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Nurse practitioner knowledge of child sexual abuse in children with cognitive disabilities

Koetting, Cathy DNP, APRN, NP‐C, CPNP1; Fitzpatrick, Joyce J. PhD, MBA, RN, FAAN2; Lewin, Linda PhD, APRN, BC3; Kilanowski, Jill PhD, APRN, CPNP4

Journal of Forensic Nursing: June 2012 - Volume 8 - Issue 2 - p 72–80
doi: 10.1111/j.1939-3938.2011.01129.x
Original Articles

The purpose of this study was to describe the knowledge level of nurse practitioners regarding symptoms of child sexual abuse in children with cognitive disabilities. A total sample of 43 nurse practitioners from two professional nurse practitioner organizations was surveyed to assess child sexual abuse symptoms identification in intellectually disabled children using a revised edition of the Child Sexual Abuse Knowledge Survey. Data collected showed nurse practitioners have deficits in identifying various parts of prepubescent female genitalia. The majority of nurse practitioners did not check genitalia in regular physical exams, did not feel competent to perform this type of evaluation, and were not aware of their professional organizations' position regarding checking for child sexual abuse. When assessing a child with an intellectual disability, nurse practitioners must accurately assess physical symptoms and behaviors that could have resulted from sexual abuse. Examining children for sexual abuse is a required duty of the nurse practitioner as evidenced by the position statements of the various professional organizations and nurse practitioners must be aware of their required scope of practice.

1 Assistant Teaching Professor, Sinclair School of Nursing University of Missouri–Columbia, Missouri

2 Elizabeth Brooks Ford Professor of Nursing, Frances Payne Bolton School of Nursing, Case Western Reserve Unversity, Cleveland, Ohio

3 Assistant Professor, College of Nursing Wayne State University, Detroit, Michigan

4 Nurse Scientist, Cincinnati Children's Medical Center, Cincinnati, Ohio

Correspondence Cathy Koetting, DNP, APRN, NP‐C, CPNP, Sinclair School of Nursing University of Missouri–Columbia, S 446, MO 65211. Tel: 314 780–7663; E‐mail:

Received: July 5, 2011; accepted: September 20, 2011

Due to a paucity of data, prevalence regarding sexual abuse of children with intellectual disabilities is difficult to determine (Horner‐Johnson & Drum, 2006). Few studies have made direct comparisons of sexual abuse of children with intellectual disabilities to nondisabled peers (Lin, Yen, Kuo, Wu, & Lin, 2009; Jaudes & Mackey‐Bilaver, 2008; Sullivan & Knutson, 1998). These studies found that children with intellectual disabilities are sexually abused two to three times more than nondisabled children (Lin Yen, Kuo, Wu, & Lin, 2009; Jaudes & Mackey‐Bilaver, 2008; Sullivan & Knutson, 1998).

Children with intellectual disabilities are especially vulnerable because such children are often not able to verbally disclose abuse, nor understand which acts are abusive (Murphy, O'Callaghan, & Clare, 2007). They are rarely able to protect themselves or obtain assistance in the criminal justice system (Gammachia & Gammachia, 2011). They may have extended dependence on caregivers (either parents or multiple caregivers in a residential facility), place higher emotional, social, and economic demands on their families, and may lack the ability to access resources such as transportation to the police station or appropriate sex education (Hershkowitz, Lamb, & Horowitz, 2007; Hibbard & Desch, 2007; Sullivan, 2009). Children with intellectual disabilities may experience social isolation, have poor communication skills, and many have comorbid psychological diagnoses that decrease their credibility when disclosing sexual abuse (Hershkowitz, Lamb, & Horowitz, 2007; Henry, Ridley, Perry, & Crane, 2011).

The term intellectual disability is the most current and preferred term in place of mental retardation (Szymanski, Friedman, & Leonard, Chapter 31). Developmental disability is a legal term pertaining to entitlements in the law such as determination for Medicaid. At the 2011 National Child Advocacy Conference, speakers from the disciplines of psychology, social work, and education noted the new terminology (Baladerian, 2011; Johnson & Pawleski, 2011). For example, intellectual disabilities include the diagnoses of autism, Down syndrome, mental retardation, cerebral palsy, and traumatic brain injury. Levy and Packman (2004) indicated that when treating children with intellectual disabilities, healthcare providers must be cognizant of the fact that disabled children are not entirely capable of knowing, thinking, learning, and judging like their nondisabled peers. According to Hibbard & Desch (2007), the existence of a disability is a risk factor for sexual exploitation of a child.

Assessing for abuse is a responsibility of pediatric nurse practitioners (PNPs) and family nurse practitioners (FNPs). The American Academy of Pediatrics (AAP), the National Association of Pediatric Nurse Practitioners (NAPNAP), and the American Academy of Family Physicians (AAFP) all have position statements addressing required practitioner knowledge of the need to identify symptoms of childhood sexual abuse (CSA). Of note, NAPNAP identifies disability as a risk factor.

Because little is known about the knowledge that PNPs and FNPs have regarding CSA in intellectually disabled children, the study was undertaken. The purpose of the study was to examine the accuracy of nurse practitioner knowledge of sexual abuse in clinical case studies that included descriptors of children with intellectual disabilities. Although the bulk of the study focused on knowledge about physical signs, behavioral signs were also assessed in the clinical case study questions that specifically pertained to children with intellectual disabilities.

Because identification of sexual abuse in children with intellectual disabilities is the focus of this paper, a discussion of the importance of behavioral assessment is included. This information will help NPs identify CSA in this population by becoming aware of behavior and behavior changes that are consistently identifiable. Since physical symptoms and a verbal disclosure may not be present, NPs need to understand that behavior may be the only diagnostic indicator of CSA in the intellectually disabled population. However, diagnosing CSA from behaviors is a formidable task to undertake for an NP. Nurse practitioners treating children with intellectual disabilities must attempt the task as it can help protect these vulnerable children from the population of perpetrators who wish to abuse them.

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Literature review

Rank ordering of the probability of sexual abuse was developed by Adams et al. (2007) based on research establishing a gold standard for physical findings. These guidelines (Adams et al., 2007) help NPs performing CSA assessments to evaluate their findings. Because only 5% of the abused population reveal physical findings strongly suggestive of abuse, it is important for nurse practitioners to realize that intellectually disabled children along with nondisabled peers will most likely have normal exams (Adams, Harper, Knudson, & Revilla, 1994; Berenson, Chacko, Wiemann, & Mishaw, 2000). Hence, the nurse practitioner must rely on other findings such as behavior. Behavioral assessment is difficult to evaluate in this population.

Hornor and McCleery (2000) surveyed the knowledge of PNPs regarding physical symptoms of child sexual abuse. They used a revised version of a questionnaire developed from two previous studies by Lentsch and Johnson (1999) and Ladson, Johnson, and Doty (1987). Results of the Hornor and McCleery's study found that 67% of PNPs said that they check the genitalia of prepubescent females more than 50% of the time, and that when asked to identify anatomic parts of the genitalia on a 6 year old, fewer than 60% of the PNPs identified the hymen and vaginal opening correctly. Findings also included data showing the extent to which nurse practitioners knew that sexually transmitted infections contributed to findings of CSA.

Horner and McCleery (2000) concluded that PNPs may lack the ability to interpret the significance of physical findings or lack an understanding of mandated child abuse reporting laws. Although 84.7% of the PNPs correctly identified that one figure had a missing hymen, only 77.6% stated that they would report those findings to child protection services (CPSs).

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Evaluation of childhood sexual abuse in children with intellectual disabilities

Kvam (2000) highlighted two major issues for NPs by evaluating intellectually disabled children for sexual abuse. First, as most intellectually impaired children may not be able to verbalize abuse, sexual abuse may only be diagnosed when children are seen for physical symptoms of sexually transmitted infections or pregnancy. Studies have shown that victims of CSA were twice as likely to report having had a sexually transmitted disease (STD) and were three times more likely to report more than one type of STD (Allsworth, Anant, Redding, & Peipert, 2009; Buffardi, Thomas, Holmes, & Manhart, 2008; Wilson and Widom, 2009). Second, the presence of any change in behaviors, particularly those that may be reported by parents, should be seen as a possible sign of sexual abuse in intellectually disabled children and should be investigated and reported to CPS.

The foundational study that used behavioral assessment to evaluate sexual abuse in children with intellectual disabilities was reported by Mansell, Sobsey, and Moskal (1998). Behavioral findings from this study are relevant for practitioners today. Mansell and colleagues used the Sexual Abuse Information Record (SAIR), a 149‐item instrument designed to provide a precise and organized reporting record for events and findings associated with CSA. Data were obtained from counseling sessions with sexual abuse victims, 43 with intellectual disabilities and 43 without. Behavioral symptoms for children with intellectual disabilities were similar to those of children without intellectual disabilities. The researchers concluded that some counseling session data were the result of responses to sexual abuse by the children with learning disabilities rather than symptoms of the disability because data on these variables showed statistical significance (Mansell, Sobsey, & Moskal, 1998). These variables were withdrawal, self‐injurious behavior, inappropriate sexual remarks, and unusual comments about family members and home (Mansell, Sobsey, & Moskal, 1998). In his role as a clinical psychologist for Canadian courts, Albin (1992) discussed observed behaviors of young intellectually disabled females who had a history of sexual abuse. Overt random sexualized behaviors such as reaching out, grabbing, or hitting adult genitals and lying on top of other children were observed by teachers and healthcare providers. Unusual positioning at bath and bedtime plus self‐caressing, masturbation along with the use of obscene language was also observed. Albin noted that these behaviors occurred with greater frequency than in other intellectually disabled children, and they occurred quite randomly and during inappropriate social situations. Symptomology noted by Mansell, Sobsey, and Moskal and Albin comprise the bulk of behaviors documented in other studies.

Specifically focused on children with Autism spectrum disorder (ASD), Mehtar and Mukaddes (2011) used three different instruments to investigate the prevalence of problematic behaviors and behavioral change, diagnosis of post‐traumatic stress disorder (PTSD), and presence of trauma symptoms in a population of 69 children with ASD. Trauma history was positive in 18 of the 69 children (11 boys and 7 girls). Of those, 12 met the full DSM‐IV criteria for PTSD. Trauma symptoms most frequently seen were regression/deterioration in verbal communication, regression in social interactions, increases in aggression, anger bursts and distractibility, and increases in disruptive behavior, self‐harm behavior and ritual behaviors, and stereotypic movements (Mehtar & Mukkaddes, 2011).

In Edelson's (2008) review, factors that increase sexual abuse risk and interfere with recognition of abuse in children with autism were summarized. It was noted that research regarding missed behavioral signs of sexual abuse in children with autism is limited. Edelson reported that sexually abused children with autism may have an increase in their stereotypical behaviors or even development of new behaviors. Nonverbal children with autism may try to disclose their abuse with behavioral symptoms such as self‐injurious behaviors, but those behaviors are written off many times as symptoms of the autism (Edelson).

Sexualized behaviors may be indicative of sexual abuse when classified as sexually reactive and sexually abusive behaviors. Sexually reactive and sexually abusive behaviors typically develop as a reaction to traumatic events, over stimulating environments, and abuse (Edelson, 2008; Cavanagh‐Johnson, 2002). Sexually reactive behaviors are the result of exposure or direct contact with inappropriate sexual activities, sexual behaviors, or relationships.

As a clinical expert, Peckham (2007) notes that in referral letters to the clinical practice, the symptoms of sexualized behavior, anger management, and self‐harm are most frequently mentioned in learning disabled patients, needing support and interventions for a history of sexual abuse. Focht‐New, Clements, Barol, Faulkner, and Service (2008) describe distinct patterns of behaviors in people with intellectual disabilities exposed to trauma including sexual abuse. Avoidant patterns emerge as excessive fear of others, particularly those who may be in close contact with the patient during shift work in a group home or agency. The patient may verbalize memories of events that seem unrelated to the observer. This pattern is also manifested in distant daydreaming and withdrawal, avoidance through phobic‐type mannerisms, and a regression of skill development.

Focht‐New et al. (2008) also describe an aggressive pattern. The main symptom of this pattern is hostility toward self or self‐injurious behavior. There is acting out that is beyond baseline, and actions may include suicide attempts over insignificant appearing events. These findings are supported by Sequeira, Howlin, and Hollins (2003). In the only case‐controlled study to date, 54 adults with intellectual disabilities who had experienced sexual abuse were matched with 54 adults without history of sexual abuse and assessed by several instruments for behavior, mental health problems, general symptoms, and PTSD symptoms. Results showed the median age at which the patient was abused was 15 years. Behavioral scores in the abused group were significantly higher when rating the presence of lethargy, stereotypical behavior, self‐injurious behavior, and sexualized behavior. Comorbid mental health problems were found to be significantly higher in the abuse group. These comorbid conditions were depression, panic disorder, and hyperinsomnia (Sequeira, Howlin, & Hollins, 2003).

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Summary of the literature

The NP has a duty to assess for symptoms of sexual abuse in children. If a child has intellectual disabilities, the NP should have a heightened awareness of the increased risk for sexual abuse. What constitutes physical symptoms of CSA have been outlined in the Adams et al. (2007) standards, and every NP evaluating children with intellectual disabilities should be acquainted with the probability descriptions. The results of the study by Hornor and McCleery exemplify that many PNPs still lack basic knowledge regarding CSA.

Like their nondisabled peers, children with intellectual disabilities may not present with any positive physical symptoms of CSA, so NPs must also be aware of possible behavioral symptoms of sexual abuse. Investigators that describe significant specific behaviors following sexual abuse found that children with intellectual disabilities may present with a history that shows recent withdrawal, increase in self‐injurious behavior, verbalizations of inappropriate sexual comments, and new and random presentations of sexualized behavior. Children with a history of stereotypic behaviors may have an increase in this behavior. Along with these behaviors, NPs must also evaluate for other comorbid disorders such as depression, anxiety, and PTSD, especially if there is an increase in the severity of symptoms.

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Gaps in the literature

Children with intellectual disabilities have largely been excluded from research on child sexual abuse (Theodore & Runyan, 1999; Mandell, Walrath, Manteuffel, Sgro, & Pinto‐Martin, 2005). Healthcare professionals need increased awareness of the vulnerability of intellectually disabled children (Kendall‐Tackett, Lyon, Taliaferro, & Little, 2005).

A critical gap in information is the prevalence of sexual abuse in children with intellectual disabilities. The Child Maltreatment Report is compiled from the National Child Abuse Neglect and Data System (NCANDS) (2011) with information submitted by each state. NCANDS includes the source of CSA reports, age, and gender of victims and perpetrators, relationship of perpetrator to victim, services received, and incidence of child maltreatment by race and ethnicity. However, none of the characteristics include disability. Healthcare providers need to know how to evaluate CSA in intellectually disabled children by increasing their clinical skills through training (Sequeira, Howlin, & Hollins 2003; Foct‐New, Clements, Barol, Faulkner, & Pekala Service, 2008). Demonstrated knowledge deficits by NPs support the need for further education (Hornor & McCleery, 2000). Thus, a complete evaluation would include both physical and behavioral assessment. The focus of this study was on the accuracy of identification of physical and behavioral symptoms in the clinical scenarios.

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This descriptive study was conducted among FNPs and PNPs who were members of their local NP associations in the state of Missouri. Board officers from two NP organizations granted permission to solicit participation from their members. Following Institutional Review Board approval, the entire population of 250 NPs who were members was sent a questionnaire by U.S. Postal Service to complete. The questionnaire recipients were given 2 months to complete and return the packet to the investigators. Each subject had to be a certified PNP or certified FNP in the states of Missouri or Illinois.

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The Child Sexual Abuse Findings Knowledge Assessment (CSAFKA) was adapted from the questionnaire developed by Hornor and McCleery (2000) and revised to reflect information about evaluation of CSA in children with intellectual disabilities. The 26‐item questionnaire asked NPs whether they check the genitalia of prepubescent patients presenting for physical exams; knowledge of normal and abnormal prepubescent genital anatomy; and the recognition of the association between STDs and sexual abuse. These concepts were retained from the Hornor and McCleery survey. In the CSAFKA, items were scored by adding the correct number of answers and obtaining a score of child sexual abuse knowledge. A score of 26 was the highest possible total score.

Content validity of the CSAFKA questionnaire was established by a panel of three expert reviewers. The original instrument used in the Horner and McCleery study was sent to two expert PNPs actively practicing in CSA. The reviewers evaluated each test item using the Child Sexual Abuse Knowledge Questionnaire Expert Reviewer Assessment Tool, a four‐point ordinal rating scale (1 = not relevant; 2 = unable to assess relevance without item revision; 3 = relevant but needs minor alteration; 4 = relevant and succinct) (Burns & Grove, 2005). Each expert rated the test items as a 3 or 4. The CSAFKA questionnaire was revised based on the expert review recommendations. Since revisions were made, the questionnaire was sent to a third reviewer, a PhD, prepared PNP who used the same expert reviewer assessment guide to complete a content validity evaluation. All expert reviewers provided independent reviews without consultation with each other. The suggestions for improvement were implemented by the primary investigator and appeared in the final version. The original photographs included in the questionnaire were deleted and the addition of HIV and HPV as STDs were added as a result of the two‐tier content validity review. The new photographs used for the CSAFKA were given to the primary investigator from a colleague who is a practitioner in evaluation of CSA and gave permission for their use. These particular photographs were from a set used for teaching and were all photographs of normal anatomy to show the diversity of normal prepubescent anatomy. Their quality was improved over the original photographs and they were shot using a state‐of‐the‐art colposcope.

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A total of 50 survey packages were returned for a response rate of 20%. Of those 50 responses, 43 packages (86% of responders) were included in the data analysis. Seven of the 50 responders (14%) were excluded because they did not meet inclusion criteria. Demographics and educational characteristics of the sample population are presented in Table 1.

Nearly all of the respondents (97.7%) reported treating children with intellectual disabilities; 93% treated 0–21 years of age group and 7% treated the 18 months to 99 years range. Eighty‐six percent had never provided any testimony in court regarding child sexual abuse about a patient. Less than half stated they regularly examine the genitalia of prepubescent girls when performing a physical exam (46.5%); 32.6% do so less than 50% of the time, and 20.9% stated they never check. Most NPs (83.7%) indicated that they were not comfortable performing a CSA assessment. Lastly, 69.8% replied that they did not know their professional organization's position regarding checking for CSA during an examination. The average sexual abuse training received to perform job duties was 6.02 hours (SD = 12.26) and the average child abuse continuing education over a 1 year period was 2.45 hours (SD = 7.85)

Knowledge was measured by a score on the CSAFKA. A frequency distribution showed a range of 9–24. The mean score was 17.95 (SD = 3.13). The median score was 18.5 and the mode was 19. There were a total of 26 items that were scored, each item was worth one point. Because of the small response rate, the primary investigator checked for a normal distribution of the knowledge scores using values for skewness and kurtosis calculated from SPSS. A normal distribution contains a value of zero for skewness and kurtosis. The 95% confidence interval for skewness was −0.86–0.419; the 95% confidence interval for kurtosis was −0.85–1.95. Because both of these confidence intervals capture zero, the conclusion is that the variable knowledge scores is probably normally distributed in the population.

Participants were asked to identify the anatomic structures of the genitalia from a photograph of a 6‐year‐old female labeled as photograph A. The genital structures were highlighted in the photograph. The rate of correct response by NPs is in Table 2

The CSAFKA evaluated nurse practitioners’ knowledge of STDs. Respondents were asked if a positive genital/anal/oral culture report or a positive blood test for gonorrhea, Chlamydia, syphilis, Herpes genitalis, trichomonas, HIV, or HPV in an otherwise healthy 6‐year‐old female was suggestive of sexual abuse, and/or was reportable to CPS. Respondents were also given the option to apply multiple answers. Another part of the CSAFKA survey evaluated nurse practitioners’ accuracy of identification of abuse as a cause of sexually transmitted infections. Gonorrhea, Chlamydia, syphilis, herpes genitalis, trichomonas, HIV, and HPV knowledge was tested. These results are included in Table 3.

Items 17–25 presented four photographs with questions regarding the photos. Photograph A was also used to determine whether respondents could identify it as representing normal prepubescent anatomy; 81% identified it correctly as a photograph of normal anatomy of a 6‐year‐old girl. Respondents were also told that the female in photograph A had given a history of penile penetration by her stepfather. When asked, 73.8% of respondents correctly replied that a child could have a normal genital examination after a reported history of penile penetration of the vagina.

Two questions were posed of the respondents for photograph B, identified as representing a 7‐year‐old female with autism and limited language skills, a history of self‐stimulation of her genital area, and no disclosure of sexual abuse. Regarding photograph B, 64.3% of respondents correctly identified that it was a photograph of normal genital anatomy, while 73.8% correctly identified that the child should not be reported to CPS for sexual abuse.

Photograph C was described as a photograph of a 4‐year‐old female with a history of severe brain injury from shaken baby syndrome at age 8 months and presenting with a history of dysuria. An overwhelming 78.6% of respondents stated that photograph C was not normal, while 21.4% correctly identified photograph C as normal genitalia of a 4‐year‐old. In reality, the photograph was of a 4‐year‐old female who presented with a history of dysuria and blood in her underwear, yet upon examination did not have any visible blood and had a normal crescentic hymen.

For the two questions for photograph D, respondents were told that this was a photograph of a 14‐year‐old male with Down syndrome. This 14‐year‐old presented with a red, triangular indentation with thick edges in his anus, and was not disclosing sexual abuse. Respondents were also told that the child's mother reported that he had constipation problems about 6 months ago, but has been “soft and regular” since that time. In this scenario, 57.1% of the respondents correctly identified that the photograph depicted an anal fissure and this was a nonspecific finding that did not warrant a report to CPS, considering that the child was not reporting abuse. However, 33.3% incorrectly identified it as an anal fissure that was diagnostic of sexual abuse and reportable to CPS. The last question had never been asked in any of the previous studies. When asked if respondents knew whether children with disabilities are sexually abused three times more than nondisabled children, 97.6% answered true, a correct answer.

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Healthcare providers need to know how to evaluate CSA in intellectually disabled children (Sequeira, Howlin, & Hollins, 2003; Focht‐New et al., 2008). The demonstrated knowledge deficit in this study supports the need for further education. In determining the knowledge NPs possess, it is important to uncover some of their daily assessment practices. Routinely examining the genitalia of prepubescent females was one assessment practice that was of interest in the study. Only 46.5% of the respondents stated that they checked the genitalia more than 50% of the time. This figure is considerably lower than the 67% found in the study by Hornor and McCleery (2000), and 72% in the Lentsch and Johnson study of physicians’ rate of checking. Knowing that less than half of the sample performed this assessment gives insight into the data about the accuracy of identifying normal anatomic genital structures. The participants identified the clitoris with 69% accuracy; posterior fourchette, 52.4%; hymen, 71.4%; labia minora, 47.6%; urethral orifice, 90.5%; and vaginal orifice, 78.6%.

Respondents looked at photographs of genitalia and responded to questions about interventions and outcomes given a particular scenario that highlighted behaviors of children with intellectual disabilities. The results of question 23 showed that only 21.4% correctly identified photograph C as normal prepubescent genitalia. This finding demonstrates that NPs have difficulty recognizing the diversity of 4‐year‐old prepubescent female anatomy, perhaps, because they are not looking at it on a regular basis in everyday practice. However, it may also indicate that in the case scenario, the behavior and disability were a significant distracter for the NP, which may indicate that some respondents were assessing the child's behavior as a part of the total evaluation.

The data for question 25 showed that 57.1% of the sample correctly identified the photograph as an anal fissure and not diagnostic of CSA in the absence of a verbal disclosure. A finding of an anal fissure is not necessarily diagnostic of sexual abuse (Adams et al., 2007)

Lastly, an important contribution of this study is its coverage of the issue of CSA in children with intellectual disabilities. This is the first study of its kind to study NP knowledge about assessing sexual abuse in children with intellectual disabilities.

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Study limitations

The self‐selected sample from these two memberships may be representative of NPs who have a higher degree of professional interest that may not be present in other NPs who are not members of these two organizations. This limits the ability to generalize the findings of the study to other local nurse practitioner organizations.

Other limitations are the small sample size and low response rate. Hornor and McCleery (2000) theorized that nonresponders may have been intimidated by the subject matter or lacked sufficient time to complete the survey. This sample was given 8 weeks to complete the survey. Because all the photographs had case scenarios that pertained to the assessment of children with intellectual disabilities, the difficulty of the questions was increased.

Sample data regarding evaluation of CSA in children with intellectual disabilities could be attributed to the case study questions that focused on children with intellectual disabilities. As a result, it would be helpful to compare data obtained through one sample evaluating disabled children and nondisabled children using the same photographs. This research could help determine whether the results of the present study were obtained due to NP's lack of ability in assessing children with disabilities.

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Clinical implications for forensic practice

NPs practicing in all specialties that treat children must be aware that they may observe symptoms of CSA. In particular, primary care NPs who assess and provide care to children in their daily practice should become more familiar with the four: routine screening, risk, recognize and report, specifically when they are evaluating a child with an intellectual disability.

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Routine screening

As a part of daily clinical practice, NPs should be screening all children for possible sexual abuse. Routine screening as the standard of care is mandated by professional NP organizations; therefore, NPs should examine all anatomical structures during routine physical examinations. This study provided evidence that many NPs do not do this screening on a daily basis.

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Responses regarding case scenarios about possible sexual abuse in children with intellectual disabilities showed that NPs may not be aware of the increased risk factors for this population. NPs must realize that this population has an increased risk due to heightened family stressors, poor communication skills, dependence on caregivers, and possible comorbid psychological disorders. Asking parents about how they cope and handle stress due to their child's intellectual disability is one way to connect with parents and gain information about risk. Practicing use of empathic communication skills will help NPs with this task.

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NPs need to increase their skill of recognition of possible symptoms of sexual abuse. Children with intellectual disabilities may present with an absence of physical symptoms. However, learning to evaluate the child's baseline patterns of behavior and changes in this behavior will help NPs determine possible behavioral symptoms of sexual abuse. This study showed that NPs have knowledge deficits regarding the ability to identify anatomic structures and difficulty recognizing normal variants of female prepubescent genitalia. Although the participants said that they treat children with intellectual difficulties regularly, it appears that when evaluating a child with an intellectual disability who may have been sexually abused, NPs are unsure if the symptoms present are a result of CSA or a behavioral symptom of the disability. Knowing and understanding the child's typical behavior as manifested in the disability will help NPs to determine worrisome behavioral symptoms that may be indicative of CSA.

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In a case of suspected abuse, particularly in a child with intellectual disabilities, NPs are mandated to report these concerns immediately to law enforcement and the local child protection agency. The agency will assign a caseworker and investigative officer to the case. These individuals will help to set up a child sexual abuse evaluation at a local Child Advocacy Center (CAC). CAC employees have special training to interview and examine sexually abused children. Many have experience working with children with intellectual disabilities.

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Recommendations for further research

Children with intellectual disabilities are encountered by NPs in family and pediatric primary care. In order for NPs to increase their competency in identifying symptoms of sexual abuse in this population, further studies should focus on the assessment of skills in the identification of anatomical deviance and the ability to discern normal genital anatomy in all children. The CSAFKA can be used to compare the NPs ability to evaluate children with and without intellectual disabilities.

More research may also include the development of tools to help NPs accurately assess the behavior of intellectually disabled children. These should focus on the fact that an evaluation for CSA includes both physical and behavioral assessment of the child. In addition, if a child has an intellectual disability, the NP should be knowledgeable about the disability and the associated spectrum of behaviors.

Lastly, studies that focus on accurate rates of CSA prevalence in children with intellectual disabilities are also needed. All forensic providers doing intake assessments on children should be provided with a section on the form to check whether the child has a disability if that information is known. This information would start to build a database from which to gather more accurate statistics about the extent of this problem.

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The population of people with disabilities continues to grow. In 2007, the Centers for Disease Control (CDC) reported that the Autism spectrum disorder was the fastest growing developmental/intellectual disorder in the United States and it is estimated that one in every 110 American children has an ASD. The report also stated that the experts predict that rate will continue to rise (CDC, 2007).

Children with intellectual disabilities are also a result of the large amount of premature births in the United States. The rate has risen 13% with one in eight babies born before 37 weeks (Stowkowski, 2006). It is known that premature birth increases a child's risk of learning and other intellectual disabilities, which include low IQ, language delay, poorer school achievement, and learning and intellectual disabilities (Rose, Feldman, Janksowski, & Van Rosem, 2005). As the intellectually disabled population grows, the need for NPs who are knowledgeable in their care also increases. Knowledgeable NPs will be able to improve recognition and treatment of CSA.

As children with disabilities grow into adults with disabilities, NPs who treat children with intellectual disabilities have an opportunity to become expert in the evaluation of CSA symptoms in this population. Expert NPs can become the foundation for educating and training fellow healthcare providers. They have the opportunity to play a pivotal role in disability research and policy with the goal of becoming knowledgeable advocates for people with intellectual disabilities, and a part of the solution to help stop the abuse.

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Key Words: Child sexual abuse; children with intellectual disabilities; forensic nursing; nurse practitioner

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