Adams Classification Table,
April 2003: Physical and Laboratory Findings
Used with permission of Joyce Adams, MD
Key point to remember in evaluating children and adolescents
who may have been sexually abused:
As many as 85-95% of children who give a clear history of sexual
abuse may have normal or nonspecific physical examinations, due to healing
of trauma or acts that do not result in trauma.
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Female Genitalia
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Anus
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Penis/Scrotum
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Other
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Class 1 Normal or Unrelated to Abuse Found in newborns: |
Class 1 Normal or Unrelated to Abuse - Tag at 6 o’clock from redundant perineal raphe - Thickening of perineal raphe - Blue tint from underlying veins Normal variants: - Diastasis ani - Perianal skin tag - Increased perianal skin pigmentation - Anal dilation with stool present - Venous congestion, or venous pooling, in perianal tissues (vi) |
Class 1 Normal or Unrelated to Abuse - Circle of brown pigment around shaft of penis from healed circumcision - Raised, dark line along penis/scrotum (median raphe) |
Class 1 Not related to abuse: - Candida infections - Strep infections - Urinary tract infections - Vaginitis caused by enteric or respiratory organisms - Gardnerella vaginalis cultured from vagina, in the absence of any other signs of bacterial vaginosis Also, conditions such as urethral prolapse, lichen sclerosis, genital hemangiomas, Crohn’s Disease, and Bechet’s Disease may be mistaken for abuse. |
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Class 2 Nonspecific |
Class 2 Nonspecific |
Class 2 Nonspecific - Erythema of penis, lower abdomen or inner thighs - Edema of penis/scrotum (These may result from self-manipulation, poor hygiene, contact irritation/inflammation, or infection) - Superficial abrasions on the penis/scrotum - Warty lesions or vesicular lesions on the penis/scrotum |
Class 2 Nonspecific: May be transmitted
by sexual or nonsexual means: - Herpes type I or II in a child who requires caretaker assistance with toileting or hygiene, or who may have self-innoculated from an oral lesion - Bacterial vaginosis in a child or adolescent - Any STD (including HPV or genital wards) in an infant who may have acquired it perinatally (vii) |
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Class 3 Concerning for Abuse |
Class 3 Concerning for Abuse |
Class 3 Concerning for Abuse Acute trauma - suspect physical or sexual abuse: - Banding of penis with child’s hair or other objects (this may be accidental in infants, from hair of a caretaker) - Bite or pinch marks on penis, scrotum, or inner thighs near genitalia - Sucker/hickey marks on inner thighs near genitalia |
Class 3 Concerning for Abuse: Sexual transmission
is likely cause of infection: - Herpes type I or II lesions in the genital area in a child who has no oral lesions and requires no assistance with toileting or hygiene - Trichomonas infection diagnosed by wet mount preparation or culture of vaginal secretions - HPV infection in a child in whom perinatal transmission is considered unlikely (vii) |
| Class 4 Clear evidence of blunt force or penetrating
trauma to or beyond the hymen: Findings that can have no explanation other than trauma to the hymen or vaginal tissues. Acute trauma: - Partial or complete tear of the hymen - Ecchymosis (bruising) on the hymen - Vaginal laceration Healed trauma: - Hymenal transection (healed), defined as an area where the hymen has been torn through, to the base, so there is no hymenal tissue remaining between the vaginal wall and the fossa or vestibular wall.(viii) This finding has also been referred to as a “complete cleft” in adolescent and young adult women.(x) - Wide areas in the posterior (inferior) half of the hymenal rim with an absence of hymenal tissue, extending to the base of the hymen, which is confirmed using additional examination technique (swab, Foley catheter, prone knee-chest position). |
Class 4 Clear evidence penetration beyond the anal sphincter: - Perianal lacerations extending deep to the external anal sphincter (ix) |
Class 4 Clear Evidence: Sexual abuse/contact
is certain: - Pregnancy - Sperm or semen found in or on child’s body - Video or photo documentation of child being abused - Confirmed positive genital, anal or pharyngeal cultures for Neisseria gonorrhea - Positive cultures (not rapid antigen tests) from genital or anal area for Chlamydia trachomitis - Positive serology for syphilis or HIV, if perinatal or blood transmission has been ruled out (vii) |
This table was developed from multiple sources, including published classification scales authored by David Muram, MD and Joyce Adams, MD. Penis and scrotum classification and “other” by Charles Johnson, MD.
Adapted from:
Muram D. Classification of genital findings in prepubertal girls who
are victims of sexual abuse. Adolesc Pediatr Gynecol 1988; 1:151.
Adams JA. Evolution
of a classification scale: Medical evaluation of suspected child sexual
abuse. Child Maltreatment 2001;6:31-36.
Johnson CF. Is it normal or not? SCAN 2001;13:4-5.
Psychosocial Indicators of Sexual Abuse
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Sexualized Behaviors
•
Nonspecific Behaviors
The following factors may influence the intensity and type of reaction a child has to the experience of sexual abuse (although some important issues related to any one child’s experience may not be included in this list):
• Parental support (willingness to entertain the possibility that sexual abuse might have occured)
• Identity of perpetrator and perpetrator’s relationship with child (closer relationships are associated with longer delays in disclosure and more severe after effects)
• Child’s age
• Child’s developmental status, including whether or not the child has any developmental disabilities
• History of prior, or concurrent maltreatment, trauma or stress
• Duration (time span) of the abuse
• Circumstances/context of the abuse (i.e. has the child been afraid, embarrassed, etc?)
• Type and intensity of abuse or neglect
• Family, social and community support
• Child’s coping strategies, and generality personal characteristics (i.e. temperament)
A child’s reactions may involve behaviors that can be observed by other people, or may simply involve the child’s innermost thoughts and/or subjective emotional feelings. Some of the reactions to sexual abuse can be similar across age groups, while other reactions may be more common in younger or in older children. In general, it may be difficult to differentiate children who have been sexually abused from children who have experienced other kinds of stressful experiences. It is important to remember that research in the area of child maltreatment suggests that many abused children do not exhibit any obvious reactions to sexual abuse. Therefore, if a child is not exhibiting concerning behaviors, but you have reason to suspect sexual abuse (for instance, if the child has been exposed to a known sexual offender), it is strongly recommended that you consult a professional with expertise in the area of child maltreatment for guidance.
The following list includes general signs and symptoms that may sometimes be observed in sexually abused children. When reviewing this list, it is very important to remember that fears and behavioral difficulties are commonly associated with normal child development. Many of the following are concerning only when behavioral changes are extreme or occur suddenly. If you have concerns, it is often helpful to consult a professional with expertise in this area.
While there is no one symptom which is diagnostic of sexual abuse, with the exception of pregnancy or some sexually transmitted diseases in a non-sexually active child or adolescent, the literature indicates that the symptoms most commonly associated with sexual abuse are sexualized behaviors, particularly trying to engage other children in sexual behaviors, and indicators of age-inappropriate sexual knowledge. However, it is extremely important to understand that many children who have been sexually abused do not exhibit sexualized behaviors. It is equally important to understand that children who have never been sexually abused may exhibit sexual behaviors.(4)
Risk Factors for Sexualized Behaviors
As a general comment, it is important to note that
there are numerous factors that may be associated with
age-inappropriate acting out sexually. The following life
circumstances are thought to increase the risk of children
engaging in inappropriate sexual play or activities:
• Sexual abuse
• Exposure to individuals (adults, adolescents or other children) known to have committed prior sexual offenses
• Living in a highly sexualized/over-stimulating atmosphere where personal boundaries are lacking
• Exposure to adult/adolescent sexual intimacy
• Exposure to sexually explicit materials including printed materials, videotapes, or pornography
• Living with needy adults who may turn to children to meet their emotional needs or unmet needs for affection
Functions of Sexualized Behaviors
The functions of sexualized behaviors varies from child
to child. Sexualized behaviors are thought to serve the
following functions:
• To decrease a child’s anxiety, fear or overall distress; to reduce tension or other unpleasant internal sensations
• To retaliate or hurt others
• To reflect re-experiencing behaviors consistent with reactions often noted in children who have been sexually abused
• To elicit an intense reaction from other children or adults
• To be motivated by needs of attention or power.
• To reflect natural curiosity at times, but may be misinterpreted on occasion as deviant
Sometimes sexual behaviors in children may actually be age-appropriate and likely contribute to normal and healthy sexual development. Sometimes children may not understand social expectations, or that the sexualized behaviors are socially unacceptable.
Distinguishing Worrisome from Healthy Sexual
Behaviors
A number of authors have written about sexualized behaviors
in children. William Friedrich has done considerable research
in this area and has begun to identify which sexual behaviors
are most likely to occur in boys and girls of different ages.(5)
For instance, touching one’s own sexual parts in private is
common for most children and usually not a worrisome behavior.
Toni Cavanaugh Johnson has identified characteristics that can help a parent or caregiver figure out if a sexual behavior is cause for concern or is simply a normal part of growing up.(6) However, even if you think that a behavior is normal and unrelated to sexual abuse, it is often helpful to discuss the behaviors with a professional who has expertise in this area if you have any concerns.
The following information has been adapted from the work of Toni Cavanaugh Johnson regarding Natural and Healthy Sexual Behaviors exhibited by children. It is her view that sexualized behaviors classified as natural and healthy represent an information gathering process. It is important to note that children engaging in normative sexual behaviors are:
- of similar age, size and/or developmental status
- engaged in mutual sexual exploration
- likely to display a lighthearted emotional expression
- limited in time and frequency
- balanced by curiosity about other aspects of his/her life
- may result in embarrassment when discovered by someone else
- ceases (in the presence of adults) when children are instructed to stop engaging in the behaviors
Dr. Johnson has also identified Problematic Sexual Behaviors in children. The list that follows is not exhaustive which means that other characteristics that are not included on the list can also be worrisome. Even worrisome behaviors do not mean that a child has been sexually abused. However, if you are concerned about a child’s sexual behavior, it is often a good idea to consult a professional with expertise in this area. The following sexualized behaviors are thought to be problematic:
• Sexual behaviors engaged in by children of different ages and/or developmental levels
• Sexual behaviors which are significantly different than those of same age peers
• Sexual behaviors that progress in frequency, intensity and intrusiveness over time
• Sexual behaviors that include animals
• Sexual behaviors that are intended to inflict pain or hurt others
• Sexual behaviors that have been coerced by other children by the use of force, bribery, manipulation or threats
• Sexual behaviors that cause children to react with fear, anxiety, shame or guilt
Sexually abused children may exhibit a range of emotional or behavioral problems as a result of their abuse experience. The type and degree of disturbance varies from child to child ranging from no obvious reaction to very mild reactions to extreme behavior changes. According to one published article, up to 40% of sexually abused children are asymptomatic.(4) This means that no symptoms or concerning behaviors were observed. It is important to note that no single symptom or behavioral profile can distinguish a maltreated child from his/her age-mates who have not been maltreated. Most of the behaviors exhibited by abused or neglected children are often associated with non-abuse related difficulties or other types of trauma experienced by children. Of the behaviors that may be seen in sexually abused children, most are also linked to extreme stress reactions in children and/or general child trauma. That means that a child’s behavioral changes can cause concern and be quite alarming because he or she has been sexually abused, but can also be caused by circumstances completely unrelated to child abuse.
The following behaviors are sometimes seen in sexually abused children. They are significant when they occur in conjunction with a child’s disclosure and/or if the child has been exposed to a known sexual offender. These symptoms and behaviors in and of themselves do not necessarily indicate sexual abuse, but may be indicative of some other problem or trauma.
Behavioral Reactions:
• Sleep distiurbances: night terrors; nightmares; trouble falling asleep; trouble staying asleep or sleeping alone.
• Changes in eating habits: compulsive or overeating; loss of appetite
• Changes in toileting habits including urinary or bowel accidents
• Increased aggression: directed toward self (including suicide attempts) or others
• Increased impulsivity and activity
• Academic problems: distractibility, concentration problems, lack of focus
• Reluctance or refusal to go home or to other environments
• Easily startled; seems to be tense quite often; difficulty relaxing and calming down
• Unexplained fears of, or avoidance of, specific individuals, places, objects or situations
• Separation anxieties: clinginess, school refusal
• Negative statements about oneself; a negative or pessimistic outlook
• Low energy
• Social withdrawal
• Somatic/medical complaints: commonly include gastrointestinal complaints, headaches, pain and general physical malaise
• Antisocial acts, such as hurting animals, setting fires and stealing
• Running away from home
Cognitive Reactions:
Emotional Reactions:
Some emotional reactions can be associated with the behavioral and cognitive reactions described above, as well as physiological changes that are more difficult to observe (e.g., increased heart rate). Children who have been sexually abused or otherwise exposed to extreme stress are often described as anxious, depressed, or as labile (having unusually strong mood swings) and they may have difficulty calming down or soothing themselves when they are upset. They can also appear to be very needy of adult attention, fearful of inciting adult displeasure, and/or unusually suspicious or fearful in situations that might not cause discomfort in others.
References:
(1) Massachusetts Department
of Social Services. Investigation Training: Evidence and Indicators of
Maltreatment. March 2002.
(2) U.S. Department of Justice. Portable Guides
to Investigating Child Abuse: Child Neglect and Munchausen Syndrome by
Proxy. September 1996.
(3) U.S. Department of Justice. Portable Guides
to Investigating Child Abuse: Recognizing
When a Child’s Injury or Illness is Caused by Abuse. June 1996.
(4) Kendall-Tackett KA, Williams
LM, Finklehor D. Impact of sexual abuse on children: a review and synthesis
of recent empirical studies. Psychol Bull, 1993; 113:164-80.
(5) Friedrich WN, Fisher J, Broughton D, Houston
M, Shafran CR. Normative sexual behavior in children: a contemporary sample.
Pediatrics, 1998; 101(4):E9.
(6) Cavanaugh Johnson T. Understanding the sexual
behaviors of young children. Siecus Report, August/September.
Adams Classification
Table Specific References:
(i) Berenson A, Heger A, Andrews S. Appearance of the hymen in newborns.
Pediatrics, 1991; 87:458-465.
(ii) Berenson AB, Heger AH, et al. Appearance of the hymen in prepubertal
girls. Pediatrics, 1992; 89:387-394.
(iii) McCann J, Wells R, Simon M, Voris J. Genital findings in prepubertal
girls selected for non-abuse: A descriptive study. Pediatrics, 1990; 86:428-439.
(iv) Heger AH, Ticson L, Guerraq L, et al. Appearance of the genitalia
in girls selected for nonabuse: Review of hymenal morphology and non-specific
findings. J Pediatr Adolesc Gynecol 2002;15:27-35.
(v) Berenson AB, Chacko MR, Wiemann CM, Mishaw CO, Friedrich WN, Grady
JJ. A case-control study of anatomic changes resulting from sexual abuse.
Am J Obstet Gynecol, 2000;182:820-834.
(vi) McCann, J, Voris J, Simon M, Wells R. Perianal findings in prepubertal
children selected for non-abuse: A descriptive study. Child Abuse &
Neglect, 1989; 13:179-193.
(vii) Centers for Disease Control and Prevention (CDC) Guidelines, MMWR,
Vol. 51, May 10, 2002. http://www.cdc.gov/std/treatment/rr5106.pdf
(viii) McCann J, Voris J, Simon M. Genital injuries resulting from sexual
abuse, A longitudinal study. Pediatrics, 1992; 89:307-317.
(ix) McCann J, Voris J. Perianal injuries resulting from sexual abuse:
A longitudinal study. Pediatrics, 1993; 91:390-397.
(x) Emans SJ, Woods ER, Allred EN, Grace E. Hymenal findings in adolescent
women: Impact of tampon use and consensual sexual activity. J Pediatr,1994;
125:153-160.
(xi) Berenson AB, Grady JJ. A longitudinal study of hymenal development
from 3 to 9 years of age. J Pediatr 2002;140:600-607.