A case of Child sexual abuse with emphasis on POCSO act

1. Clinico
Psychosocial
Case
Dr Shruthi Rajan, Junior Resident
Prof. Arun Aggarwal,
DCM&SPH, PGIMER

2. Index Case- 11 year old
female child
Advanced Paediatric Centre
PGIMER

3. Family profile
36 30
11 10 9 8 7
10
years
11
years
8
years
5
years
2
years

4. Sr No Member/Age Education Occupation Income/month
1 Father- 42 4th std Labourer (Daily
wage earner)
7000-10000
2 Mother- 38 4th std Homemaker ---
3 Daughter- 11 No formal schooling ----
4 Daughter- 10 No formal schooling ----
5 Daughter- 8 No formal schooling ----
6 Son- 5 No formal schooling ----
7 Son- 2 ---- ----

5. Originally from
Raebareli, UP
• Balongi village, Kharar,
Punjab – last 5 years
• Sister – Ramdarbar,
Chandigarh
• 2 kids in UP
(2nd & 3rd child)

6. Socioeconomic Status
– Score 5 (Modified Kuppuswamy Classification 2020)
– LOWER CLASS
– Assets owned- had a TV, sold it
– No cycle/refrigerator/land owned etc
– No Bank Accounts held

7. Housing and Environment
– Type – Pucca House, 1st floor
– Area – 1 single room (kitchen within, bathroom outside-
shared by 4-5 families)
– Lighting – Inadequate
– Ventilation – No Cross Ventilation
– Kitchen Space – No separate kitchen space
– Safe Drinking water – Tap water from corporation

8. Housing and Environment
– Pests and Rodents – Present
– Child friendly – No
– Access to Health Care – Daun Sub Center (4.7 km), CH Phase
6, Sector 56 - SAS Nagar (3.2 km), Behlolpur Sub Center (4.1
km)
– Nearby Pollution – No
– Nearby Areas – Balongi police station, no deserted areas

9. How the patient came
to us
– Referred by a child welfare activist
– Case of Child Sexual Abuse
– Child found no relief
– Reached out for professional help
– Child, Father – APC, PGIMER on
23/06/20
– Social Emergency

10. Ice Breaking
– There was an ice-breaking session with
the child to make her comfortable and
familiarise her to the environment
– Since taking history again would
retraumatise the child, nothing
regarding the incident was asked
– The history in this presentation was
collected from various sources
PC: Junior resident Dr Gautham B C

11. – The father’s drinking partner whom he knew for the past
1 ½ months, came home and sent the child out in the
pretext of getting lassi
– He followed her, used force to close her mouth and take
her away
– He sexually abused (raped) her and fled
Incident – 30, May 2020

12. – The mother saw her daughter in torn clothes and blood
stains and burst into tears
– She wanted to call/ inform the child’s father but did not
have a phone
– The father was at work
– She waited till he returned home
– By then, she had cleaned and dressed the child

13. Narrative History
- in verbatim of child
– “ Ma kaam kar rahe the. “Uncle” aa gaye. Lassi peene ke
liye manga. Ma ne mujhe lassi khareedne ke liye bheja.
Uncle ne peeche se aaya aur muh bhand kiya aur bola 500
rupay denge, kisi ko nahi batana. Churi lekar Daraya
Mummy Pappa ko nahi batana. Mere saath galath kiya.
Phir mummy aaya, puncha kyu kapada phatta hua hai aur
rone laga.”

14. Chief Complaints
– Unable to sleep in the night
– Having nightmares
– Pain in the legs while walking
– Lower abdominal pain occasionally

15. History of Presenting Illness
– Patient was apparently well 3 months back until when the
incident occurred, following which she
– Inability to sleep in the night
– Did not sleep – 2 days straight
– Difficulty to initiate sleep (3-4 hrs)
– 3-4 hrs of sleep maintenance & early morning awakening
– Quantity of sleep – 4-5 hrs
– Quality of sleep - Poor (Nightmares)

16. – Mood of the child
– Anxious and worried throughout the day
– Did not talk to anyone, did not eat
– Occasional irritability
– Did not go out to play

17. – c/o pain in the B/L lower limbs, diffuse, non specific in
nature, non progressive, non radiating, present only
while walking and relieved on taking rest
– c/o occasional lower abdominal pain, dull aching type,
no diurnal or positional variations not associated with
vomiting, loose stools

18. – No h/o any active bleeding per vagina
– No h/o burning micturition, discharge per vagina
– No h/o swelling, redness, bruise on any body part
– No h/o fever

19. Event
• Threatened
the child
Signs &
Symptoms
• Flashbacks
(Nightmares)
• Avoidance
behaviour
(avoids
interaction)
• Social
Impairment
(reduced
sleep,
appetite)
Suggestive
of
• Post
Traumatic
Stress
Disorder
(PTSD)

20. Post Traumatic Stress Disorder
(PTSD) Screening
– The child PTSD Symptom scale for DSM-5 (CPSS-5 SR)
– Initial Score = 58 (Severe)
– At 1 month post incident

21. Chronology of Events
Incident-30/05/2020
Parents shattered by incident, 2 days passed by
Contacted freelance social worker
Case filed by local police under the POCSO Act

22. Chronology of Events
Medical examination & forensic samples – CH,
Kharar
Social worker contacted Paediatrician, PGIMER
Government Protocol for CSA (Pandemic)
Received Support person
No relief in symptoms

23. Examination
Of
Child

24. General Physical Examination
– Moderately built, poorly nourished
– Well oriented to time, space and person
– Pallor – PRESENT
– Icterus
– Cyanosis
– Clubbing
– Lymphadenopathy
NOT PRESENT

25. Anthropometry
Parameter Result Z score
Height 109.8 cm 1.05
Weight 15.8 kg -1.45
BMI 13.1 -0.98
– Under weight

26. Vitals
– Temperature – Afebrile
– Pulse Rate – 86/min
– Respiratory Rate – 20/min
– SpO2 – 98% on room air
– BP – 94/50 mm Hg
– CFT – <2 sec

27. Examination of Genitalia
– Done prior coming to PGIMER
– Inspection of anogenital area – no signs of injury or
infection
– Mons pubis, labia majora, minora, clitoris, urethral
meatus, posterior fourchette, fossa navicularis - Normal
– Hymen – ? tear

28. Systemic Examination
– CVS
– S1 , S2 heard. No murmurs
– RS
– B/L Normal vesicular breath sounds heard. No added sounds
– GI
– Soft, non tender. Bowel sounds heard
– CNS
– No abnormality detected

29. At the time of Examination
– Forensic samples
– Confirmation of accused
– Rule out STDS

30. Past History
– No instances of abuse in the past
– One time incident
– No other medical history in the past

31. Antenatal, Birth and Immunisation
History
– First born to nonconsanguineous couple
– Uneventful T1,T2,T3
– Full Term Normal Vaginal Delivery – Institutional
– Immunised till date as per National Immunisation
Schedule

32. Growth & Developmental
History
– Attained gross motor, fine motor, social and language
milestones at appropriate age
– Has never been formally schooled (shifted to Chandigarh)
– Has not been enrolled in any Anganwadi (Chandigarh),
enrolled in UP
– Home schooled by a teacher, occasionally
– Can read the English alphabet, Hindi Varnamala
– Can count to 100 in English and Hindi

33. Diet History
– Her calorie intake per day is 1600 kcals. Required =2200
kcals/day.
– His protein intake is 32 gm . Required =60 gm.
– Deficit
– 27% total kcals
– 46% protein deficit

34. Menstrual history and Sexual
Maturity
– Menarche not attained
– Tanner’s Stage 3

35. Family History
– No significant medical history (TB, DM, HTN etc) in the
family
– 5 child births (no contraceptive use)
– All Institutional deliveries
– Male preference

36. Bonding & Relationship with
Family
– Share a loving bond
– Child feels bad when she sees her parents crying
– Both parents were shattered by the incident and are still
disturbed
– Not a neglected child
– No h/o domestic violence
– Happy and healthy family

37. Expenditure incurred
– Nil for case filing, proceedings of court etc
– Travel expenses
– Debt of Rs. 20,000 (borrowed from Employer)
– Will work without pay for repayment
– Unable to pay rent for past 6 months
– Rough terms with the owner
– Takes wife and children along for work
Money for
drinking?

38. – Known person
– Used to stay in ground floor
– Father’s drinking partner since 1 ½ months
– Since lockdown, at home
– Grooming of child
Lockdown- Free time ?
Exposure to explicit
content ?
The Perpetrator

39. Psychosocial History

40. Child
– Insomnia, nightmares
– Does not go out to play
– Mostly spending time indoors
– Aloof
“Muhje neend
nahi aati. Raath
bhar jaagthi
rehti hoon.”

41. 3 Wishes test
– Hope
– Positivity
– Loving bond with parents
“ Mujhe
padna hai,
bade hokar
teacher
banna hai”
“Mere saath
jo hua, woh
aur kisi ke
saath nahi
hona hai”
“Main mere
mummy papa
ko dukh nahi
dena hai”

42. – “Baar baar yaad a jatha hai. Humare saath galath hua
hai. Usko 5 saal bhi kam hai. Kuch kaarthe toh, man teek
rahta hai. Ghar aathe hi bahut dukh hota hai.”
– Father was tearing up every 15 minutes
– Guilt (Done by someone who he considered friend)
Father’s Perspective

43. “Maine socha insaan
sahi hai. Uska dimag
main kya chalta hai
mujhe nahi patha
tha”
“Yadi ghar valon ko patha
chala tho Ghar khoon
karenge. Rape hua hai,
shaadi ke liye dikhat ho
jayenge. Mujhe yeh bath
chupana padega. Yeh
mere ander hi rah jayega.
Majboori bahut hai”
Verbatims of father

44. “Mauja mang rahe hai
Insaaf dila dijiye. Jo
mere saath hua hai,
dusron ke saath bhi ho
saktha hai. Mujhe
paisa ki koi lalchi nahi”
“Rajnaama nahi
karenge. Ladai
ladna hai. Peeche
hatunga toh haar
jaunga.”

45. • Perceived
Barriers
• Perceived
Benefits
• Perceived
Severity
• Perceived
Susceptibil
ity
Considered
neighbour as
friend
No threat
Shame
Fear of
Stigma
Societal
status
Marriage
Neighbours
Low SES
Wants
justice not
money
Future for
the child

46. Theory of Reasoned Action
Belief,
Attitude,
Value to
Outcome
Intention
Subjective
Norms
Desired
Action/
Behaviour

47. Socio Ecological Model
Female child, mostly at
home (soft target)
Family lowest economic strata
No Social security, no School,
no Anganwadi
Stigma – victimisation,
quarrel with neighbours
Law – Lockdown, insensitivity
(police- compensation)

48. Summary
– A 11 year old female child, belonging to lower socioeconomic strata,
non formally schooled, first born with 4 siblings, sexually abused
(raped) by a known perpetrator, complains of having nightmares,
insomnia, abdominal pain ever since the incident. The incident was
brought to notice to the Police authority and FIR was lodged. She
received Support person, but did not experience any relief whereby
she was referred to paediatrician (PGIMER) for mental, emotional
and psychosocial well being where she was diagnosed to have PTSD.

49. MANAGEMENT

50. Medical
Assistance
Psychosocial
interventions
Legal
Assistance

51. Individual Level
– Medical assistance
• Emergency Care (received in CH, Kharar)
• Iron Syrup and Vitamin supplementation
• NSAIDS for Pain
– Emotional support
• Counselling sessions
• Safe space
– Education
• Formal schooling and Anganwadi registration

52. Psychosocial
Interventions Art Therapy
•Provided her with
regular supply of colour
pencils, crayons, art
paper etc
•Opportunity to express
negative emotions in a
safe way

53. Art Therapy
S- 3
Mangoes,
Flowers, Toys,
Butterflies, Child
(Behen)
S- 2
“Shaithan”,
Dinosaur
emitting fire
to kill
“khatarnaak
aadmi”
Session 1
House,
Tree,
Flowers
• Happy Pictures
• Forgotten the
incident
• Diagram of 6
year old
• Surges of Traumatic
memories in between
– Asked to draw whatever
comes to her mind
– To show it during next
consultation

54. – Gradual increase in tasks given with each session (need
based)
– Eg: Write date on every drawing, “Join the dots” exercise
– Exercises to read words/sentences/rhymes
– Provided with a mini laptop with pre-recorded audio
books, educational videos and other educational material
– Rehabilitation until enrolment in school

55. – Involve in co-curricular activities
• Takes away the idle time
• Buys time from house hold chores

56. Repeat PTSD Scoring
– The child PTSD Symptom scale for DSM-5
(CPSS-5 SR)
– After two months of therapy
– Score= 18 (Mild)

57. Family Level
– Emotional support
– Father and mother to hold spirits high and create a
nurturing environment at home
– Relocating home (social security)
– Not under Ayushman Bharat scheme
– Focus on empowering the child (education)

58. Incident
• Prevention
• Delay to
report
• Reported
with help of
social
worker
(freelance)
POCSO Case
• Police tried to
settle the case
• No real
psychological
benefit from
Support
person
Rehabilitation
• Time taking
• Low SES
• Struggling to
make ends
meet
• No Social
Security
• Taking
advantage
Community Level
– Gaps in this case

59. Strengths
Incident
• Reported
• Medical and
forensic
examination
done
POCSO Case
• FIR Lodged
• Accused
currently
under the
bars. Case
in court.
Judgement
not
pronounced
yet.
Rehabilitation
• Receiving
professional
help
• Collaboratio
n of free
lance
workers/
NGOs

60. Highlights
– Gap in reporting
• Intension to act was present
• Assistance received – more confident to report
– Role of NGOs
• May have gone unnoticed
• At work during lockdown

61. – Improvement in condition of child with
professional help
• Goes out to play (with mother around)
• Spends time colouring, learning new things
• PTSD has come down from severe to mild
– Family
• Accepted what has happened to the child
• Willing to fight the case in court
• Want to educate all children

62. Thank you!