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A total of 130 children were identified in whom both evidence of sexual abuse and nonaccidental, non-genital physical injuries (bruises, fractures, scratches, burns and scalds, including failure to thrive) were found. There were 77 girls and 53 boys with mean ages 5-7 and 6-8 years respectively and the peak age between the second and seventh birthdays; this reflects previous reports indicating that physical and sexual abuse predominantly involves young children.Patterns of injury that suggested sexually motivated assault included bruises, scratches, and burns around the lower trunk and genitalia, thighs, buttocks, and upper legs including knees. Pinch and grip marks were found where the child was held. The sexual abuse often involved attempted or achieved penetration of mouth, vagina, or anus, and physical signs were seen relatively more often than in sexually abused children as a whole. Four children died and sexual aggression and child death in the domestic setting may be linked. One in six of 769 physically abused children (16-9%) and one in seven of 949 sexually abused children (13-6%) have suffered both forns of abuse.Children studied In the four years 1985-8 inclusive we diagnosed physical abuse in 769 children and sexual abuse in 949 children. These totals included 130 children in whom both physical and sexual abuse was diagnosed. Details of the number of children in each year are to be found in table 1. These 1588 children represented 55% of 2883 children referred with suspected child abuse or neglect over the four years to paediatricians in Leeds, an industrial city with a population of 750 000. In the latter half of 1988 additional numbers of paediatricians in the two major hospitals in the city became involved in seeing abused children and most of these children are included in the data.Details of this larger group will be provided elsewhere in due course. Of the 130 physically and sexually abused children, there were 77 girls (mean age 5 7 years) and 53 boys (mean age 6-8 years). Sixty four (49%) of the children were aged less than 5 years (41 (31%) girls, 23 (18%) boys), 47 (36%) were 5-10 years (27 (21%) girls, 20 (15%) boys), 18 (14%) were 10-15 years (eight (6%) girls, 10 (8%) boys), and one girl was aged over 15 (fig 1). Kingdom found that in 15% of sexually abused children there was evidence of physical injury and in 7% there was a history of previous injury.4 In an earlier publication we described our finding that one in 10 of 337 sexually abused children had presented to us after physical abuse.5 Since then our experience of both physical and sexual abuse has increased and the presence of an overlap between these forms of abuse has become clear. We therefore decided to review our experience over the four years in which increasing numbers of sexually abused children have come to our attention.

Aim-To study the outcome over an eight year period of children determined by paediatricians in 1989 as definitely or probably sexually abused. Method-Information was obtained on 140 of 148 children diagnosed in 1989 when aged 7 or less. Sources were hospital medical records and school health records. School health records of a comparison group of 83 children were also examined. Results-A variety of problematic characteristics were found significantly more often in the abused group than the comparison group. These included surname changes (30% v 2%), removal from home (25% v 1%), number of home addresses (2.8 v 1.4), and schools attended (3.4 v 2.2). Other significant findings included further abuse (35% v 0%), adverse behaviours (60% v 16%), educational problems (24% v 5%), chronic health problems (54% v 36%), and involvement of mental health services (32% v 1%).

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We report a retrospective cohort study in which clinical and outcome features of 237 cases of child sexual abuse diagnosed by Leeds paediatricians after Cleveland in 1989 were compared with previously published characteristics of 337 children diagnosed by the same paediatricians before Cleveland in 1985 and 1986. Clinical and diagnostic features also were analysed in two subgroups of the 1989 cohort, those for whom there was no case conference and those in whom further abuse was detected at follow‐up examination. The number of cases diagnosed annually remained high, and source of referrals and age and sex distribution were similar. Most suspected perpetrators were from within the home in both cohorts. Some clinical features of the 1989 cohort suggested more physically severe abuse. In 1989 fewer children were registered as sexually abused, or were taken into care, and fewer suspected perpetrators were convicted. From the 1989 cohort those children for whom there was no case conference tended to be older, to disclose and were abused less severely by someone outside their home as compared to those for whom a case conference was held. The children in whom further abuse was detected tended to be younger, to not disclose. to be more severely abused by a perpetrator within the home and to be taken into care as compared to those in whom further abuse was not detected. One or more case conferences were held for nearly all of the children in whom further abuse was detected. For most of the 1989 children no evidence was found indicating receipt of mental health services from other than the key social worker. Implications of these findings are discussed in terms of professional and public knowledge and attitudes regarding children's and parental rights and family preservation.

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Comparison of sixjet nebulising systems for the nebulisation of rhDNase (2-5 mg in 2 5 ml)Recommended systems RMCH systems Compressor Pulmo-aid CR50