INTRODUCTION
Adolescence (latin = adolescere, (to grow) is a transitional stage of physical and mental human development that occurs between childhood and adulthood. This transition involves biological (i.e. pubertal), social, and psychological changes, though the biological or physiological ones are the easiest to measure objectively.
The teenage years are from ages 13 to 19. However, the end of adolescence and the beginning of adulthood varies by country and by function, and furthermore even within a single nation-state or culture there can be different ages at which an individual is considered to be (chronologically and legally) mature enough to be entrusted by society with certain tasks.
ADOLESCENT SEXUALITY
Adolescent sexuality refers to sexual feelings, behavior and development in adolescents and is a stage of human sexuality. Sexuality and sexual desire usually begins to intensify along with the onset of puberty.
In contemporary society, adolescents face some risks as their sexuality begins to transform. While some of these such as emotional distress (fear of abuse or exploitation) and sexually transmitted diseases (including HIV/AIDS) may not necessarily be inherent to adolescence, others such as pregnancy (through failure or non-use of contraceptives) are seen as social problems in most western societies. In terms of sexual identity, all sexual orientations found in adults are also represented among adolescents.
In a 2008 study conducted by Channel 4, 20% of the 14 “17-year-old” surveyed revealed that they had their first sexual experience at 13 or under.
The age of consent to sexual activity varies widely between international jurisdictions, ranging from 12 to 21 years. In India, a sixteen-year old girl can give consent for sexual activity which is legally, valid and acceptable.
The age of consent to sexual activity varies widely between jurisdictions, ranging from 12 to 21 years, although 14 to 16 years is more usual. In a 2008 study of 14 to 17-year-old conducted by Channel 4, it was revealed that one in three 15-year-old were sexually active.
The age at which people are allowed to marry also varies, from 17 in Yemen to 22 for males and 20 for females in China. In Western countries, 4people are typically allowed to marry at 18, although they are sometimes allowed to marry at a younger age with parental or court consent. In developing countries, the legal marriageable age does not always correspond with the age at which people actually marry; for example, the legal age for marriage in Ethiopia is 18 for both males and females, but in rural areas most girls are married by age 16. In India, 18 years for females and 21 years for male is the prescribed age for legal marriage.
PUBERTY
Puberty is a period of several years in which rapid physical growth and psychological changes occur, culminating in sexual maturity. The average onset of puberty is at 10 for girls and age 12 for boys. Every person's individual timetable for puberty is influenced primarily by heredity, although environmental factors, such as diet and exercise, also exert some influence.
Facial hair in males normally appears in a specific order during puberty: The first facial hair to appear tends to grow at the corners of the upper lip, typically between 14 to 16 years of age. It then spreads to form a moustache over the entire upper lip. This is followed by the appearance of hair on the upper part of the cheeks, and the area under the lower lip. The hair eventually spreads to the sides and lower border of the chin, and the rest of the lower face to form a full beard. As with most human biological processes, this specific order may vary among some individuals. Facial hair is often present in late adolescence, around ages 17 and 18, but may not appear until significantly later. Some men do not develop full facial hair for 10 years after puberty. Facial hair will continue to get coarser, darker and thicker for another 2–4 years after puberty.
The major landmark of puberty for males is the first ejaculation, which occurs, on average, at age 13. For females, it is menarche, the onset of menstruation, which occurs, on average, between ages 12 and 13. The age of menarche is influenced by heredity, but a girl's diet and lifestyle contribute as well. Regardless of genes, a girl must have certain proportion of body fat to attain menarche. Consequently, girls who have a high-fat diet and who are not physically active begin menstruating earlier, on average, than girls whose diet contains less fat and whose activities involve fat reducing exercise (e.g. ballet and gymnastics). Girls who experience malnutrition or are in societies in which children are expected to perform physical labor also begin menstruating at later ages.
Pubescent boys often tend to have a good body image, are more confident, secure, and more independent. Late maturing boys can be less confident because of poor body image when comparing themselves to already developed friends and peers. However, early puberty is not always positive for boys; early sexual maturation in boys can be accompanied by increased aggressiveness due to the surge of hormones that affect them.5
Indian Academy of Pediatrics’ Proposal
- Teenage care
- Late adolescence (17–19 years): Distinct identity, well formed opinion and ideas
- 18 years legally.
Syllabus for Adolescent Health Education
- RTI/HIV/AIDS
- Safe sex
- Stress management
- Substance abuse
Adolescent Friendly Health Center Services
- STD/HIV Screening counseling and treatment.
- Counseling for life skill development
Criteria for Adolescent Friendly Health Worker
- Welcoming and friendly nature
- Knowledgeable
- Presentable
- Have good communication skill
- Maintain confidentiality
- Punctuality
- Flexibility
- Understanding
- Good listener
- Non-judgmental
HISTORY FROM THE ADOLESCENT
It is easier to take a history from the adolescent victim, although there are more questions that need to be answered. Getting a full history of trauma infection surgical or obstetrical procedures and everyday sexual activity is important in assessing injuries and providing prophylaxis for pregnancy and infection. The history from an adolescent victim must include all relevant past history and the events surrounding the assault.
- History from the adolescent
- Who, what, when and where
- Penetration of which orifices and with what
- Use of force or threats
- Pain, bleeding, dysuria, etc.
- Ejaculation, condom use
- Other extragenital injuries
- Known risk factors of assailant
- Activities after the assault (shower, douche, urination, defecation, changed clothes, etc.)
- Past medical history and sexual activity.
Documentation
Although history taking is central to any medical evaluation flawless examination technique is also essential, especially in jurisdictions where corroborative medical evidence is a legal requirement. There are two main types of medical evidence: laboratory and clinical.
Laboratory evidence includes all forensic science samples and culture specimens for sexually transmitted diseases. DNA typing, which carries the potential for absolute identification of the assailant requires close attention in detail in sample selection, preservation and protection. The presence of sexually transmitted disease can provide critical corroboration that sexual contact has occurred.
Clinical documentation has become increasingly important over the past decade. Reports of early research and use of traditional protocols in detecting genital trauma after sexual assault described positive genital findings in only 10–30% of cases. The use of colposcopy and photo-documentation has improved the detection rate for findings associated with sexual assault of the adolescent and adult has been the basis for research into normal genital anatomy and post-traumatic changes associated with child sexual abuse.
Photographic Documentation Needs
In most major referral centers, photo-documentation has become standard practice in evaluating allegations of sexual assault. In medically based centers, doctors have relied mainly upon the use of colposcope. This instrument has long and widely been used in sampling and screening for cancer of the cervix. In the hands of most gynecologists and general practitioners it has also been used to diagnose lesions of the external genitalia and hymen.
The chief value of photo-documentation of the sexual assault victim is to record the findings permanently and so avert the need for re-examination.
Photo-documentation
- Hand held magnifier with light source
- Camera with macro lens
- Colposcope
- Still photography
- Video
- Video network, computer links
Legal Use
The main use of photographic documentation by the legal system in the USA has been two-fold: permanent recording of acute or chronic injuries and the 7substitution of photographs for re-examination. Photographs offer the best representation of the medical examination and can be useful in various phases of the legal process, although many jurisdictions worldwide exclude them as court exhibits for obvious reasons. In India also photographs documentation is used in many centers.
Normal Anatomy and Innocent Findings
To diagnose post-traumatic changes associated with sexual assault accurately, it is essential to have an understanding of normal anatomy. This is particularly important in the pre-adolescent victim. Many questions regarding normal and abnormal physical morphology in the pre-adolescent have been resolved only quite recently by using photo-documentation.
Pre-adolescent Hymenal Anatomy
The normal pre-adolescent hymen is essentially a two dimensional structure located 2–3 cm inside the vaginal introitus delicate membrane normally has a central or ventral opening which in due course provide outlet for the menstrual flow. Several distinct classifications of the normal anatomy exist.
- Normal morphology of the hymen
- Annular
- Crescentic
- Septate
- Fimbriated/folded/redundant
- Cribriform (multiple openings)
- Imperforate
Development Changes
The hymenal tissues undergo distinct changes from the newborn period, when it is thickened and redundant under the influence of maternal estrogen, through the non-estrogenised state or scanty hymen of childhood until puberty when the hymen is once again redundant and estrogenised.
Hymenal Opening Size
Early reports indicated that there was an apparent correlation between hymenal opening size and a history of sexual abuse. Studies of non-abused populations, comparison studies using various examination positions and techniques and comparative studies of abused and non-abused populations all indicate that hymenal opening size is not a highly sensitive or specific indicator for sexual abuse. There is, however, an association of increased hymenal opening size with a history of abuse when additional findings such as attenuation or tears are present.
Bumps and Notches
Studies of both normal and abused populations reported that bumps are often found on the hymenal edge. A study of newborn children indicated 8that notches or clefts are a frequent finding in this group but predominate in the ventral 1800. Bumps were also a common finding in that study, as well as in two major studies of a non-abused child population. Longitudinal intravaginal ridges, which may extend on to the inner edge of the hymen, were often found to give rise to bumps or tags at the point of attachment. A recent study dealing only with abused children found that 7.5% had posterior notches or concavities showing a significant correlation with penile vaginal penetration.
Perihymenal or Periurethral Bands
Early clinical descriptions attributed these bands to possible healing trauma. However, both the newborn and the non-abused populations were found to have these bands or ligaments in many cases. These structures may be present in the periurethral area alone or at various locations around the base of the hymen.
Intravaginal Findings
Studies show that vaginal ridges and rugae may be confused with post-traumatic synechiae or scarring. In studies of normal children, these structures were most easily visualized with labial traction, but excluding the ventral and suburethral ridge which was present almost.
Vascularity
Again, the studies make it clear that changes in vascularity are difficult to assess and should not be used as sensitive indicators of sexual abuse. Erythema, irregular vascularity and isolated vascularity were common in the non-abused populations.
Other Vaginal Findings
Subcutaneous follicles, or mounds of the posterior fourchette and fossa navicularis
- Labial adhesions
- Urethral dilatation
- External hymenal ridges
- Medical conditions frequently confused with abuse
- These need to be considered when children are referred for investigation of alleged sexual assault. They include;
- Lichen sclerosus
- Labial fusion
- Hemangioma
- Urethral prolapse
- Streptococcal cellulitis
- Congenital failure of midline fusion.
Anal Findings
The very nature of the anus makes the diagnosis of sexual assault more difficult when there is any delay between assault and examination. The tissue is easily stretched without damage and heals rapidly even after minor injury. In children especially, there has been a great need to appreciate normal anatomical variation and non-specific findings.
In some assaults, restraining force is severe enough to leave fingertip and other bruises on the limbs or strangling marks on the neck. Trauma to breast, inner thigh or other perigenital areas is not unusual. Group assaults may leave characteristic graffiti which can be used to identify an established gang to which the assailants belong.
Bite marks are common in sexual assault, and it is important to measure and photograph them carefully to allow matching or exclusion of the teeth of the alleged assailant. Bite marks may become clearer as time passes, and repeat photographs taken at 24 hours interval may be helpful. Orientating and detailed recording photographs should be taken at right angles to the various curves of the bite mark. The next step should always be swabbing for trace evidence of saliva, which should be done with distilled water or physiological saline. These specimens should be labeled appropriately and sent promptly to the laboratory.
Appearance of Injuries Associated with Sexual Assault
Depending upon on variety of assault, initial and healed appearance of injuries varies (Table 1.1).
Summary of Post-traumatic Changes Associated with Penetrating Sexual Assault
The relevant changes are listed in Table 1.2.
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FORENSIC CONSIDERATIONS
- Preserve and protect all laboratory specimens must be treated carefully to protect them from contamination, degradation and tampering. The chain of evidence must be maintained using signed labels and evidence books according to local requirements. In some jurisdictions, specimens must by law be maintained in special environments.
- Clinical documentation: In the initial examination of the victim it is important to document all extragenital injuries and to photograph them. Traumagrams which can be included with the reporting forms elucidate and support the photographic evidence in court. After the external genital injuries have been recorded with appropriate equipment, any additional internal injuries can be noted as the internal examination progresses.
- Laboratory documentation: Medical professionals should consult their local pathology and forensic science laboratories to find out the preferred techniques for collection and transportation of specimens. These may vary depending on the size and location of the jurisdiction in which they work.
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Trace Evidence and Evidence of Ejaculation
These are increasingly important to the crime laboratory. As already noted, the general examination should be performed on a large sheet of paper which can be included in the ‘rape kit’. This helps to ensure that critical debris will be retained for examination. The same applies to the genital examination, with pubic hair combing and collection of fibers and other trace evidence. Obviously, the most important identifying element for the examiner and the pathologist is the documented presence of ejaculate. DNA profiling has made absolute identification of the assailant possible so that the retrieval of spermatozoa is more important then ever before.
It should be stressed that lack of evidence of ejaculation by no means refutes a complaint of sexual assault.
Interpretation of Forensic Evidence
Presence of Semen
Spermatozoa: Over the past two decades, a number of studies have examined the chances of finding sperm after coitus. One study retrieved 100% of vaginal sperm during the first hours while another found only 64%, and a third found 25%. In Sharpe's (1963) study, non-motile sperm were found in the vagina up to 17 days after ejaculation. A number of studies have shown that, if properly preserved, sperm can be demonstrated for many years outside the body. In fatal assaults, sperm has been retrieved up to 10 weeks after the death of the victim.
P30 protein: This is semen-specific and is not found in vaginal fluids. It is thus a more sensitive and specific method of semen detection.
Seminal-vesicle-specific protein: A monoclonal antibody (MHS-5) has been developed to recognize a protein secretory product of human seminal vesicle epithelium and it is also semen-specific.
Assailant Identification
Hair: Various different characteristics of head and pubic hair can be explored to help narrow the pool of possible assailants.
Generic markers in blood, saliva and semen: These will include DNA and serology, (ABO typing and other blood enzyme systems).
THE ABUSED ADOLESCENT
Research indicates that there are symptoms that present frequently in young survivors of children abuse. These include the following:
- Anxiety/Numbing: Young people who have been sexually abused often exhibit the polarity of anxiety/numbing behaviors. These youth are hypervigilant, scanning the environment for threats to their safety; conversely they have learned to shut down their feelings.
- Hypersensitivity: Young people growing up in violent or abusive environments tend to be hypersensitive to their surroundings. They flinch at sudden noises and are hyper aroused or over stimulated easily. They may experience acute fear in some situations and typically “stay on alert,” which requires energy and takes a tremendous toll on their physical and mental well-being. They tend to carry a lot of tension in their bodies, so they may not move as fluidly as other children. Many of these youth present somatic concerns, such as always having headaches or stomach pains.
- Depression: Even very young children who have been abused exhibit characteristics of depression. They may have a flat affect, not make eye contact, or not laugh. There are many manifestations of depression, including self-mutilation, substance abuse, and eating or sleeping disorders. One child was referred to a therapist who used play therapy. The child would pick the play therapy rag doll up and roll its head back and forth, put one foot in front of the other, as if the doll were walking, and then make it fall. She repeated the sequence 14 times.
- Problem sexual behaviors: Children who were sexually abused may become involved in sexual acting-out behaviors, particularly when they reach adolescence, a time of increasing biological urges and exposure to sexual education. Under normal conditions, sexual behavior develops gradually overtime, with youth showing curiosity and then experimenting with themselves and others. When children are sexually abused, however, they are prematurely exposed to material they do not understand and cannot make and sense.In one case the judge who was doubting the sexual abuse of a 3-year-old child called everyone into his chambers and hoisted the young girl on his lap so that he could interview her. The moment he placed her on his lap, she reached under his robe and began fondling his genitals. She clearly had been conditioned to believe that when a man sits her on his lap, he expects this type of behavior. The judge quickly reversed his opinion and went forward with the case of sexual abuse.
- Aggression: Eventually, most abused children get angry and some start acting aggressively, typically with smaller children. This is the victim-victimizer dynamic; abused children learn that the bigger, stronger person hurts or takes advantage of the smaller, weaker person. Youth who have been victimized are conditioned to believe that when two people interact, one of them will be hurt. At each interaction with others, they may wonder who will be hurt this time. Some children adopt the victim role; others become the victimizers.
Identity Formation in Adolescence
Forming an identity is a major developmental issue during adolescence. This process of once own individualization begins when children are very young and crystallizes in adolescence. For positive identity formation to 14occur in any human being, some basic things have to be attained, including the following:
- Expressions of love: Children have to feel that somebody cares about them.
- Feelings of significance: Children must feel that they are significant or important to someone.
- A sense of virtue: Children must have a belief in their innate, inner goodness.
- A sense of belonging: Children must feel connected to a family that provides them with a sense of stable belonging.
- Mastery and control: Children must experience feelings of mastery and personal power and control.
Treating the Sexually Abused Adolescent
Therapists have identified three stages of working with survivors of childhood abuse:
- Establishing the young person's safety, both in their home situation and with the therapist;
- Processing traumatic material; and
- Fostering social reconnection.
Time and consistency of care are key factors in all three stages of therapy, but especially in stage 1. By the time an adolescent receives the help they deserve, they may have been sexually or otherwise abused over a period of time. They have built up an array of defenses to protect themselves, and making contact with them may be difficult. To establish the trust of an abused child, a therapist needs to build a relationship with that child, which takes time. Therapists need that time to demonstrate that they are trustworthy, by action as well as words.
GENERAL PRINCIPLES FOR WORKING WITH TEENAGERS SEXUALLY ABUSED
Helping youth explore past abuse is specialized work, requiring significant education, training, and expertise. The following key principles provide guidance for those working with youth who have been sexually abused:
- TO REMAIN NEUTRAL IN YOUR EARLY INTERACTIONS WITH ABUSED CHILDREN: When some youth sense that a therapist or other professional is paying attention to or trying to help them, they may withdraw because the circumstances feel risky to them. The very nature of counseling or therapy, which involves personal contact with another human being and focused, positive attention, can produce stress and anxiety for children who have been sexually abused. Youth who have been sexually abused also may associate nice behavior with seduction. In the past, people were nice to them when they wanted something. They may wonder what therapists or other adults expect from them in return for their help.
- TO ASSIST YOUTH IN UNDERSTANDING THAT THEY ARE NOT TO BLAME: Typically, left to their own resources, children make incorrect assumptions about why they were abused or neglected. When 100 youth in San Francisco were asked why they were in the foster care system, 98 of them said, “Because I am bad.” And young people's behavior often reflects how they feel about themselves. If they think they are bad, they may act in ways that perpetuate that image.
- TO BE NONJUDGMENTAL: Youth do not respond well to adults who want to tell them what to do or who are constantly critical.
- TO YOUTH DOING SOMETHING GOOD: Focus on telling young people what they are doing that is good. When they make a thoughtful decision and stick to it, for example, congratulate them on following through.
- TO HELP THEM VIEW THEIR FEELINGS WITHOUT JUDGMENT: Feelings are not good or bad, they are just feelings. Help young people understand that it is all right to feel angry, and help them to learn to express their anger in ways that are healthy for themselves and others.
- TO THINK OF YOUR INTERACTIONS WITH YOUTH AS “INVITATIONS” FOR THEM TO DO OR SAY AS MUCH OR AS LITTLE AS THEY CHOOSE: Youth need to learn to make choices about how they will participate, or not, in different situations. Offering youth options gives them a chance to practice making choices in a safe environment. If a young person does not complete an assignment, for example, consider talking with him or her about what the assignment might have looked like if they had finished it. Or, discuss what might have been the biggest problem in completing the task. Through this process, you might accomplish more than if you focus on the young person's failure to complete the task.
- TO AVOID POWER STRUGGLES WITH YOUNG PEOPLE: It is generally nonproductive to spend time arguing a point with an adolescent. Move on to other discussions that might prove more useful. Keep in mind that if a young person is feeling defensive, they are not feeling safe.
- TO REMEMBER THAT ABUSED ADOLESCENTS HAVE A REASON TO BE DEFENSIVE: If you are hit enough, emotionally or physically, you learn to stand ready to protect yourself or even to ward off attacks by attacking first. Young people who have been abused need time and a trusted relationship to feel safe.
- TO UNDERSTAND HOW EASY IT IS FOR ABUSED CHILDREN TO BE FURTHER VICTIMIZED: Without question, once abused, children become more vulnerable to further victimization. It is not just the abuse that leaves them exposed to exploitation; it is the concomitant loss of love, nurturing, and feelings of being safe and valued. Often adult predators provide, at least at first, the very things missing from an abused child's history: time, attention, caring, and a sense of belonging.16
- TO BE AWARE THAT SOME BEHAVIORS PROVIDE YOUTH WITH A SENSE OF CONTROL: When children are treated well, nurtured, loved, and accepted, they learn to expect that treatment from others. When children are abused, they similarly expect others will abuse them. These children may engage in aggressive behavior as a defense mechanism; their behavior is a means of taking control of a situation they anticipate will occur anyway. When you work with youth to stop behaviors that place them at risk, it is important to be aware that those behaviors may be the only current means they have for mastery and control.
- TO HELP EDUCATE OTHERS THAT YOUNG PEOPLE ARE NEVER RESPONSIBLE FOR THEIR ABUSE: Often, people suggest that adolescents should have told someone or fought back. The expectation is that adolescents should be able to protect themselves. It is important to remember that many young people have long histories of abuse, which makes them vulnerable; they are not “normal” (nonabused) adolescents suddenly confronted with dangerous circumstances. Moreover, it is critical to remember that children are relating to their parents, the people they love and need most in the world. When asked, “Who is bad, you or your Mom and Dad?” children will always choose themselves. Children need to protect the idealized image of their parents; those are the people they long for.
- THERAPEUTIC APPROACHES OTHER THAN TALK THERAPY: Direct talk therapy generally is not the most effective approach with adolescents. Well-trained therapists will use art or play therapy in working with abused youth. They also might discuss news clippings or watch a video and let youth comment on another young person's situation. It may be easier for youth to talk about another person as a means of sharing how they feel. Moreover, helping young people develop empathy for others often can be the first step in developing self-empathy.
- TO HELP YOUTH CHANGE BEHAVIORS THAT CAUSE NEGATIVE REACTIONS IN OTHERS: Therapists examine a child's behavior, describe it, and then try to determine why the child is acting in this manner. A 12-year-old girl, for example, who threw temper tantrums explained that she felt quiet inside when the tantrum was over. She said she felt calm because “everything inside had come out.” This child had been beaten whenever she showed any emotion, so she had learned to keep her feelings bottled up inside.
- TO APPRECIATE THAT CHILDREN SUSTAIN INJURIES DIFFERENTLY: Some young people are more resilient than others. A therapist needs to assess how well the young person has survived the abuse, what they think about themselves, and how they manage to reach out to others. Through this process, it is important to help the youth build a history of accomplishment by emphasizing the young person's strengths and successes.17
- TO HELP YOUTH PROCESS TRAUMATIC MATERIAL: Young people need support to deal with what happened to them, discharge their feelings, and develop a sense of mastery about that process. Unless this happens, images similar to those associated with the abusive event may trigger a posttraumatic stress reaction. A youth may blow up or go into trancelike behavior for no apparent reason. This is an indication that they have unresolved traumatic material and they need help in processing that material in a structured way that creates feelings of empowerment.
- TO WORK WITH YOUTH TO ASSIMILATE THE INFORMATION AND FEELINGS ASSOCIATED WITH THEIR PRIOR ABUSE: By processing traumatic material, therapists can help youth talk about the event and feel the associated feelings at the same time.
- TO RECOGNIZE THAT WHILE ABUSE AND NEGLECT HAVE THE POTENTIAL TO BE TRAUMATIC, NOT EVERY ABUSED CHILD IS TRAUMATIZED: Traumatized children are a subset of abused children. Factors that distinguish the two groups tend to include the child's relationship to the abuser, age at the onset of abuse, and biology, and the chronicity and severity of the abuse. All abused children are hurt and exploited, but, depending on a broad set of variables, some children continue to live in the climate of the trauma.
- TO HELP YOUTH LEARN HOW TO MANAGE THEIR FEELINGS IN SETTINGS IN WHICH IT WOULD NOT BE APPROPRIATE TO ACT UPON THEM: Some youth need to learn affect regulation, which is the ability to control feelings in certain situations. Adults, for example, who had a fight with a spouse prior to making a presentation at work are able to refocus themselves. They are able to control the feelings they are experiencing as a result of the fight while they make the presentation.
- TO WORK WITH YOUTH TO DEVELOP IMPULSE CONTROL: Children growing up with abusive parents did not have impulse control modeled for them. Many abusive parents think and act at the same time; when they are angry, they strike their children. Nonabusive parents also get angry at their children; they simply have the impulse control not to act on every thought. Children who grew up with abusive parents may need to learn that thoughts and action can be distant on the time spectrum. They need help in determining how to go through a series of steps to make decisions about what they will do in response to their thoughts.
- TO ACCEPT THAT ALL CHILDREN ARE DIFFERENT: Some children act out in ways that continue the climate of trauma through behavioral reenactments that keep the victim dynamic present in their life. Others want to talk constantly about the abuse and will do so even with strangers. Still other youth refuse to talk about the abuse; they say it is over and they do not want to deal with it. A good therapist will develop a plan for working with a young person on the basis of that child's behavior, presenting problems, personality, and coping style.18
SUGGESTED READING
- Child maltreatment. Administration on Children and Families. US Department of Health and Human Services Washington: 2005.
- Faller KC. Child Sexual Abuse: Intervention and Treatment Issues. National Clearinghouse on Child Abuse and Neglect Information Washington, DC 1993.
- Greenspan S. Developmentally Based Psychotherapy. Aronson Publishers, Northvale: NJ 1997.
- Gupte S. Stormy teens. In: Speaking of Child Care, 3rd edn. Sterling New Delhi: 2007: 120–135.
- Gupte S. Adolescence. In: Gutpe S (ed): The Short Textbook of Pediatrics, 11th edn. Jaypee New Delhi: 2009: 60–69.
- Keuhnle K. Assessing Allegations of Child Sexual Abuse. Professional Resources Press Sarastota, FL: 1996.
- Linesch DG. Adolescent Art Therapy. Brunner/Mazel, New York: 1988.
- Plucker JJ, Keeney KS, Atallo JF. Responding to Sexual Abuse of Children with Disabilities: Prevention, Investigation and Treatment. Child Abuse and Neglect Information Washington: 2003.
- Shakeshaft, C. Educator Sexual Misconduct: A Synthesis of the Literature. Department of Education Washington: US. 2004.