Aim To highlight difficulties in differentiating abuse from accidents in disabled children.

Method Examination of community, hospital medical and safeguarding records.

Resullts A 6 year old autistic girl was brought to A&E with a history of a foreign body in the vagina. She had been in the bath with a 6 inch plastic doll. Ten minutes later when the parents returned the dolls round head measuring about an inch in diameter was missing. The child explained that it had “gone up her tuppence”. “Tuppence” is a term young children often use for the vaginal orifice There was no pain, discomfort or vaginal discharge and child seemed well.

The professionals contacted social services who had no prior knowledge of the family. Overnight she remained well opening her bladder but not her bowels. There was no prior history of constipation.

Multiagency assessment of family did not reveal any child protection concerns A joint examination with oral sedation by a paediatrician and a gynaecologist was unsuccessful. An examination under general anaesthetic showed no external evidence of trauma or discharge. The hymen was crescentic and intact. No foreign object was seen in the vagina.

Rectal examination was performed and the small dolls round head was retrieved easily.

Retrospectively it was evident that the child may have been confused between her vagina and anal orifice as many small children are. If the object had entered her hymenal orifice there was increased likelihood of pain and trauma both of which were not present in this case.

Results Young children are often not sure of the distinctions between their vaginal and anal orifices. Additionally the presence of other developmental problems, communication difficulties and learning disability made it harder to obtain a full history to discriminate between abuse and accident resulting in an escalation to referral for safeguarding concerns.

Conclusion Disabled children are more likely to be abused and also more likely to be referred for suspected abuse. There are additional factors with these children that may be barriers to easy resolution of presenting concerns. Whilst it is most important to refer children for suspected abuse, these additional factors also need consideration.