August 7, 2018

Identifying Signs of Sexual Abuse in Children with Special Needs

Hello Everyone,

      I hope you are enjoying your summer!  At the beginning of August, a child with special needs was sexually abused by a school bus driver in our local community.  It is not known how long the abuse has been going on for or if this was a single instance.  What is known is that the child was a vulnerable target and unable to defend themselves against this individual.  So what about my child?!  What about other children with special needs?  How can I tell if my child is a victim of sexual abuse?  What if my child does not tell me they are being abused?  How can I get them help?  I am going to attempt to address these concerns in today's post, drawing on my personal past experiences as a child welfare worker with children with special needs who were victims of sexual abuse.
      Ok, so before we begin to look at warning signs of sexual abuse in children with special needs, we need review why they may not be able to use their words to communicate the abuse in the first place.  I have written a previous post discussing this in detail, which you can read here: Factors Contributing to Aggression in Sexual Abuse Victims with Autism.  To summarize in brief, children with special needs often present with significant limitations around interpreting, processing, and appropriately communicating complex thoughts and emotions.  They are not at all unlike non-special needs children in that they are able to understand trauma as a significant, damaging event, or that they often react to trauma as any other individual will.  Sexual abuse IS trauma, yet the child with special needs will experience that trauma's associated fear of the perpetrator, anxiety, shame, confusion, lack of knowledge and so on as an much heavier insult on their brain's already limited ability to multi-task the processes of accurately receiving, processing, contextualizing, and accurately understanding the event itself to be able to report it.  As we know, many children with special needs rely on using comparison of facts and information within existing frameworks of past experience to generate understanding and internally driven responses to new occurrences in their lives.  Often, the result in this context, is not reporting sexual abuse at all (or waiting to report until they recognize something is inappropriate) or shutting down as a way of either avoiding the stresses involved in processing the trauma or fear of the perpetrator.
      During my time in child welfare, we were taught to observe children with special needs for signs of sexual abuse, physical and behavioral, using the same criteria as for non-special needs children.  Very quickly, we began to notice that while children with special needs do present symptoms in similar ways to other children, they also present with some significant differences.  Here is what to look for:

Physical Signs:

Physical injury such as cuts, scrapes, bruises, etc. (child welfare does not distinguish between physical injury done by the child to themselves or that done by someone else)

Complaints of pain or burning in "private areas" (your child may have their own terms for private parts so listen for any instances when they speak about something being different with them)

Increased or decreased expulsion of body waste (complaints of pain or burning can create the sensation of having to use the bathroom; they can also create pain making toiletting too difficult to perform without significant discomfort, leading to toiletting avoidance)

Other signs of physical trauma to private areas such as difficulty walking/sitting, blood in under garments, difficulty toiletting or presence of "sudden" venereal disease (from a former worker standpoint, as a parent make sure you rule out any other possible medical reasons for these injuries)

Increased presence of self-inflicted wounds/injury (I consider this one separate from physical injury as these wounds can be closely linked with increased self-injurious behavior being used to self-sooth after trauma)

Physical changes in child's affect or non-verbal expression of emotion (how do their expressions actually look different when they register emotion, not the behavior of showing emotion)

Weight loss (the physical effect of the behavior change of not eating by refusing to let objects near the mouth.  I encountered this complication in several circumstances where the child's sudden weight loss and refusal to eat was the result of trauma from sexual abuse)

      These may sound obvious so why are you wasting a post, and more importantly MY time with your ramblings?  I cannot stress enough from the child welfare perspective that physical signs of sexual abuse are one of those warnings equivalent to pushing the red button that launches the nukes only to result in an irreversible nuclear holocaust with an "oops...sorry wrong way to deal with this situation" response that does not fix the damage.  In child welfare, all physical injuries or signs of sexual abuse are cause for report and investigation by child protective services; the majority of child welfare workers are not taught about the unique aspects of physical injury to children with special needs such as for purposes of self-soothing or expressing emotion.  However, child welfare will not draw any conclusions confirming the presence of abuse or not without a "preponderance of evidence", and therefore will not take conclusive action until such evidence is gathered.  It is very unfortunate that this often means the abuse continues while evidence to support the presence of abuse is being gathered.  In other situations, where the abuse is stopped, the perpetrator is not comprehensively punished due to the lack of gathered evidence to link them to the child.  This results in a very catch-22 situation for parents and I think gets at much of the rage in the community over the lack of action taken against perpetrators.
      No parent should be expected to allow their child with special needs to continue to suffer sexual abuse to have it proven; sexual abuse is sexual abuse regardless of frequency or types of inappropriate sexual behavior by the perpetrator.  However, speaking from experience, the same investigatory system that will immediately investigate reports of abuse will also work against many victims and their families by forcing them to prove that it was not another cause of the injury and was instead abuse.  Parents are likely to be investigated for their role in the injury and often times jurisdictions will not include the testimony of the victim due in large part to societal views of children, especially children with special needs as unreliable reporters or as being unable to accurately understand what occurred.  We also live in a society where sexual abuse of minors is very taboo and to think of it being done to children by the same institutions designed to help them grow, is horrific.  Unfortunately, and not to sound like a conspiracy theorist, many institutions will not consider the issue as being an issue affecting them, and if they do, they often will expend great resources to disprove or mitigate the impact on their position in society.  I cannot tell you how many times I have had to testify on behalf of the child welfare system against another government institution that a child with special needs was sexual abused only for the other institution to challenge the credibility of mine and the child/their family reports.

Behavioral Signs:

Behavior signs like physical signs require a preponderance of proof and will be challenged more rigorously than physical signs as being conclusive.  Again this has to do with the same reasons as mentioned above.  There will be much more examination of other possible causes of the behavior change as being responsible before sexual abuse will be acknowledged as the culprit.  Unfortunately, the behavior signs can be much more conclusive indicators of sexual abuse, but do not get the intensive treatment as physical indicators.  Do not be surprised to hear that your observations of behavior change do not constitute a reportable or investigable incident.  Here are the behavior signs used by child welfare and some that are not, but which experience has shown to be important to notice.

Sleep issues (many children with and without special needs will experience night terrors or disruptions to sleep, however children with special needs often have significant sleep issues unrelated to abuse or trauma so be very careful when examining this one)

Increased or decreased toilet use (pain caused by sexual abuse to private areas can contribute to urges to go to the bathroom as well as contributing to avoidance due to pain associated with going)

Changes in eating or refusal to eat (mentioned above under physical signs, weight loss caused by refusal to eat may be an indicator of possible fear or repulsion of objects near/in the mouth.  Can present as sudden new sensory aversion)

Increased rumination (for many children with special needs, rumination is a form of self-soothing, especially for non-verbal children; an increase in ruminative behaviors may be worth noting)

Also be aware of cognitive rumination such as repetitive statements about body parts, self-hate remarks, repetitive discussion of sexual behavior or questions, a hyper-focus on certain individuals and discussing their body parts, and so on.

Sudden changes in mood and increased irritability (there are many causes for this one so it helps to observe for any sudden changes in behavior around known stressors or known pleasures to the child)

New fear of specific places or individuals (can be caused by many factors, yet worth noting)

Increased aggression towards certain trusted individual(s) (this does not mean the trusted individual is by any means the perpetrator, yet the child may take out their aggression on this individual because they are a safe outlet.  In several cases children with special needs I worked with took aggression out on trusted individuals physically and verbally for not "protecting them").

Increased presence of fear of being left alone or abandoned by a trusted individual

Statements of betrayal by trusted individual (many children with special needs think in very concrete terms of the role trusted individuals play; they can often feel betrayed if the individual fails to perform their role or shifts in their performance)

Increased extremes in emotional expression (individuals with special needs experience emotions very strongly and may experience greater difficulty regulating themselves in response to trauma.  Conversely they may withdraw or shut down emotionally.  Both of these are closely involved in the discussion of cognitive limitation impacts on processing trauma)

Increased presence of self-injurious behavior (This is a complex one owing in part to an increased societal focus on preventing suicide.  It is not uncommon for child welfare workers or other professionals involved in the care of children to "jump the gun" and attribute self-injurious behavior as a sign of suicidal thinking.  Do not discount the possibility as this has a history of occurring in response to sexual abuse.  Unfortunately, there is not much literature on suicidality in sexual abuse victims with special needs and even less on individuals with special needs ability to distinguish between self-injurious behavior and self-harm)

Disrupted routines (There are always disruptions to routines, but not by the individual with special needs if they can help it.  Routine is comforting and safe so observations of self-initiated deviation from routine and increased disorganization can be a sign worth noting)

Previously non-existent phobias (some children may develop a phobia to a specific aspect of the sexual abuse that may seem strange or random to outside observers)

 Increased presence/persistence of negative behaviors (especially common in non-verbal children as a means of self-expression.  I have also witnessed on several occasions where a child with special needs would engage in behaviors upsetting to trusted individuals as a way of showing anger toward them for not helping them)

Changes in metaphorical expression (children with special needs often use metaphors centered around topics of interest to better understand/relate to their world.  Watch for changes of how these metaphors are used, especially increases in aggressive or fear-based use as well as sudden changes to the repertoire of use.  For example one child I worked with used football players as a metaphor for understanding social interactions; he began talking about the players punching each other in their private parts when they were angry and grabbing each other inappropriately when they wanted to tell another player they liked how they played.

      Ok, so I have thrown a lot at you and this is no easy or pleasant topic to deal with.  But what about psychological/emotional signs of abuse?  Unfortunately, your best bet as a parent is to focus on the physical and behavior warning signs when dealing with child welfare.  Psychological and emotional signs outside of those related to visible behaviors are very hard to use since they are subjective and do not have concrete evidence to back them up.
      As a former child welfare worker, I cannot stress the importance of understanding the warning signs and being able to not only recognize them when they happen but to CRITICALLY evaluate them and their implications when considering the possibility of sexual abuse in your child with special needs.  In a number of respects your job of protecting your child is made more difficult by their diagnoses and increased vulnerability.  However, you are the expert on your child and if you suspect something is wrong, then go with it.  Just remember to carefully evaluate all symptoms very carefully if for no other reason than your own peace of mind and for building your case when you report.  I wish you all the best of luck and please know that you have allies in the community who want to help despite the red-tape of the system.  Thank you for reading and take care!

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