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Research Article                                                                                                                                                        Open Access

## Child Abuse Management Units: How can Mental Health Services be Further Improved?

Hanne K. Greger 1 , Thomas Jozefiak 1 , Arne K. Myhre 2

1 Department of Child and Adolescent Mental Health, St. Olav's University Hospital, Trondheim, Norway; Regional Centre for Child and Youth Mental Health and Child Welfare, Norwegian University of Science and Technology, Trondheim, Norway;  2 Children's Clinic, St. Olav's University Hospital, Trondheim, Norway; Department of Public Health and General Practice, Norwegian University of Science and Technology and Regional Resource Center, St. Olav's University Hospital, Trondheim, Norway

Corresponding Author: hanne.k.greger@ntnu.no

## Abstract

Background: Child abuse is  a  broad  term  that  includes  physical, sexual, and emotional (e.g., psychological, verbal) abuse. There are huge variations with regard to the level of severity and the consequences of abuse. Because child abuse is such a sensitive topic, it is a challenging task to conduct studies concerning this subject.

Objective: The aim of the study was to identify areas that could be improved to offer better health care services to patients. Therefore, routine assessments, the characteristics of the cases, and the types of follow up were emphasized.

Method: The Norwegian Ministry of Health and Care Services provided an exception from the principle of informed consent so that this study could be conducted. We had access to the medical records of all children between the ages of 0 and 14 years old who were referred to the regional child abuse management unit in 2006 and 2007. A descriptive, cross-sectional study was performed.

Results: One hundred and six children were referred to the child abuse management unit. For the majority of these patients (80.2%), sexual abuse was the only concern. The children presented diverse psychological and somatic symptoms and problems. Psychosocial functioning was in general not properly described in the records. Four out of five of the children were referred to services for follow up after the first examination in the child abuse management unit. Only 36% of the children were referred to child protective services.

Conclusion: This  study  revealed  that  psychosocial  functioning  is  seldom  documented  and  that  psychological  symptoms could be described more reliably and in more detail. A systematic approach may be helpful for health care providers, and we suggest the implementation of valid evidence-based instruments, such as the Child Behavior Checklist and the Children's Global Assessment Scale.

Key words: Child abuse, abuse management, health services, psychosocial functioning

## Introduction

Child  abuse is  a  broad  term  that  includes  physical, sexual,  and  emotional  (e.g.,  psychological,  verbal) abuse. There are huge variations with regard to the level of severity and the consequences of abuse. In extreme  cases,  abuse  can  cause  death,  but  mostly the  physical  damage  will  have  limited  influence  on the development and future well-being of the child. The psychological effects and the long-term consequences of abuse on the child's cognitive, emotional, and neurological development will generally be more important (1-3). Previous studies have shown an association between  childhood  abuse  and  a number  of  mental  and  physical  health  problems later in life, such as depression, post-traumatic stress disorder  (PTSD),  anxiety  disorders,  and  attentiondeficit/hyperactivity disorder (2-10).  The young human  brain  is  highly  plastic  and  able  to  change. Adverse experiences, such as childhood abuse, can modify  brain  structures  and  increase  the  risk  of impaired health later in life (7;11-14).

The  estimated  prevalence  of  child  abuse  is  substantial  throughout the world. International studies in high-income countries based on self- or parental reports estimate a yearly prevalence of child physical abuse of 5% to 35%, of child psychological abuse of 4% to  33%,  and  of  child  sexual  abuse  of  15%  to 30% for girls  and  5%  to  15%  for  boys  (5).  These numbers seem to be representative for the Norwegian population as well (15).

Health  care  for  alleged  victims  of  abuse  can  be organized in different ways. The main purposes of child abuse management units (CAMUs) are to treat acute and long-term health problems and to provide forensic  services.  One  of  the  challenges  involving the organization of CAMUs concerns how to provide  mental  health  care  to  patients  (16).  In  the county  of  Sør-Trøndelag  in  Norway,  one  CAMU has  chosen  to  establish  a  low-threshold  hospitalbased  service  for  children  that  is  organized  in  the specialist  health  care  service  located  at  St.  Olav's Hospital  in  Trondheim.  Nurses,  pediatricians,  and psychologists work as an interdisciplinary team that optimizes services and care for these patients. Patients are offered emergency medical care, which is available at all hours, as well as long-term followup care with professionals, if needed. The treatment team  also  cooperates  with  law  enforcement,  child protective services, and child and adolescent mental health services (CAMHS).

When organizing an interdisciplinary, lowthreshold,  hospital-based  unit  of  this  kind,  healthservice research should also be included. However, few  studies  have  been  conducted  in  Scandinavian countries on this topic, and matters of confidentiality complicate this task.

Adult survivors of childhood abuse are at severely increased  risk  of  developing  impaired  physical  and mental  health  (2-3;7).  An  optimized  health  service for  children  and  adolescents  who  have  been  exposed  to  abuse  may  prevent  some  of  these  problems,  but,  to  achieve  this,  it  is  essential  for  the clinician  to  know  what  kinds  of  assessments  and treatments  are  best  for  each  patient.  A  systematic and  evidence-based  assessment  would  be  an  important prerequisite for gaining this knowledge.

The primary aim of this study was to identify areas that could be improved to offer better and more holistic health care services to patients. To achieve this, we wanted to focus on the routine assessment that  occurs  in  the  unit;  the  characteristics  of  the abuse, including the diversity of symptoms presented;  and  the  type  of  follow-up  services  provided  to children referred to the CAMU.

## Methods

Subjects

This is a descriptive, cross-sectional study in which we have included all patients between the ages of 0 and 14 years old who were assessed by a psychologist  in  a  hospital-based  CAMU  from  January  1, 2006, to December 31, 2007. The majority (79%) of these patients were also examined by a pediatrician. The patients were identified by searching the hospital  patient  administrative  system  and  by  gathering information from colleagues in the CAMU. A total of 106 patients (79 girls and 27 boys) were seen in the  unit,  either  by  direct  contact  or  after  referral from other professionals. The patient records were studied,  and  they  contained  the  reports  of  both psychologists  and  pediatricians.  The  ages  of  the patients were registered in age intervals (0 to 4, 5 to 9,  and  10 to  14)  after  a  recommendation from the Norwegian  Ministry  of  Health  and  Care  Services. The demographic distribution is shown in Table 1.

TABLE 1. Demographic distribution

|               |                              |   n |    % |
|---------------|------------------------------|-----|------|
| Sex           | Girl                         |  79 | 74.5 |
|               | Boy                          |  27 | 25.5 |
| Age           | 0 to 4 years                 |  25 | 23.6 |
|               | 5 to 9 years                 |  41 | 38.7 |
|               | 10 to 14 years               |  40 | 37.7 |
| Residence     | City                         |  45 | 42.5 |
| (missing = 1) | Village                      |  31 | 29.2 |
|               | District                     |  29 | 27.4 |
| Care          | Both biol. parents           |  28 | 26.7 |
| situation     | One biol. parent             |  41 | 39.0 |
| (missing = 1) | Biol. parent and step-parent |  19 | 18.1 |
|               | Other*                       |  17 | 16.2 |

*adoptive parents, foster parents, child welfare institution

## Instruments

Scoring manual

We developed a scoring manual for retrospectively collecting  information  from  the  patient  records. Before reading the records, scoring categories were chosen after literature studies and discussions with experienced  colleagues  (17).  For  example  some  of the  variables  related  to  mental  symptoms  (e.g.,  externalizing,  internalizing,  attention  problems)  were constructed on the basis of the main categories of the  Child  Behavior  Checklist  (CBCL)  (18).  The CBCL is an integrated part of the Achenbach System  of  Empirically  Based  Assessment,  which  provides  an  evaluation  of  children  and  adolescents from  several  informants.  The  CBCL  measures  the total  emotional  and  behavioral  problems  of  the child,  and  it  can  identify  different  syndrome  clusters, including the variables mentioned previously.

One  of  our  variables  addressed  whether  it  was concluded that abuse had taken place or not. This scoring was based on the following: 1) medical findings (i.e., the presence of hymenal transection, sex- ually transmitted disease, scars, and wounds (19)); 2) information in the patient record about a suspected abuser's conviction in court; and 3) information in the  patient  record  about  whether  the  abuser  had confessed  to  the  incident.  We  chose  to  categorize abuse with regard to its  type  and  severity,  because we wanted to investigate whether there were differences  in  symptom  load  or  assessment  that  were dependent  on  these  factors.  It  has  been  shown  in earlier  studies  that  different  types  of  childhood abuse can have long-term consequences on mental and  physical  health  (5;20).  Severe  sexual  abuse  included  forced  masturbation  and  anal,  vaginal,  or oral  penetration.  Moderate  sexual  abuse  included the  touching  or  fondling  of  an  intimate  area,  the viewing  of  pornography,  and  other  sexual  acts. Severe physical abuse included violence that resulted  in  fractures,  internal  bleeding,  or  other  injuries that demanded medical attention and care, whereas moderate  physical abuse included violence that resulted in wounds, bruises, or no visible marks at all.  Psychological  abuse  was  not  categorized  by severity.

We  also  registered  what  kind  of  follow  up  the children  received  after  their  first  examination.  For some  of  the  patients,  especially  those  from  other regions of the country, this included the follow-up care that was recommended by either pediatricians or psychologists at the CAMU. Further adjustments were made after reading the medical records. Variables that proved not to be useful for organizing the text  of  the  medical  records  were  omitted,  and  we ended up with a scoring manual that included 171 variables (Appendix).

## The Children's Global Assessment Scale

The Children's Global Assessment Scale (CGAS) is widely  used  by  health  professionals  to  assess  the psychosocial  functioning  of  children  and  adolescents on a scale from 0 to 100, where 100 = 'Excellent  psychosocial  functioning'  and  0  =  'Extreme and pervasive dysfunction.' The CGAS has demonstrated satisfactory psychometric properties (21). In this  study,  we  tried  to  set  a  CGAS  value  that  was based  on  information  taken  only  from  the  patient records.  The  CGAS  is  mainly  used  for  children  in the age range of 4 to 16 years. We therefore chose not to use the CGAS to rate children in the youngest age group.

## Procedures

The  first  author  read  all  of  the  identified  patients' medical  and  psychological  records  (DocuLive)  and registered the information according to the scoring manual  during  the  period  from  October  2011  to December  2011.  The  second  author  also  read  11 medical  records,  which  were  arbitrarily  selected.

Potential  differences  in  interpretation  and  scoring between the authors were then discussed to increase the quality of the scoring procedures.

## Statistics

We used descriptive statistics.  Categorical  variables were analyzed with the chi-squared test. An alpha of .05 was chosen to indicate the level of significance needed for the study.

## Ethics

Because  of  the  sensitive  nature  of  the  study,  we applied  to  the  Norwegian  Ministry  of  Health  and Care  Services  for  exception  from  the  principle  of informed consent. The reason for this was that we wanted to protect children and their families from retraumatization  by  reliving  unpleasant  memories that  may  occur  during  the  process  of  asking  for their consent. We also expected a very low response rate from parents if we applied the principle of informed consent, because some of the parents would have been suspected of abusing their own children. It  is  highly  probable  that  many  of  these  parents would not have wanted to participate in this kind of study. Ethics approval was obtained from the Norwegian Ministry of Health and Care Services, which provided  us  with  an  exception  from  professional secrecy to perform the study as described (201005216-/SVE).

As a result of the sensitivity of the subject and related  matters  of  confidentiality,  the  list  of  patients included in the study was destroyed after the reading  and  scoring  of  the  medical  records.  Thus,  all information was registered anonymously  in  the research  database.  We  hope  that  the  knowledge gained  from  this  study  will  help  the  team  at  the CAMU to improve their  services  for  children  and their  families  and  that  it  will  also  be  of  value  for other  CAMUs.  It  was  felt  that  these  advantages were greater than the disadvantages involved in the avoidance of the principle of informed consent.

## Results

Routine assessment in the child abuse management unit Somatic medical examination

The  medical examination was performed by a trained  pediatrician.  It  routinely  included  a  history from  the  child  and  his  or  her  caregiver;  a  general physical examination from head to toe; an anogenital examination with a colposcope; and supplementary  examinations  as  indicated  (e.g.,  microbiology, blood tests, forensic sampling, radiographs).

## Psychological interview

The  psychological  interviews  were  performed  by trained  psychologists.  The  consultations  with  the children and  their caregivers  focused  on  background history, the family and social environment, symptom load, coping, and supporting factors around the child. Instruments and methods such as rating  scales,  play  sessions,  and  structured  interviews were used when indicated. The psychologists would routinely discuss reporting to the police with the children or the parents.

## General  characteristics  of  cases  seen  at  the child abuse management unit

In  80.2%  of  the  cases,  sexual  abuse  was  the  only concern. In 10.3% of the cases, physical abuse was the  only  concern.  In  1.9%  of  cases,  psychological abuse and neglect were the only concerns. For 7.5% of  the  children,  combinations  of  these  types  of abuse were suspected.

TABLE 2. Percentages of children and their relationships to suspected abusers

| Relationship to sus- pected abuser   |   0 to 4 years old n = 25 |   5 to 9 years old n = 41 |   10 to 14 years old n = 40 | P value   |
|--------------------------------------|---------------------------|---------------------------|-----------------------------|-----------|
| Biological father                    |                      72.0 |                      51.3 |                        20.0 | <.001     |
| Stepfather/foster father             |                       0.0 |                      10.3 |                        17.5 | .083      |
| Biological mother                    |                       0.0 |                      10.3 |                         5.0 | .221      |
| Siblings                             |                       4.0 |                       0.0 |                         2.5 | .495      |
| Uncle/aunt/cousin                    |                       0.0 |                       2.6 |                        10.0 | .132      |
| Other relative                       |                       0.0 |                       2.6 |                         5.0 | .498      |
| Friend/acquaintance                  |                       4.0 |                      12.8 |                        25.0 | .063      |
| Person of authority                  |                      12.0 |                       2.6 |                         2.5 | .156      |
| Stranger                             |                       4.0 |                       5.1 |                         7.5 | .821      |
| Unknown                              |                       4.0 |                       7.7 |                         7.5 | .822      |

The same child can be represented more than once as a result of exposure to several abusers

In the youngest group of children, biological fathers were the most commonly suspected abusers (Table 2).  The  next  most  likely  suspect  was  a  person  of authority to the child (e.g., teacher, adult working in a  kindergarten,  sports  coach).  In  the  middle  age group, the biological father still was the most common suspected abuser, followed by a friend or acquaintance,  a  stepfather  or  foster  father,  and  the biological mother. For the oldest children, the abuser  most  often  was  a  friend  or  acquaintance  of  the child, followed by the biological father, a stepfather or  foster  father,  and  an  uncle  or  another  relative. When comparing the age groups, there were significant differences with regard to the biological father being the suspected abuser ( P < .001). For the other categories, the differences were not significant.

The children and their caregivers reported a wide spectrum  of  symptoms  and  problems  during  their contact  with  the  unit.  Several  children  reported sadness  and  anxiousness,  and  some  were  also  de- scribed  in  the  records  as  demonstrating  sexualized behavior in addition to abusing others. As shown in Table 3, some children reported symptoms that may be part of PTSD, including flashbacks, nightmares, avoidance,  and  irritability.  A  total  of  53  children (50.0%) were described as having one or more psychological symptoms.

We  were  interested  in  studying  the  psychosocial functioning  of  the  children,  because  this  can  be  a valuable  variable  when  it  comes  to  assessing  the needs  of  the  individual  child.  When  it  is  scored appropriately,  with  the  use  of  all  available  information about the child, the CGAS can help to identify  persons  in  need  of  psychiatric  treatment,  have predictive  value,  and  measure  changes  over  time, including treatment effects (21). In this study, functioning in school or kindergarten was mentioned in the  patient  records  in  only  27  out  of  106  cases; therefore,  it  was  not  possible  to  set  a  valid  CGAS score.

Table  4  shows  the  spectrum  of  psychosomatic and physical complaints of the children in question. Several  of  the  children  reported  pain,  either  as headaches, pelvic pain, or diffuse pain. A total of 40 children were registered as having 'other symptoms and findings from sexual organs or anal area.' These  include  findings  such  as  genital  redness  and synechiae,  which  are  fairly  common  abnormalities, especially  in  the  youngest  age  group.  Sixty-three children  reported  one  or  more  somatic  or  psychosomatic symptoms (59.4%). There were no significant differences between the age groups with regard to  psychological,  psychosomatic,  or  somatic  symptoms, except for the presence of significantly more 'other  symptoms  and  findings  from  sexual  organs or anal area' in the youngest age group ( P < 0.05).

In 24.5% of cases, it was concluded in the records that abuse had probably taken place. This was based on convincing medical findings (i.e., hymenal transection, sexually transmitted disease, scars, and wounds),  information  about  a  suspected  abuser's conviction  in  court  (5.7%),  or  information  in  the patient record system that the abuser had admitted to  the  incident.  In  70.8%  of  cases,  no  conclusion was possible, and abuse was found to be unlikely in 4.7% of cases. For those cases in which abuse was confirmed, it was significantly more likely (as compared  with  the  cases  in  which  abuse  was  not  confirmed) that the child belonged to the oldest group of children (i.e.,  10  to  14  years  old; P < .001) and that  the  suspected  offender  was  a  friend  or  acquaintance ( P = .002) or a relative other than a parent  ( P = .001). The type of abuse was more often categorized as severe sexual ( P = .002) or moderate physical  ( P =  .003);  there  was  significantly  more often suspected previous abuse ( P = .003); and the examination  was  completed  during  the  first  24

TABLE 3. Numbers and percentages of children in the child abuse management unit reporting different psychological symptoms*

|                                                    | Symptoms                             |   0 to 4 years old (%) |   n |   5 to 9 years old (%) |   n |   10 to 14 years (%) |   n |   Total (n) |   P value |
|----------------------------------------------------|--------------------------------------|------------------------|-----|------------------------|-----|----------------------|-----|-------------|-----------|
| Internalizing problems                             | Tired/ exhausted/lack of initiative  |                    4.0 |   1 |                    0.0 |   0 |                  7.5 |   3 |           4 |      .208 |
| Internalizing problems                             | Sadness                              |                    4.0 |   1 |                    2.4 |   1 |                 20.0 |   8 |          10 |      .015 |
| Internalizing problems                             | Suicidal thoughts                    |                    0.0 |   0 |                    0.0 |   0 |                  5.0 |   2 |           2 |      .186 |
| Internalizing problems                             | Anxious                              |                   12.0 |   3 |                   17.1 |   7 |                 15.0 |   6 |          16 |      .855 |
| Attention problems                                 | Attention problems                   |                    0.0 |   0 |                    7.3 |   3 |                 12.5 |   5 |           8 |      .178 |
| Externalizing problems                             | Hyperactivity                        |                    8.0 |   2 |                    7.3 |   3 |                  0.0 |   0 |           5 |      .202 |
| Externalizing problems                             | Impulsivity                          |                    4.0 |   1 |                    4.9 |   2 |                  7.5 |   3 |           6 |      .807 |
| Externalizing problems                             | Sexualized behavior                  |                    8.0 |   2 |                   19.5 |   8 |                  5.0 |   2 |          12 |      .100 |
| Externalizing problems                             | Antisocial behavior                  |                    8.0 |   2 |                   12.2 |   5 |                  0.0 |   0 |           7 |      .083 |
| Post-traumatic stress disorder-associated symptoms | Flashbacks                           |                    0.0 |   0 |                    0.0 |   0 |                  7.5 |   3 |           3 |      .078 |
| Post-traumatic stress disorder-associated symptoms | Nightmares                           |                   16.0 |   4 |                    4.9 |   2 |                  7.5 |   3 |           9 |      .279 |
| Post-traumatic stress disorder-associated symptoms | Avoidance                            |                   16.0 |   4 |                    7.3 |   3 |                  2.5 |   1 |           4 |      .134 |
| Post-traumatic stress disorder-associated symptoms | Nervous/alert                        |                    0.0 |   0 |                    0.0 |   0 |                  2.5 |   1 |           1 |      .435 |
| Post-traumatic stress disorder-associated symptoms | Irritable/ tantrums                  |                    8.0 |   2 |                    4.9 |   2 |                  2.5 |   1 |           5 |      .595 |
| Post-traumatic stress disorder-associated symptoms | Delusions/ memory loss/ dissociation |                    0.0 |   0 |                    0.0 |   0 |                  0.0 |   0 |           0 |           |
| Other mental symptoms                              |                                      |                    8.0 |   2 |                   19.5 |   8 |                  7.5 |   3 |          13 |      .195 |

TABLE 4. Percentages of children in the child abuse management unit reporting different somatic and psychosomatic symptoms and findings

| Symptoms                                                    | 0 to 4 years old   | 0 to 4 years old   | 5 to 9 years old   | 5 to 9 years old   | 10 to 14 years old   |    | Total   | P     |
|-------------------------------------------------------------|--------------------|--------------------|--------------------|--------------------|----------------------|----|---------|-------|
|                                                             | (%)                | n                  | (%)                | n                  | (%)                  | n  | (n)     | value |
| Sleeping difficulties                                       | 4.0                | 1                  | 1.9                | 2                  | 15.0                 | 6  | 9       | .172  |
| Eating difficulties                                         | 0.0                | 0                  | 2.4                | 1                  | 7.5                  | 3  | 4       | .258  |
| Headache/migraine                                           | 4.0                | 1                  | 2.4                | 1                  | 10.0                 | 4  | 6       | .311  |
| Gastrointestinal problems                                   | 8.0                | 2                  | 2.4                | 1                  | 5.0                  | 2  | 5       | .583  |
| Diffuse pain                                                | 0.0                | 0                  | 2.4                | 1                  | 7.5                  | 3  | 4       | .258  |
| Pelvic pain                                                 | 4.0                | 1                  | 7.3                | 3                  | 20.0                 | 8  | 12      | .082  |
| Dysuria                                                     | 0.0                | 0                  | 7.3                | 3                  | 15.0                 | 6  | 9       | .102  |
| Other symptoms and findings from sexual organs or anal area | 56.0               | 14                 | 39.0               | 16                 | 25.0                 | 10 | 40      | .042  |
| Other somatic symptoms                                      | 16.0               | 4                  | 19.5               | 8                  | 2.5                  | 1  | 13      | .053  |

TABLE 5. Characteristics of cases in which abuse was confirmed

|                             |                          | Abuse confirmed (n)   | Abuse not confirmed (n)   | P value   |
|-----------------------------|--------------------------|-----------------------|---------------------------|-----------|
| Sex                         | Girl                     | 20 (77%)              | 59 (74%)                  |           |
|                             | Boy                      | 6 (23%)               | 21 (26%)                  | .747      |
| Age                         | 0 to 4 years old         | 1 (4%)                | 24 (30%)                  |           |
|                             | 5 to 9 years old         | 6 (23%)               | 35 (44%)                  |           |
|                             | 10 to 14 years old       | 19 (73%)              | 21 (26%)                  | <.001     |
| Suspected offender          | Father                   | 6 (23%)               | 40 (50%)                  | .012      |
|                             | Stepfather/foster father | 3 (12%)               | 8 (10%)                   | .854      |
|                             | Mother                   | 0                     | 6 (8%)                    | .145      |
|                             | Other relative           | 7 (27%)               | 3 (4%)                    | .001      |
|                             | Friend/acquaintance      | 9 (35%)               | 7 (9%)                    | .002      |
|                             | Person of authority      | 0                     | 5 (6%)                    | .186      |
|                             | Stranger                 | 2 (8%)                | 4 (5%)                    | .627      |
|                             | Unknown                  | 0                     | 7 (9%)                    | .114      |
| Type of abuse               | Severe sexual abuse      | 13 (50%)              | 15 (19%)                  | .002      |
|                             | Moderate sexual abuse    | 8 (31%)               | 18 (23%)                  | .433      |
|                             | Severe physical abuse    | 0                     | 0                         |           |
|                             | Moderate physical abuse  | 8 (31%)               | 6 (8%)                    | .003      |
|                             | Psychological abuse      | 3 (12%)               | 4 (5%)                    | .259      |
| Suspected previous abuse    |                          | 15 (58%)              | 21 (26%)                  | .003      |
| Medical examination         |                          | 12 (63%)              | 17 (26%)                  | .003      |
| Contact with unit within 24 |                          | 4 (2%)                | 2 (3%)                    | .011      |

- *Twenty-two patients were not examined

hours after the assault ( P = .011). Table 5 lists some additional  characteristics  of  cases  in  which  abuse was confirmed.

TABLE 6. Numbers and percentages of children with or without confirmed abuse referred to different services after first contact with the child abuse management unit

| Follow-up services                                       | Abuse confirmed (n)   | Abuse not confirmed (n)   | Total (n)   |
|----------------------------------------------------------|-----------------------|---------------------------|-------------|
| Child and adolescent mental health services              | 8 (31%)               | 24 (30%)                  | 32 (30%)    |
| Pediatrician                                             | 0                     | 2 (3%)                    | 2 (2%)      |
| Psychologist employed at the child abuse management unit | 15 (58%)              | 24 (30%)                  | 39 (37%)    |
| Child protective services                                | 8 (31%)               | 30 (38%)                  | 38 (36%)    |
| Community health services                                | 3 (12%)               | 8 (10%)                   | 11 (10%)    |
| School psychologist                                      | 1 (4%)                | 9 (11%)                   | 10 (9%)     |
| Others                                                   | 0                     | 4 (5%)                    | 4 (4%)      |
| None                                                     | 3 (12%)               | 17 (21%)                  | 20 (19%)    |
| Two or more services                                     | 9 (35%)               | 29 (36%)                  | 38 (36%)    |

## Follow-up after the first examination

Four out of five of the children received some kind of follow-up care or were referred to other services for  follow  up  after  the  first  examination  at  the CAMU.  The  most  common  follow-up  care  was provided by a psychologist at the unit, by child protective  services,  and  by  CAMHS.  Several  of  the children  were  later  evaluated  by  more  than  one service unit (Table 6). Of those children with confirmed  abuse,  significantly  more  were  followed  up with  by  a  psychologist  in  the  CAMU  ( P =  .011). Otherwise  there  were  no  significant  differences  in follow-up treatment between those with or without confirmed abuse. Significantly more of the youngest children  were  among  those  not  referred  for  any kind  of  follow-up  care  ( P <  .05),  but  there  were otherwise  no  significant  differences  regarding  sex, type of abuse, symptom pattern, symptom load, or documented findings in the patient record.

## Discussion

## Strengths and limitations

One strength of this study is that we had access to complete patient record files for all children referred to the CAMU during a 2-year period. The age distribution  is  also  balanced,  with  the  age  groups  including 25 (0 to 4 years old), 41 (5 to 9 years old), and 40 children (10 to 14 years old). There are limited  personnel connected to the CAMU (i.e., three to  five  people),  which  was  helpful  in  that  the  records were written in a uniform manner. Because the involved staff members are well aware that the records may be used for legal purposes, one could also assume that the records are more carefully obtained than  what  might  be  expected  in  other  medical  departments. However, the awareness of the possible use of the records as legal documents may also have limited  what  was  actually  written  in  them.  Retrospective assessment by reading and scoring medical records  has  clear  methodological  limitations.  We had to rely  on the  information  that  was  written  in the records, without being able to confirm that this information  was  correct.  We  did  not  know  if  the children  and  their  parents  were  asked  about  more details  than  were  documented  or  if  some  details may have been left out. To assess the validity of our text  interpretations,  the  first  and  second  authors discussed every tenth record, thereby excluding variables  that  proved  to  not  reflect  the  content  of the  medical  record  text  appropriately.  This  procedure  may  have  had  an  impact  on  the  registered prevalence of, for example, the somatic and mental symptoms registered for each child. These numbers are therefore most certainly slightly underestimated, but  they  are  nonetheless  interesting  as  minimum estimates.  Further,  the  retrospective  assessment  of psychological  and  psychosomatic symptoms resulted in a variety of categories, thereby reducing statistical power as compared with an assessment involving standardized questionnaires.

Our  list  of  variables  was  very  comprehensive  as result of the chosen research method of investigating  medical  records.  To  obtain  meaningful  scoring categories, we had to reduce the original number of variables, which was 235, to the final 171. A shorter list from the beginning might have resulted in more significant  results  given  the  limitations  of  the  present sample size, but it could also have resulted in the  loss  of  important  information.  However,  we found this approach useful, and the resulting scoring manual was convenient for our purposes.

## General characteristics of the cases seen at the child abuse management unit

The  results  demonstrated  that  children  of  both genders and all age groups that we investigated had been  referred  to  the  CAMU.  Among  the  children, only 26.7% were living with both of their biological parents  (see  Table  1).  In  the  general  population, 75% of children who are less than 18 years old are living with both parents. The proportion decreases with age, from 88% during the first year of life to 62% when the children reach 17 years of age (22). Similar  patterns  have  also  been  reported  in  other studies  (23). There could be different possible reasons  for  this  deviation.  Abusive  behavior  on  the part of one parent can, in some cases, be the reason for  splitting  up  the  family.  However,  this  pattern may also reflect conflicts between parents who are not living together or even more complex difficulties in certain families.

Sexual  abuse  was  the  main  concern  in  the  vast majority  of  the  referred  cases.  In  Norway,  a  tradition  for  the  assessment  of  child  abuse  has  developed in which the larger pediatric departments are responsible for medical examinations in sexual abuse  cases.  Victims  of  other  kinds  of  abuse  are often  taken  care  of  locally,  either  by  local  health care  services,  surgical  departments,  child  welfare services,  or  other  organizations.  The  use  of  this tradition can be questioned. It is known that exposure  to  physical  abuse  during  childhood  is  as  important a risk factor as exposure to sexual abuse for the development of somatic and psychiatric disease.

The prevalence of sexual and physical abuse is approximately equal in the general population (5, 15). One could argue that all children exposed to abuse of the same degree of severity should be offered the best  possible  and  most  competent  health  services. Another  reason  for  this  skewness  in  the  cause  of referral  in  our  study  may  be  that  the  public  and health workers are not aware that the CAMU is also concerned with physical and emotional abuse.

The patient records in our study describe a variety of  both  mental  and  somatic  symptoms  and  problems. We assume that the problem rates registered were a minimum rate, because the children and their parents were  not  systematically asked  about  all problem areas. The heterogeneity of the expressed and  reported  symptoms  reflects  what  is  already known about victimized children, their diversity of symptoms,  and  the  challenges  of  identifying  the optimal treatment plan for each individual child (24, 25). There were only limited significant differences in  the  expression  of  mental,  somatic, or  psychosomatic symptoms among the age groups. The oldest children  expressed  more  sadness  than  the  younger ones  ( P =  .015),  and  the  youngest  age  group  had significantly  more  'other  symptoms  and  findings from sexual organs or anal area,' including soreness ( P <  .05).  This  is  not  a  rare  finding,  especially  in toddlers, and it was also the main cause of referral in  some  of  the  cases.  Irritation  and  soreness  in young  children  are  seldom  signs  of  sexual  abuse, unless  there  are  other  findings  that  confirm  the suspicion (26). Some of the children reported symptoms that could be part of PTSD. However, these symptoms are often vague and unspecific, especially in  children,  and  they  could  often  be  explained  by other  means.  Diagnosing  PTSD  in  children  is  a challenging task by itself; in addition, the time span between the assault and the examination may not be long  enough  for  PTSD  to  develop.  According  to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, the symptoms must last for more than one month after the event for the diagnostic criteria to be fulfilled (27). Some patients may present with their symptoms later as part of delayed-onset PTSD.

It is often difficult to conclude whether suspected abuse  has  taken  place.  Medical  findings  are  often unspecific, and, depending on the age of the child, there can be doubts about to what degree the child's statements are valid. In this study, we chose a rather narrow definition. Therefore, only those cases with convincing  medical  findings,  a  convicted  offender, or  a  confession  would  be  coded  as  'confirmed.' Information  about  the  status  of  the  legal  process was often lacking; this  is due  to  the fact  that  legal processes  may  take  years  to  conclude.  However, most  patients  are  not  followed  for  years  by  the CAMU, and results would therefore not be provid- ed in the victim's medical file. Because many of the children had only limited contact with the unit and during a short time span, the registered percentage of cases in which an offender was convicted (5.7%) was probably underestimated.

It  is  not  surprising  that  most  of  the  cases  that could  be  concluded  were  found  among  the  oldest children. Younger children are less likely to verbalize their victimization. The older children were also more exposed to severe sexual abuse. In these cases, the chance of documenting confirmed medical findings  is  higher.  The  results  in  Table  5  show  that, when abuse is confirmed, the offender is most often a  relative  other  than  a  parent  (e.g.,  sibling,  uncle, aunt, cousin) or a friend or acquaintance. Victims of severe  sexual  abuse  are  more  likely  to  seek  help within the first 24 hours. This increases the chance of documenting substantial medical findings as well as the success of forensic sampling. These variables seem  to  reflect  different  aspects  of  the  same  patterns. Some of the huge challenges in this field are how to conclude cases in which young children and toddlers are exposed to abuse and in which no certain findings are documented.

## Follow-up after the first examination

Not  all  children  will  require  specialized  follow-up care after being referred to a CAMU. Therefore, it is satisfactory  that  four  out  of  five  children  were  referred  to  a  health  or  social  service  provider  after contact with the CAMU. Many of the children were referred to (or recommended referral to) more than one service;  most  commonly, this was a psychologist at the unit, CAMHS, or child protective service. We consider it a positive sign that so many children and  their  families  have  had  further  contact  with health  or  social  services  after  such  a  serious  and potentially  distressful  experience  as  a  referral  to  a CAMU can be. However,  the  number  of  children that  are  referred  to  (or  recommended  referral  to) child  protective  services  is  only  38  out  of  106, which is a surprisingly low figure. We found that, in 4.7% of cases,  abuse  was  unlikely;  thus,  this  study reveals that, in about 95% of cases, abuse is either confirmed or suspected. It is possible that a larger proportion of these children and their families could benefit from child protective services. Several of the children in the study were referred from police authorities, who represent a main collaborator for the CAMU and who also play an important role in following up with some of the children afterward. In this study, however, follow-up evaluation was registered  only  with  regard  to  medical  and  social  services.

## How can services be further improved?

The  organization  of  CAMUs  nationwide  has  been performed in different ways. The units are supposed to  serve  several  functions,  including  advising  the judiciary authorities and decreasing the health problems of the children. In what ways units of this kind should handle psychosocial  problems has been questioned (28),  and the  unit  in  Trondheim  is  one of only a few that provide routine interdisciplinary assessment. Nevertheless, we observed through this study  that  psychosocial  functioning  was  seldom documented in the patient record. Children in different age groups are at different levels with regard to their ability to describe their own problems and symptoms. Mental health providers will often have to rely on the interpretation of children's behavior. A systematic approach would be helpful for identifying  children  who  need  more  extensive  help  (29). There are several reliable and valid instruments that are already commonly used by the regional CAMHS that could easily be incorporated into daily practice. Such measures should not be too time consuming for  the  staff,  and  they  should  reflect  different  perspectives, such as the clinician's evaluation and the parent report. Examples of such instruments are the CGAS,  which  measures  psychosocial  functioning, and the CBCL, which measures competence as well as emotional and behavioral problems.

## Clinical significance

The CAMU in Trondheim serves the population of middle Norway and is available to children in all age groups and of both sexes. It is challenging to meet children  and  parents  in  crisis  and  to  decide  who requires more extensive evaluation and mental health  care.  This  case  study  reveals  that  psychosocial  functioning  is  seldom  documented  and  that psychological  symptoms  could  be  described  in  a more  detailed  and  reliable  manner.  A  systematic approach could be helpful for health care providers, and  we  suggest  the  implementation  of  valid  and reliable  instruments  such  as  the  CBCL  and  the CGAS. It is important to remember the documented negative long-term health effects of child abuse. In addition to sexual abuse, physical child abuse and emotional child abuse are important risk factors that seem  to  contribute  substantially  to  the  burden  of health problems in the adult population. The observed skewness with regard to the cause of referral  should  therefore  be  discussed  further.  For now, there is a wider target group of children that could possibly profit from this unique interdisciplinary competence.

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## Appendix

## List of variables

| 1                                           | Sex Girl                                                       |
|---------------------------------------------|----------------------------------------------------------------|
| 2 Age                                       | Boy 0 to 4, 5 to 9, 10 to 14                                   |
| 3 Number of siblings                        |                                                                |
| 4 Care situation                            | Both biological parents, single parent, foster care, and so on |
| 5 Familial disease                          | Yes/no                                                         |
| 6 Kind of familial disease                  |                                                                |
| 7 Biol. Parents drug abuse                  | Yes/no                                                         |
| 8 Biol. Parents chronic somatic illness     | Yes/no                                                         |
| 9 Biol. Parents chronic psychiatric disease | Yes/no                                                         |
| 10 Biol. Parents other health problem       | Yes/no                                                         |
| 11 Caregiver (if not biological             | Yes/no                                                         |

|       | parent) drug abuse Caregiver chronic somatic                  | Yes/no                  |       | munity health service for                                    |                                                        |
|-------|---------------------------------------------------------------|-------------------------|-------|--------------------------------------------------------------|--------------------------------------------------------|
| 12    | illness                                                       |                         | 57    | psychiatric difficulties Type of health service              |                                                        |
| 13    | Caregiver chronic psychiat- ric disease                       | Yes/no                  | 58    | Former referred to child and adolescent mental               | Yes/no                                                 |
| 14    | Caregiver other health                                        | Yes/no                  |       | health service (CAMHS) or pediatric clinic for psychi-       |                                                        |
| 15    | problem Parents in conflict with each other                   | Yes/no                  |       | atric difficulties of health                                 |                                                        |
|       | in conflict                                                   | Yes/no                  | 59    | Type service Present medication                              |                                                        |
| 16    | Parents with others                                           |                         | 60 61 | Type of medication                                           |                                                        |
| 17    | Residence                                                     | City, village, district | 62    | Who referred patient                                         | Direct contact, police, general prac- titioner, school |
| 18    | Former disease/disability of the child:                       |                         |       |                                                              | nurse, child                                           |
|       | Reduced vision                                                | Yes/no                  |       |                                                              | protective service,                                    |
| 19    | Reduced hearing                                               | Yes/no                  |       |                                                              | CAMHS, and so on                                       |
| 20    | Reduced mobility                                              | Yes/no                  | 63    | Other referral                                               |                                                        |
| 21    | Mentally disabled                                             | Yes/no                  |       |                                                              |                                                        |
| 22    | Chronic somatic                                               | Yes/no                  |       | in                                                           |                                                        |
| 23    | disease Type of somatic disease                               |                         |       | Registered contacts patient record system                    |                                                        |
| 24    | Chronic psychiatric disease                                   | Yes/no                  | 64    | Indirect contact (with                                       | Number                                                 |
| 25    | Type of psychiatric disease                                   |                         |       | other services)                                              |                                                        |
| 26    | Learning difficulties behav-                                  | Yes/no                  | 65    | Direct contact with child                                    | Number                                                 |
| 27    | Self-harm, suicidal                                           | Yes/no                  |       | present                                                      | Number                                                 |
| 28    | ior Fractures/trauma                                          | Yes/no                  | 66    | Direct contact without child present                         |                                                        |
| 29    | Allergy/intolerance                                           | Yes/no                  | 67    | Phone/email contact                                          | Number                                                 |
| 30    | Headache/migraine                                             | Yes/no                  |       |                                                              |                                                        |
| 31    | Stomachache                                                   | Yes/no                  |       | Judiciary actions                                            |                                                        |
| 32    | Eating problems                                               | Yes/no                  | 68    | Police report                                                | Yes/no                                                 |
| 33    | Other pain                                                    | Yes/no                  | 69    | Police interrogation                                         | Yes/no                                                 |
| 34    | Constipation/diarrhea                                         | Yes/no                  | 70    | Trial conducted                                              | Yes/no                                                 |
| 35    | Urinary tract infection or                                    | Yes/no                  | 71    | Conviction                                                   | Yes/no                                                 |
|       | other symptoms                                                |                         | 72    | Acquitted                                                    | Yes/no                                                 |
|       |                                                               | Yes/no                  | 73    | Dismissed                                                    | Yes/no                                                 |
| 36    | Other problems Later diagnosed dis- ease/problems with possi- |                         | 74 75 | Other Non-judiciary actions (e.g., regulation of visitation) | Yes/no                                                 |
| 37    | ble relevance Reduced vision                                  | Yes/no                  | 76    | Child protective actions                                     | Yes/no                                                 |
| 38    | Reduced hearing                                               | Yes/no                  |       |                                                              |                                                        |
| 39    | Reduced mobility                                              | Yes/no                  |       | Characteristics of abuse                                     |                                                        |
| 40    | Mentally disabled                                             | Yes/no                  | 77    | Psychological abuse                                          | Yes/no                                                 |
| 41    | Chronic somatic disease                                       | Yes/no                  | 78    | Physical abuse                                               | Yes/no                                                 |
| 42    | Type of somatic disease                                       |                         | 79    | Sexual abuse                                                 | Yes/no                                                 |
| 43    | Chronic psychiatric disease                                   | Yes/no                  |       |                                                              |                                                        |
| 44 45 | Type of psychiatric disease Learning difficulties             | Yes/no                  |       | Relationship to suspected offender                           |                                                        |
| 46    | Self-harm, suicidal behav-                                    | Yes/no                  | 80    | Biological father                                            | Yes/no                                                 |
|       | ior                                                           |                         | 81    | Stepfather/foster father                                     | Yes/no                                                 |
| 47    | Fractures/trauma                                              | Yes/no                  | 82    | Biological mother                                            | Yes/no                                                 |
| 48    | Allergy/intolerance                                           | Yes/no                  | 83    | Stepmother/foster mother                                     | Yes/no                                                 |
| 49    | Headache/migraine                                             | Yes/no                  | 84    | Sibling                                                      | Yes/no                                                 |
| 50    | Stomachache                                                   | Yes/no                  | 85    | Stepsibling/half-sibling                                     | Yes/no                                                 |
| 51    | Eating problems                                               | Yes/no                  | 86    | Grandfather/grandmother                                      | Yes/no                                                 |
| 52    | Other pain                                                    | Yes/no                  | 87    | Uncle/aunt/cousin                                            | Yes/no                                                 |
| 53    | Constipation/diarrhea                                         | Yes/no                  | 88    | Other relative                                               | Yes/no                                                 |
| 54    | Urinary tract infection or                                    | Yes/no                  | 89    | Boyfriend/girlfriend                                         | Yes/no                                                 |
|       | other symptoms                                                |                         | 90    | Friend/acquaintance                                          | Yes/no Yes/no                                          |
| 55    | Other problems                                                | Yes/no                  | 91    | Person of authority Stranger                                 | Yes/no                                                 |
| 56    | Former referred to com-                                       | Yes/no                  | 92 93 | Unknown                                                      | Yes/no                                                 |

by caregiver

| 94                    | Psychological reaction at first contact                                    | None, moderate (e.g., anxious, sad- ness), severe (e.g.,                       | 126     | Other problems reported by others                                                                         | Yes/no                      |               |     |               |
|-----------------------|----------------------------------------------------------------------------|--------------------------------------------------------------------------------|---------|-----------------------------------------------------------------------------------------------------------|-----------------------------|---------------|-----|---------------|
|                       | Severity of abuse                                                          | depression, despair, disorientation), not possible to evaluate                 | 127     | If others, who Psychiatric findings re- ported by doctor or psy- chologist:                               |                             |               |     |               |
| 95                    | Severe physical violence (e.g., fractures, internal                        | Yes/no                                                                         | 128     | Anxious/depressed Withdrawn/depressed                                                                     | Yes/no Yes/no               |               | 129 |               |
| 96                    | bleeding) Moderate physical violence (e.g., bruises, wounds)               | Yes/no                                                                         | 131 132 | problems Thought problems Attention problems                                                              | Yes/no Yes/no               | Social        | 130 |               |
| 97                    | Severe sexual abuse (oral, vaginal, anal penetration, forced masturbation) | Yes/no                                                                         | 133 134 | Rule-breaking behavior Aggressive behavior                                                                | Yes/no Yes/no Yes/no        |               |     |               |
| 98                    | Moderate sexual abuse (e.g., touching/fondling of intimate area, showing   | Yes/no                                                                         | 135 136 | Somatic and psychosomat- ic symptoms and findings Sleeping problems Eating problems                       | Yes/no Yes/no Yes/no        |               |     |               |
| Psychological Unknown | pornography) abuse severity                                                |                                                                                | 137     | Headache                                                                                                  | Yes/no                      |               | 138 | Yes/no Yes/no |
| 99 100                | Threats from offender Conclusion                                           | abuse, disproved Yes/no                                                        | 139 140 | Muscle/skeletal pain Gastrointestinal problems Diffuse pain                                               | Yes/no Yes/no               |               |     | Yes/no        |
| 101 102               | Previous abuse (sexual, physical, psychological)                           | Confirmed, uncer- tain/suspected                                               | 141 142 | Pelvic pain symptoms and                                                                                  | Yes/no Yes/no               | Dysuria Other | 143 |               |
| 103 104               | Time span since abuse at time of examination                               | <24 hours, 1 to 7 days, 1 to 4 weeks, 1 to 2 months, 3 to 6 months, >6 months, | 144 145 | from sexual or- gans or anal area Other problems reported by patient Other problems reported by caregiver | Yes/no Yes/no               | findings      |     |               |
|                       | repeated abuse, time first event                                           | unknown <2 months, 2 to 6 months, 6 to 12 months, 1 to 2                       | 146     | Other problems reported by others If others, who                                                          | Yes/no Yes/no               |               |     |               |
| 105                   | If since                                                                   | years, 2 to 5 years,                                                           | 147     | Physical findings Physical findings docu-                                                                 |                             |               |     |               |
| Psychological         | symptoms                                                                   | >5 years, unknown                                                              | 148 149 |                                                                                                           | Yes/no                      |               |     |               |
| reported 106          | by pa- tient/caregiver or other Sadness                                    | Yes/no                                                                         | 150     | mented in patient record Light (superficial wounds, bruises)                                              | Yes/no                      |               |     |               |
| 107 108               | Anxiety Tired/exhausted/lack of                                            | Yes/no                                                                         | 151     | Moderate (wounds, cuts) internal                                                                          | Yes/no Yes/no               |               |     | Yes/no        |
| 109                   | initiative Suicidal thoughts behavior                                      | Yes/no                                                                         | 152 153 | Severe (fractures, bleeding) Marks on neck/throat                                                         | Yes/no                      |               |     |               |
| 110 111               | Antisocial Abusing others                                                  | Yes/no Yes/no                                                                  | 154     | Injuries in sexual area                                                                                   | Yes/no Yes/no               |               |     |               |
| 112 113               | Impulsivity                                                                | Yes/no Yes/no                                                                  | 155     | Injuries in anal area                                                                                     |                             |               |     |               |
|                       | Sexualized                                                                 |                                                                                |         | Sexually transmitted dis- ease                                                                            | Yes/no                      |               |     |               |
|                       | Delusions                                                                  | Yes/no                                                                         | 156     | Other                                                                                                     | Yes/no                      |               |     |               |
|                       | behavior                                                                   |                                                                                |         |                                                                                                           |                             |               |     |               |
| 114 115               | Attention                                                                  | Yes/no                                                                         |         |                                                                                                           |                             |               |     |               |
| 116 117               | Hyperactivity                                                              | Yes/no Yes/no                                                                  | 157     | Academic difficulties                                                                                     | Yes/no                      |               |     |               |
|                       | problems                                                                   |                                                                                |         | School functioning                                                                                        |                             |               |     |               |
|                       |                                                                            |                                                                                | 158     |                                                                                                           | Yes/no                      |               |     |               |
| 118 119               | Flashbacks Nightmares                                                      | Yes/no Yes/no                                                                  |         | Increased absence since time of abuse                                                                     |                             |               |     |               |
| 120                   | Avoidance Memory loss                                                      | Yes/no Yes/no                                                                  | 159 160 | Unchanged                                                                                                 | Yes/no Yes/no               |               |     |               |
| 121                   | Nervous/alert Irritability/tantrums                                        | Yes/no                                                                         |         | Social problems                                                                                           |                             |               |     |               |
| 122                   |                                                                            |                                                                                |         |                                                                                                           |                             |               |     |               |
|                       | Dissociation                                                               | Yes/no Yes/no                                                                  |         | Alcohol use                                                                                               | Never, mild (1 to 2 times), |               |     |               |
| 124                   | Other problems reported by patient                                         |                                                                                | 162     |                                                                                                           | heavy (several times)       |               |     |               |
|                       | Other problems reported                                                    |                                                                                |         | Drug abuse                                                                                                |                             |               |     |               |
|                       |                                                                            | Yes/no                                                                         |         |                                                                                                           |                             |               |     |               |
|                       |                                                                            |                                                                                |         |                                                                                                           | Never, mild                 |               |     |               |
| 125                   |                                                                            |                                                                                |         |                                                                                                           |                             |               |     |               |
| 123                   |                                                                            |                                                                                |         |                                                                                                           |                             |               |     |               |
|                       |                                                                            |                                                                                | 161     |                                                                                                           |                             |               |     |               |

|     |                                   | (cannabis), heavy   |
|-----|-----------------------------------|---------------------|
|     | Follow-up                         |                     |
| 163 | Referred to CAMHS                 | Yes/no              |
| 164 | Pediatrician at children's clinic | Yes/no              |
| 165 | Psychologist at children's clinic | Yes/no              |
| 166 | Child protective service          | Yes/no              |
| 167 | Community health service          | Yes/no              |
| 168 | School psychologist               | Yes/no              |
| 169 | Other                             | Yes/no              |
| 170 | C-GAS                             | 0-100               |
| 171 | Commentary                        |                     |