1 |
Sex |
Girl |
|
|
Boy |
2 |
Age |
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 parent) drug abuse |
Yes/no |
12 |
Caregiver chronic somatic illness |
Yes/no |
13 |
Caregiver chronic psychiatric disease |
Yes/no |
14 |
Caregiver other health problem |
Yes/no |
15 |
Parents in conflict with each other |
Yes/no |
16 |
Parents in conflict with others |
Yes/no |
17 |
Residence |
City, village, district |
|
Former disease/disability of the child: |
|
18 |
Reduced vision |
Yes/no |
19 |
Reduced hearing |
Yes/no |
20 |
Reduced mobility |
Yes/no |
21 |
Mentally disabled |
Yes/no |
22 |
Chronic somatic disease |
Yes/no |
23 |
Type of somatic disease |
|
24 |
Chronic psychiatric disease |
Yes/no |
25 |
Type of psychiatric disease |
|
26 |
Learning difficulties |
Yes/no |
27 |
Self-harm, suicidal behavior |
Yes/no |
28 |
Fractures/trauma |
Yes/no |
29 |
Allergy/intolerance |
Yes/no |
30 |
Headache/migraine |
Yes/no |
31 |
Stomachache |
Yes/no |
32 |
Eating problems |
Yes/no |
33 |
Other pain |
Yes/no |
34 |
Constipation/diarrhea |
Yes/no |
35 |
Urinary tract infection or other symptoms |
Yes/no |
36 |
Other problems |
Yes/no |
|
Later diagnosed disease/problems with possible relevance |
|
37 |
Reduced vision |
Yes/no |
38 |
Reduced hearing |
Yes/no |
39 |
Reduced mobility |
Yes/no |
40 |
Mentally disabled |
Yes/no |
41 |
Chronic somatic disease |
Yes/no |
42 |
Type of somatic disease |
|
43 |
Chronic psychiatric disease |
Yes/no |
44 |
Type of psychiatric disease |
|
45 |
Learning difficulties |
Yes/no |
46 |
Self-harm, suicidal behavior |
Yes/no |
47 |
Fractures/trauma |
Yes/no |
48 |
Allergy/intolerance |
Yes/no |
49 |
Headache/migraine |
Yes/no |
50 |
Stomachache |
Yes/no |
51 |
Eating problems |
Yes/no |
52 |
Other pain |
Yes/no |
53 |
Constipation/diarrhea |
Yes/no |
54 |
Urinary tract infection or other symptoms |
Yes/no |
55 |
Other problems |
Yes/no |
56 |
Former referred to community health service for psychiatric difficulties |
Yes/no |
57 |
Type of health service |
|
58 |
Former referred to child and adolescent mental health service (CAMHS) or pediatric clinic for psychiatric difficulties |
Yes/no |
59 |
Type of health service |
|
60 |
Present medication |
|
61 |
Type of medication |
|
62 |
Who referred patient |
Direct contact, police, general practitioner, school nurse, child protective service, CAMHS, and so on |
63 |
Other referral |
|
|
Registered contacts in patient record system |
|
64 |
Indirect contact (with other services) |
Number |
65 |
Direct contact with child present |
Number |
66 |
Direct contact without child present |
Number |
67 |
Phone/email contact |
Number |
|
Judiciary actions |
|
68 |
Police report |
Yes/no |
69 |
Police interrogation |
Yes/no |
70 |
Trial conducted |
Yes/no |
71 |
Conviction |
Yes/no |
72 |
Acquitted |
Yes/no |
73 |
Dismissed |
Yes/no |
74 |
Other |
|
75 |
Non-judiciary actions (e.g., regulation of visitation) |
Yes/no |
76 |
Child protective actions |
Yes/no |
|
Characteristics of abuse |
|
77 |
Psychological abuse |
Yes/no |
78 |
Physical abuse |
Yes/no |
79 |
Sexual abuse |
Yes/no |
|
Relationship to suspected offender |
|
80 |
Biological father |
Yes/no |
81 |
Stepfather/foster father |
Yes/no |
82 |
Biological mother |
Yes/no |
83 |
Stepmother/foster mother |
Yes/no |
84 |
Sibling |
Yes/no |
85 |
Stepsibling/half-sibling |
Yes/no |
86 |
Grandfather/grandmother |
Yes/no |
87 |
Uncle/aunt/cousin |
Yes/no |
88 |
Other relative |
Yes/no |
89 |
Boyfriend/girlfriend |
Yes/no |
90 |
Friend/acquaintance |
Yes/no |
91 |
Person of authority |
Yes/no |
92 |
Stranger |
Yes/no |
93 |
Unknown |
Yes/no |
94 |
Psychological reaction at first contact |
None, moderate (e.g., anxious, sadness), severe (e.g., depression, despair, disorientation), not possible to evaluate |
|
Severity of abuse |
|
95 |
Severe physical violence (e.g., fractures, internal bleeding) |
Yes/no |
96 |
Moderate physical violence (e.g., bruises, wounds) |
Yes/no |
97 |
Severe sexual abuse (oral, vaginal, anal penetration, forced masturbation) |
Yes/no |
98 |
Moderate sexual abuse (e.g., touching/fondling of intimate area, showing pornography) |
Yes/no |
99 |
Psychological abuse |
Yes/no |
100 |
Unknown severity |
Yes/no |
101 |
Threats from offender |
Yes/no |
102 |
Conclusion |
Confirmed, uncertain/suspected abuse, disproved |
103 |
Previous abuse (sexual, physical, psychological) |
Yes/no |
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, unknown |
105 |
If repeated abuse, time since first event |
<2 months, 2 to 6 months, 6 to 12 months, 1 to 2 years, 2 to 5 years, >5 years, unknown |
|
Psychological symptoms reported by patient/caregiver or other |
|
106 |
Sadness |
Yes/no |
107 |
Anxiety |
Yes/no |
108 |
Tired/exhausted/lack of initiative |
Yes/no |
109 |
Suicidal thoughts |
Yes/no |
110 |
Antisocial behavior |
Yes/no |
111 |
Abusing others |
Yes/no |
112 |
Impulsivity |
Yes/no |
113 |
Sexualized behavior |
Yes/no |
114 |
Delusions |
Yes/no |
115 |
Attention problems |
Yes/no |
116 |
Hyperactivity |
Yes/no |
117 |
Flashbacks |
Yes/no |
118 |
Nightmares |
Yes/no |
119 |
Avoidance |
Yes/no |
120 |
Memory loss |
Yes/no |
121 |
Nervous/alert |
Yes/no |
122 |
Irritability/tantrums |
Yes/no |
123 |
Dissociation |
Yes/no |
124 |
Other problems reported by patient |
Yes/no |
125 |
Other problems reported by caregiver |
Yes/no |
126 |
Other problems reported by others |
Yes/no |
127 |
If others, who |
|
|
Psychiatric findings reported by doctor or psychologist: |
|
128 |
Anxious/depressed |
Yes/no |
129 |
Withdrawn/depressed |
Yes/no |
130 |
Social problems |
Yes/no |
131 |
Thought problems |
Yes/no |
132 |
Attention problems |
Yes/no |
133 |
Rule-breaking behavior |
Yes/no |
134 |
Aggressive behavior |
Yes/no |
|
Somatic and psychosomatic symptoms and findings |
|
135 |
Sleeping problems |
Yes/no |
136 |
Eating problems |
Yes/no |
137 |
Headache |
Yes/no |
138 |
Muscle/skeletal pain |
Yes/no |
139 |
Gastrointestinal problems |
Yes/no |
140 |
Diffuse pain |
Yes/no |
141 |
Pelvic pain |
Yes/no |
142 |
Dysuria |
Yes/no |
143 |
Other symptoms and findings from sexual organs or anal area |
Yes/no |
144 |
Other problems reported by patient |
Yes/no |
145 |
Other problems reported by caregiver |
Yes/no |
146 |
Other problems reported by others |
Yes/no |
147 |
If others, who |
|
|
Physical findings |
|
148 |
Physical findings documented in patient record |
Yes/no |
149 |
Light (superficial wounds, bruises) |
Yes/no |
150 |
Moderate (wounds, cuts) |
Yes/no |
151 |
Severe (fractures, internal bleeding) |
Yes/no |
152 |
Marks on neck/throat |
Yes/no |
153 |
Injuries in sexual area |
Yes/no |
154 |
Injuries in anal area |
Yes/no |
155 |
Sexually transmitted disease |
Yes/no |
156 |
Other |
Yes/no |
|
School functioning |
|
157 |
Academic difficulties |
Yes/no |
158 |
Increased absence since time of abuse |
Yes/no |
159 |
Unchanged |
Yes/no |
160 |
Social problems |
Yes/no |
161 |
Alcohol use |
Never, mild (1 to 2 times), heavy (several times) |
162 |
Drug abuse |
Never, mild (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 |
|