sexual abuse from Newcastle seen in the study period is deceptively high because it includes children with long-standing difficulties who continued to attend long-term. The new cases referred from outside the district were invariably very complex cases referred for second opinion.
Of the children seen, 30% were male and 70% female. Over 40% of our sample were in the pre school/infant school age range and 30% fell into the adolescent age group. We note that just over 10%   were under the age of five years. Fewer of the validated cases were under eight years of age (33%) compared with those who were merely suspected (47%). This may be an indicator of the problems in identifying sexual abuse in younger children.
The distribution of the referral sources is interest ing. The highest percentage (30%) of cases came from statutory and voluntary social services agen cies, but even this is an underestimate as some of those designated 'legal' had been initiated by legal departments acting for social services. One in five cases came from consultants working in paediatrics or child psychiatry who had requested second opinions. One in four of the cases were referred by general practitioners, though these were mostly cases referred for other conditions where the question of sexual abuse had been raised subsequently. Finally, one in ten of the children were referred from educational sources, including educational psychol ogists, school doctors and school nurses. A distinc tion needs to be made between the old and new cases with a heavy preponderance (60%) of new cases coming from social service agencies and legal sources.
An attempt was made to estimate the amount of time spent by medical and other professionals in relation to the 66 cases. At this time our assessment philosophy was for initial assessment to be made by medical staff before asking other disciplines to become involved. An average of 2.8 hours was spent by medical staff and in total just under four hours was spent on each case. This is an underestimate of the time spent on individual cases and staff com mented that this was due to the great number of chil dren being seen at the time of the study. The pressure of referrals was such that professionals were unable to complete individual assessments within four weeks and the same children were seen for further time beyond that recorded.
An alternative way of examining performance indicators is to look at the number of hours spent per family rather than per child. Two hundred and sixty hours were spent with 54 families averaging 4.8 hours per family. The seven families where more than one child was seen accounted for 19out of the 66 children and they took up a total of 52.5 hours of professional time, i.e. mean 7.5 hours, range 3-12 hours per fam ily. For the same reasons, this is also felt to be an underestimate of the actual time spent seeing families in which there are suspicions of child sexual abuse.

Comment
It is evident that much time is spent on cases of child sexual abuse; our data suggest a minimum of 184 hours of patient/family contact time by medical staff over a period of ten weeks, most of which is for assessment purposes. A single professional confining him/herself to child sexual abuse cases would take about five weeks to complete this work. Alterna tively, one senior member of medical staff working part-time would need to spend a minimum of five medical sessions per week for about ten weeks merely on clinical contact time. We have not attempted to assess the implications for non medical disciplines.
Our departmental policy is to do a careful and detailed evaluative psychiatric assessment and to work in the context of a multidisciplinary approach, in accordance with published guidelines (Kolvin et al. 1988 andButler Sloss, 1988). However, the amount of time recorded above was that spent on direct contact with children and families and excludes preliminary discussions with referral agencies, preparation of reports, attendance at Social Services case conferences or court appearances. Inevitably, because of medico-legal implications, preparation of these reports takes longer than rou tine reports and is often undertaken outside normal working hours. As most cases are second opinions, Court appearance is commonly necessary, with at least one whole day needing to be set aside. Fortu nately, because of the high profile of the University Department, the Courts courteously set times for appearance, but we are aware that this does not always occur. Hence patient contact time constitutes only a fraction of the clinician's total involvement in a case. If, as our data suggest, medical patient contact time is on average about three and a half hours, we estimate the total time spent on each case will be at least three times that.
Performance indicators are statistics used to com pare the performance of different district health authorities with the object of improving the pro vision of health care. A recent paper (Nicol, 1989) demonstrated how performance indicators based on the KÃ ¶rnerminimum data set are of limited relevance to the professional activities of child and adolescent psychiatrists. We suggest that a further difficulty in applying such criteria is the type and complexity of the clinical problem, with cases of child sexual abuse occupying an inordinate proportion of professional time. Our data demonstrate that the time spent on assessment in these cases is very much higher than that of most other new referrals to a child psychiatry department. It is not unusual for an assessment to include more than one child in a family and we note that up to 12 hours have been spent on an initial assessment of a family, including all children. For these reasons, performance indicators are likely to reflect inadequately the clinical time spent on individ ual cases and fail to take into account the much longer time necessitated by complex child protection cases. Unless due allowance is made, those depart ments seeing a substantial number of such cases would fare poorly in performance indicator terms. So far no mention has been made of 'hidden' work 601 and time undertaken in relation to child sexual abuse; for instance, the report of the Royal College of Psychiatrists Working Group (1988) and subsequent correspondence has emphasised the role of child psy chiatrists both in training and in consultative work with other disciplines. Such consultation may be a significant component of the workload but as yet there is no way of counting it for performance indicator purposes.

Conclusions
We estimate that the amount of patient contact time spent on child sexual abuse cases attending our university-based child psychiatry department would exceed the total working hours of a single senior pro fessional for two weeks in every four and the total time devoted to cases is likely to be three times as much. However, full-time allocation to child sexual abuse work is not in the interests of either children, families or professionals (Butler-Sloss, 1988). In accordance with the Royal College of Psychiatrists Working Group (1988), we suggest that this type of clinical practice should be shared both within and across the professional disciplines working in child psychology and psychiatry.
We also are concerned that the extent of involve ment in working with child sexual abuse cases is not recognised in the current methods of collecting infor mation for performance indicators and as a result these statistics are of limited relevance to clinical work in this field.